Translation, cultural adaptation and validation of Patient Health Questionnaire and generalized anxiety disorder among adolescents in Nepal.

BACKGROUND: Depression and anxiety are significant contributors to the global burden of disease among young people. Accurate data on the prevalence of these conditions are crucial for the equitable distribution of resources for planning and implementing effective programs. This study aimed to culturally adapt and validate data collection tools for measuring depression and anxiety at the population level. METHODS: The study was conducted in Kathmandu, Nepal, a diverse city with multiple ethnicities, languages, and cultures. Ten focus group discussions with 56 participants and 25 cognitive interviews were conducted to inform adaptations of the Patient Health Questionnaire adapted for Adolescents (PHQ-A) and Generalized Anxiety Disorder (GAD-7). To validate the tools, a cross-sectional survey of 413 adolescents (aged 12-19) was conducted in three municipalities of Kathmandu district. Trained clinical psychologists administered the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS-DSM 5 version) to survey participants. RESULTS: A number of cultural adaptations were required, such as changing statements into questions, using a visual scale (glass scale) to maintain uniformity in responses, and including a time frame at the beginning of each item. For younger adolescents aged 12 to 14 years, a PHQ-A cut-off of > = 13 had a sensitivity of 0.93, specificity of 0.80, positive predictive value (PPV) of 0.33, and negative predictive value (NPV) of 0.99. For older adolescents aged 15-19, a cut-off of > = 11 had a sensitivity of 0.89, specificity of 0.70, PPV of 0.32, and NPV of 0.97. For GAD-7, a cut-off of > = 8 had a sensitivity of 0.70 and specificity of 0.67 for younger adolescents and 0.71 for older adolescents, with a PPV of 0.39 and NPV of 0.89. The individual symptom means of both PHQ-A and GAD-7 items showed moderate ability to discriminate between adolescents with and without depression and anxiety. CONCLUSION: The PHQ-A and GAD-7 demonstrate fair psychometric properties for screening depression but performed poorly for anxiety, with high rates of false positives. Even when using clinically validated cut-offs, population prevalence rates would be inflated by 2-4 fold with these tools, requiring adjustment when interpreting epidemiological findings.

A mixed methods evaluation of a World Health Organization competency-based training package for foundational helping skills among pre-service and in-service health workers in Nepal, Peru and Uganda.

Health systems globally demand more competent workers but lack competency-based training programs to reach their goals. This study evaluates the effectiveness of a competency-based curriculum (EQUIP-FHS) for trainers and supervisors to teach foundational helping knowledge, attitudes and skills, guided by the WHO/UNICEF EQUIP platform, to improve the competency of in-service and pre-service workers from various health and other service sectors. A mixed-methods, uncontrolled before-and-after trial was conducted in Nepal, Peru, and Uganda from 2020 to 2021. Trainees' (N = 150) competency data were collected during 13 FHS trainings. Paired t-tests assessed pre- to post-change in ENACT competency measures (e.g., harmful, helpful). Qualitative data was analyzed using thematic analysis. EQUIP-FHS trainings, on average, were 20 h in duration. Harmful behaviors significantly decreased, and helpful behaviors significantly increased, across and within sites from pre-to post-training. Qualitatively, trainees and trainers promoted the training and highlighted difficult competencies and areas for scaling the training. A brief competency-based curriculum on foundational helping delivered through pre-service or in-service training can reduce the risk that healthcare workers and other service providers display harmful behaviors. We recommend governmental and nongovernmental organizations implement competency-based approaches to enhance the quality of their existing workforce programming and be one step closer to achieving the goal of quality healthcare around the globe.

Development and testing the feasibility of a sports-based mental health promotion intervention in Nepal: a protocol for a pilot cluster-randomised controlled trial.

BACKGROUND: Mental wellbeing encompasses life satisfaction, social connectedness, agency and resilience. In adolescence, mental wellbeing reduces sexual health risk behaviours, substance use and violence; improves educational outcomes; and protects mental health in adulthood. Mental health promotion seeks to improve mental wellbeing and can include activities to engage participants in sport. However, few high-quality trials of mental health promotion interventions have been conducted with adolescents, especially in low- and middle-income countries. We sought to address this gap by testing SMART (Sports-based Mental heAlth pRomotion for adolescenTs) in a pilot cluster-randomised controlled trial (cRCT) in Bardiya, Nepal. METHODS: The objectives of the trial are to assess the acceptability and feasibility of SMART, test trial procedures, explore outcome distributions in intervention and control clusters and calculate the total annual cost of the intervention and unit cost per adolescent. The trial design is a parallel-group, two-arm superiority pilot cRCT with a 1:1 allocation ratio and two cross-sectional census surveys with adolescents aged 12-19, one pre-intervention (baseline) and one post-intervention (endline). The study area is four communities of approximately 1000 population (166 adolescents per community). Each community represents one cluster. SMART comprises twice weekly football, martial arts and dance coaching, open to all adolescents in the community, led by local sports coaches who have received psychosocial training. Sports melas (festivals) and theatre performances will raise community awareness about SMART, mental health and the benefits of sport. Adolescents in control clusters will participate in sport as usual. In baseline and endline surveys, we will measure mental wellbeing, self-esteem, self-efficacy, emotion regulation, social support, depression, anxiety and functional impairment. Using observation checklists, unstructured observation and attendance registers from coaching sessions, and minutes of meetings between coaches and supervisors, we will assess intervention fidelity, exposure and reach. In focus group discussions and interviews with coaches, teachers, caregivers and adolescents, we will explore intervention acceptability and mechanisms of change. Intervention costs will be captured from monthly project accounts, timesheets and discussions with staff members. DISCUSSION: Findings will identify elements of the intervention and trial procedures requiring revision prior to a full cRCT to evaluate the effectiveness of SMART. TRIAL REGISTRATION: ISRCTN, ISRCTN15973986 , registered on 6 September 2022; ClinicalTrials.gov, NCT05394311 , registered 27 May 2022.

Understanding Nepali widows' experiences for the adaptation of an instrument to assess Prolonged Grief Disorder.

The experience of grief varies across different cultures and contexts. Women in Nepal who lose their husbands confront discrimination, social isolation, and abuse that influence their experience of grief. Through eight focus group discussions with Nepali widows, we elicited socially sanctioned grief reactions and local idioms used to describe common cognitive, behavioral, and emotional symptoms of grief. Accordingly, modifications to an existing instrument for Prolonged Grief Disorder, the PG-13, are suggested to capture grief symptoms as experienced by Nepali widows. Items in the PG-13 were translated to colloquial Nepali and adapted to maintain comprehensibility, acceptability, relevance, and completeness. Based on the grief-related issues reported in the focus group discussions, the addition of five new items and a new criterion to capture symptoms related to social discrimination are proposed. Widows perceived elevated symptoms one year after the loss to be problematic. It is thus recommended that the duration criterion in the original PG-13 be adjusted from at least six months to at least one year after the loss. These proposed modifications to the instrument should be validated through future psychometric testing.

Social determinants of impaired functioning among Nepali widows: A mixed methods study.

Despite considerable stigmatisation of widows in Nepal, little is known about factors affecting their ability to function in society. Using mixed methods, we studied psychosocial factors associated with impaired functioning among Nepali widows. For the qualitative analysis, we analysed 3 focus groups, 25 in-depth interviews, and 12 key-informant interviews. The quantitative analysis was based on data from 204 widows. Odds ratios were calculated linking psychosocial exposures to impaired functioning using adjusted logistic regression models. Low social support (aOR = 2.35, 95% CI: 1.2, 4.6, generally; aOR = 3.3, 95% CI: 1.7, 6.42, specifically from family members), experiences of discrimination (aOR = 2.97, 95% CI: 1.43, 6.14), and low life control (aOR = 4.3, 95% CI: 1.86, 10.1) were risk factors for impaired functioning. Qualitative findings suggested how discrimination and lack of control contribute to impaired functioning. Support from the husband's family appeared to be more important to a widow's functioning, compared to from her own parents. Knowledge about risk factors for impaired functioning can help inform interventions for Nepali widows.

Adaptation and psychometric validation of the Prolonged Grief Disorder scale among widows in central Nepal.

BACKGROUND: Symptoms of grief vary by culture and societal reactions to death may be gender specific. We aimed to validate a Nepali language version of the Prolonged Grief-13 item scale (PG-13) among widows. METHODS: We tested two adapted versions of a Prolonged Grief Disorder (PGD) instrument with 204 Nepali-speaking widows: one was a Nepali translation of the original PG-13 items, while the other contained five additional items derived from qualitative research. We evaluated internal consistency, factor structure, and construct and criterion validity. RESULTS: Participants were on average 44 years old (SD=9.3), completed 6.7 years of school (SD=3.3) and had survived their husbands by 10 years (SD=8.1). Thirteen percent met global criteria for PGD. The removal of one original PG-13 item (felt emotionally numb) from both versions due to poor discriminant validity resulted in 12- and 17-item versions. Exploratory factor analysis supported a one-factor structure for the PG-12 and PG-17. Both versions of the scale exhibited high internal consistency (0.89 and 0.93 respectively). Confirmatory factor analysis suggested that symptoms of PGD were distinct from post-traumatic stress disorder (PTSD), anxiety and depressive symptoms. The PG-12 had lower sensitivity (74.1%) but higher specificity (83.6%) compared to the PG-17 (81.5% and 73.5% respectively). LIMITATIONS: Psychosocial counselors' clinical interview global ratings were used as the standard for comparison in criterion validity analyses. Generalizability to other socio-cultural (e.g. non-widowed, low-caste) populations and men in Nepal cannot be assumed. CONCLUSIONS: Results indicate satisfactory psychometric properties and validity of both versions of the PG instruments, supporting their use with Nepali speaking widows.

Situational analysis to inform development of primary care and community-based mental health services for severe mental disorders in Nepal.

BACKGROUND: Nepal is representative of Low and Middle Income Countries (LMIC) with limited availability of mental health services in rural areas, in which the majority of the population resides. METHODS: This formative qualitative study explores resources, challenges, and potential barriers to the development and implementation of evidence-based Comprehensive Community-based Mental Health Services (CCMHS) in accordance with the mental health Gap Action Programme (mhGAP) for persons with severe mental health disorders and epilepsy. Focus Group Discussions (FGDs, n = 9) and Key-Informant Interviews (KIIs, n = 26) were conducted in a rural district in western Nepal. Qualitative data were coded using the Framework Analysis Method employing QSR NVIVO software. RESULTS: Health workers, general community members, and persons living with mental illness typically attributed mental illness to witchcraft, curses, and punishment for sinful acts. Persons with mental illness are often physically bound or locked in structures near their homes. Mental health services in medical settings are not available. Traditional healers are often the first treatment of choice. Primary care workers are limited both by lack of knowledge about mental illness and the inability to prescribe psychotropic medication. Health workers supported upgrading their existing knowledge and skills through mhGAP resources. Health workers lacked familiarity with basic computing and mobile technology, but they supported the introduction of mobile technology for delivering effective mental health services. Persons with mental illness and their family members supported the development of patient support groups for collective organization and advocacy. Stakeholders also supported development of focal community resource persons to aid in mental health service delivery and education. CONCLUSION: Health workers, persons living with mental illness and their families, and other stakeholders identified current gaps and barriers related to mental health services. However, respondents were generally supportive in developing community-based care in rural Nepal.