Psychometric performance of the Mental Health Implementation Science Tools (mhIST) across six low- and middle-income countries.

BACKGROUND: Existing implementation measures developed in high-income countries may have limited appropriateness for use within low- and middle-income countries (LMIC). In response, researchers at Johns Hopkins University began developing the Mental Health Implementation Science Tools (mhIST) in 2013 to assess priority implementation determinants and outcomes across four key stakeholder groups-consumers, providers, organization leaders, and policy makers-with dedicated versions of scales for each group. These were field tested and refined in several contexts, and criterion validity was established in Ukraine. The Consumer and Provider mhIST have since grown in popularity in mental health research, outpacing psychometric evaluation. Our objective was to establish the cross-context psychometric properties of these versions and inform future revisions. METHODS: We compiled secondary data from seven studies across six LMIC-Colombia, Myanmar, Pakistan, Thailand, Ukraine, and Zambia-to evaluate the psychometric performance of the Consumer and Provider mhIST. We used exploratory factor analysis to identify dimensionality, factor structure, and item loadings for each scale within each stakeholder version. We also used alignment analysis (i.e., multi-group confirmatory factor analysis) to estimate measurement invariance and differential item functioning of the Consumer scales across the six countries. RESULTS: All but one scale within the Provider and Consumer versions had Cronbach's alpha greater than 0.8. Exploratory factor analysis indicated most scales were multidimensional, with factors generally aligning with a priori subscales for the Provider version; the Consumer version has no predefined subscales. Alignment analysis of the Consumer mhIST indicated a range of measurement invariance for scales across settings (R2 0.46 to 0.77). Several items were identified for potential revision due to participant nonresponse or low or cross- factor loadings. We found only one item, which asked consumers whether their intervention provider was available when needed, to have differential item functioning in both intercept and loading. CONCLUSION: We provide evidence that the Consumer and Provider versions of the mhIST are internally valid and reliable across diverse contexts and stakeholder groups for mental health research in LMIC. We recommend the instrument be revised based on these analyses and future research examine instrument utility by linking measurement to other outcomes of interest.

Maintenance of intervention effects: long-term outcomes for participants in a group talk-therapy trial in the Democratic Republic of Congo.

Background: Despite the growth of psychotherapy trials in low- and middle-income countries, there have been limited follow-up studies of more than 2 years. This study follows up female sexual violence survivors approximately 6 years after completing a 12-session group cognitive processing therapy (CPT) program in the eastern Democratic Republic of Congo. Methods: Baseline trial data were collected in December 2010 from 134 women in 7 study villages randomly allocated to CPT. Study women were over 18 years, reported personally experiencing or witnessing sexual violence, and reported elevated depression, anxiety and/or posttraumatic stress symptoms. Women were followed up (1) post-treatment (6-months after baseline); (2) 6 months later; (3) 12 months later; and (4) in March 2017 (6.3 years after baseline). At the long-term follow-up, 103 women (77%) in 6 of 7 CPT villages were re-assessed; one village was not visited due to ongoing insecurity. Results: We found strong continued intervention effects; nearly all women maintained treatment impacts over the first two years; at long-term follow-up, approximately half continued to maintain low symptom scores. Relapse rates for probable PTSD and probable depression and anxiety were 20%. Conclusions: This study extends prior research to show that treatment impacts can be maintained for several years despite experiences of ongoing trauma. The women described continuing to meet with the women in their therapy group and using the skills they learned in the psychotherapy, providing evidence of the potential for these programs to provide valuable social supports and skills that people use as they continue to face adversity.

Two-year treatment effects of the common elements treatment approach (CETA) for reducing intimate partner violence and unhealthy alcohol use in Zambia.

BACKGROUND: Intimate partner violence (IPV) and unhealthy alcohol use are common yet often unaddressed public health problems in low- and middle-income countries. In a randomized trial, we found that the common elements treatment approach (CETA), a multi-problem, flexible, transdiagnostic intervention, was effective in reducing IPV and unhealthy alcohol use among couples in Zambia at a 12-month post-baseline assessment. In this follow-up study, we investigated whether treatment effects were sustained among CETA participants at 24-months post-baseline. METHODS: Participants were heterosexual couples in Zambia in which the woman reported IPV perpetrated by the male partner and in which the male had hazardous alcohol use. Couples were randomized to CETA or treatment as usual plus safety checks. Measures were the Severity of Violence Against Women Scale (SVAWS) and the Alcohol Use Disorders Identification Test (AUDIT). The trial was stopped early upon recommendation by the trial's DSMB due to CETA's effectiveness following the 12-month assessment. Control participants exited the study and were offered CETA. This brief report presents data from an additional follow-up assessment conducted among original CETA participants at a 24-month visit. RESULTS: There were no meaningful changes in SVAWS or AUDIT scores between 12- and 24-months. The within-group treatment effect for SVAWS from baseline to 24-months was d = 1.37 (p < 0.0001) and AUDIT was d = 0.85 (p < 0.0001). CONCLUSIONS: The lack of change in levels of IPV and unhealthy alcohol use between the 12- and 24-month post-baseline timepoints suggests that treatment gains were sustained among participants who received CETA for at least two years from intervention commencement.

Experiences of mental health and functioning among conflict-affected populations: A qualitative study with military veterans and displaced persons in Ukraine.

Objective: This article reports findings from a qualitative study that sought to identify and describe psychosocial and mental health consequences of conflict among internally displaced persons (IDPs) and military veterans in Ukraine. The study was the first phase of a clinical intervention trial and was designed to understand local experiences of mental health problems and function, inform the selection and adaptation of local measures, and guide the modification, and implementation of a psychotherapy intervention that could support conflict-affected persons. Method: Free-list interviews (FLs), key informant interviews (KIIs), and focus group discussions (FDGs) were conducted with IDPs, military veterans, and providers working with these two groups. A total of 227 respondents were interviewed from two study regions in eastern Ukraine-Zaporizhia and Kharkiv-including 136 IDPs and 91 military veterans. Results: Both IDPs and veterans were described as experiencing high levels of psychological stress symptoms, including depression, isolation, anxiety, and intrusive memories. Although IDPs and veterans were exposed to different traumas, they both identified struggles with social adaptation, including feeling isolated and misunderstood by their communities. Both groups also described relational conflict within and outside the family. Social support mechanisms were considered essential for recovery, and positive social interaction was described as a key example of healthy functioning. Conclusion: Findings suggest a need for community-based programming that facilitates social adaptation, supports social network building, and helps engage conflict-affected people into mental health services. Programs that promote greater awareness, interaction, and understanding among the general public, military veterans, and IDPs are also warranted. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Understanding mechanisms of change: An unpacking study of the evidence-based common-elements treatment approach (CETA) in low and middle income countries.

There is a recognized need to better understand "essential ingredients" of psychological treatments, and refine interventions to be more scalable and sustainable. The goal of the present study was to look within a specific modular, flexible, multi-problem transdiagnostic psychological intervention -the Common Elements Treatment Approach (CETA) - and examine questions that would lead to optimizing CETA for scale up and sustainment. Utilizing data from two trials of CETA in two different countries (Thailand and Iraq), this manuscript aims to: 1) determine the "active treatment dose" or how many sessions are needed to achieve clinically meaningful change overall, in CETA); and 2) test how trajectories of client symptom change varied based on client characteristics and/or on delivery of certain elements. Results showed that overall 50% of CETA clients show some improvement after 4-6 sessions (1 SD) and large improvement (2 SD) after 7-10 sessions. Trajectories of change show steady symptom decline over time. Results support gradual exposure as one of the "active ingredients". Findings suggest that modular, flexible transdiagnostic models may allow for more efficient, targeted treatment as we gain more knowledge about key ingredients, their timing within treatment, and client outcomes.

Adaptation and testing of an assessment for mental health and alcohol use problems among conflict-affected adults in Ukraine.

BACKGROUND: In Ukraine, a large number of internally displaced persons (IDPs) and veterans experience social and psychological problems as a result of the ongoing conflict between Ukraine and Russia. Our purpose was to develop reliable and valid instruments to screen for common mental health and alcohol use problems in these populations. METHODS: We used a three-step process of instrument adaptation and testing. The instrument-the Mental Health Assessment Inventory (MHAI)-combines adapted standard screeners with items derived locally in Ukraine. A validity study was conducted using a sample of 153 adults (54% male) ages 18 years and older. All participants in the sample were IDPs or veterans living in or near the major urban areas of Kyiv and Zaporizhia. Reliability testing (internal consistency, test-retest) and validity testing (construct, criterion) of the MHAI were conducted using classical test theory. After initial testing, we used Item Response Theory (IRT) to shorten and further refine the instrument. RESULTS: The MHAI showed good internal consistency and test-retest reliability for the main outcomes: depression (α = 0.94; r = .84), post-traumatic stress (PTS; α = 0.97; r = 0.87), anxiety (α = 0.90; r = 0.80), and alcohol use (α = 0.86; r = 0.91). There was good evidence of convergent construct validity among the scales for depression, PTS, and anxiety, but not for alcohol use. Item Response Theory (IRT) analysis supported use of shortened versions of the scales for depression, PTS, and anxiety, as they retained comparable psychometric properties to the full scales of the MHAI. CONCLUSION: The findings support the reliability and validity of the assessment-the MHAI-for screening of common mental health problems among Ukrainian IDPs and veterans. Use of IRT shortened the instrument to improve practicality and potential sustainability.

Outcomes of an individual counselling programme in Grozny, Chechnya: a randomised controlled study.

OBJECTIVES: To evaluate the effectiveness of individual counselling on functioning of clients participating in a mental health intervention in a humanitarian setting. DESIGN: Randomised controlled trial. SETTING: Mental health programme implemented by Médecins Sans Frontières in Grozny, Republic of Chechnya. PARTICIPANTS: 168 eligible clients were randomly assigned to the intervention and waitlisted (2 months) arms between November 2014 and February 2015. INTERVENTION: Individual counselling sessions. MAIN OUTCOME MEASURES: Change in functioning was measured using the Short Form 6 (SF6) and gender-specific locally adapted Chechen functioning instruments in the intervention group at the end of counselling and the waitlisted group after their waitlisted period. Unadjusted differences in gain scores (DGSs) between intervention and waitlisted groups were calculated with effect size (Cohen's d) for both tools. Linear regression compared the mean DGS in both groups. RESULTS: The intervention group (n=78) improved compared with waitlisted controls (n=80) on the SF6 measures with moderate to large effect sizes: general health (DGS 12.14, d=0.52), body pain (DGS 10.26, d=0.35), social support (DGS 16.07, d=0.69) and emotional functioning (DGS 16.87, d=0.91). Similar improvement was seen using the Chechen functioning instrument score (female DGS -0.33, d=0.55; male DGS -0.40, d=0.99). Adjusted analysis showed significant improvement (p<0.05) in the intervention group for all SF6 measures and for the Chechen functioning instrument score in women but not men (p=0.07). CONCLUSIONS: Individual counselling significantly improved participants' ability to function in the intervention group compared with the waitlisted group. Further research is needed to determine whether similar positive results can be shown in other settings and further exploring the impact in male clients' population. TRIAL REGISTRATION NUMBER: NTR4689.

"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.

Effectiveness of Trauma-Focused Cognitive Behavioral Therapy Among Trauma-Affected Children in Lusaka, Zambia: A Randomized Clinical Trial.

IMPORTANCE: Orphans and vulnerable children (OVC) are at high risk for experiencing trauma and related psychosocial problems. Despite this, no randomized clinical trials have studied evidence-based treatments for OVC in low-resource settings. OBJECTIVE: To evaluate the effectiveness of lay counselor-provided trauma-focused cognitive behavioral therapy (TF-CBT) to address trauma and stress-related symptoms among OVC in Lusaka, Zambia. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial compared TF-CBT and treatment as usual (TAU) (varying by site) for children recruited from August 1, 2012, through July 31, 2013, and treated until December 31, 2013, for trauma-related symptoms from 5 community sites within Lusaka, Zambia. Children were aged 5 through 18 years and had experienced at least one traumatic event and reported significant trauma-related symptoms. Analysis was with intent to treat. INTERVENTIONS: The intervention group received 10 to 16 sessions of TF-CBT (n = 131). The TAU group (n = 126) received usual community services offered to OVC. MAIN OUTCOMES AND MEASURES: The primary outcome was mean item change in trauma and stress-related symptoms using a locally validated version of the UCLA Posttraumatic Stress Disorder Reaction Index (range, 0-4) and functional impairment using a locally developed measure (range, 0-4). Outcomes were measured at baseline and within 1 month after treatment completion or after a waiting period of approximately 4.5 months after baseline for TAU. RESULTS: At follow-up, the mean item change in trauma symptom score was -1.54 (95% CI, -1.81 to -1.27), a reduction of 81.9%, for the TF-CBT group and -0.37 (95% CI, -0.57 to -0.17), a reduction of 21.1%, for the TAU group. The mean item change for functioning was -0.76 (95% CI, -0.98 to -0.54), a reduction of 89.4%, and -0.54 (95% CI, -0.80 to -0.29), a reduction of 68.3%, for the TF-CBT and TAU groups, respectively. The difference in change between groups was statistically significant for both outcomes (P < .001). The effect size (Cohen d) was 2.39 for trauma symptoms and 0.34 for functioning. Lay counselors participated in supervision and assessed whether the intervention was provided with fidelity in all 5 community settings. CONCLUSIONS AND RELEVANCE: The TF-CBT adapted for Zambia substantially decreased trauma and stress-related symptoms and produced a smaller improvement in functional impairment among OVC having experienced high levels of trauma. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01624298.

Testing the validity and reliability of the shame questionnaire among sexually abused girls in Zambia.

PURPOSE: The aim of the current study is to test the validity and reliability of the Shame Questionnaire among traumatized girls in Lusaka, Zambia. METHODS: The Shame Questionnaire was validated through both classical test and item response theory methods. Internal reliability, criterion validity and construct validity were examined among a sample of 325 female children living in Zambia. Sub-analyses were conducted to examine differences in construct validity among girls who reported sexual abuse and girls who did not. RESULTS: All girls in the sample were sexually abused, but only 61.5% endorsed or reported that sexual abuse had occurred. Internal consistency was very good among the sample with alpha = .87. Criterion validity was demonstrated through a significant difference of mean Shame Questionnaire scores between girls who experienced 0-1 trauma events and more than one traumatic event, with higher mean Shame Questionnaire scores among girls who had more than one traumatic event (p = .004 for 0-1 compared to 2 and 3 events and p = .016 for 0-1 compared to 4+ events). Girls who reported a history of witnessing or experiencing physical abuse had a significantly higher mean Shame Questionnaire score than girls who did not report a history of witnessing or experiencing physical abuse (p<.0001). There was no significant difference in mean Shame Questionnaire score between girls who reported a sexual abuse history and girls who did not. Exploratory factor analysis indicated a two-factor model of the Shame Questionnaire, with an experience of shame dimension and an active outcomes of shame dimension. Item response theory analysis indicated adequate overall item fit. Results also indicate potential differences in construct validity between girls who did and did not endorse sexual abuse. CONCLUSIONS: This study suggests the general utility of the Shame Questionnaire among Zambian girls and demonstrates the need for more psychometric studies in low and middle income countries.

The unknown role of mental health in global development.

In this paper, the author contrasts the substantial impact of mental health problems on global disability with the limited attention and resources these problems receive. The author discusses possible reasons for the disparity: Compared to physical disorders, mental health problems are considered less important, perhaps due to lower priority of disorders that primarily cause dysfunction rather than mortality, and skepticism that mental disorders are treatable in low-resource countries. He argues that achieving improved global health and development requires addressing problems causing disability, particularly mental health problems among populations in which the common mental disorders are frequent due to deprivation, war, and disasters. The author contends that services addressing the common mental disorders could be made widely and relatively cheaply accessible if provided by non-professional workers at the community level.

A longitudinal investigation of changes to social resources associated with psychological distress among Kurdish torture survivors living in Northern Iraq.

Social resources can buffer against psychological distress following potentially traumatic events. Psychological distress can also lead to social resource deterioration. This longitudinal study evaluated whether baseline psychological distress symptoms and changes in these symptoms were associated with changes in social resources 5 months later among 96 adult male (52.6%) and female treatment-seeking torture survivors residing in Kurdistan, Iraq. Adapted versions of the Hopkins Symptom Checklist-25, Harvard Trauma Questionnaire, and a traumatic grief measure were used. Locally derived scales measured perceived social support, social integration, and frequency of social contact. Multinomial logistic regression models assessed the association between symptoms and loss or gain in social resources. We hypothesized that higher mental health symptoms would relate to decreased social resources. Higher baseline depression (adjusted conditional odds ratio [ACOR] = 1.14), posttraumatic stress disorder (PTSD; ACOR = 1.09), and traumatic grief symptoms (ACOR = 1.14) increased the odds of loss of social integration. For some, higher traumatic grief symptoms were associated with increased social integration (ACOR = 1.17). Increased anxiety (ACOR = 1.23) and PTSD symptoms (ACOR = 1.07) was associated with declines in social contact; decreased depression (ACOR = 1.06) and PTSD symptoms (ACOR = 1.04) were related to gaining social contact. This study highlights the complex relationship between mental health symptoms and losses and gains in social resources among torture survivors.

The effect of cognitive therapy on structural social capital: results from a randomized controlled trial among sexual violence survivors in the Democratic Republic of the Congo.

OBJECTIVES: We evaluated changes in social capital following group-based cognitive processing therapy (CPT) for female survivors of sexual violence. METHODS: We compared CPT with individual support in a cluster-randomized trial in villages in South Kivu province, Democratic Republic of the Congo. Local psychosocial assistants delivered the interventions from April through July 2011. We evaluated differences between CPT and individual support conditions for structural social capital (i.e., time spent with nonkin social network, group membership and participation, and the size of financial and instrumental support networks) and emotional support seeking. We analyzed intervention effects with longitudinal random effects models. RESULTS: We obtained small to medium effect size differences for 2 study outcomes. Women in the CPT villages increased group membership and participation at 6-month follow-up and emotional support seeking after the intervention compared with women in the individual support villages. CONCLUSIONS: Results support the efficacy of group CPT to increase dimensions of social capital among survivors of sexual violence in a low-income conflict-affected context.

The importance of establishing reliability and validity of assessment instruments for mental health problems: An example from Somali children and adolescents living in three refugee camps in Ethiopia.

Assessing mental health problems cross-culturally for children exposed to war and violence presents a number of unique challenges. One of the most important issues is the lack of validated symptom measures to assess these problems. The present study sought to evaluate the psychometric properties of two measures to assess mental health problems: the Achenbach Youth Self-Report and the Child Posttraumatic Stress Disorder Symptom Scale. We conducted a validity study in three refugee camps in Eastern Ethiopia in the outskirts of Jijiga, the capital of the Somali region. A total of 147 child and caregiver pairs were assessed, and scores obtained were submitted to rigorous psychometric evaluation. Excellent internal consistency reliability was obtained for symptom measures for children and their caregivers. Validation of study instruments based on local case definitions was obtained for the caregivers but not consistently for the children. Sensitivity and specificity of study measures were generally low, indicating that these scales would not perform adequately as screening instruments. Combined test-retest and inter-rater reliability was low for all scales. This study illustrates the need for validation and testing of existing measures cross-culturally. Methodological implications for future cross-cultural research studies in low- and middle-income countries are discussed.

Counselor and client perspectives of Trauma-focused Cognitive Behavioral Therapy for children in Zambia: a qualitative study.

This study examined Zambian counselors, children, and caregivers' perceptions of an evidence-based treatment (EBT) for trauma (Trauma-Focused Cognitive Behavioral Therapy [TF-CBT]) utilized in Zambia to address mental health problems in children. Semistructured interviews were conducted with local counselors trained in TF-CBT (N = 19; 90% of those trained; 12 female) and children/caregivers who had received TF-CBT in a small feasibility study (N = 18; 86% of the children and N = 16; 76% of the caregivers) who completed TF-CBT (total completed; N = 21). Each client was asked six open-ended questions, and domain analysis was used to explore the data. Counselors were positive about the program, liked the structure and flexibility, reported positive changes in their clients, and discussed the cultural adaptation around activities and language. Counselors stated the training was too short, and the supervision was necessary. Challenges included client engagement and attendance, availability of location, funding, and a lack of community understanding of "therapy." Children and caregivers stated multiple positive changes they attributed to TF-CBT, such as better family communication, reduction of problem behaviors, and ability to speak about the trauma. They recommended continuing the program. This study brings a critical examination of providers' and clients' perspectives of the implementation of an EBT for children in a low-resource setting. Clinical implications include changing implementation methods based on responses. Research implications include future study directions such as an effectiveness trial of TF-CBT and an examination of implementation factors.

Controlled trial of psychotherapy for Congolese survivors of sexual violence.

BACKGROUND: Survivors of sexual violence have high rates of depression, anxiety, and post-traumatic stress disorder (PTSD). Although treatment for symptoms related to sexual violence has been shown to be effective in high-income countries, evidence is lacking in low-income, conflict-affected countries. METHODS: In this trial in the Democratic Republic of Congo, we randomly assigned 16 villages to provide cognitive processing therapy (1 individual session and 11 group sessions) or individual support to female sexual-violence survivors with high levels of PTSD symptoms and combined depression and anxiety symptoms. One village was excluded owing to concern about the competency of the psychosocial assistant, resulting in 7 villages that provided therapy (157 women) and 8 villages that provided individual support (248 women). Assessments of combined depression and anxiety symptoms (average score on the Hopkins Symptom Checklist [range, 0 to 3, with higher scores indicating worse symptoms]), PTSD symptoms (average score on the PTSD Checklist [range, 0 to 3, with higher scores indicating worse symptoms]), and functional impairment (average score across 20 tasks [range, 0 to 4, with higher scores indicating greater impairment]) were performed at baseline, at the end of treatment, and 6 months after treatment ended. RESULTS: A total of 65% of participants in the therapy group and 52% of participants in the individual-support group completed all three assessments. Mean scores for combined depression and anxiety improved in the individual-support group (2.2 at baseline, 1.7 at the end of treatment, and 1.5 at 6 months after treatment), but improvements were significantly greater in the therapy group (2.0 at baseline, 0.8 at the end of treatment, and 0.7 at 6 months after treatment) (P<0.001 for all comparisons). Similar patterns were observed for PTSD and functional impairment. At 6 months after treatment, 9% of participants in the therapy group and 42% of participants in the individual-support group met criteria for probable depression or anxiety (P<0.001), with similar results for PTSD. CONCLUSIONS: In this study of sexual-violence survivors in a low-income, conflict-affected country, group psychotherapy reduced PTSD symptoms and combined depression and anxiety symptoms and improved functioning. (Funded by the U.S. Agency for International Development Victims of Torture Fund and the World Bank; ClinicalTrials.gov number, NCT01385163.).

Post-partum depression in Kinshasa, Democratic Republic of Congo: validation of a concept using a mixed-methods cross-cultural approach.

OBJECTIVE: To determine if a post-partum depression syndrome exists among mothers in Kinshasa, Democratic Republic of Congo, by adapting and validating standard screening instruments. METHODS: Using qualitative interviewing techniques, we interviewed a convenience sample of 80 women living in a large peri-urban community to better understand local conceptions of mental illness. We used this information to adapt two standard depression screeners, the Edinburgh Post-partum Depression Scale and the Hopkins Symptom Checklist. In a subsequent quantitative study, we identified another 133 women with and without the local depression syndrome and used this information to validate the adapted screening instruments. RESULTS: Based on the qualitative data, we found a local syndrome that closely approximates the Western model of major depressive disorder. The women we interviewed, representative of the local populace, considered this an important syndrome among new mothers because it negatively affects women and their young children. Women (n = 41) identified as suffering from this syndrome had statistically significantly higher depression severity scores on both adapted screeners than women identified as not having this syndrome (n = 20; P < 0.0001). CONCLUSIONS: When it is unclear or unknown if Western models of psychopathology are appropriate for use in the local context, these models must be validated to ensure cross-cultural applicability. Using a mixed-methods approach we found a local syndrome similar to depression and validated instruments to screen for this disorder. As the importance of compromised mental health in developing world populations becomes recognized, the methods described in this report will be useful more widely.

Violence and abuse among HIV-infected women and their children in Zambia: a qualitative study.

HIV and violence are two major public health problems increasingly shown to be connected and relevant to international mental health issues and HIV-related services. Qualitative research is important due to the dearth of literature on this association in developing countries, cultural influences on mental health syndromes and presentations, and the sensitive nature of the topic. The study presented in this paper sought to investigate the mental health issues of an HIV-affected population of women and children in Lusaka, Zambia, through a systematic qualitative study. Two qualitative methods resulted in the identification of three major problems for women: domestic violence (DV), depression-like syndrome, and alcohol abuse; and children: defilement, DV, and behavior problems. DV and sexual abuse were found to be closely linked to HIV and alcohol abuse. This study shows the local perspective of the overlap between violence and HIV. Results are discussed in relation to the need for violence and abuse to be addressed as HIV services are implemented in sub-Saharan Africa.