Comparing the validity of the self reporting questionnaire and the Afghan symptom checklist: dysphoria, aggression, and gender in transcultural assessment of mental health

Gendered Health Outcome Among Somali Refugee Youth in Displacement: A Role of Social Support and Religious Belief

This study examines the factors influencing physical health status, specifically focusing on the gender differences in risk and promotive factors affecting health outcomes among Somali refugee youth displaced in Nairobi, Kenya (n = 227). A survey was used to assess participants' physical health along with psychosocial factors, somatic symptoms, and demographic characteristics. The study shows that religious belief and somatic symptoms among the total sample were significant predictors in influencing the outcome of physical health. A moderated mediation analysis and logistic regression analyses also revealed gender differences in associated factors as well as health status; female participants reported higher somatic symptoms, associated with a decline in physical health, whereas the protective effect of social support and religious belief promote was found only among male counterparts. Future studies and interventions would be benefited from a gender-specific approach to health promotion and coping mechanisms in this population.

Afghan mental health and psychosocial well-being: thematic review of four decades of research and interventions

BACKGROUND

Four decades of war, political upheaval, economic deprivation and forced displacement have profoundly affected both in-country and refugee Afghan populations.

AIMS

We reviewed literature on mental health and psychosocial well-being, to assess the current evidence and describe mental healthcare systems, including government programmes and community-based interventions.

METHOD

In 2022, we conducted a systematic search in Google Scholar, PTSDpubs, PubMed and PsycINFO, and a hand search of grey literature (N = 214 papers). We identified the main factors driving the epidemiology of mental health problems, culturally salient understandings of psychological distress, coping strategies and help-seeking behaviours, and interventions for mental health and psychosocial support.

RESULTS

Mental health problems and psychological distress show higher risks for women, ethnic minorities, people with disabilities and youth. Issues of suicidality and drug use are emerging problems that are understudied. Afghans use specific vocabulary to convey psychological distress, drawing on culturally relevant concepts of body-mind relationships. Coping strategies are largely embedded in one's faith and family. Over the past two decades, concerted efforts were made to integrate mental health into the nation's healthcare system, train cadres of psychosocial counsellors, and develop community-based psychosocial initiatives with the help of non-governmental organisations. A small but growing body of research is emerging around psychological interventions adapted to Afghan contexts and culture.

CONCLUSIONS

We make four recommendations to promote health equity and sustainable systems of care. Interventions must build cultural relevance, invest in community-based psychosocial support and evidence-based psychological interventions, maintain core mental health services at logical points of access and foster integrated systems of care.

Why local concepts matter: Using cultural expressions of distress to explore the construct validity of research instruments to measure mental health problems among Congolese women in Nyarugusu refugee camp

There is considerable variation in the presentation of mental health problems across cultural contexts. Most screening and assessment tools do not capture local idioms and culturally specific presentations of distress, thus introducing measurement error and overlooking meaningful variation in mental health. Before applying screening and assessment tools in a particular context, a qualitative exploration of locally salient idioms and expression of distress can help assess whether existing measures are appropriate in a specific context as well as what adaptations may improve their construct validity. We aimed to employ a mixed-methods approach to describe and measure cultural concepts of distress among female Congolese survivors of intimate partner violence in Nyarugusu refugee camp, Tanzania. This sequential study used data from 55 qualitative (free-listing and in-depth) interviews followed by 311 quantitative interviews that included assessments of symptoms of common mental disorder to explore whether the symptom constellations were consistent across these methodologies. Results from thematic analysis of qualitative data and exploratory factor analysis of quantitative data converged on three concepts of distress: huzuni (deep sadness), msongo wa mawazo (stress, too many thoughts), and hofu (fear). The psychometric properties of these constructs were comparable to those of the three original common mental disorders measured by the quantitative symptom assessment tools-anxiety, depression, and post-traumatic stress disorder-adding weight to the appropriateness of using these tools in this specific setting. This mixed-methods approach presents an innovative additional method for assessing the local "cultural fit" of globally used tools for measuring mental health in cross-cultural research.

Using the WHO Self-Reporting Questionnaire-20 (SRQ-20) to Detect Symptoms of Common Mental Disorders among Pregnant Women in Vietnam: a Validation Study

Purpose

Detection of antenatal common mental disorders in low-resource settings like Vietnam is important and requires a reliable, valid and practical screening tool. Currently, there is no such tool validated for use among pregnant women in Vietnam. This study aims to assess the validity of the Vietnamese version of the 20-item Self Reporting Questionnaire (SRQ-20) by evaluating its reliability, factorial structure, and performance in detecting common mental disorder (CMD) symptoms, thereby identifying the optimum cut-off score for CMD screening among pregnant women in Vietnam.

Participants and Methods

A total of 210 pregnant women from four rural communes participated in a face-to-face interview using the Vietnamese version of the SRQ-20, followed by a clinical diagnostic interview based on ICD-10 diagnostic criteria of CMDs. The reliability of the SRQ-20 was assessed by calculating the scale's Cronbach's alpha to measure internal consistency. Factor analyses were undertaken to examine the factor structure of the instrument. The Receiver Operating Characteristic (ROC) curve analysis was performed to assess the performance of the SRQ-20 against the clinical diagnosis and to identify the optimum cut-off score.

Results

Internal consistency was good, with a Cronbach's alpha of 0.87. Factor analyses resulted in a 4-factor solution. The area under the ROC curve (AUC) for detection of CMDs was 0.90. The optimum cut-off score of the SRQ-20 for detection of CMD symptoms among Vietnamese pregnant women was 5/6.

Conclusion

The Vietnamese version of the SRQ-20 has the capacity to detect CMDs among pregnant women effectively and is recommended for use as a screening tool for CMDs in antenatal care settings in Vietnam.

Multidimensional poverty is associated with dementia among adults in Afghanistan

Background

Multidimensional poverty is associated with dementia, but no evidence is available for countries in conflict.

Methods

A cross-sectional study was conducted in two provinces of Afghanistan between February 15th 2022 and April 20th 2022 among adults age 50 and older. Multidimensional poverty included six dimensions of well-being and 16 indicators of deprivation. The Rowland Universal Dementia Assessment Scale measured dementia. Poverty between adults with and without dementia was examined, adjusting for sex. Associations between dementia and poverty were investigated using multivariate regression model.

Findings

Of the 478 adults included, 89 (52.7%) had mild, and 25 (14.8%) had moderate to severe dementia. More women than men had mild (52.7% vs 33.3%) and moderate-to-severe dementia (14.8% vs 5.8%). Approximately 33.9% adults with mild and 51.2% adults with moderate-to-severe dementia were found to be deprived in four or more dimensions compared to 21.8% without dementia. The difference in four dimensions of multidimensional poverty between adults with mild and moderate-to-severe dementia and adults without dementia was respectively 59.5% and 152.88%. Education, employment, health, and living conditions were the main contributors to the adjusted poverty head count ratio. Multidimensional poverty in four or five dimensions was strongly associated with dementia among older adults particularly over 70 years old (odds ratio [OR], 17.38; 95% CI, 2.22-135.63), with greater odds for older women overall (OR, 2.69; 95% CI, 1.76-4.11).

Interpretation

Our findings suggest that early improvement in social determinants of health through targeted structural policies may lower dementia risk later in life. Specifically, better access to free, quality education, healthcare, and basic living standard together with employment opportunities could reduce risk of dementia.

Funding

The present study was funded by a grant from the Alzheimer Association (AARG-NTF-21-851241).

Considerations in designing trauma-focused interventions for displaced Afghan women

In light of the 2021 United States military withdrawal from Afghanistan, as well as the humanitarian crises of mass displacement and subsequent health system strain that have ensued, practitioners worldwide will need to develop a more nuanced understanding of the adverse life experiences that women from Afghanistan frequently endorse. As they bear a disproportionate impact of constraints within Afghan society, and as patriarchal systems affect most of their life domains, women from Afghanistan may present with high levels of baseline trauma upon resettlement, and health systems may seek to attenuate this distress; However, the nature of these traumatogenic events may shape women's receptivity to psychosocial interventions, particularly those which are at least partially rooted in Western modalities. In the absence of sufficient literature on evidence-based interventions for this population, a diversity of ethnographic and clinical literature is synthesized, including literature on interventions alleged to be compatible with Afghan norms. As it will be essential to support Afghan women's mental health following social reorganization on a massive scale, considerations arising from the interdisciplinary literature are offered so that they may inform the development of structured, trauma-focused interventions and so that the health systems with which they interface may be better prepared to serve them.

Understanding Mental Health Status of Syrian Refugee and Jordanian Women: Novel Insights from a Comparative Study

(1) Background: War and displacement are well-known predictors of negative mental health outcomes among affected populations. This is especially relevant for refugees of war, particularly women, who often repress their mental health needs due to family responsibilities, social stigma, and/or cultural pressures. In this study, we compared the mental health status of urban Syrian refugee women (n = 139) with local Jordanian women (n = 160). (2) Methods: Psychometrically validated Afghan Symptom Checklist (ASC), Perceived Stress Scale (PSS), and Self-Report Questionnaire (SRQ) examined psychological distress, perceived stress, and mental health, respectively. (3) Results: According to independent t-tests, Syrian refugee women scored higher than Jordanian women on the ASC [mean score (SD): 60.79 (16.67) vs. 53.71 (17.80), p < 0.001], PSS [mean score (SD): 31.59 (8.45) vs. 26.94 (7.37), p < 0.001], and SRQ [mean score (SD): 11.82 (4.30) vs. 10.21 (4.72), p = 0.002]. Interestingly, both Syrian refugee and Jordanian women scored higher than the clinical cutoff in the SRQ. Regression analyses indicated that more educated women were less likely to score high on the SRQ (β = -0.143, p = 0.019), particularly in the anxiety and somatic symptoms subscale (β = -0.133, p = 0.021), and were less likely to exhibit symptoms of ruminative sadness (β = -0.138, p = 0.027). Employed women were more likely to exhibit high coping ability than unemployed women (β = 0.144, p = 0.012). (4) Conclusions: Syrian refugee women scored higher than Jordanian women in all used mental health scales. Access to mental health services and enhancing educational opportunities would help mitigate perceived stress and may enhance stress-coping abilities.

Psychometric properties of two mental health screening tools in southeast Liberia: The Liberian Distress Screener and Patient Health Questionnaire

Evidence suggests that locally developed and/or adapted screening tools for mental ill-health can have higher validity than directly translated tools developed in other settings. We administered the locally developed Liberian Distress Screener (LDS) and the Liberian-adapted Patient Health Questionnaire-9 (PHQ-9L) to a random sample of 142 outpatients at a regional hospital in Maryland County, Liberia. In the LDS, seven items demonstrated poor model fit and were excluded, resulting in an 11-item screener (LDS-11). Exploratory factor analysis of the 11-item screener (LDS-11) showed a single latent variable construct with significant factor loadings. Cronbach's alpha revealed good internal consistency (α = 0.81). Rasch analyses showed that "brain hot" and "heart fall down" were the most difficult idioms of distress to endorse while "things playing on the mind" was the easiest. All LDS-11 elements were associated with elevated function impairment, with "things playing on the mind," "worry too much," "head is hurting," and "heart cut/beat fast" achieving statistical significance. One item in the PHQ-9L demonstrated poor model fit and was excluded from psychometric analyses. The resultant eight-item PHQ demonstrated internal consistency (α = 0.76) and Rasch analysis revealed that "moving/talking too slowly/fast" was the most difficult item to endorse, while "not happy when doing things" was the easiest. Twelve items were significantly associated with functional impairment. Exploratory analyses reveal items that demonstrate ease and appropriateness of use for assessing mental distress in this population. Implementation research is needed to incorporate idioms of distress and screeners into Liberia's mental healthcare system.

Displacement and Isolation: Insights from a Mental Stress Survey of Syrian Refugees in Houston, Texas, USA

(1) Background: Syrians are the largest forcibly displaced population in the world. Approximately 20,000 Syrian refugees have resettled in the United States (US) since the civil war in Syria began in 2011, with an estimated 130 families resettling in Houston, Texas. We conducted a pilot study with the objective of examining the physical and mental well-being of the Houston Syrian refugee population. (2) Methods: Online surveys were conducted using psychometrically valid instruments including Afghan Symptom Checklist (ASC), Refugee Post-Migration Stress Scale (RPMSS), Perceived Stress Scale (PSS), and Self-Report Questionnaire (SRQ) (3) Results: According to independent t-tests, Syrian refugee females scored higher than males on ASC (37.78 vs. 31.64, p = 0.0446), particularly in the subscales of sadness with social withdrawal (28.89 vs. 24.31, p = 0.0495), and stress-induced reactivity (6.56 vs. 4.86, p = 0.0004). Similarly, females scored higher than males in RPMSS (60.54 vs. 45.15, p = 0.0022), including the social strain domain (8.08 vs. 5.18, p = 0.0204). In PSS and SRQ, Syrian refugee females reported comparable stress and distress scores as males. (4) Conclusions: Syrian refugee females reported higher stress and distress than males. Displacement from their home country and social strain were the major sources of stress in Syrian refugee females, as indicated in RPMSS.

Autobiographical memory impairment among Rohingya refugee people: roles of direct and indirect trauma exposures and PTSD symptom severity

Literature indicates that trauma exposure leads to autobiographical memory (AM) impairment, but the differential effects of direct and indirect trauma on memory remain unclear. We investigated AMs of 100 Rohingya refugees (Mean_age= 35.79; SD_age= 15.36) recruited from camps in Bangladesh and communities in Malaysia. Each participant retrieved ten memories to word cues and rated to what extent those memories were self-defining on a 5-point scale. They also completed the PTSD-8 scale and a trauma checklist reporting the types of traumatic events they experienced. Results showed that participants with frequent exposure to direct and indirect trauma recalled more traumatic memories. Surprisingly, more direct-trauma memories appeared to be specific than indirect trauma and non-trauma memories. As expected, individuals who scored higher on the PTSD-8 scale recalled more non-specific AMs. Rohingyas in Bangladesh who migrated months before data collection, thus retaining recent trauma experiences , retrieved more non-specific memories than those in Malaysia who migrated years ago. The direct trauma memories of the Malaysian cohort were more self-defining than their counterparts. The participant's ability to recall more direct trauma memories with specificity could be attributed to the repeated recall of those memories to the relevant authorities of the host countries to justify their refugee status.

The development of a contextually appropriate measure of psychological distress in Sierra Leone

Background

Studies of psychological distress in Sierra Leone have typically used measures which were developed for use in other contexts, and which often have not been adapted or validated for use in Sierra Leone. This has resulted in a lack of reliable information about the patterns of psychological distress within the population, which is a barrier to the development of effective and appropriate mental health services. The aim of the study was to develop a locally-appropriate measure of psychological distress for Sierra Leone.

Methods

The new measure consists of two instruments: the Sierra Leone Psychological Distress Scale (SLPDS) and a gendered measure of ability to carry out daily tasks—a Function scale—as an indication of the severity of distress. A three-phase mixed methods exploratory sequential study was conducted. Phase 1 was item generation and testing, leading to the development of a set of potential items for both instruments. Phase 2 was a small pilot study (N = 202) leading to the selection of the final set of items for both measures. Phase 3 was a validation phase where the SLPDS and the Function scale were administered with a larger sample of 904 respondents. Item analysis was used to assess the internal consistency of the scales, and Exploratory Factor Analysis to explore the properties of the SLPDS.

Results

Exploratory factor analysis using the principal axis factoring with an oblique rotation identified a three-factor structure for the 18-item SLPDS. Internal consistency for the SLPDS (Cronbach’s alpha = 0.89) and three subscales was good (Cronbach’s alpha > 0.73). The internal reliability of the male and female versions of the Function scale was also found to be acceptable (Cronbach’s alpha = 0.90 for the female scale and 0.79 for the male scale).

Conclusions

Together the SLPD and Function scales provide a locally-validated tool which will enable government bodies and local and international non-governmental organisations in Sierra Leone to assess mental health and psychosocial needs. This will support both effective service provision and the evaluation of initiatives designed to improve mental health and psychosocial wellbeing.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-021-00610-w.

The Relationship of Acculturation, Traumatic Events and Depression in Female Refugees

Recent research has identified significant correlations between traumatic events and depression in refugees. However, few studies have addressed the role of acculturation strategies in this relationship. This study explored the relationship between cultural orientation, traumatic events and depression in female refugees from Syria, Afghanistan, Eritrea, Iran, Iraq, and Somalia living in Germany. We expected acculturation strategies to moderate the effect of traumatic experiences on depression. The sample included 98 female refugees in Germany. The depression scale of the Hopkins Symptom Checklist (HSCL) represented the dependent measure. The trauma checklists derived from the Post-traumatic Diagnostic Scale (PDS) and the Harvard Trauma Questionnaire (HTQ) as well as the Frankfurt Acculturation Scale (FRACC) were used as independent measures for traumatic events and orientation toward the host culture as well as orientation toward the culture of origin, respectively. A moderation analysis was conducted to examine whether the relationship between the number of traumatic events and depression was influenced by the women's orientation toward the culture of origin and the host culture. We identified a significant model explaining 26.85% of the variance in depressive symptoms (Cohen's f2 = 0.37). The number of traumatic events and the orientation toward the host culture exerted significant effects on depressive symptoms. The moderating effect was not significant, indicating that the effect of the number of traumatic events was not influenced by cultural orientation. Based on our results, orientation toward the host culture as well as traumatic experiences exert independent effects on depressive symptoms in refugees.

Validation of a cross-NTD toolkit for assessment of NTD-related morbidity and disability. A cross-cultural qualitative validation of study instruments in Colombia

Background

Many neglected tropical diseases (NTDs) are not fatal, but they are disabling, disfiguring and stigmatizing. More accurate data on these aspects would benefit planning, monitoring and evaluation of interventions, as well as provision of appropriate services for the often life-long consequences. In 2015, a cross-NTD toolkit was developed, consisting of a variety of existing questionnaires to measure morbidity, disability and health-related quality of life. The toolkit covers the domains of the International Classification of Functioning, Disability and Health (ICF) framework. These tools have been developed in a source country, however, it was intended for the cross-NTD toolkit to be applicable across NTDs in many countries with different cultures and languages in order to generate universally comparative data. Therefore; the present study aimed to validate several tools of the toolkit among people affected by leprosy or leishmaniasis in the cultural settings of Cartagena and Cúcuta, Colombia.

Methodology

This study aimed to validate the following tools among 55 participants between 18–85 years old, affected by leprosy and leishmaniasis: (I) Clinical Profile, (II) Self-Reporting Questionnaire (SRQ), (III) WHO Quality of Life assessment-abbreviated version (WHOQOL-BREF), and (IV) WHO Quality of Life assessment-Disability (WHOQOL-DIS). The tools were administered during face-to-face interviews and were followed by open questions about the respondents’ thoughts on format of the tool and the understanding, relevance and acceptability of the items. The tools were validated using a qualitative method approach based on the framework for cultural equivalence, measured by the cultural, item, semantic and operational equivalences.

Results

The Clinical Profile was seen as acceptable and relevant, only the semantic equivalence was not as satisfying and needs a few adaptations. The SRQ was very well understood and shows to reach the equivalences for the population of Colombia without any additional changes. Several items of the WHOQOL-BREF and the WHOQOL-DIS were not well understood and changes are recommended due to semantic difficulties. Operational equivalence of both questionnaires was not as desired in relation to the used response scales. The participants shared that the tools are relevant and important for their particular situation.

Conclusions/Significance

The SRQ is found to be a valid tool for Colombia and can be included in the cross-NTD toolkit. The Clinical Profile, WHOQOL-BREF & WHOQOL-DIS need changes and retesting among Colombian people affected by an NTD. The toolkit as a whole is seen as useful to show the effects leprosy and leishmaniasis have on the participants. This cultural validation will contribute to a universally applicable cross-NTD toolkit.

Culturally sensitive assessment of anxious-depressive distress in the Cambodian population: Avoiding category truncation

In a large national survey in Cambodia (N = 2689), the present study investigated the prominence of certain culturally salient symptoms and syndromes in the general population and among those with anxious-depressive distress (as determined by the Hopkins Symptom Checklist-25, or HSCL). Using an abbreviated Cambodian Symptom and Syndrome Addendum (CSSA), we found that the CSSA complaints were particularly elevated among those with anxious-depressive distress. Those with anxious-depressive distress had statistically greater mean scores on all the CSSA items as well as severity of endorsement analyzed by percentage: among those with HSCL caseness, 75.3% were bothered "quite a bit" or "extremely" by "thinking a lot" (vs. 27.5% without caseness); 53.8% were bothered by "standing up and feeling dizzy" (vs. 13.8%); and 45.6% by blurry vision (vs. 16.8%). In a logistic regression analysis to predict anxious-depressive distress, 51% of the variance was accounted for by five predictors: "weak heart," "thinking a lot," dizziness, "khyâl hitting up from the stomach," and sleep paralysis. Using ROC analysis, a cut-off score of 1.81 on the CSSA was optimal as a screener to indicate anxious-depressive distress, giving a sensitivity of 0.86. The study results suggest that to avoid category truncation (i.e., the omission of key complaints that are part of an assessed distress domain) when profiling anxious-depressive distress among Cambodia population that items other than those in standard psychopathology measures should be assessed such as "thinking a lot," "weak heart," "blurry vision," and "dizziness upon standing up."

Prevalence of prolonged grief disorder in a sample of female refugees

BACKGROUND

Prolonged Grief Disorder (PGD) is a distinct syndrome that follows bereavement. It is different from other mental disorders and is characterized by symptoms such as yearning for the bereaved, or intense emotional pain or distress. Violent loss is one major risk factor for the development of PGD.

OBJECTIVES

PGD has been studied in different populations, mostly in small samples, with only a few of them being representative. Although research highlighted that traumatic experiences paired with challenges related to migration make refugees particularly vulnerable to PGD, PGD has only rarely been studied in refugees. Thus, this article a) examines the prevalence of PGD in female refugees in Germany according to the criteria proposed by Prigerson and colleagues in 2009, and b) associates PGD with other common psychopathology (e.g. anxiety, depression, somatization and trauma).

METHOD

A total of 106 female refugees were assessed for bereavement and PGD. Of these 106 individuals, 85 were interviewed using the Prolonged Grief Disorder Scale (PG-13). Symptoms of anxiety and depression were assessed by the Hopkins Symptom Checklist-25 (HSCL-25), somatization was assessed by the Somatization Subscale of the Symptom-Checklist-90 (SCL-90), and the number of witnessed and experienced trauma was assessed by the Posttraumatic Diagnostic Scale (PDS/HTQ).

RESULTS

Ninety of the 106 participants had experienced bereavement, and among those, 9.41% met criteria for PGD. The most frequent PGD symptoms were bitterness, longing or yearning for the bereaved, and lack of acceptance of the loss. Furthermore, grief symptoms were significantly associated with symptoms of depression, anxiety, somatization, and the number of experienced traumatic events.

CONCLUSION

The PGD prevalence rate found corresponds with previous studies, demonstrating that prevalence rates for PGD are especially high in refugees. High prevalence rates of bereavement as well as PGD highlight the need for assessment and specifically tailored treatment of PGD in refugees. PGD goes along with significant psychopathology, which further emphasizes the need for treatment.

The integration of idioms of distress into mental health assessments and interventions: a systematic review

BACKGROUND

Psychiatric diagnostic manuals recognise the importance of local expressions of distress in culturally diverse settings [i.e. idioms/cultural concepts of distress (CCDs)], yet there is a lack of consensus on how these should be incorporated into mental health related research.

AIMS

To perform a narrative synthesis and critical review of research exploring how idioms/CCDs have been integrated into assessment measures and interventions.

METHOD

A systematic review was conducted in accordance with PRISMA guidelines. An adapted version of the COSMIN checklist was used to assess the quality of the linguistic translation of the idioms/CCDs.

RESULTS

Twenty-nine papers were included in the final review. Primary qualitative research was the most common method of gathering information about idioms/CCDs. The majority of studies described integrating idioms/CCDs into assessment measures as opposed to interventions. Some studies used information relating to idioms/CCDs to develop novel assessment measures, while others adapted pre-existing assessment measures. The measures generated moderate to high levels of validity. Information relating to the linguistic translation conducted in the completion of the studies tended to be inadequately reported.

CONCLUSIONS

Integrating information about idioms/CCDs into assessment measures can enhance the validity of these assessments. Allocating greater research attention to idioms/CCDs can also promote more equitable exchanges of knowledge about mental health and wellbeing between the Global North and the Global South.

Cultural expressions of depression and the development of the Indonesian Depression Checklist

Depression may manifest differently across cultural settings, suggesting the value of an assessment tool that is sensitive enough to capture these variations. The study reported in this article aimed to develop a depression screening tool for Indonesians derived from ethnographic interviews with 20 people who had been diagnosed as having depression by clinical psychologists at primary health centers. The tool, which we have termed the Indonesian Depression Checklist (IDC), consists of 40 items. The tool was administered to 125 people assessed to have depression by 40 clinical psychologists in primary health centers. The data were analyzed with Confirmatory Factor Analysis (CFA) (IBM SPSS AMOS Software). CFA identified a five-factor hierarchical model ( χ ² = 168.157, p = .091; CFI = .963; TLI = .957; RMSEA = .036). A 19-item inventory of the IDC, with five factors - Physical Symptoms, Affect, Cognition, Social Engagement and Religiosity - was identified. There was a strong correlation between the total score of the IDC and total score of the Center for Epidemiological Studies-Depression scale (revised version CES-D), a standard tool for assessing symptoms of depression. The IDC accommodates culturally distinctive aspects of depression among Indonesians that are not included in the CES-D.

Risk and protective factors associated with the mental health of young adults in Kabul, Afghanistan

BACKGROUND

We examined the mental health status and severity of psychological distress symptoms among young adults residing in Kabul, Afghanistan and determined how such outcomes might be influenced by an array of risk and protective factors.

METHODS

A cross-sectional study design was adopted using convenience, snowball, and street-intercept recruitment techniques. Surveys were completed by 232 young adults between 18 and 35 years of age in September 2015. We used both etic (mental health component of the SF-8) and emic (Afghan Symptom Checklist) measures of mental health and psychological distress, respectively, and regressed these outcome measures against socio-demographic, physical health, and psychological variables (resilience, hope-optimism) using ordinary least squares (OLS) regression methods.

RESULTS

We found that poor mental health is common in this sample, affecting 75% of participants; and, that distress symptoms (depressive, anxiety, and somatoform symptoms) occur often. Regression models were consistent in showing higher education as a risk-factor for both outcomes, whereas, age, ethnicity, and income significantly contributed only to the ASCL model as risk-factors. However, both outcomes were strongly influenced by protective factors such as good physical health status and higher perceived hope-optimism.

CONCLUSIONS

Our study provides further evidence of how current economic conditions in Kabul contribute to poor mental health and symptom severity, but also show how positive physical health and perceived hope-optimism can be protective. This study provides support for developing culturally-competent policies and interventions that build on protective factors.

Six-year longitudinal study of pathways leading to explosive anger involving the traumas of recurrent conflict and the cumulative sense of injustice in Timor-Leste

PURPOSE

Cumulative evidence suggests that explosive anger may be a common reaction among survivors of mass conflict. However, little is known about the course of explosive anger in the years following mass conflict, or the psychosocial factors that influence the trajectory of that reaction pattern. We examined these issues in a 6-year longitudinal study (2004-2010) conducted among adult residents of a rural and an urban village in Timor-Leste (n = 1022).

METHODS

We derived a brief, context-specific index of explosive anger using qualitative methods. Widely used measures of post-traumatic stress disorder (PTSD) and severe psychological distress were calibrated to the Timor context. We developed an index of the cumulative sense of injustice related to consecutive historical periods associated with conflict in Timor-Leste. We applied partial structural equation modeling (SEM) to examine pathways from baseline explosive anger, socio-demographic factors, recurrent trauma, mental health indices (PTSD, severe psychological distress) and the sense of injustice, to explosive anger.

RESULTS

Half of the sample with explosive anger at baseline continued to report that reaction pattern after 6 years; and a third of those who did not report explosive anger at baseline developed the response by follow-up. A symmetrical pattern of younger age, female gender and the trauma count for the preceding historical period predicted explosive anger at each assessment point. The sense of injustice was related to explosive anger at follow-up. Explosive anger was associated with impairment in functioning and conflict with the intimate partner and wider family.

CONCLUSIONS

Sampling constraints caution against generalizing our findings to other populations. Nevertheless, our data suggest that explosive anger may persist for a prolonged period of time following mass conflict and that the response pattern is initiated and maintained by recurrent trauma exposure associated with a sense of injustice. Averting recurrence of mass violence and addressing persisting feelings of injustice may assist in reducing anger in conflict-affected societies. Whether explosive anger at the individual level increases risk of collective violence under conditions of social and political instability requires further inquiry.

"Developing culturally sensitive affect scales for global mental health research and practice: Emotional balance, not named syndromes, in Indian Adivasi subjective well-being"

We present a perspective to analyze mental health without either a) imposing Western illness categories or b) adopting local or "native" categories of mental distress. Our approach takes as axiomatic only that locals within any culture share a cognitive and verbal lexicon of salient positive and negative emotional experiences, which an appropriate and repeatable set of ethnographic procedures can elicit. Our approach is provisionally agnostic with respect to either Western or native nosological categories, and instead focuses on persons' relative frequency of experiencing emotions. Putting this perspective into practice in India, our ethnographic fieldwork (2006-2014) and survey analysis (N = 219) resulted in a 40-item Positive and Negative Affect Scale (PANAS), which we used to assess the mental well-being of Indigenous persons (the tribal Sahariya) in the Indian states of Rajasthan and Madhya Pradesh. Generated via standard cognitive anthropological procedures that can be replicated elsewhere, measures such as this possess features of psychiatric scales favored by leaders in global mental health initiatives. Though not capturing locally named distress syndromes, our scale is nonetheless sensitive to local emotional experiences, frames of meaning, and "idioms of distress." By sharing traits of both global and also locally-derived diagnoses, approaches like ours can help identify synergies between them. For example, employing data reduction techniques such as factor analysis-where diagnostic and screening categories emerge inductively ex post facto from emotional symptom clusters, rather than being deduced or assigned a priori by either global mental health experts or locals themselves-reveals hidden overlaps between local wellness idioms and global ones. Practically speaking, our perspective, which assesses both emotional frailty and also potential sources of emotional resilience and balance, while eschewing all named illness categories, can be deployed in mental health initiatives in ways that minimize stigma and increase both the acceptability and validity of assessment instruments.

Daily stressors, trauma exposure, and mental health among stateless Rohingya refugees in Bangladesh

The Rohingya of Myanmar are a severely persecuted minority who form one of the largest groups of stateless people; thousands of them reside in refugee camps in southeastern Bangladesh. There has been little research into the mental health consequences of persecution, war, and other historical trauma endured by the Rohingya; nor has the role of daily environmental stressors associated with continued displacement, statelessness, and life in the refugee camps, been thoroughly researched. This cross-sectional study examined: trauma history, daily environmental stressors, and mental health outcomes for 148 Rohingya adults residing in Kutupalong and Nayapara refugee camps in Bangladesh. Results indicated high levels of mental health concerns: posttraumatic stress disorder (PTSD), depression, somatic complaints, and associated functional impairment. Participants also endorsed local idioms of distress, including somatic complaints and concerns associated with spirit possession. The study also found very high levels of daily environmental stressors associated with life in the camps, including problems with food, lack of freedom of movement, and concerns regarding safety. Regression and associated mediation analyses indicated that, while there was a direct effect of trauma exposure on mental health outcomes (PTSD symptoms), daily environmental stressors partially mediated this relationship. Depression symptoms were associated with daily stressors, but not prior trauma exposure. These findings indicate that daily stressors play a pivotal role in mental health outcomes of populations affected by collective violence and statelessness. It is, therefore, important to consider the role and effects of environmental stressors associated with life in refugee camps on the mental health and psychosocial well-being of stateless populations such as the Rohingya, living in protracted humanitarian environments.

Community based system dynamic as an approach for understanding and acting on messy problems: a case study for global mental health intervention in Afghanistan

Background

Afghanistan lacks suitable specialized mental healthcare services despite high prevalence of severe mental health disorders which are aggravated by the conflict and numerous daily stressors. Recent studies have shown that Afghans with mental illness are not only deprived of care but are vulnerable in many other ways. Innovative participatory approaches to the design of mental healthcare policies and programs are needed in such challenging context.

Methods

We employed community based system dynamics to examine interactions between multiple factors and actors to examine the problem of persistently low service utilization for people with mental illness. Group model building sessions, designed based on a series of scripts and led by three facilitators, took place with NGO staff members in Mazar-I-Sharif in July 2014 and in Kabul in February 2015.

Results

We identified major feedback loops that constitute a hypothesis of how system components interact to generate a persistently low rate of service utilization by people with mental illness. In particular, we found that the interaction of the combined burdens of poverty and cost of treatment interact with cultural and social stigmatizing beliefs, in the context of limited clinical or other treatment support, to perpetuate low access to care for people with mental disorders. These findings indicate that the introduction of mental healthcare services alone will not be sufficient to meaningfully improve the condition of individuals with mental illness if community stigma and poverty are not addressed concurrently.

Conclusions

Our model highlights important factors that prevent persons with mental illness from accessing services. Our study demonstrates that group model building methods using community based system dynamics can provide an effective tool to elicit a common vision on a complex problem and identify shared potential strategies for intervention in a development and global health context. Its strength and originality is the leadership role played by the actors embedded within the system in describing the complex problem and suggesting interventions.

Contextualizing Afghan refugee views of depression through narratives of trauma, resettlement stress, and coping

This qualitative study explored how Afghan refugees conceptualize frames of mind that may reflect depression in general and as it relates to trauma they experienced. We performed in-depth interviews with 18 Afghans residing in the San Diego area. Views regarding the causes, symptoms, and perceived treatments of depression were gathered through free-listing techniques, and supplemented with narratives relating to pre- and post-resettlement stressors and coping mechanisms. Data were analyzed with standard qualitative content analysis methods. Items endorsed with relation to depression causality included pre-migration war traumas, notably separation from family, and post-migration stressors including status dissonance and cultural conflicts that ranged from linguistic challenges to intergenerational problems. Depressive symptoms were viewed as highly debilitating, and included changes in temperament, altered cognitions, avoidance and dissociative behaviors, and somatic complaints. Relief was sought through family reunification and community support, reliance on prayer, and the academic success of their children in the US. The findings underscore the need for practitioners to take into account situational stressors, cultural aspects of mourning and symptomatology, and existing coping mechanisms in developing interventions that are based on refugees' articulated needs.

Biocultural research in global mental health: mapping idioms of distress onto blood pressure in a population survey

OBJECTIVES

Biocultural research remains a challenge in the field of global mental health. We sought to test associations between blood pressure and idioms of distress in a population survey.

METHODS

We drew on a randomly selected sample of 991 adults (498 men, 493 women) in Afghanistan, for whom physiological and psychosocial data were systematically collected. Assessment of mental health (Self-Reported Questionnaire, Afghan Symptom Checklist) included conceptualizations of distress related to pressure (fishar), anxiety, and dysphoria, as well as dimensions of negative affect and aggression. We used principal component analysis to map survey responses to fishar, and multiple regressions to examine associations with systolic/diastolic blood pressure, controlling for age, body mass index, and wealth, and differentiating by gender, mental health, and medication.

RESULTS

The Afghan sample averaged 129/80 mmHg, with 27.14% of hypertensive individuals. SBP showed inverse associations with reports of low fishar (β = -4.58, P < .001) and high fishar (β = 6.90, P < .001), as did DPB with low fishar (β = -1.55, P < .001) and high fishar (β = 3.77, P < .001). Low and high fishar responses accounted for substantial proportions of SBP data variation (R²  = 20% and R²  = 24%), especially in adults on blood pressure medication (R²  = 58% and R²  = 49%).

CONCLUSIONS

Subjective reports of fishar map onto physiological blood pressure more robustly than other conceptualizations of mental distress related to anxiety, dysphoria, negative affect, or aggression. Our results point to the utility of mapping biological and cultural measures of stress and distress, advancing biopsychosocial understandings of wellbeing in global mental health surveys.

Afghan Refugee Explanatory Models of Depression: Exploring Core Cultural Beliefs and Gender Variations

Relatively little empirical attention has been paid to understanding how refugees conceptualize depression and how this concept varies between genders. The purpose of this study was to explore beliefs about depression among Afghans residing in San Diego County, California, using cultural consensus analysis. Using the prescribed mixed-method approach, we employed results from in-depth interviews to develop a culturally meaningful questionnaire about depression. Consensus analysis of responses to questionnaire items from 93 Afghans (50 men, 43 women) indicates shared beliefs that associates depression causality with mild traumatic experiences and post-resettlement stressors, symptomatology to include culturally salient idioms of distress, and treatment selections ranging from lay techniques to professional care. Divergence between genders occurred most in the symptoms subdomain, with women associating depression with more somatic items. This study contributes to understanding the etiology of and cultural responses to depression among this population, which is critical to improving culturally sensitive intervention for Afghan refugees.

Community Water Improvement, Household Water Insecurity, and Women's Psychological Distress: An Intervention and Control Study in Ethiopia

BACKGROUND

Over 650 million people worldwide lack access to safe water supplies, and even among those who have gained access to 'improved' sources, water may be seasonally unreliable, far from homes, expensive, and provide insufficient quantity. Measurement of water access at the level of communities and households remains crude, and better measures of household water insecurity are urgently needed to inform needs assessments and monitoring and evaluation. We set out to assess the validity of a quantitative scale of household water insecurity, and to investigate (1) whether improvements to community water supply reduce water insecurity, (2) whether water interventions affect women's psychological distress, and (3) the impacts of water insecurity on psychological distress, independent of socio-economic status, food security, and harvest quality.

METHODS AND FINDINGS

Measures were taken before and one to six months after a community water supply improvement in three villages in rural northern Ethiopia. Villages similar in size and access to water sources and other amenities did not receive interventions, and served as controls. Household water insecurity was assessed using a 21-item scale based on prior qualitative work in Ethiopia. Women's psychological distress was assessed using the WHO Self-Reporting Questionnaire (SRQ-20). Respondents were either female heads of household or wives of the heads of household (n = 247 at baseline, n = 223 at endline); 123 households provided data at both rounds. The intervention was associated with a decline of approximately 2 points on the water insecurity scale between baseline and endline compared to the control (beta -1.99; 95% CI's -3.15, -0.84). We did not find evidence of impact of the intervention on women's psychological distress. Water insecurity was, however, predictive of psychological distress (p <0.01), independent of household food security and the quality of the previous year's harvest.

CONCLUSION

These results contribute to the construct validity of our water insecurity scale, and establish our approach to measuring water insecurity as a plausible means of evaluating water interventions. Improvements to community water supplies were effective in reducing household water insecurity, but not psychological distress, in this population. Water insecurity was an important predictor of psychological distress. This study contributes to an emerging literature on quantitative assessment of household water insecurity, and draws attention to the potential impact of improved access to water on women's mental well-being.

Community Water Improvement, Household Water Insecurity, and Women's Psychological Distress: An Intervention and Control Study in Ethiopia

Background

Over 650 million people worldwide lack access to safe water supplies, and even among those who have gained access to ‘improved’ sources, water may be seasonally unreliable, far from homes, expensive, and provide insufficient quantity. Measurement of water access at the level of communities and households remains crude, and better measures of household water insecurity are urgently needed to inform needs assessments and monitoring and evaluation. We set out to assess the validity of a quantitative scale of household water insecurity, and to investigate (1) whether improvements to community water supply reduce water insecurity, (2) whether water interventions affect women’s psychological distress, and (3) the impacts of water insecurity on psychological distress, independent of socio-economic status, food security, and harvest quality.

Methods and Findings

Measures were taken before and one to six months after a community water supply improvement in three villages in rural northern Ethiopia. Villages similar in size and access to water sources and other amenities did not receive interventions, and served as controls. Household water insecurity was assessed using a 21-item scale based on prior qualitative work in Ethiopia. Women’s psychological distress was assessed using the WHO Self-Reporting Questionnaire (SRQ-20). Respondents were either female heads of household or wives of the heads of household (n = 247 at baseline, n = 223 at endline); 123 households provided data at both rounds. The intervention was associated with a decline of approximately 2 points on the water insecurity scale between baseline and endline compared to the control (beta -1.99; 95% CI’s -3.15, -0.84). We did not find evidence of impact of the intervention on women’s psychological distress. Water insecurity was, however, predictive of psychological distress (p <0.01), independent of household food security and the quality of the previous year’s harvest.

Conclusion

These results contribute to the construct validity of our water insecurity scale, and establish our approach to measuring water insecurity as a plausible means of evaluating water interventions. Improvements to community water supplies were effective in reducing household water insecurity, but not psychological distress, in this population. Water insecurity was an important predictor of psychological distress. This study contributes to an emerging literature on quantitative assessment of household water insecurity, and draws attention to the potential impact of improved access to water on women’s mental well-being.

Psychometric Validation and Comparison of the Self-Reporting Questionnaire-20 and Self-Reporting Questionnaire-Suicidal Ideation and Behavior Among Congolese Refugee Women

BACKGROUND

The Self-Reporting Questionnaire (SRQ) has long been used among refugee populations to detect common mental health disorders.

PURPOSE

Our purpose was to compare findings from psychometric validation of the 20-item SRQ with a modified version, the SRQ-SIB (suicidal ideation and behavior).

METHODS

Factor analysis of both scales was performed in a sample of Congolese refugee women as well as predictive validity, contrast validity, and internal consistency.

RESULTS

Both scales exhibited a reliability of .911. The SRQ-SIB exhibited a three-factor solution; somatic, psychological, and SIB. The SIB was highly predictive for having experienced sexual violence. Analyses validate the use of both, but the SIB is useful for differentiating more severe cases of common mental disorder (CMD).

CONCLUSIONS

The SRQ-SIB may be an important tool for the nursing assessment of suicide among refugee women.

"Thinking too much": A systematic review of a common idiom of distress

Idioms of distress communicate suffering via reference to shared ethnopsychologies, and better understanding of idioms of distress can contribute to effective clinical and public health communication. This systematic review is a qualitative synthesis of "thinking too much" idioms globally, to determine their applicability and variability across cultures. We searched eight databases and retained publications if they included empirical quantitative, qualitative, or mixed-methods research regarding a "thinking too much" idiom and were in English. In total, 138 publications from 1979 to 2014 met inclusion criteria. We examined the descriptive epidemiology, phenomenology, etiology, and course of "thinking too much" idioms and compared them to psychiatric constructs. "Thinking too much" idioms typically reference ruminative, intrusive, and anxious thoughts and result in a range of perceived complications, physical and mental illnesses, or even death. These idioms appear to have variable overlap with common psychiatric constructs, including depression, anxiety, and PTSD. However, "thinking too much" idioms reflect aspects of experience, distress, and social positioning not captured by psychiatric diagnoses and often show wide within-cultural variation, in addition to between-cultural differences. Taken together, these findings suggest that "thinking too much" should not be interpreted as a gloss for psychiatric disorder nor assumed to be a unitary symptom or syndrome within a culture. We suggest five key ways in which engagement with "thinking too much" idioms can improve global mental health research and interventions: it (1) incorporates a key idiom of distress into measurement and screening to improve validity of efforts at identifying those in need of services and tracking treatment outcomes; (2) facilitates exploration of ethnopsychology in order to bolster cultural appropriateness of interventions; (3) strengthens public health communication to encourage engagement in treatment; (4) reduces stigma by enhancing understanding, promoting treatment-seeking, and avoiding unintentionally contributing to stigmatization; and (5) identifies a key locally salient treatment target.

Psychometric properties of the self-reporting questionnaire (SRQ-20): measurement invariance across women from Brazilian community settings

BACKGROUND

SRQ-20 is a validated screening tool for common psychiatric disorders in several countries. Exploration of the latent structure of this instrument resulted in conflicting evidence. This study aimed to explore the latent structure of SRQ-20 among Brazilian women from community settings. We also tested the model invariance across different sociodemographic conditions.

METHODS

Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted on a sample of 1668 women from four different geographical regions of Brazil. Invariance of the model was tested through multi-group CFA according to sociodemographic variables.

RESULTS

EFA has shown two potential solutions with two and three factors. CFA resulted in indices of the two-factor solution slightly worse than the three-factor solution. Invariance testing has shown this model was not invariant across cities, but was invariant across different social classes. The structure was also invariant for the two lower educated groups. The respecified model (i.e., excluding item 16) was not invariant across groups with different educational levels.

CONCLUSION

The three-factor solution seems to be the most suitable model of SRQ-20 for Brazilian women in community settings. Furthermore, sociodemographic variables seem to reflect on the latent structure of this instrument. Validation of screening tools should consider sociodemographic variables.