Screening for depression in Andean Latin America: Factor structure and reliability of the CES-D short form and the PHQ-8 among Bolivian public hospital patients.

Objective We assessed the validity and reliability of the Center for Epidemiologic Studies-Depression scale (CES-D) short form and the Patient Health Questionnaire-8 (PHQ-8) (two measures of depressive symptoms) among urban, low-income patients from a heavily indigenous area of Andean Latin America. This is a patient population that is in many ways culturally distinct from the populations that have been included in previous Spanish language validation studies of these instruments. Methods We administered the CES-D Yale version short form and the PHQ-8 to 107 outpatients at public hospitals in La Paz and El Alto, Bolivia. We conducted exploratory factor analysis, checked internal reliability, and examined concordance between the two measures in identifying patients with clinically significant depressive symptoms. Results Internal reliability was high for both scales: PHQ-8 (Cronbach's α = 0.808) and CES-D (α = 0.825). A one-factor solution for the PHQ-8 was maintained after the removal of one poorly loading item. The CES-D showed a two-factor solution, with items for somatic symptoms and interpersonal problems loading on the same factor as negative affect. Using both the cutoff for depression recommended in prior studies and a sample specific cutoff of ≥1 standard deviation above the mean, the two scales demonstrated only moderate agreement (κ = 0.481-0.486). Conclusions The PHQ may be more appropriate for clinical use in the Andean region, given its greater specificity; however, lower than expected agreement between the scales suggests that they also measure different elements of depression. Irregularities with the factor structure of both scales suggest that further research with this population is needed to better understand depressive symptomology and improve screening in the region.

A study of mobile phone use among patients with noncommunicable diseases in La Paz, Bolivia: implications for mHealth research and development.

BACKGROUND: While global momentum supporting mobile health (mHealth) research and development is increasing, it is imperative to assess the potential fit of mHealth programs in local settings. We describe the penetration of mobile technologies among Bolivian patients with noncommunicable diseases (NCDs) to inform research on mHealth interventions for the Andean region as well as low- and middle-income countries more generally. METHODS: Five-hundred and fifty-nine NCD patients were identified from outpatient clinics affiliated with four hospitals in the cities of La Paz and El Alto. Respondents completed surveys about their use of standard mobile phones and smartphones. Respondents also provided information about their sociodemographic characteristics, health status, and access to care. We used descriptive statistics and logistic regression to understand the variation in mobile phone use across groups defined by patient characteristics associated with health service access and socioeconomic vulnerability. RESULTS: Respondents were on average 52 years of age, 33% had at most a sixth grade education, and 30% spoke an indigenous language in their home. Eighty-six percent owned a mobile phone and 13% owned a smartphone. Fifty-eight percent of mobile phone users sent or received a text message at least once a week. Some mobile phone owners reported connectivity problems, such as lacking mobile signal (9%) or credit to make a call (17%). Younger age, male gender, high health literacy, more years of education, and having fewer previously diagnosed NCDs were positively related to mobile phone ownership. Among mobile phone users, respondents with lower education and other indicators of vulnerability were less likely than their counterparts to report frequent usage of texting services. CONCLUSIONS: Mobile phones have high penetration among NCD patients in La Paz, Bolivia, including among those who are older, less educated, and who have other socioeconomic risk factors. Smartphone use is still relatively uncommon, even among patients who are younger and more educated. While certain patient characteristics such as age or education impact patients' use of text messaging, mobile phone-based mHealth interventions are feasible strategies for increasing NCD patients' access to self-management support between face-to-face clinical encounters.

Establishing an independent mobile health program for chronic disease self-management support in bolivia.

BACKGROUND: Mobile health (m-health) work in low- and middle-income countries (LMICs) mainly consists of small pilot programs with an unclear path to scaling and dissemination. We describe the deployment and testing of an m-health platform for non-communicable disease (NCD) self-management support in Bolivia. METHODS: Three hundred sixty-four primary care patients in La Paz with diabetes or hypertension completed surveys about their use of mobile phones, health and access to care. One hundred sixty-five of those patients then participated in a 12-week demonstration of automated telephone monitoring and self-management support. Weekly interactive voice response (IVR) calls were made from a platform established at a university in La Paz, under the direction of the regional health ministry. RESULTS: Thirty-seven percent of survey respondents spoke indigenous languages at home and 38% had six or fewer years of education. Eighty-two percent had a mobile phone, 45% used text messaging with a standard phone, and 9% had a smartphone. Smartphones were least common among patients who were older, spoke indigenous languages, or had less education. IVR program participants completed 1007 self-management support calls with an overall response rate of 51%. IVR call completion was lower among older adults, but was not related to patients' ethnicity, health status, or healthcare access. IVR health and self-care reports were consistent with information reported during in-person baseline interviews. Patients' likelihood of reporting excellent, very good, or good health (versus fair or poor health) via IVR increased during program participation and was associated with better medication adherence. Patients completing follow-up interviews were satisfied with the program, with 19/20 (95%) reporting that they would recommend it to a friend. CONCLUSION: By collaborating with LMICs, m-health programs can be transferred from higher-resource centers to LMICs and implemented in ways that improve access to self-management support among people with NCDs.