Validity and Item Response Theory Properties of the Patient Health Questionnaire-9 for Primary Care Depression Screening in Mozambique (PHQ-9-MZ)

Abstract

Background: Depression is one of the leading causes of disability in Mozambique; however, few patients with depression are identified in primary care. To our knowledge, there are no validated tools for depression screening in Mozambique. The aim of this study was to validate the Patient Health Questionnaire-9 (PHQ-9) for use in primary care settings in Mozambique. Methods: The PHQ-9 was adapted using a structured multi-phase process led by a team of bilingual experts followed by a review by lay individuals and pilot-testing including cognitive interviews. The final Mozambican PHQ-9 (PHQ-9-MZ) was applied among 503 individuals randomly selected from antenatal, postpartum, and general outpatient consultations in three Ministry of Health primary healthcare clinics in Sofala Province, Mozambique. The PHQ-9-MZ was evaluated against the MINI 5.0-MZ as a gold standard diagnostic tool. Results: The majority of participants were female (74%), with a mean age of 28. Using the MINI 5.0-MZ, 43 (9%) of the sample tested positive for major depressive disorder. Items of the PHQ-9-MZ showed good discrimination and factor loadings. One latent factor of depression explained 54% of the variance in scores. Questions 3 (sleep) and 5 (appetite) had the lowest item discrimination and factor loadings. The PHQ-9-MZ showed good internal consistency, with a Cronbach’s alpha of 0.84, and an area under the receiver operating characteristic curve (AUROC) of 0.81 (95% CI: 0.73, 0.89). The PHQ-2-MZ had an AUROC of 0.78 (95% CI: 0.70, 0.85). Using a cut-point of ≥9, the PHQ-9-MZ had a sensitivity of 46.5% and a specificity of 93.5%. Using a cut-point of ≥2, the PHQ-2-MZ had a sensitivity of 74.4% and a specificity of 71.7%. Increasing the cut-point to ≥3, the PHQ-2-MZ has a sensitivity of 32.6% and a specificity of 94.6%. Conclusions: The PHQ-9-MZ and PHQ-2-MZ emerge as two valid alternatives for screening for depression in primary health care settings in Mozambique. Depending on program needs and weighing the value of minimizing false positives and false negatives, the PHQ-9-MZ can be employed with cut-points ranging from ≥8 to ≥11, and the PHQ-2-MZ with cut-points ranging from ≥2 to ≥3.

isiXhosa translation of the Patient Health Questionnaire (PHQ-9) shows satisfactory psychometric properties for the measurement of depressive symptoms [Stage 2]

“…α = 0 864 observed for our isiXhosa PHQ-9 is compatible with previous reports of Cronbach's α of 0.76 (South Africa (Bhana et al, 2015)), 0.78 (Kenya (Monahan et al, 2009)), and 0.83 (Tanzania (Fawzi et al, 2019)) for the PHQ-9 in other African contexts. Similarly, the factor structure of our isiXhosa PHQ-9 was comparable with other versions in African nations (Kenya (Monahan et al, 2009) and Mozambique (Cumbe et al, 2020)). Overall, we have shown that our isiXhosa PHQ-9 performs comparably to other versions, which supports the adoption of this translation into research and clinics.…”

“…To demonstrate the comparability of our isiXhosa-language PHQ-9 with other versions of the PHQ-9, in addition to describing the inherent psychometric properties of our translation, we also present comparisons with published psychometric properties of other PHQ-9 versions in African and global contexts. These include a seTswana version in South Africa (Bhana et al, 2015), an English version in Kenya (Monahan et al, 2009), a Portuguese version in Mozambique (Cumbe et al, 2020), a Swahili version in Tanzania (Fawzi et al, 2019), and a recent multi-country, multi-language validation study (Bianchi et al, 2022).…”

“…However, Tucker's coefficients of factor congruence indicated high congruence between factor loadings in our sample and those reported by Monahan et al (2009) ( . φ = 0 98) and Cumbe et al (2020) ( . ) φ = 0 98 .…”