A cross-cultural adaptation of a psychiatric epidemiologic instrument: The diagnostic interview schedule's adaptation in Puerto Rico

The advent of the use of structured interview schedules that generate psychiatric diagnoses in epidemiologic studies has promoted an intense interest in its cross-cultural use. However, the valid use of these instruments across cultures requires a careful adaptation process which goes beyond mere language translation. In this article the authors illustrate the application of a comprehensive cross-cultural adaptation model to both the translation into Spanish and the adaptation to the population of Puerto Rico of a widely used psychiatric epidemiologic research instrument: the Diagnostic Interview Schedule (DIS). The process aimed to ensure the development of a research instrument that is not only in correct Spanish and comprehensible for most Spanish-speaking people, but also culturally adapted to Puerto Rico's population. Various steps were taken (including bilingual committee, back-translation, instrument testing and diagnostic comparisons) to address cross-cultural validity in five important dimensions (i.e., semantic, technical, content, criterion and conceptual equivalence). The result is an interview schedule that is not only linguistically and culturally adequate for the targeted population but also includes elements which can contribute to the development of the instrument both in its original English language and in its translated versions.     

The Spanish translation and cultural adaptation of the Diagnostic Interview Schedule for Children (DISC) in Puerto Rico

This article illustrates a comprehensive cross-cultural adaptation model used to translate into Spanish and to culturally adapt the Diagnostic Interview Schedule for Children (DISC). The process strived to identify similar phenomena to those identified by the original English version in a dissimilar context. To attain cross-cultural equaivalency five important dimensions were addressed: semantic, technical, content, criterion and conceptual. To meet this challenge various steps were taken, including bilingual committee, back-translation, reliability and validity testing. The result is an instrument which could be used, not only in Puerto Rico, but also in other Spanishspeaking child and adolescent populations after appropriate cultural adaptations.     

Cross-cultural adaptation of instruments assessing breastfeeding determinants: a multi-step approach

Background

Cross-cultural adaptation is a necessary process to effectively use existing instruments in other cultural and language settings. The process of cross-culturally adapting, including translation, of existing instruments is considered a critical set to establishing a meaningful instrument for use in another setting. Using a multi-step approach is considered best practice in achieving cultural and semantic equivalence of the adapted version. We aimed to ensure the content validity of our instruments in the cultural context of KwaZulu-Natal, South Africa.

Methods

The Iowa Infant Feeding Attitudes Scale, Breastfeeding Self-Efficacy Scale-Short Form and additional items comprise our consolidated instrument, which was cross-culturally adapted utilizing a multi-step approach during August 2012. Cross-cultural adaptation was achieved through steps to maintain content validity and attain semantic equivalence in the target version. Specifically, Lynn’s recommendation to apply an item-level content validity index score was followed. The revised instrument was translated and back-translated. To ensure semantic equivalence, Brislin’s back-translation approach was utilized followed by the committee review to address any discrepancies that emerged from translation.

Results

Our consolidated instrument was adapted to be culturally relevant and translated to yield more reliable and valid results for use in our larger research study to measure infant feeding determinants effectively in our target cultural context.

Conclusions

Undertaking rigorous steps to effectively ensure cross-cultural adaptation increases our confidence that the conclusions we make based on our self-report instrument(s) will be stronger. In this way, our aim to achieve strong cross-cultural adaptation of our consolidated instruments was achieved while also providing a clear framework for other researchers choosing to utilize existing instruments for work in other cultural, geographic and population settings.

     

Translation And Cultural Adaptation Of A Mental Health Outcome Measure: The Basis-R©

Culturally and linguistically appropriate outcome measures are needed to address the needs of Latino consumers of mental health services. The revised Behavior and Symptom Identification Scale (BASIS-R(c)) is an English-language consumer self-report measure designed to assess outcome of behavioral health or substance abuse treatment. This study sought to develop a culturally and linguistically appropriate version of the BASIS-R(c) for Spanish-speaking Latinos. To achieve this goal, the English instrument was translated and adapted into Spanish by an international bilingual committee and tested in four focus groups and 45 cognitive interviews with Puerto Ricans, Dominicans, and Mexicans living in the United States and Puerto Rico. Focus groups and cognitive interviews provided qualitative and quantitative information about the instrument's content and format, and respondents' understanding of the instructions, questionnaire items, time frame, and response options. Respondents' ratings of the clarity and importance of each item were also obtained. Analyses of focus group and cognitive interview data identified items that were confusing or difficult for participants. Findings suggest that the Spanish version of the BASIS-R(c) incorporated the cultural diversity of the three groups of Latinos in this study without compromising the validity of the English version of the BASIS.     

ARNTL,CLOCK and PER3 polymorphisms – links with chronotype and affective dimensions

Recently, seven single nucleotide polymorphisms (SNPs) of ARNTL, TIM and PER3 genes were found associated with affective temperaments in bipolar disorder patients. This study aimed to test whether a) the same associations appear in a non-clinical sample; b) the SNPs are related to other affective dimensions; c) the SNPs underpin the associations between chronotype and affective temperaments/dimensions. Three hundred thirty-eight university students completed the Temperament Scale of Memphis, Pisa, Paris and San Diego Auto-questionnaire, the Centre for Epidemiological Studies Depression Scale, the Perceived Stress Scale, the General Health Questionnaire, the Seasonal Pattern Assessment Questionnaire and the Composite Scale of Morningness. Seven SNPs of the ARNTL, TIM and PER3 genes were genotyped. According to nominal significance, ARNTL rs7107287 was associated with a cyclothymic temperament, depressive and stress symptoms, general mental health and perceived negative impact of seasonality, while TIM rs10876890 was associated with a hyperthymic temperament, and the TIM rs2291738 was associated with chronotype. Different SNPs were related to chronotype and affective temperaments/dimensions, and therefore, they seem to not underpin relationships between chronotype and affective dysfunction, that is, in the present study, eveningness was related to dysthymic, cyclothymic and irritable temperaments, more symptoms of depression, stress, worse mental health and a negative impact of seasonality, while morningness was related to hyperthymic temperament. The SNPs associations need further replication given that they did not achieve Bonferroni criteria of significance accounting for the number of polymorphisms considered and tests conducted.     

Principal Semantic Components of Language and the Measurement of Meaning

Metric systems for semantics, or semantic cognitive maps, are allocations of words or other representations in a metric space based on their meaning. Existing methods for semantic mapping, such as Latent Semantic Analysis and Latent Dirichlet Allocation, are based on paradigms involving dissimilarity metrics. They typically do not take into account relations of antonymy and yield a large number of domain-specific semantic dimensions. Here, using a novel self-organization approach, we construct a low-dimensional, context-independent semantic map of natural language that represents simultaneously synonymy and antonymy. Emergent semantics of the map principal components are clearly identifiable: the first three correspond to the meanings of “good/bad” (valence), “calm/excited” (arousal), and “open/closed” (freedom), respectively. The semantic map is sufficiently robust to allow the automated extraction of synonyms and antonyms not originally in the dictionaries used to construct the map and to predict connotation from their coordinates. The map geometric characteristics include a limited number (∼4) of statistically significant dimensions, a bimodal distribution of the first component, increasing kurtosis of subsequent (unimodal) components, and a U-shaped maximum-spread planar projection. Both the semantic content and the main geometric features of the map are consistent between dictionaries (Microsoft Word and Princeton''s WordNet), among Western languages (English, French, German, and Spanish), and with previously established psychometric measures. By defining the semantics of its dimensions, the constructed map provides a foundational metric system for the quantitative analysis of word meaning. Language can be viewed as a cumulative product of human experiences. Therefore, the extracted principal semantic dimensions may be useful to characterize the general semantic dimensions of the content of mental states. This is a fundamental step toward a universal metric system for semantics of human experiences, which is necessary for developing a rigorous science of the mind.     

Validation of the Diagnostic Interview for Genetic Studies (DIGS) in Colombia

An interview tool, Diagnostic Interview for Genetic Studies (DIGS 3.0), was translated into Spanish for application in studies of psychiatric disorders in Colombia. Two Spanish translations of the original English version of DIGS were prepared and back-translated into English. A review committee verified the linguistic and cultural equivalence of the translations. The evaluator and test-retest reliability were assessed calculating Cohen's kappa for samples of 65 and 91 patients respectively. DIGS proved valid in both appearance and content. The confidence interval (C.I.) was excellent for schizophrenia (kappa = 0.81, C.I. 95% = 0.68-0.93), bipolar disorder (kappa = 0.87, C.I. 95% = 0.75-0.99), major depressive disorder (kappa = 0.86, C.I. 95% = 0.70-1.00), and for a normal diagnosis (kappa = 0.65, C.I. 95% = 0.41-0.89); it was good for other psychiatric diagnosis (kappa = 0.65, C.I. 95% = 0.41-0.89) and poor for schizoaffective disorder (kappa = 0.37, C.I. 95% = -0.02-0.76). Test-retest reliability was excellent for all diagnoses (kappa > 0.8), except for "other psychiatric diagnoses" (kappa = 0.64, C.I. 95% = 0.31-0.96). The Spanish translation of the DIGS was comprehensible, with face and content validity, and good test-retest and evaluator reliability. This translation will be a useful tool for genetic studies of psychiatric disorders in Latin America, particularly where schizophrenia and affective disorders are involved.     

Disability Mediates the Impact of Common Conditions on Perceived Health

Background

We examined the extent to which disability mediates the observed associations of common mental and physical conditions with perceived health.

Methods and Findings

WHO World Mental Health (WMH) Surveys carried out in 22 countries worldwide (n = 51,344 respondents, 72.0% response rate). We assessed nine common mental conditions with the WHO Composite International Diagnostic Interview (CIDI), and ten chronic physical with a checklist. A visual analog scale (VAS) score (0, worst to 100, best) measured perceived health in the previous 30 days. Disability was assessed using a modified WHO Disability Assessment Schedule (WHODAS), including: cognition, mobility, self-care, getting along, role functioning (life activities), family burden, stigma, and discrimination. Path analysis was used to estimate total effects of conditions on perceived health VAS and their separate direct and indirect (through the WHODAS dimensions) effects.Twelve-month prevalence was 14.4% for any mental and 51.4% for any physical condition. 31.7% of respondents reported difficulties in role functioning, 11.4% in mobility, 8.3% in stigma, 8.1% in family burden and 6.9% in cognition. Other difficulties were much less common. Mean VAS score was 81.0 (SD = 0.1). Decrements in VAS scores were highest for neurological conditions (9.8), depression (8.2) and bipolar disorder (8.1). Across conditions, 36.8% (IQR: 31.2–51.5%) of the total decrement in perceived health associated with the condition were mediated by WHODAS disabilities (significant for 17 of 19 conditions). Role functioning was the dominant mediator for both mental and physical conditions. Stigma and family burden were also important mediators for mental conditions, and mobility for physical conditions.

Conclusions

More than a third of the decrement in perceived health associated with common conditions is mediated by disability. Although the decrement is similar for physical and mental conditions, the pattern of mediation is different. Research is needed on the benefits for perceived health of targeted interventions aimed at particular disability dimensions.     

精神病患者家属心理健康状况调查研究

目的:探讨精神病患者家属的心理健康状况,并找出相关的影响因素.方法:对中山市91位住院以及门诊精神科病人家属进行问卷调查和访谈,采用的是症状自评量(SCL-90)和家庭疾病负担量表(Family Burden Scale of Disease).结果:家属心理健康状况与患者给家庭带来的负担存在明显的相关,患者患病对配偶的心理健康的影响明显大于对其他亲人或者朋友的影响(F=5.358,P＜0.001),15-30岁年龄段的SCL-90的得分要明显的高于其他年龄段(F=1.436,P＜0.01),而精神分裂症患者的家属SCL-90的得分也要明显高于其他疾病家属的得分.结论:影响家属心理健康的因素有多个方面,应该有针对性的采取家庭护理措施并加强家庭健康教育.     

The relationships between dream content and physical health, mood, and self-construal.

Research is presented that examines the relationship among dream content, physical health, mood, and self-construal. Participants were 27 undergraduate students who completed the Medical Outcomes SF-36 Health Survey (SF-36), the Profile of Mood States Scale (POMS-SF), and the Self-Construal Scale (SCS). Each participant handed in four dream reports, which were analyzed according to the Hall and Van de Castle (1966) system of content analysis. Multiple significant correlations were observed between dream content and the SF-36, the POMS-SF, and the SCS. Most notable were the findings between physical health and dream content. Participants displaying poor physical health reported more bodily misfortunes, injuries and illnesses, medical themes, and body parts in their dreams. Findings support continuity between dreams and waking life physical and mental functioning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Role of Health Systems Factors in Facilitating Access to Psychotropic Medicines: A Cross-Sectional Analysis of the WHO-AIMS in 63 Low- and Middle-Income Countries

Background

Neuropsychiatric conditions comprise 14% of the global burden of disease and 30% of all noncommunicable disease. Despite the existence of cost-effective interventions, including administration of psychotropic medicines, the number of persons who remain untreated is as high as 85% in low- and middle-income countries (LAMICs). While access to psychotropic medicines varies substantially across countries, no studies to date have empirically investigated potential health systems factors underlying this issue.

Methods and Findings

This study uses a cross-sectional sample of 63 LAMICs and country regions to identify key health systems components associated with access to psychotropic medicines. Data from countries that completed the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS) were included in multiple regression analyses to investigate the role of five major mental health systems domains in shaping medicine availability and affordability. These domains are: mental health legislation, human rights implementations, mental health care financing, human resources, and the role of advocacy groups. Availability of psychotropic medicines was associated with features of all five mental health systems domains. Most notably, within the domain of mental health legislation, a comprehensive national mental health plan was associated with 15% greater availability; and in terms of advocacy groups, the participation of family-based organizations in the development of mental health legislation was associated with 17% greater availability. Only three measures were related with affordability of medicines to consumers: level of human resources, percentage of countries'' health budget dedicated to mental health, and availability of mental health care in prisons. Controlling for country development, as measured by the Human Development Index, health systems features were associated with medicine availability but not affordability.

Conclusions

Results suggest that strengthening particular facets of mental health systems might improve availability of psychotropic medicines and that overall country development is associated with affordability. Please see later in the article for the Editors'' Summary     

Mental and Substance Use Disorders in Sub-Saharan Africa: Predictions of Epidemiological Changes and Mental Health Workforce Requirements for the Next 40 Years

The world is undergoing a rapid health transition, with an ageing population and disease burden increasingly defined by disability. In Sub-Saharan Africa the next 40 years are predicted to see reduced mortality, signalling a surge in the impact of chronic diseases. We modelled these epidemiological changes and associated mental health workforce requirements. Years lived with a disability (YLD) predictions for mental and substance use disorders for each decade from 2010 to 2050 for four Sub-Saharan African regions were calculated using Global Burden of Disease 2010 study (GBD 2010) data and UN population forecasts. Predicted mental health workforce requirements for 2010 and 2050, by region and for selected countries, were modelled using GBD 2010 prevalence estimates and recommended packages of care and staffing ratios for low- and middle-income countries, and compared to current staffing from the WHO Mental Health Atlas. Significant population growth and ageing will result in an estimated 130% increase in the burden of mental and substance use disorders in Sub-Saharan Africa by 2050, to 45 million YLDs. As a result, the required mental health workforce will increase by 216,600 full time equivalent staff from 2010 to 2050, and far more compared to the existing workforce. The growth in mental and substance use disorders by 2050 is likely to significantly affect health and productivity in Sub-Saharan Africa. To reduce this burden, packages of care for key mental disorders should be provided through increasing the mental health workforce towards targets outlined in this paper. This requires a shift from current practice in most African countries, involving substantial investment in the training of primary care practitioners, supported by district based mental health specialist teams using a task sharing model that mobilises local community resources, with the expansion of inpatient psychiatric units based in district and regional general hospitals.     

Early detection of depression by primary care physicians.

The overall prevalence of depression is from 3.5% to 27%. The burden of suffering is high and includes death through suicide. In most cases treatment is effective, but important episodes of depression are being missed. To determine whether a brief, systematic assessment for the early detection of depression should be part of the periodic health examination we searched MEDLINE and the Science Citation Index for randomized controlled trials that evaluated the effectiveness of early detection of depression with a questionnaire. Seven instruments met our quality criteria; the Beck Depression Inventory, the Center for Epidemiologic Studies Depression Scale, the Zung Self-Assessment Depression Scale, the General Health Questionnaire, the Hopkins Symptom Checklist, the Mental Health Inventory and the Hospital Anxiety and Depression Scale. The four randomized controlled trials failed to provide adequate evidence of the benefit of routine screening. Early detection is difficult because of depression''s natural history, the role of symptoms, the cultural diversity of Canada and how detection instruments have been developed. Depression deserves careful attention from primary care physicians; however, further research and development is required before the widespread routine use of any detection test can be recommended.     

Detecting mental disorders in primary care

Managing mental health problems of people around the world is a major challenge for health workers as well as for policy makers. It is a particular problem for low- and middle-income countries for many reasons, especially due to lack of recourses.A computer-assisted interview, the GMHAT/PC (Global Mental Health Assessment Tool - Primary Care) has been developed to assist general practitioners and other health professionals to make a quick, convenient, and comprehensive, standardised mental health assessment. It has proved to be a reliable and valid tool in various studies. Its use by other health professionals may help in detecting and managing mental disorders in primary care and general health settings more effectively. The article outlines the development and potential use of the GMHAT/PC.     

The oral health of older people from minority ethnic communities in south east England

Objectives: To describe the clinical health status and subjective oral health status of older adults from minority ethnic communities resident in South East England. Design: Cross sectional survey incorporating a clinical examination and a questionnaire assessment of subjective oral health status. Setting: Community groups working with individuals from minority ethnic communities. Subjects: A total of 540 individuals from 7 minority ethnic communities. Measures: Clinical assessment of oral health status using BASCD criteria. Assessment of oral symptoms and impact experienced together with satisfaction with oral status, by structured questionnaire. Results: On all measures of clinical health status the participants were healthier than a comparison group based on data from the Adult Dental Health Survey. The participants expressed high levels of subjective oral symptoms. Levels of satisfaction were lower than those found in the Adult Dental Health Survey. There was evidence of some variation across minority ethnic communities in clinical and subjective oral health status. Conclusions: Approximately 20% of the 540 adults from minority ethnic communities resident in the South East of England surveyed were relatively fit orally. They experienced a great many oral symptoms, and in approximately 30% of individuals these were sufficient to interfere with their quality of life. Ethical approval: The research described in this paper was approved by the Ethics committee of King's College London.     

Construction of a scale to signal personality disorders in the elderly

Till now, no specific diagnostic instruments to detect personality disorders in the elderly are available. The aim of our study was to contribute to the construction of a reliable en valid instrument for the detection of personality disorders in older adults. Therefore, a draft version of the instrument was constructed both for the patient and the informant. Both the patient and the informant version of the instrument included 52 items with the same content. These items concerned Habitual behaviour (HAB), Biographical information (BIO) and Observation of actual behaviour (OBS). 159 clients of 60 years and older of a Dutch ambulatory mental health care organisation were assessed with the screening instrument. In 96 of the 159 outpatients one or more informants were included. The results indicate that the internal consistency of seven HAB items, nine BIO items and five OBS items was moderate to good with regard to both the patient and informant instrument. Test-retest reliability of the 21 items of the patient instrument was moderate with regard to HAB, excellent with regard to BIO and moderate with regard to OBS. Interrater reliability of OBS was also moderate. The criterion validity (criterion: DSM-IV TR Axis II classification) of HAB, BIO and OBS based on the 21 items of the patient instrument was fair and with regard to the same 21 items of the informant instrument insufficient. In conclusion, sixteen out of 52 potential items of the patient's draft version of the screening instrument can be used to detect a possible personality disorder. These sixteen items from the HAB and BIO scale are named the Gerontological Personality disorder Scale (GPS). Medical doctors, psychologists and nurses working in ambulatory mental health organisation can use the GPS as a resource during the diagnostic process. Whether the GPS can be used beyond mental health organisations, for example by general practitioners is a subject for future studies.     

The Global Burden of Disease Assessments—WHO Is Responsible?

The Global Burden of Disease (GBD) concept has been used by the World Health Organization (WHO) for its reporting on health information for nearly 10 years. The GBD approach results in a single summary measure of morbidity, disability, and mortality, the so-called disability-adjusted life year (DALY). To ensure transparency and objectivity in the derivation of health information, WHO has been urged to use reference groups of external experts to estimate burden of disease. Under the leadership and coordination of WHO, expert groups have been appraising and abstracting burden of disease information. Examples include the Child Health Epidemiology Reference Group (CHERG), the Malaria Monitoring and Evaluation Reference Group (MERG), and the recently established Foodborne Disease Burden Epidemiology Reference Group (FERG). The structure and functioning of and lessons learnt by these groups are described in this paper. External WHO expert groups have provided independent scientific health information while operating under considerable differences in structure and functioning. Although it is not appropriate to devise a single "best practice" model, the common thread described by all groups is the necessity of WHO's leadership and coordination to ensure the provision and dissemination of health information that is to be globally accepted and valued.     

Integrated health information system based on Resident Assessment Instruments

The paper explores the meaning of Resident Assessment Instruments. It gives a summary of existing RAI instruments and derived applications. It argues how all of these form the basis for an integrated health information system for "chain care" (home care, home for the elderly care, nursing home care, mental health care and acute care). The primary application of RAI systems is the assessment of client care needs, followed by an analysis of the required and administered care with the objective to make an optimal individual care plan. On the basis of RAI, however, applications have been derived for reimbursement systems, quality improvement programs, accreditation, benchmarking, best practice comparison and care eligibility systems. These applications have become possible by the development on the basis of the Minimum Data Set of RAI of outcome measures (item scores, scales and indices), case-mix classifications and quality indicators. To illustrate the possibilities of outcome measures of RAI we present a table and a figure with data of six Dutch nursing homes which shows how social engagement is related to ADL and cognition. We argue that RAI/MDS assessment instruments comprise an integrated health information system because they have consistent terminology, common core items, and a common conceptual basis in a clinical approach that emphasizes the identification of functional problems.     

Indicators of vulnerability associated with less healthy circadian rhythms in undergraduate medical interns

ABSTRACT

To evaluate the association between circadian health parameters and psychological and biological vulnerability, a cross-sectional study was conducted with 15 undergraduate medical interns using the Brief Resilience Scale, the Mini International Neuropsychiatric Interview, and an ambulatory circadian monitoring device. Circadian Health construct was confirmed by factor analysis. Vulnerability factors (history of depression and low resilience) were associated to lower circadian health of motor activity and temperature rhythms. The findings suggest that not only being depressed but also having had depressive episodes in the past, as well as having low resilience, are associated with chronodisruption, and may increase the risk for developing new episodes of depression.     

Who is susceptible to perceive higher smog-induced health risk? Comparative analysis between physical and mental health dimensions

Abstract

Smog pollution can significantly affect the health of skilled workers. This paper explores the concept, structure and characteristics of smog-induced health risk perception. Based on face-to-face interviews with 30 skilled workers in a smog pollution area of China and quantitative analysis, we determined the dimensions of smog-induced health risk perception. The different effects of demographic variables on the dimensions of smog-induced health risk perception were investigated through 715 questionnaires distributed to skilled workers living in areas polluted by smog. The results showed that smog-induced health risk perception is a two-dimensional concept. We found that 86.3% of skilled workers perceived that physical health risk level was higher than mental health risk level. One-third of the population in most groups perceived higher degree of physical health risk than that of mental health risk, but the difference between physical and mental health risk for them was small. Moreover, skilled workers with a high level of smog-induced health risk perception were distributed mainly in groups of long employment duration, older skilled workers and skilled workers living in areas severely polluted by smog. Based on our results, we propose practical suggestions to help government, enterprises and skilled workers improve physical and mental health of skilled workers.