Testing the EPDS and PHQ-9 Among Peripartum Adolescents in Nairobi, Kenya: a Mixed-Methods Study

Abstract

Background: Cognitive interviewing is a well-recognised methodology to identify clinical and commonsensical relevance of mental health questionnaire items by our research participants. Depression is amongst the most common condition impacting pregnant and parenting adolescents in sub-Saharan Africa (SSA). In Kenya, studies have reported depression prevalence estimates of 12-50% in peripartum adolescents. While young people prefer using English, there has not been enough data to point to how well they respond to Kiswahili translations of the commonly used tools. Method: Thirty-two participants between ages 14-18 years were approached and through informed consent for them to participate. We used Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire-9 (PHQ-9) in English and Kiswahili versions to carry out the interviews and were coded along with 4 domains of comprehension, retrieval, judgement, and patient response. The interviews were discussed within the team and tables were shared between 3 raters for further consensus. The interview transcripts were analyzed manually using thematic analysis. We used the findings from the interviews to make modifications to the existing English versions of EPDS and PHQ-9 and to modify Kiswahili versions too. Discussion: We found that adolescents had challenges in fully understanding items in both sets of tools however, EPDS was better received than PHQ-9. Psychometrically, the EPDS English version and Kiswahili versions fared better than the PHQ-9 English and Kiswahili versions. PHQ-9 presented considerable issues with regards to semantic clarity however had simpler response options in comparison to EPDS which was more experientially appropriate, but response options were not simple. On our thematic analysis, we felt that the adolescents were significantly challenged by the new, unanticipated pregnancy or motherhood experience. Poverty, poor partner support, discord with parents and distress in the family, and traumatic end of supportive and helpful relationships were the notable problems. We believe the cultural and linguistic modifications made on these tools would make them more suitable to be validated with a sample of pregnant adolescents. Conclusion: While sensitive cross-cultural translations for the commonly used open access depression tools is critical, it is also pertinent to understand whether these are developmentally appropriate. Our participants had multiple psychosocial and material challenges that necessitate measures sensitive to their age, social context, and health experiences. Additionally, we felt that both the tools may not be suitable for self-administration and may need the involvement of a case worker or community health worker.

Psychometric evaluation of PHQ–9 and GAD–7 among community health volunteers and nurses/midwives in Kenya following a nation-wide telephonic survey

“…Respondents were asked how often they had been bothered by each of the symptoms over the previous 2 weeks, and a score ranging from 0 to 27 derived from summation of their responses. A cut-off score of ≥10 was used to define a positive screen for depressive symptoms, which is consistent with previous studies from Kenya (35)(36)(37).…”

“…The commonly used tools to measure anxiety and depression are the 9-item Patient Health Questionnaire (PHQ-9) and the 7-item Generalized Anxiety Disorder (GAD-7), respectively. PHQ-9 has been used among different populations in Kenya including adolescents and people living with HIV ( 35–37 ), while GAD-7 has been used among adolescents and adults living with HIV, and caregivers of children in community based early child development program ( 38–40 ).…”

Cultural and contextual adaptation of mental health measures in Kenya: An adolescent-centered transcultural adaptation of measures study

“…For instance, a visual aid represented the number of days in different stone sizes. For not at all (hapana kabisa) , the smallest "stone" was used, several days (siku kadhaa) bigger “stone,” more than seven days (Zaidi ya siku saba) a much bigger “stone,” and nearly every day (Karibu kila siku) the biggest “stone” was used (see Fig 2 for this illustration) [ 36 ]. Participants preferred response options with visuals and words.…”

Investigating the PHQ-9 With Mokken Scale Analysis and Cognitive Interviews

“…For Item 7, we recommend changing or omitting the given examples (reading the newspaper or watching television) as they led to comprehension issues in Study II. This problem has also been noted in cognitive interviews on other PHQ-9 translations (Kumar et al, 2021;Malpass et al, 2016;Velloza et al, 2020), with some studies suggesting more culturally relevant examples (Harrington et al, 2021;Velloza et al, 2020). For example, Harrington et al (2021) opted to change ''reading the newspaper'' to ''participating in a meeting'' in a Chichewa version of PHQ-9.…”