The Association Between HIV-Related Stigma and the Uptake of HIV Testing and ART Among Older Adults in Rural South Africa: Findings from the HAALSI Cohort Study.

HIV testing and antiretroviral therapy (ART) remain critical for curbing the spread of HIV/AIDS, but stigma can impede access to these services. Using data from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI), we used a multivariable logistic regression to examine the correlation between HIV-related stigma, HIV testing and ART uptake in older adults. We used four questions to measure stigma, with three assessing social stigma (reflecting social distancing preferences) and one assessing anticipated stigma (disclosure concern). We combined the three social stigma questions to generate a social stigma score ranging from 0 to 3, with higher scores indicating higher stigma. Anticipated stigma was prevalent 85% (95% CI 0.84-0.86), and social stigma was also frequent 25% (95% CI 0.24-0.27). Higher social stigma scores correlated with decreased HIV testing for all participants with social stigma. Compared to those with a score of 0, odds of testing decreased with higher stigma scores (OR = 0.66, 95% CI 0.53-0.81, p = 0.000) for a score of 1 and (OR = 0.56, 95% CI 0.38-0.83, p = 0.004) for a score of 3. ART uptake also decreased with higher social stigma scores among people living with HIV (PLWH), although it was significant for those with a score of 2 (OR = 0.41, 95% CI 0.19-0.87, p = 0.020). These findings emphasize that HIV-related stigma hampers testing and ART uptake among older adults in rural South Africa. Addressing stigma is crucial for improving testing rates, early diagnosis, and treatment initiation among the older population and achieving UNAIDS 95-95-95 targets.

Acceptability and Feasibility of a Smartphone-Based Real-Time Assessment of Suicide Among Black Men: Mixed Methods Pilot Study.

BACKGROUND: Suicide rates in the United States have increased recently among Black men. To address this public health crisis, smartphone-based ecological momentary assessment (EMA) platforms are a promising way to collect dynamic, real-time data that can help improve suicide prevention efforts. Despite the promise of this methodology, little is known about its suitability in detecting experiences related to suicidal thoughts and behavior (STB) among Black men. OBJECTIVE: This study aims to clarify the acceptability and feasibility of using smartphone-based EMA through a pilot study that assesses the user experience among Black men. METHODS: We recruited Black men aged 18 years and older using the MyChart patient portal messaging (the patient-facing side of the Epic electronic medical record system) or outpatient provider referrals. Eligible participants self-identified as Black men with a previous history of STB and ownership of an Android or iOS smartphone. Eligible participants completed a 7-day smartphone-based EMA study. They received a prompt 4 times per day to complete a brief survey detailing their STB, as well as proximal risk factors, such as depression, social isolation, and feeling like a burden to others. At the conclusion of each day, participants also received a daily diary survey detailing their sleep quality and their daily experiences of everyday discrimination. Participants completed a semistructured exit interview of 60-90 minutes at the study's conclusion. RESULTS: In total, 10 participants completed 166 EMA surveys and 39 daily diary entries. A total of 4 of the 10 participants completed 75% (21/28) or more of the EMA surveys, while 9 (90%) out of 10 completed 25% (7/28) or more. The average completion rate of all surveys was 58% (20.3/35), with a minimum of 17% (6/35) and maximum of 100% (35/35). A total of 4 (40%) out of 10 participants completed daily diary entries for the full pilot study. No safety-related incidents were reported. On average, participants took 2.08 minutes to complete EMA prompts and 2.72 minutes for daily diary surveys. Our qualitative results generally affirm the acceptability and feasibility of the study procedures, but the participants noted difficulties with the technology and the redundancy of the survey questions. Emerging themes also addressed issues such as reduced EMA survey compliance and diminished mood related to deficit-framed questions related to suicide. CONCLUSIONS: Findings from this study will be used to clarify the suitability of EMA for Black men. Overall, our EMA pilot study demonstrated mixed feasibility and acceptability when delivered through smartphone-based apps to Black men. Specific recommendations are provided for managing safety within these study designs and for refinements in future intervention and implementation science research. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/31241.

Peptide-mimetic treatment of Pseudomonas aeruginosa in a mouse model of respiratory infection.

The rise of drug resistance has become a global crisis, with >1 million deaths due to resistant bacterial infections each year. Pseudomonas aeruginosa, in particular, remains a serious problem with limited solutions due to complex resistance mechanisms that now lead to more than 32,000 multidrug-resistant (MDR) infections and over 2,000 deaths annually. While the emergence of resistant bacteria has become concerningly common, identification of useful new drug classes has been limited over the past 40+ years. We found that a potential novel therapeutic, the peptide-mimetic TM5, is effective at killing P. aeruginosa and displays sufficiently low toxicity for mammalian cells to allow for use in treatment of infections. Interestingly, TM5 kills P. aeruginosa more rapidly than traditional antibiotics, within 30-60 minutes in vitro , and is effective against a range of clinical isolates. In vivo , TM5 significantly reduced bacterial load in the lungs within 24 hours compared to untreated mice and demonstrated few adverse effects. Taken together, these observations suggest that TM5 shows promise as an alternative therapy for MDR P. aeruginosa respiratory infections.

Ixodes scapularis nymph saliva protein blocks host inflammation and complement-mediated killing of Lyme disease agent, Borrelia burgdorferi.

Tick serine protease inhibitors (serpins) play crucial roles in tick feeding and pathogen transmission. We demonstrate that Ixodes scapularis (Ixs) nymph tick saliva serpin (S) 41 (IxsS41), secreted by Borrelia burgdorferi (Bb)-infected ticks at high abundance, is involved in regulating tick evasion of host innate immunity and promoting host colonization by Bb. Recombinant (r) proteins were expressed in Pichia pastoris, and substrate hydrolysis assays were used to determine. Ex vivo (complement and hemostasis function related) and in vivo (paw edema and effect on Bb colonization of C3H/HeN mice organs) assays were conducted to validate function. We demonstrate that rIxsS41 inhibits chymase and cathepsin G, pro-inflammatory proteases that are released by mast cells and neutrophils, the first immune cells at the tick feeding site. Importantly, stoichiometry of inhibition analysis revealed that 2.2 and 2.8 molecules of rIxsS41 are needed to 100% inhibit 1 molecule of chymase and cathepsin G, respectively, suggesting that findings here are likely events at the tick feeding site. Furthermore, chymase-mediated paw edema, induced by the mast cell degranulator, compound 48/80 (C48/80), was blocked by rIxsS41. Likewise, rIxsS41 reduced membrane attack complex (MAC) deposition via the alternative and lectin complement activation pathways and dose-dependently protected Bb from complement killing. Additionally, co-inoculating C3H/HeN mice with Bb together with rIxsS41 or with a mixture (rIxsS41 and C48/80). Findings in this study suggest that IxsS41 markedly contributes to tick feeding and host colonization by Bb. Therefore, we conclude that IxsS41 is a potential candidate for an anti-tick vaccine to prevent transmission of the Lyme disease agent.

Depressive symptoms and their association with age, chronic conditions and health status among middle-aged and elderly people in peri-urban Tanzania.

Background: Depression is a global mental health challenge. We assessed the prevalence of depressive symptoms and their association with age, chronic conditions, and health status among middle-aged and elderly people in peri-urban Dar es Salaam, Tanzania. Methods: Depressive symptoms were measured in 2,220 adults aged over 40 years from two wards of Dar es Salaam using the ten-item version of the Center of Epidemiologic Studies Depression Scale (CES-D-10) and a cut-off score of 10 or higher. The associations of depressive symptoms with age, 13 common chronic conditions, multimorbidity, self-rated health and any limitation in six activities of daily living were examined in univariable and multivariable logistic regressions. Results: The estimated prevalence of depressive symptoms was 30.7% (95% CI 28.5-32.9). In univariable regressions, belonging to age groups 45-49 years (OR 1.35 [95% CI 1.04-1.75]) and over 70 years (OR 2.35 [95% CI 1.66-3.33]), chronic conditions, including ischemic heart disease (OR 3.43 [95% CI 2.64-4.46]), tuberculosis (OR 2.42 [95% CI 1.64-3.57]), signs of cognitive problems (OR 1.90 [95% CI 1.35-2.67]), stroke (OR 1.56 [95% CI 1.05-2.32]) and anemia (OR 1.32 [95% CI 1.01-1.71]) and limitations in activities of daily living (OR 1.35 [95% CI 1.07-1.70]) increased the odds of depressive symptoms. Reporting good or very good health was associated with lower odds of depressive symptoms (OR 0.48 [95% CI 0.35-0.66]). Ischemic heart disease and tuberculosis remained independent predictors of depressive symptoms in multivariable regressions. Conclusion: Depressive symptoms affected almost one in three people aged over 40 years. Their prevalence differed across age groups and was moderated by chronic conditions, health status and socioeconomic factors.

Mental Health Treatment-Seeking Appraisal, Afrocentric Cultural Norms, and Mental Health Functioning: Buffering Factors of Young Black Men's Externalizing Behavior.

BACKGROUND: Depression rates are disproportionately high among Black American Men. This disparity--compounded by low mental healthcare seeking rates and high incorrect diagnosis rates in men--could be related to masculine norms, including self-reliance, restrictive emotionality, and stoicism. Furthermore, men are more likely to engage in externalized behavior, such as aggression, to cope with mental health challenges; this pattern is influenced by cultural and environmental factors. Contrary to these detrimental factors, social relationships, belief in social networks, and collectivism have been associated with positive mental health in these populations. Similarly, an Afrocentric worldview (including concepts like Ubuntu and African self-consciousness) has been hypothesized to promote positive mental health outcomes among Black American men. However, little research exists on harnessing these factors as a means of increasing health-seeking behaviors in young Black males. AIM: To elucidate the effect of region, depression, African humanism, collectivism, and help-seeking values and needs concerning aggression in young Black males. METHOD: This study included Black or African American participants (n = 428) identifying as male, aged 18-25 years, who responded to a Qualtrics survey with questions on region, aggression, depression, African humanism, collectivism, and help-seeking value and need. RESULTS: Hierarchical linear regression revealed that collectivism, humanness, value, and the need for seeking treatment were inversely associated with aggression (p < 0.001). DISCUSSION/CONCLUSION: Highlighting the effect of cultural norms and help-seeking behaviors and the aggravating effect of depression on aggression in young Black males can help to develop aggression-mitigating interventions rooted in Afrocentric Norms.

The relationship between neighborhood typologies and self-rated health in Maryland: A latent class analysis.

Despite widespread evidence that neighborhood conditions impact health, few studies apply theory to clarify the physical and social factors in communities that drive health outcomes. Latent class analysis (LCA) addresses such gaps by identifying distinct neighborhood typologies and the joint influence that neighborhood-level factors play in health promotion. In the current study, we conducted a theory-driven investigation to describe Maryland neighborhood typologies and examined differences in area-level self-rated poor mental and physical health across typologies. We conducted an LCA of Maryland census tracts (n = 1384) using 21 indicators of physical and social characteristics. We estimated differences in tract-level self-rated physical and mental health across neighborhood typologies using global Wald tests and pairwise comparisons. Five neighborhood classes emerged: Suburban Resourced (n = 410, 29.6%), Rural Resourced (n = 313, 22.6%), Urban Underserved (n = 283, 20.4%), Urban Transient (n = 226, 16.3%), Rural Health Shortage (n = 152, 11.0%). Prevalence of self-rated poor physical and mental health varied significantly (p < 0.0001) by neighborhood typology, with the Suburban Resourced neighborhood class demonstrating the lowest prevalence of poor health and the Urban Underserved neighborhoods demonstrating the poorest health. Our results highlight the complexity of defining "healthy" neighborhoods and areas of focus to mitigate community-level health disparities to achieve health equity.

Demographic predictors of emergency service utilization patterns in youth at risk of suicide.

OBJECTIVE: To explore demographic predictors of Emergency Department (ED) utilization among youth with a history of suicidality (i.e., ideation or behaviors). METHODS: Electronic health records were extracted from 2017 to 2021 for 3094 8-22 year-old patients with a history of suicidality at an urban academic medical center ED in the Mid-Atlantic. Logistic regression analyses were used to assess for demographic predictors of ED utilization frequency, timing of subsequent visits, and reasons for subsequent visits over a 24-month follow-up period. RESULTS: Black race (OR = 1.45, 95% CI = 1.11-1.92), Female sex (OR = 1.59, 95% CI = 1.26-2.03), and having Medicaid insurance (OR = 1.71, 95% CI = 1.37-2.14) were associated with increased utilization, while being under 18 was associated with lower utilization (<12: OR = 0.38, 95% CI = 0.26-0.56; 12-18: OR = 0.47, 95% CI = 0.35-0.63). These demographics were also associated with ED readmission within 90 days, while being under 18 was associated with a lower odds of readmission. CONCLUSIONS: Among patients with a history of suicidality, those who identify as Black, young adults, patients with Medicaid, and female patients were more likely to be frequent utilizers of the ED within the 2 years following their initial visit. This pattern may suggest inadequate health care access for these groups, and a need to develop better care coordination with an intersectional focus to facilitate utilization of other health services.

Factors Associated With Suicide in Four West African Countries Among Adolescent Students: An Analysis Using the Global School-Based Student Health Survey.

PURPOSE: Globally, suicide is a leading cause of death among adolescents, with the highest burden of suicide occurring in Africa. Despite this, little is known about the epidemiology of suicide among adolescents in West Africa. In this study, we explore suicidality among West African adolescents. METHODS: Using pooled data from the Global School-Based Student Health Survey in four West African countries (Ghana, Benin, Liberia, and Sierra Leone), we investigated the prevalence of suicidal ideation and suicide attempt and examined associations with 15 covariates using univariate and multivariable logistic regression. RESULTS: Overall, 18.6% of adolescents in the pooled sample (N = 9,726) had considered suicide, while 24.7% reported attempting suicide. Significant correlates of suicide attempt included older age (16+ years; odds ratio [OR]: 1.70, confidence interval [CI]: 1.09-2.63), difficulty sleeping due to worry (OR: 1.27, CI: 1.04-1.56), loneliness (OR: 1.65, CI: 1.39-1.96), truancy (OR: 1.38. CI: 1.05-1.82), being a target of bullying (OR: 1.53, CI: 1.26-1.85), getting physically attacked (OR: 1.73, CI: 1.42-2.11), physical fighting (OR: 1.47, CI: 1.21-1.79), current cigarette use (OR: 2.71, CI: 1.88-3.89), and initiation of drug use (OR: 2.19, CI: 1.71-2.81). Conversely, having close friends was associated with lower odds of suicide attempt (OR: 0.67, CI: 0.48-0.93). Several covariates were also significantly associated with suicidal ideation. DISCUSSION: Suicidal ideation and attempts are highly prevalent among school-going adolescents in these West African countries. Multiple modifiable risk and protective factors were identified. Programs, interventions, and policies aimed at addressing these factors may play a significant role in preventing suicides in these countries.

A tale of two vulvar angiomyxomas: Two cases and review of literature.

Vulvar angiomyxomas are rare benign mesenchymal neoplasms. Superficial and Aggressive angiomyxomas are two distinct phenotypes that present similarly to other more common vulva-perineal pathologies. Albeit both angiomyxomas carry a risk of recurrence, especially in the setting of incomplete resection, simple excision is insufficient for Aggressive angiomyxoma. It requires wide local excision because of its unique potential for local invasion, infiltration of the paravaginal and pararectal tissue, and more distant metastasis. Here, we present a case of Superficial angiomyxoma and a case of Aggressive angiomyxoma to highlight the diagnostic challenges and management strategies of each tumor. In both cases, angiomyxomas were initially misdiagnosed because of their rarity and nonspecific presentation. Magnetic resonance imaging is the modality of choice for evaluation due to inherent higher spatial resolution of soft tissue anatomical details. Early diagnosis of Aggressive angiomyxoma can prevent incomplete excision and recurrence, spare additional surgery, and offer hormonal therapy options.

Achieving mental health equity in Black male suicide prevention.

Despite a steady decrease in suicide rates in the United States, the rate among Black males has increased in recent decades. Moreover, suicide is now positioned as the third leading cause of death in this population, signaling a public health crisis. Enhancing the ability for future suicide prevention scholars to fully characterize and intervene on suicide risk factors is an emerging health equity priority, yet there is little empirical evidence to robustly investigate the alarming trends in Black male suicide. We present fundamental areas of expansion in suicide prevention research focused on establishing culturally responsive strategies to achieve mental health equity. Notably, we identify gaps in existing research and offer future recommendation to reduce suicide death among Black males. Our perspective aims to present important and innovative solutions for ensuring the inclusion of Black males in need of suicide prevention and intervention efforts.

When Death Hits You in Your Face, You Have to Listen": A Qualitative Investigation of Peer Bereavement Support Volunteers in Black American Communities.

Efforts to support grief in Black American communities are often under-recognized despite their potential to address negative mental health outcomes in this population. The aim of the current study was to qualitatively assess the community-level influence of bereavement support programs on predominantly Black communities in Baltimore, Maryland. Five focus groups (n = 23) were conducted with volunteers from a non-profit bereavement organization. Participants were queried about how their training may be sustainably applied as a community resource in Baltimore City. Thematic analysis from focus groups revealed three main themes: (1) enhancing feelings of belongingness fosters a sense of community cohesion, (2) use of bereavement support tools as a source of personal healing, and (3) applications of bereavement support in the community. Implications of our study support the widespread influence of peer-led bereavement support training to reduce the reverberating impact of personal and collective grief in Black American communities.

Investigating the Role of Suicidality and Ethnic Identity among Black Adolescents: A Latent Profile Analysis.

OBJECTIVE: Suicide among Black adolescent youth has steadily increased in recent years, yet few studies describe how facets of social identity shape suicidal thoughts and behaviors (STBs) during this critical stage of development. Ethnic identity represents an underexplored, yet important element of social identity among Black youth that may contribute to differential associations with STBs. This study examined the association between ethnic identity and self-reported suicidal ideation, planning, and attempts. METHODS: Data were drawn from 1,170 African American (n = 810) and Caribbean Black (n = 368) adolescents aged 13-17 (Mean age = 15) that participated in the National Survey of American Life Adolescent supplement study. RESULTS: Using latent profile analyses, three patterns of ethnic identity were identified: Undifferentiated, Low Ethnic Identification, and Alienated. Caribbean Black adolescents were more likely to be in the Low Ethnic Identification class relative to the Undifferentiated class. Adolescents in the Undifferentiated group reported higher proportions of suicidal ideation, planning, and attempts compared to the remaining latent profile groups. CONCLUSION: Findings demonstrate that ethnic identity is an important aspect of social identity that can influence STBs among Black adolescents. Considering increased suicide attempts and death rates among Black youth, findings underscore the importance of examining culturally relevant developmental processes that may shape suicidal beliefs and behaviors.

Marital experiences and depressive symptoms among older adults in rural South Africa.

This paper advances the understanding of how marital transitions may influence mental health by investigating these associations among a population of rural, Black South Africans aged 40+ that was directly impacted by apartheid. Using two waves of data from 4,176 men and women in Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI), we investigated associations between marital experiences and depressive symptoms, by gender, and explored whether economic resources is a moderator of these associations. We found that experiencing a marital dissolution was associated with more depressive symptoms than remaining married for both men and women. We also found that men, but not women, report greater depressive symptoms if they remained separated/divorced, remained widowed, or remained never married between waves. We found no evidence that a decline in wealth moderated the impact of marital dissolution on depressive symptoms for women or men. These findings suggest that the documented benefits of marriage for mental health, and differences by gender in those benefits, may extend to older, rural South Africans, despite the unique experiences of this population.

Factor analysis of the Center for Epidemiological Studies Depression Scale in American Indian women.

The Center for Epidemiological Studies Depression Scale (CES-D) is widely used to assess depressive symptoms in the general population. It lacks validation for widespread use within the American Indian population, however. To address this gap, we explored and confirmed the factor structure of the CES-D among a community sample of southeastern American Indian women. We analyzed data from a sample of 150 American Indian women ages 18-50 from a southeastern tribe who had complete responses on the CES-D as part of a larger cross-sectional, community-engaged study. We performed exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) to assess the measure's validity. We examined EFA models ranging from one to five factors, with the four-factor structure yielding the best overall model fit (CFI = 1.00, TLI = 0.99, RMSEA = 0.03). Differences between the four-factor EFA-retained structure from our sample and Radloff's four-factor structure emerged. Only the interpersonal factor was common to both factor structures. Our study findings confirm the validity of the original four-factor structure of the CES-D for younger adult American Indian women in the southeast. Contrasting findings with the EFA-retained structure, however, provide a more nuanced interpretation of our results.

Perceived healthcare discrimination and well-being among older adults in the United States and Brazil.

Despite well-documented evidence illustrating the relationship between discrimination and health, less is known about the influence of unfair treatment when receiving medical care. Moreover, our current knowledge of cross-national and racial variations in healthcare discrimination is limited in aging populations. This article addresses these gaps using two harmonized data sets of aging populations to clarify the relationship between healthcare discrimination and health in the United States and Brazil. We use nationally representative, harmonized data from the Health and Retirement Study in the United States and the Brazilian Longitudinal Study of Aging to examine and compare perceived discrimination in the healthcare setting and its relationship to self-rated health, depression diagnosis, and depressive symptoms across national contexts. Using Poisson regression models and population attributable risk percent estimates, we found that aging adults reporting healthcare discrimination were at higher risk of poor self-rated health, diagnosed depression, and depressive symptoms. Our results also suggest that reducing perceived healthcare discrimination may contribute to improved self-rated health and mental well-being in later life across racialized societies. In two comparative settings, we highlight the differential impact of healthcare discrimination on self-rated health and depression. We describe the implications of our study's findings for national public health strategies focused on eliminating discrimination in the healthcare setting, particularly among aging countries.

Rapid and Deferred Help Seeking Among African American Parents of Children With Emotional and Behavioral Difficulties.

OBJECTIVE: Little is known about the factors African American parents consider when seeking care for their child after emotional and behavioral difficulties emerge. This study aimed to examine factors associated with seeking professional care within 30 days after identifying a child's need (i.e., rapid care seeking) and with deferring care for ≥1 year. METHODS: This cross-sectional study surveyed African American parents raising a child with emotional or developmental challenges (N=289). Logistic regression was used to examine associations of parent activation, medical mistrust, and care-seeking barriers with two outcomes: rapidly seeking care and deferring care seeking. RESULTS: About 22% of parents rapidly sought care, and 49% deferred care for 1 year or longer. Parents were more likely to rapidly seek care if they had higher parent activation scores; lived with other adults with mental health challenges; or, contrary to the authors' hypothesis, mistrusted doctors. Parents were less likely to rapidly seek care if the challenge did not initially bother them much or if their health insurance would not cover the service. Parents were more likely to defer care if they feared involuntary hospitalization for their child or if their health insurance would not cover the service. Parents were less likely to defer care if they had at least some college education or lived with other adults with mental health challenges. CONCLUSIONS: Community-based pediatric and child welfare professionals should be informed about facilitators and barriers to mental health care seeking as part of efforts to develop interventions that support African American families.

Suicide attempt endophenotypes: Latent profiles of child and adolescent aggression and impulsivity differentially predict suicide attempt in females.

Suicide is a leading cause of death in young adulthood. Identifying early prevention targets to reduce later suicide is a public health priority. Impulsivity and aggression in early childhood may represent actionable early prevention candidate endophenotypes for later suicidal behavior. Our objective is to to understand the association of aggression and impulsivity trajectories with mental health outcomes to inform future prevention efforts. Participants were part of a longitudinal cohort of a preventative intervention trial (n = 597) and predominantly Black. They were assessed for aggressive and impulsive behaviors yearly in 1st-3rd and 6th-12th grades, and provided mental health data via self-report beginning in 6th grade. Longitudinal latent profiles of aggressive and impulsive behaviors were derived for males and females and used to determine whether profiles was associated with lifetime suicide attempt and meeting diagnostic criteria for major depressive disorder. Two impulsivity and aggression classes were found for males, characterized by low behaviors or moderate to high behaviors across development. Three classes were found for females, one of which was characterized by an undulating pattern of behaviors. For females, the class of severe behaviors was associated with significant risk of suicide attempt (Wald = 6.01, p = 0.05). No relationship was found for males or for MDD diagnosis. An endophenotype model of impulsivity and aggression in predicting later suicide attempt was supported in females, but not males. Results underscore the importance of evaluating sex differences in suicide research and the potential identification of females at risk for later suicidal behavior in school settings.

Methodological Considerations in Scale Refinement with Diverse Populations: A Case Example Using the CES-D with a Community Sample of American Indian Women.

Although many psychometric assessments are used extensively in population-based research to determine psychopathology, these tools have not been thoroughly validated or appropriately adapted for use in diverse populations. Indeed, depression measurement studies among American Indian and female populations are scarce, omitting key opportunities to tailor psychological measurement for this population. To build psychometric evidence of measures in this population, we used a procedural method to examine a standard psychological instrument-the Center for Epidemiological Studies Depression Scale (CES-D)-with a community sample of southeast American Indian women. Our results showed strong psychometric reliability of the 20-item CES-D. The "effort" item presented diminished validity, as demonstrated by a negative counter-intuitive item-to-total correlation (ITC) value. Dropping the "effort" item resulted in a 19-item scale with a better fit in the within-group examination of community-based American Indian women. Compared to the 20-item CES-D scale, the revised 19-item measure ("effort" item removed) resulted in minimal changes to women's depression categories. However, we did detect patterns in shifts such that the 19-item scale generally underestimated (i.e., placed women in a lower category) depressive symptoms compared to the 20-item scale. Depending on their study goals, researchers engaging in population-based research should carefully weigh the use of original scales that allow for consistency in reporting with refined scales that fit psychometrically. We present the outlined method as a tool that expands on current approaches in scale refinement, and aids researchers in making more informed decisions regarding refined scales with diverse populations.