Systematic review and meta-analysis on the mental health of emergency and urgent call-handlers and dispatchers.

BACKGROUND: Call-handlers and dispatchers (CHDs) working in specialized emergency and urgent communication centres are essential in supporting public safety and health. Evidence suggests that these professionals are at increased risk of mental health conditions, including post-traumatic stress disorder (PTSD), depression, anxiety and alcohol abuse among other conditions; however, reliable prevalence estimates remain undetermined. AIMS: We provide the estimated pooled prevalence for PTSD, depression, anxiety and hazardous drinking among emergency and urgent CHDs globally. METHODS: We searched 10 electronic databases, grey literature and the Annals of Emergency Dispatch and Response. Eligible studies reported original quantitative data and used validated self-reported measures on the prevalence of mental health conditions of interest (i.e. PTSD, depression, anxiety and alcohol use) within CHD professionals. Three reviewers independently screened results for eligibility. Prevalence estimates were pooled using random-effects meta-analyses. RESULTS: In total, 16 857 references were retrieved. From these, 183 full-text articles were assessed for eligibility, of which 37 articles were included in this systematic review, and 13 articles provided necessary quantitative information for meta-analyses. In total, 7759 CHDs were considered across nine different countries. The overall pooled prevalence for PTSD was 17.8% (95% confidence interval [CI] 12.4-24.0%), depression was 28.2% (95% CI 20.7-36.2%), anxiety was 17.2% (95% CI 6.6-31.5%) and hazardous drinking was 17.8% (95% CI 6.9-32.2%). CONCLUSIONS: These findings indicate CHDs are at significant risk of mental health problems. Further quantitative and qualitative research is warranted to help understand the psychological risks of working as a CHD and guide appropriate psychological support.

Cardiovascular and lifestyle risk factors of mild cognitive impairment in UK veterans and non-veterans.

BACKGROUND: The link between poor cardiovascular health (CVH), lifestyle and mild cognitive impairment (MCI) has been well established in the general population. However, there is limited research exploring these associations in ageing UK veterans. AIMS: This study explored the risk of MCI and its association with nine CVH and lifestyle risk factors (including diabetes, heart disease, high cholesterol, high blood pressure, obesity, stroke, physical inactivity, the frequency of alcohol consumption and smoking) in UK veterans and non-veterans. METHODS: This prospective cohort study comprised data from the PROTECT study between 2014 and 2022. Participants comprised of UK military veterans and non-veterans aged ≥50 years at baseline. Veteran status was defined using the Military Service History Questionnaire. CVH and lifestyle risk factors were defined using a combination of self-report measures, medication history or physical measurements. MCI was defined as the presence of subjective and objective cognitive impairment. RESULTS: Based on a sample of 9378 veterans (n = 488) and non-veterans (n = 8890), the findings showed the risk of MCI significantly reduced in veterans with obesity, those who frequently consumed alcohol and were physically inactive compared to non-veterans. The risk of MCI significantly increased in veterans with diabetes (hazards ratio [HR] = 2.22, 95% confidence interval [CI] 1.04-4.75, P ≤ 0.05) or high cholesterol (HR = 3.11, 95% CI 1.64-5.87, P ≤ 0.05) compared to veterans without. CONCLUSIONS: This study identified CVH and lifestyle factors of MCI in UK veterans and non-veterans. Further work is needed to understand these associations and the underpinning mechanisms which could determine intervention strategies to reduce the risk of MCI.

Depression, anxiety and PTSD symptoms before and during the COVID-19 pandemic in the UK.

BACKGROUND: The impact of the coronavirus disease 2019 (COVID-19) pandemic on mental health is still being unravelled. It is important to identify which individuals are at greatest risk of worsening symptoms. This study aimed to examine changes in depression, anxiety and post-traumatic stress disorder (PTSD) symptoms using prospective and retrospective symptom change assessments, and to find and examine the effect of key risk factors. METHOD: Online questionnaires were administered to 34 465 individuals (aged 16 years or above) in April/May 2020 in the UK, recruited from existing cohorts or via social media. Around one-third (n = 12 718) of included participants had prior diagnoses of depression or anxiety and had completed pre-pandemic mental health assessments (between September 2018 and February 2020), allowing prospective investigation of symptom change. RESULTS: Prospective symptom analyses showed small decreases in depression (PHQ-9: -0.43 points) and anxiety [generalised anxiety disorder scale - 7 items (GAD)-7: -0.33 points] and increases in PTSD (PCL-6: 0.22 points). Conversely, retrospective symptom analyses demonstrated significant large increases (PHQ-9: 2.40; GAD-7 = 1.97), with 55% reported worsening mental health since the beginning of the pandemic on a global change rating. Across both prospective and retrospective measures of symptom change, worsening depression, anxiety and PTSD symptoms were associated with prior mental health diagnoses, female gender, young age and unemployed/student status. CONCLUSIONS: We highlight the effect of prior mental health diagnoses on worsening mental health during the pandemic and confirm previously reported sociodemographic risk factors. Discrepancies between prospective and retrospective measures of changes in mental health may be related to recall bias-related underestimation of prior symptom severity.

Self-reported auditory problems are associated with adverse mental health outcomes and alcohol misuse in the UK Armed Forces.

PURPOSE: Auditory problems, such as hearing loss and tinnitus, have been associated with mental health problems and alcohol misuse in the UK general population and in the US Armed Forces; however, few studies have examined these associations within the UK Armed Forces. The present study examined the association between auditory problems and probable common mental disorders, post-traumatic stress disorder and alcohol misuse. METHODS: 5474 serving and ex-service personnel from the UK Armed Forces were examined, selected from those who responded to phase two (data collection 2007-09) and phase three (2014-16) of a military cohort study. Multivariable logistic regression was used to examine the association between auditory problems at phase two and mental health problems at phase three. RESULTS: 9.7% of participants reported ever experiencing hearing problems alone, 7.9% reported tinnitus within the last month alone, and 7.8% reported hearing problems with tinnitus. After adjustment, hearing problems with tinnitus at phase two was associated with increased odds of probable common mental disorders (AOR = 1.50, 95% CI 1.09-2.08), post-traumatic stress disorder (AOR = 2.30, 95% CI 1.41-3.76), and alcohol misuse (AOR = 1.94, 95% CI 1.28-2.96) at phase three. Tinnitus alone was associated with probable post-traumatic stress disorder (AOR = 1.80, 95% CI 1.03-3.15); however, hearing problems alone were not associated with any outcomes of interest. CONCLUSIONS: The association between auditory problems and mental health problems emphasises the importance of the prevention of auditory problems in the Armed Forces: through enhanced audiometric screening, improved hearing protection equipment, and greater levels of utilisation of such equipment.

Chronic fatigue syndrome and occupational status: a retrospective longitudinal study.

BACKGROUND: Few studies into chronic fatigue syndrome (CFS) have emphasized work-related consequences, including return to work after illness. AIMS: This paper explores socio-demographic, work and clinical characteristics that are associated with occupational status among patients who were assessed at baseline and a follow-up point. METHODS: Longitudinal data were assessed from patients affected by CFS who attended an outpatient CFS treatment service between 2007 and 2014. Employment status at baseline and follow-up was available for 316 patients. Data were also included on gender, age, duration of CFS, fatigue severity, type and number of treatment sessions, coping strategies, functional impairment, common mental disorders and physical functioning. RESULTS: Most patients were female (73%) and had been affected by CFS for longer than 2 years (66%). Patients were followed up for an average of 285 days and over this period 53% of patients who were working remained in employment. Of the patients who were not working at baseline, 9% had returned to work at follow-up. However, of those working at baseline, 6% were unable to continue to work at follow-up. Age, fatigue severity, functional impairment, cognitive and behavioural responses, and depressive symptoms impacted on a patients' work status at follow-up. CONCLUSIONS: The findings indicated that it is possible for people with CFS to remain in work or return to work, despite having had a disabling illness. Work-related outcomes should be targeted in all people of working age.

Factors associated with work status in chronic fatigue syndrome.

BACKGROUND: Work status in people with chronic fatigue syndrome (CFS) has not been extensively researched. AIMS: To explore occupational outcomes in patients with CFS by socio-demographic, well-being and disease characteristics. METHODS: We assessed cross-sectional data from patients attending a UK specialist CFS treatment service between 1 January 2007 and 31 December 2014. The main outcome was self-reported current employment status: currently in employment, temporarily interrupted employment or permanently interrupted employment. Other variables included sex, age, ethnicity, education, marital status, CFS duration, fatigue severity, anxiety, depression, activity limitations and functional impairment. We used multinominal logistic regression models to identify factors associated with current work status. RESULTS: Two hundred and seventy-nine (55%) patients were currently working, with 83 (16%) reporting temporarily interrupted employment and 146 (29%) stopping work altogether. Factors strongly associated with permanently interrupted employment were older age (adjusted odds ratio (AOR) 5.24; 95% CI 2.67-10.28), poorer functioning (AOR 6.41; 95% CI 3.65-11.24) and depressive symptoms (AOR 2.89; 95% CI 1.82-4.58) compared to patients currently working. Higher educated patients (AOR 0.60; 95% CI 0.37-0.97) and being in a relationship (AOR 0.34; 95% CI 0.21-0.54) were associated with being currently employed. Anxiety symptoms were common; 230 patients (45%) met caseness criteria. CONCLUSIONS: Many patients with CFS were not working. This was exacerbated by high levels of depressive symptoms. Health professionals should assess co-morbid mental health conditions and consider treatment options when patients with CFS present themselves. The early involvement of occupational health practitioners is recommended to maximize the chances of maintaining employment.

Dementia, post-traumatic stress disorder and major depressive disorder: a review of the mental health risk factors for dementia in the military veteran population.

BACKGROUND: Dementia is currently incurable, irreversible and a major cause of disability for the world's older population. The association between mental health difficulties, such as post-traumatic stress disorder (PTSD) and major depressive disorder (MDD), and dementia has a long history within the civilian population. Despite the increased importance of this link within the military veteran population, who suffer a greater propensity of mental health difficulties and consist largely of over 65s, attention is only recently being paid to the salience of such an association for this group. This paper aims to explore the relationship between PTSD and MDD with dementia within the military veteran population. METHOD: A systematic review was conducted on articles from 1990 to July 2016 on MEDLINE, EMBASE, EBSCO and Web of Science electronic databases with an update conducted in February 2017. RESULTS: Six empirical studies were identified from the review, the majority of which originated from the USA. Five of the studies asserted that veterans with a diagnosis of either PTSD or MDD are at a significantly greater risk of developing dementia than 'healthy' controls. The final study, conducted in Australia, found only a small, but non-significant, correlation between earlier MDD and future dementia, but no concurrent correlation. CONCLUSIONS: While causality cannot be determined, it is likely that PTSD and depressive disorders are related to an increased risk of dementia in military veterans. Potential pathological explanations and risk factors are reviewed and the clinical and neuroscience implications of these findings are explored.

Post-traumatic growth in (ex-) military personnel: review and qualitative synthesis.

BACKGROUND: Military service can be a traumatic experience and cause mental health problems in a minority of personnel, such as post-traumatic stress disorder (PTSD), which is linked to negative long-term outcomes. As a result, PTSD has received significant research attention. However, post-traumatic growth (PTG) is a newer construct, with comparatively little known about its presentation and development. AIMS: To qualitatively examine the experience of (PTG) in military and ex-military personnel. METHODS: A qualitative systematic search of electronic databases was conducted, with studies assessed for methodological quality and data analysed using thematic analysis. Nine qualitative studies, carried out between 2011 and 2016, met the inclusion criteria with 195 participants in total, including both military and ex-military personnel. RESULTS: Six themes were identified: appreciation for life, re-evaluating sense of purpose, improvement of personal human traits, bonding and connecting with others, integrating into society, and being proud of heritage and feeling valuable to society. CONCLUSIONS: The results of this review illustrate that military personnel may experience PTG due to deployment-related trauma exposure, and the presentation of PTG in this population is not dissimilar to that of civilians. This study highlights the need for additional research to quantify the long-term psychological impact of PTG and whether a focus on PTG may be helpful in psychological treatment for (ex-) military personnel.

Stigma-related barriers and facilitators to help seeking for mental health issues in the armed forces: a systematic review and thematic synthesis of qualitative literature.

A recent quantitative review in the area of stigma and help seeking in the armed forces has questioned the association between these factors (Sharp et al. 2015). To date, the contribution of qualitative literature in this area has largely been ignored, despite the value this research brings to the understanding of complex social constructs such as stigma. The aim of the current systematic review of qualitative studies was to identify appropriate literature, assess the quality and synthesize findings across studies regarding evidence of stigma-related barriers and facilitators to help seeking for mental health issues within the armed forces. A multi-database text word search incorporating searches of PsycINFO, MEDLINE, Social Policy and Practice, Social Work Abstracts, EMBASE, ERIC and EBM Review databases between 1980 and April 2015 was conducted. Literature was quality assessed using the Critical Appraisal Skills Programme tool. Thematic synthesis was conducted across the literature. The review identified eight studies with 1012 participants meeting the inclusion criteria. Five overarching themes were identified across the literature: (1) non-disclosure; (2) individual beliefs about mental health; (3) anticipated and personal experience of stigma; (4) career concerns; and (5) factors influencing stigma. The findings from the current systematic review found that unlike inconsistent findings in the quantitative literature, there was substantial evidence of a negative relationship between stigma and help seeking for mental health difficulties within the armed forces. The study advocates for refinement of measures to accurately capture the complexity of stigma and help seeking in future quantitative studies.

Parental reports of serious illness and disability among children aged 3-16†years from UK military families.

BACKGROUND: Prevalence rates of child illness according to parents have been found to vary greatly in the general population, with even less known about children of military parents. Mothers are generally considered more informed about their children's problems than fathers. This paper aimed to establish the prevalence of serious illness and disability among children from military families, noting the difference between parental reports. METHODS: Male serving and ex-serving personnel with children aged 3-16 years were invited to take part in an online questionnaire and telephone interview based on their child's health. The mothers of their children were invited via post if the father gave permission to make contact. Data were analysed using descriptive statistics and Cohen's kappa. RESULTS: 378 fathers and 383 mothers provided information for 610 children. The vast majority of parents did not perceive their child to have a serious illness or disability; fathers reported problems in 7.7% of their children (respiratory conditions most common), while mothers reported problems in 6.2% (physical health problems rated most prevalent). A moderate agreement was found between parent's reports; kappa=0.51 (p<0.001). CONCLUSIONS/IMPLICATIONS: The prevalence of serious illnesses and disabilities is low among military children according to parent reports. Fathers were more likely to disclose a problem in their child, and these differences were visible in the type of problem reported also. This disparity suggests mothers' and fathers' views should both be considered when making decisions that involve the child's care, in addition to clinical diagnoses.

What are the best and worst things about having a father in UK Armed Forces? Analysis of free text responses.

OBJECTIVE: This study aims to explore what adolescents report as the best and worst aspects of having a father in the UK military. METHODS: Qualitative data were collected from 171 adolescents aged 11-16 years, via an online questionnaire exploring the impact of paternal military service on childhood well-being (response rate=70%). Questions about the best and worst aspects of their father's military role were examined. Content analysis has been used to code the qualitative data into themes. RESULTS: 85 girls and 86 boys were included with a mean age of 13 years (SD 1.92). The results showed lack of contact as the single most commonly reported negative factor of having a father in the military (61%). Positive aspects of their fathers' job most frequently reported included a sense of pride (25%) and financial benefits (25%). CONCLUSIONS: Adolescents take a great deal of pride in their father's jobs in the military, and they enjoy the financial benefits. A majority, however, feel a lack of contact with their father is the most negative factor.

The prevalence of mental health disorders in (ex-)military personnel with a physical impairment: a systematic review.

BACKGROUND: Having a visual, hearing or physical impairment (defined as problems in body function or structure) may adversely influence the mental well-being of military personnel. This paper reviews the existing literature regarding the prevalence of mental health problems among (ex-)military personnel who have a permanent, predominantly, physical impairment. METHOD: Multiple electronic literature databases were searched for relevant studies (EMBASE (1980-January 2014), MEDLINE (1946-January 2014), PsycINFO (2002-January 2014), Web of Science (1975-January 2014)). RESULTS: 25 papers were included in the review, representing 17 studies. Studies conducted among US military personnel (n=8) were most represented. A range of mental health disorders were investigated; predominately post-traumatic stress disorder (PTSD), but also depression, anxiety disorder (excluding PTSD), psychological distress and alcohol misuse. The findings indicate that mental health disorders including PTSD (range 2-59%), anxiety (range 16.1-35.5%), depression (range 9.7-46.4%) and psychological distress (range 13.4-36%) are frequently found whereby alcohol misuse was least common (range 2.2-26.2%). CONCLUSIONS: Common mental health disorders were frequently identified among (ex-)military personnel with a physical impairment. Adequate care and support is necessary during the impairment adaptation process to facilitate the psychosocial challenges (ex-)military personnel with an impairment face. Future research should be directed into factors impacting on the mental well-being of (ex-)military personnel with an impairment, how prevalence rates vary across impairment types and to identify and act on specific needs for care and support.

Care pathways for UK and US service personnel who are visually impaired.

OBJECTIVES: The aim of this paper is to outline the different care pathways for sudden and gradual vision loss within UK and US military systems, as well as the provision of support by the main third-sector organisations looking after visually impaired (ex-) service personnel. METHODS: The Defence Medical Rehabilitation Centre, Headley Court and Queen Elizabeth Hospital Birmingham were consulted to obtain information and relevant documentation on UK care pathways. Experts in the field of visual impairment and the military-provided information on care pathways for US service personnel were consulted. The majority of the information on US care pathways was gathered from the Department of Veterans Affairs website and unclassified documents. RESULTS: The care pathways for UK and US service personnel with a visual impairment vary depending on the cause of visual impairment. Blind Veterans UK and the Blinded Veterans Association are the main organisations that support UK and US (ex-) service personnel, often filling in the gaps that other services do not have the resources to provide. The main difference between the two pathways, other than the UK healthcare system being free at the point of service, is that the Veteran Health Administration is one of the first national healthcare systems to integrate rehabilitation services for personnel with a visual impairment into the health services provided. DISCUSSION: The UK could benefit from having specific care coordinators for service personnel that specifically integrate rehabilitation, medical care and treatment for their visual impairment.

Sickness absence and associations with sociodemographic factors, health risk behaviours, occupational stressors and adverse mental health in 40,343 UK police employees.

AIMS: Police employees may experience high levels of stress due to the challenging nature of their work which can then lead to sickness absence. To date, there has been limited research on sickness absence in the police. This exploratory analysis investigated sickness absence in UK police employees. METHODS: Secondary data analyses were conducted using data from the Airwave Health Monitoring Study (2006-2015). Past year sickness absence was self-reported and categorised as none, low (1-5 days), moderate (6-19 days) and long-term sickness absence (LTSA, 20 or more days). Descriptive statistics and multinomial logistic regressions were used to examine sickness absence and exploratory associations with sociodemographic factors, occupational stressors, health risk behaviours, and mental health outcomes, controlling for rank, gender and age. RESULTS: From a sample of 40,343 police staff and police officers, forty-six per cent had no sickness absence within the previous year, 33% had a low amount, 13% a moderate amount and 8% were on LTSA. The groups that were more likely to take sick leave were women, non-uniformed police staff, divorced or separated, smokers and those with three or more general practitioner consultations in the past year, poorer mental health, low job satisfaction and high job strain. CONCLUSIONS: The study highlights the groups of police employees who may be more likely to take sick leave and is unique in its use of a large cohort of police employees. The findings emphasise the importance of considering possible modifiable factors that may contribute to sickness absence in UK police forces.

Testing the psychometric properties of the Participation Scale in Eastern Nepal.

PURPOSE: To test the psychometric properties of the Participation Scale (P-scale) among people with various disabling conditions in Eastern Nepal. METHODS: A sample of 153 individuals with disabling conditions was selected through systematic random sampling. The following psychometric properties were tested: structural validity (explanatory and confirmatory factor analyses), internal consistency, inter-tester reliability, construct validity and floor and ceiling effects. RESULTS: The explanatory factor analysis indicated a two-factor structure ('work-related participation' and 'general participation'). The confirmatory factor analysis suggested good model fit. The internal consistency measured with Cronbach's alpha was 0.93 for the whole scale and 0.78 and 0.93 for the subscales. The inter-tester reliability coefficient was 0.90. All hypothesized correlations were as expected confirming the construct validity of the scale. No floor or ceiling effects were identified for the whole scale; only the subscale 'work-related participation' showed a ceiling effect. CONCLUSION: The results of the analyses suggest that the psychometric properties of the P-scale are sufficient in the context of Eastern Nepal. Use of the P-scale will require (re-) confirmation of its validity in each new cultural context.

Stigma and social participation in Southern India: differences and commonalities among persons affected by leprosy and persons living with HIV/AIDS.

Stigma is a common phenomenon worldwide and infectious diseases like HIV/AIDS and leprosy are often associated with high levels of stigma. Several studies have been conducted concerning the effects of stigma and the impact on social participation, but comparative studies are rare. The objective of this study was to identify differences and similarities between HIV/AIDS and leprosy-related stigma. From April till July 2009, 190 questionnaire-based interviews were conducted to assess the levels of internalized stigma (Internalized Stigma of Mental Illness scale), perceived stigma (Explanatory Model Interview Catalogue stigma scale) and social participation (Participation scale) in a cross-sectional sample of people affected by leprosy (PL) and people living with HIV/AIDS (PLHA). Respondents were selected from several hospitals, charity projects and during home visits in Vellore district, Tamil Nadu. Our results showed that both PLHA (n = 95) and leprosy-affected respondents (n = 95) faced a substantial burden of internalized and perceived stigma, with the former reporting a significantly higher level of stigma. As a result, PLHA faced more frequent and also more severe participation restrictions than PL. Especially, restrictions in work-related areas were reported by the majority of the respondents. In conclusion, PLHA faced a significantly higher level of stigma and participation restriction than PL. However, the latter also reported a substantial burden of stigma and participation restrictions. The study suggests that it may be possible to develop joint interventions based on the commonalities found. More research is needed to define these more precisely and to test the effectiveness of such joint interventions in reducing stigma and improving social participation.

Confidentiality and psychological treatment of moral injury: the elephant in the room.

Morally injurious incidents may present ethical or legal quandaries, yet how military or civilian clinicians should manage such disclosures is poorly understood. Individuals who experience moral injury may be reluctant to seek help due to concerns about the legal ramifications of disclosure. Guidance on breaching patient confidentiality differs by regulatory body but also by profession, geography and context. As moral injury continues to become recognised in clinical practice, in the military and elsewhere, clarity is needed regarding best practice in managing moral injury cases and the dilemmas they present.

The cross-cultural equivalence of participation instruments: a systematic review.

PURPOSE: Concepts such as health-related quality of life, disability and participation may differ across cultures. Consequently, when assessing such a concept using a measure developed elsewhere, it is important to test its cultural equivalence. Previous research suggested a lack of cultural equivalence testing in several areas of measurement. This paper reviews the process of cross-cultural equivalence testing of instruments to measure participation in society. METHODS: An existing cultural equivalence framework was adapted and used to assess participation instruments on five categories of equivalence: conceptual, item, semantic, measurement and operational equivalence. For each category, several aspects were rated, resulting in an overall category rating of 'minimal/none', 'partial' or 'extensive'. The best possible overall study rating was five 'extensive' ratings. Articles were included if the instruments focussed explicitly on measuring 'participation' and were theoretically grounded in the ICIDH(-2) or ICF. Cross-validation articles were only included if it concerned an adaptation of an instrument developed in a high or middle-income country to a low-income country or vice versa. RESULTS: Eight cross-cultural validation studies were included in which five participation instruments were tested (Impact on Participation and Autonomy, London Handicap Scale, Perceived Impact and Problem Profile, Craig Handicap Assessment Reporting Technique, Participation Scale). Of these eight studies, only three received at least two 'extensive' ratings for the different categories of equivalence. The majority of the cultural equivalence ratings given were 'partial' and 'minimal/none'. The majority of the 'none/minimal' ratings were given for item and measurement equivalence. CONCLUSION: The cross-cultural equivalence testing of the participation instruments included leaves much to be desired. A detailed checklist is proposed for designing a cross-validation study. Once a study has been conducted, the checklist can be used to ensure comprehensive reporting of the validation (equivalence) testing process and its results. IMPLICATIONS FOR REHABILITATION: • Participation instruments are often used in a different cultural setting than initial developed for. • The conceptualization of participation may vary across cultures. Therefore, cultural equivalence ­ the extent to which an instrument is equally suitable for use in two or more cultures ­ is an important concept to address. • This review showed that the process of cultural equivalence testing of the included participation instruments was often addressed insufficiently. • Clinicians should be aware that application of participations instruments in a different culture than initially developed for needs prior testing of cultural validity in the next context.

Development and structural validation of a shortened version of the Participation Scale.

PURPOSE: To validate a shortened version of the Participation Scale (P-scale) that will be quicker to use and to describe the factor structure found in the P-scale data in various study samples. METHODS: A large multi-country and multi-cultural database was compiled consisting of 5125 respondents. Item analysis, explanatory factor analysis and confirmatory factor analysis were applied to identify items for deletion and investigate the factor structure of the P-scale. RESULTS: The multi-country database included 11 databases from six different countries. Respondents were affected by a range of health conditions, including leprosy, HIV/AIDS, dermatological conditions and various disabilities. Of the respondents included 57% were male. The P-scale Short (PSS) contains 13 items. A two-factor structure, with factors named "work-related participation" (three items) and "general participation" (10 items), showed the best model fit (Comparative Fit Index = 0.983, Tucker Lewis Index = 0.979, Rooted Mean Square Error of Approximation = 0.061). The Cronbach's alphas were very good for both the whole scale and the subscales, 0.91, 0.83 and 0.90, respectively. Correlation between the two factors was high (r = 0.75) indicating that interpreting the P-scale as measuring an overall factor "participation" is still valid. A very high correlation (r = 0.99) was found between the full P-scale and the PSS. CONCLUSIONS: The findings suggest good validity of the P-scale across a range of languages and cultures. However, field testing needs to confirm the validity of the PSS to measure the level of social participation restrictions across cultures and health conditions.