Validation of the Patient Health Questionnaire (PHQ-9) in an African context M a r g u e r i t e B o t h a M i n i - d i s s e r t a t i o n ( a r t i c l e f o r m a t ) s u b m i t t e d i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r t h e d e g r e e M a s t e r o f A r t s ( R e s e a r c h P s y c h o l o g y ) a t t h e N o r t h - W e s t U n i v e r s i t y ( P o t c h e f s t r o o m C a m p u s ) S u p e r v i s o r : P r o f . Q . M . T e m a n e C o - s u p e r v i s o r : P r o f . M . P . W i s s i n g
T A B L E O F C O N T E N T S 1 . T i t l e P a g e 1 2 . S u m m a r y 4 3 . O p s o m m i n g 6 4 . P r e f a c e 8 4 . 1 A r t i c l e f o r m a t 4 . 2 S e l e c t e d j o u r n a l 4 . 3 L e t t e r o f c o n s e n t 4 . 4 P a g e n u m b e r i n g 5 . M a n u s c r i p t 1 0 5 . 1 I n s t r u c t i o n s t o a u t h o r s : S o c i a l S c i e n c e & M e d i c i n e 5 . 2 V a l i d a t i o n o f t h e P a t i e n t H e a l t h Q u e s t i o n n a i r e ( P H Q - 9 ) i n a n A f r i c a n c o n t e x t
1 . A C K N O W L E D G E M E N T S T o G o d , a l l h o n o u r , g l o r y a n d p r a i s e a r e d u e . T h a n k Y o u , F a t h e r , f o r g i v i n g m e t h e a b i l i t y t o c o m p l e t e t h i s d e g r e e . T o m y s u p e r v i s o r s , P r o f . Q . M . T e m a n e a n d P r o f . M . P . W i s s i n g f o r y o u r c o n s t a n t g u i d a n c e a n d a s s i s t a n c e . T h a n k y o u f o r b e l i e v i n g i n m e . T o m y p a r e n t s , f a m i l y a n d a l l m y f r i e n d s . T h a n k y o u , D a d d y f o r g i v i n g m e t h e o p p o r t u n i t i e s y o u n e v e r h a d , f o r t r u s t i n g i n m e a n d m o t i v a t i n g m e t o d o m y b e s t . M o m m y , I c o u l d n e v e r h a v e d o n e t h i s w i t h o u t y o u r h e l p , g u i d a n c e , s u p p o r t a n d d e d i c a t i o n , y o u a r e t r u l y i n s p i r a t i o n a l . T o m y L o v e , J u r i e , t h a n k y o u f o r y o u r l o v e a n d s u p p o r t . T h e c o n t r i b u t i o n o f t h e P s y c h o l o g y D e p a r t m e n t a t t h e N o r t h - W e s t U n i v e r s i t y a n d t h e f i n a n c i a l a s s i s t a n c e o f t h e N a t i o n a l R e s e a r c h F o u n d a t i o n t o w a r d s t h i s r e s e a r c h i s h e r e b y a c k n o w l e d g e d . T o y o u a l l , I s a l u t e y o u f r o m t h e b o t t o m o f m y h e a r t .
2 . S U M M A R Y V a l i d a t i o n o f t h e P a t i e n t H e a l t h Q u e s t i o n n a i r e ( P H Q - 9 ) i n a n A f r i c a n c o n t e x t K e y w o r d s : P a t i e n t H e a l t h Q u e s t i o n n a i r e ( P H Q - 9 ) ; d e p r e s s i o n ; r e l i a b i l i t y ; v a l i d i t y ; f a c t o r a n a l y s i s ; p s y c h o m e t r i c p r o p e r t i e s ; S o u t h A f r i c a . T h i s r e s e a r c h w a s a i m e d a t v a l i d a t i n g t h e P H Q - 9 i n a n A f r i c a n c o n t e x t . T h i s s t u d y f o r m s p a r t o f t h e p r o j e c t o f P s y c h o s o c i a l H e a l t h a n d B i o m a r k e r s i n a n A f r i c a n c o n t e x t ( F O R T 3 , W i s s i n g , 2 0 0 8 ) . T h e P a t i e n t H e a l t h Q u e s t i o n n a i r e ( P H Q - 9 ) i s a n i n e - i t e m d e p r e s s i o n s c a l e t h a t h a s t h e p o t e n t i a l o f b e i n g a d u a l - p u r p o s e i n s t r u m e n t t o e s t a b l i s h t h e d i a g n o s i s o f a d e p r e s s i v e d i s o r d e r , a s w e l l a s t h e g r a d e o f s y m p t o m s e v e r i t y ( K r o e n k e , S p i t z e r & W i l l i a m s , 2 0 0 1 ) . T h e P H Q - 9 w a s a d m i n i s t e r e d w i t h c r i t e r i o n r e l a t e d m e a s u r e s t o a m u l t i c u l t u r a l c o n v e n i e n c e s a m p l e o f 2 2 1 4 p a r t i c i p a n t s f r o m t h e N o r t h W e s t P r o v i n c e o f S o u t h A f r i c a , i n c l u d i n g t w o g r o u p s o f a d o l e s c e n t s ( n1= 1 4 8 0 a n d n2= 5 5 9 ) a n d a n a v a i l a b i l i t y s a m p l e o f a d u l t s ( n3= 1 8 5 ) . I n s t r u m e n t s t o d e t e r m i n e c r i t e r i o n v a l i d i t y w e r e t h e G e n e r a l H e a l t h Q u e s t i o n n a i r e ( G H Q ) , d e s i g n e d t o d e t e c t s y m p t o m s o f m e n t a l d i s o r d e r s ; t h e M e n t a l H e a l t h C o n t i n u u m – S h o r t F o r m f o r A d u l t s ( M H C - S F ) w h i c h m e a s u r e s t h e d e g r e e o f e m o t i o n a l , s o c i a l a n d p s y c h o l o g i c a l w e l l - b e i n g ; a n d t h e N e w G e n e r a l S e l f - E f f i c a c y S c a l e ( N G S E ) d e s i g n e d t o m e a s u r e a n i n d i v i d u a l ’ s g e n e r a l s e l f -e f f i c a c y . D e s c r i p t i v e s t a t i s t i c s f o r t h e P H Q - 9 i n c l u d i n g i t s r e l i a b i l i t y i n t h e v a r i o u s g r o u p s i s r e p o r t e d . T h e P H Q - 9 m a n i f e s t e d a C r o n b a c h A l p h a
r e l i a b i l i t y i n d e x o f 0 . 8 6 . C r i t e r i o n - r e l a t e d v a l i d i t y w a s s u p p o r t e d b y s i g n i f i c a n t c o r r e l a t i o n s b e t w e e n t h e P H Q - 9 a n d c r i t e r i o n m e a s u r e s . C o n f i r m a t o r y f a c t o r a n a l y s i s f o r t h e P H Q - 9 y i e l d e d a o n e - f a c t o r s o l u t i o n i n a l l g r o u p s . T h e p e r c e n t a g e v a r i a n c e e x p l a i n e d r a n g e d b e t w e e n 3 4 . 7 1 % a n d 4 6 . 6 2 % . E x p l o r a t o r y f a c t o r a n a l y s e s y i e l d e d t w o f a c t o r s i n a l l g r o u p s w i t h t h e s e c o n d f a c t o r c o m p r i s e d o f n o m o r e t h a n 2 i t e m s a n d t h u s i n t e r p r e t e d a s a m i n o r f a c t o r . T h e c o n s t r u c t v a l i d i t y o b t a i n e d i n t h i s r e s e a r c h i n d i c a t e s t h a t t h e P H Q - 9 m a y b e a v a l i d m e a s u r e t o i d e n t i f y d e p r e s s i o n i n a S o u t h A f r i c a n c o n t e x t . B a s e d o n t h e p s y c h o m e t r i c p r o p e r t i e s f o u n d i n t h i s s t u d y , i t c a n b e c o n c l u d e d t h a t t h e P H Q - 9 i s a v a l i d m e a s u r e o f d e p r e s s i o n i n t w o o f t h e s a m p l e s s e l e c t e d f o r t h i s s t u d y . F u t u r e s t u d i e s m a y f u r t h e r v a l i d a t e t h i s i n s t r u m e n t i n s p e c i f i c l a n g u a g e a n d c u l t u r a l g r o u p s , a n d e x p l o r e t h e c r o s s - c u l t u r a l m e a s u r e m e n t e q u i v a l e n c e .
3 . O P S O M M I N G V a l i d e r i n g v a n d i e P a t i e n t H e a l t h Q u e s t i o n n a i r e ( P H Q - 9 ) i n ‘ n A f r i k a - k o n t e k s S l e u t e l t e r m e : P a t i e n t H e a l t h Q u e s t i o n n a i r e ( P H Q - 9 ) ; d e p r e s s i e ; b e t r o u b a a r h e i d ; g e l d i g h e i d f a k t o r o n t l e d i n g P s i g o m e t r i e s e k e n m e r k e S u i d - A f r i k a . D i e n a v o r s i n g w a s d a a r o p g e m i k o m d i e g e l d i g h e i d v a n d i e P H Q - 9 i n ’ n A f r i k a k o n t e k s t e v e r i f i e ë r . D i e s t u d i e v o r m d e e l v a n d i e p r o j e k P s y c h o s o c i a l H e a l t h a n d B i o m a r k e r s i n a n A f r i c a n c o n t e x t ( F O R T 3 , W i s s i n g , 2 0 0 8 ) . . D i e P a t i e n t H e a l t h Q u e s t i o n n a i r e ( P H Q 9 ) / P a s i e n t G e s o n d h e i d s -V r a e l y s ( P G -V - 9 ) i s ’ n n e g e i t e m d e p r e s s i e s k a a l w a t d i e p o t e n s i a a l h e t o m ’ n d u b b e l e d o e l t e d i e n , n a a m l i k d i e d i a g n o s e v a n d e p r e s s i e a s o o k d i e g r a a d v a n e r n s t i g h e i d d a a r v a n . ( K r o e n k e , S p i t z e r & W i l l i a m s , 2 0 0 1 ) . D i e P H Q - 9 e n a n d e r k r i t e r i u m v e r w a n t e v r a e l y s t e i s v o l t o o i d e u r ’ n m u l t i k u l t u r e l e g e r i e f l i k h e i d s s t e e k p r o e f v a n 2 2 1 4 d e e l n e m e r s i n d i e N o o r w e s P r o v i n s i e v a n S u i d - A f r i k a . T w e e g r o e p e a d o l e s e n t e ( n 1 = 1 4 8 0 e n n 2 + 5 5 9 ) e n ’ n b e s k i k b a a r h e i d s t e e k p r o e f v a n v o l w a s s e n e s ( n 3 = 1 8 5 ) . I n s t r u m e n t e o m d i e k r i t e r i u m - v e r w a n t e g e l d i g h e i d t e b e p a a l w a s d i e G e n e r a l H e a l t h Q u e s t i o n n a i r e ( G H Q ) o f d i e A l g e m e n e G e s o n d h e i d s V r a e l y s ( A G V ) , w a t o n t w e r p i s o m s i m p t o m e v a n g e e s t e l i k e v e r s t e u r d h e i d t e b e s p e u r ; d i e M e n t a l H e a l t h C o n t i n u u m – S h o r t F o r m f o r A d u l t s ( M H C - S F ) o o k b e k e n d a s d i e G e e s t e l i k e G e s o n d h e i d s K o n t i n u u m ( G G K ) v e r k o r t e v o r m v i r V o l w a s s e n e s ( V V V ) w a t d i e g r a a d v a n e m o s i o n e l e , s o s i a l e e n s i e l k u n d i g e w e l v a a r t m e e t , e n d i e N e w G e n e r a l S e l f - E f f i c a c y S c a l e ( N G S E ) o f d i e N u w e A l g e m e n e S e l f - d o e l t r e f f e n d e s k a a l ( N A S S ) w a t
o n t w e r p i s o m ’ n i n d i v i d u s e a l g e m e n e s e l f -d o e l t r e f f e n h e i -d s b e s k o u ï n g m e e t . B e s k r y w e n d e s t a t i s t i e k v i r d i e ( P H Q - 9 ) a s o o k d i e b e t r o u b a a r h e i d s i n d e k s i n d i e o n d e r s k e i e g r o e p e w o r d g e r a p p o r t e e r . D i e P H Q - 9 h e t ’ n C r o n b a c h A l p h a b e t r o u b a a r h e i d s i n d e k s v a n 0 . 8 6 g e t o o n . K r i t e r i a v e r w a n t e g e l d i g h e i d w a s o n d e r s t e u n d e u r b e d u i d e n d e k o r r e l a s i e s t u s s e n d i e P H Q - 9 e n d i e a n d e r k r i t e r i m v e r w a n t e s k a l e . B e v e s t i g e n d e f a k t o r a n a l i s e s v i r d i e P H Q - 9 l e w e r ’ n e e n f a k t o r o p l o s s i n g i n a l l e g r o e p e . D i e p e r s e n t a s i e v a r i a n s i e v e r k l a a r w i s s e l t u s s e n 3 4 . 7 1 % e n 4 6 . 6 2 % . E k s p l o r a t i e w e f a k t o r a n a l i s e h e t t w e e f a k t o r e i n a l l e g r o e p e o p g e l e w e r . D i e t w e e d e f a k t o r h e t n e t u i t 2 i t e m s b e s t a a n , e n i s d u s a s ’ n g e r i n g e ( m i n o r ) f a k t o r g e ï n t e r p r e t e e r . D i e a a n d u i d i n g s v a n k o n s t r u k - g e l d i g h e i d w a t i n d i e n a v o r s i n g v e k r y i s , d u i a a n d a t d i e P H Q - 9 ’ n g e l d i g e m e e t i n s t r u m e n t m a g w e e s o m d e p r e s s i e i n d i e S u i d - A f r i k a a n s e k o n t e k s t e b e p a a l . G e b a s e e r o p d i e p s i g o m e t r i e s e k e n m e r k e w a t i n d i e s t u d i e g e v i n d i s , k a n g e k o n k l u d e e r w o r d d a t d i e P H Q - 9 o o r w e g e n d ’ n g e l d i g e m e e t i n s t r u m e n t v a n d e p r e s s i e i s i n t w e e v a n d i e s t e e k p r o e w e w a t v i r d i e s t u d i e g e k i e s i s . V e r d e r e n a v o r s i n g i s n o d i g o m d i e P H Q - 9 s e g e l d i g h e i d i n s p e s i f i e k e t a a l - e n k u l t u r e l e g r o e p e t e o n d e r s o e k , e n o m d i e k r u i s - k u l t u r e l e e k w i v a l e n s i e t e b e p a a l .
4 . P R E F A C E 4 . 1 A r t i c l e f o r m a t F o r p u r p o s e s o f t h i s m i n i - d i s s e r t a t i o n , w h i c h i s p a r t o f t h e r e q u i r e m e n t s f o r a p r o f e s s i o n a l m a s t e r ’ s d e g r e e , t h e a r t i c l e f o r m a t a s d e s c r i b e d b y G e n e r a l R e g u l a t i o n s A 7 . 5 . 1 o f t h e N o r t h - W e s t U n i v e r s i t y w a s c h o s e n . 4 . 2 S e l e c t e d j o u r n a l T h e t a r g e t j o u r n a l f o r s u b m i s s i o n o f t h e c u r r e n t m a n u s c r i p t i s t h e S o c i a l S c i e n c e & M e d i c i n e J o u r n a l . T h e m a n u s c r i p t a s w e l l a s t h e r e f e r e n c e l i s t h a s b e e n s t y l e d t o t h e j o u r n a l ’ s s p e c i f i c a t i o n s . 4 . 3 L e t t e r o f c o n s e n t T h e l e t t e r o f c o n s e n t f r o m t h e c o - a u t h o r s i n w h i c h t h e y g r a n t p e r m i s s i o n t h a t t h e m a n u s c r i p t V a l i d a t i o n o f t h e P a t i e n t H e a l t h Q u e s t i o n n a i r e ( P H Q - 9 ) i n a n A f r i c a n c o n t e x t m a y b e s u b m i t t e d f o r p u r p o s e s o f a m i n i - d i s s e r t a t i o n b y t h e f i r s t a u t h o r , M a r g u e r i t e N e l i s e B o t h a , a p p e a r s o n t h e n e x t p a g e . 4 . 4 P a g e n u m b e r i n g I n t h e m i n i - d i s s e r t a t i o n p a g e n u m b e r s r u n t h r o u g h t h e w h o l e d o c u m e n t . F o r s u b m i s s i o n t o t h e a b o v e - m e n t i o n e d j o u r n a l , m a n u s c r i p t n u m b e r i n g w i l l b e a c c o r d i n g t o t h e r e q u i r e m e n t s a n d w i l l t h u s s t a r t o n t h e t i t l e p a g e o f t h e m a n u s c r i p t .
L E T T E R O F C O N S E N T W e t h e c o - a u t h o r s , h e r e b y g i v e c o n s e n t t h a t M a r g u e r i t e N e l i s e B o t h a m a y s u b m i t t h e m a n u s c r i p t e n t i t l e d “V a l i d a t i o n o f t h e P a t i e n t H e a l t h Q u e s t i o n n a i r e ( P H Q - 9 ) i n a n A f r i c a n c o n t e x t ” f o r t h e p u r p o s e s o f a m i n i - d i s s e r t a t i o n . I t m a y a l s o b e s u b m i t t e d t o t h e S o c i a l S c i e n c e & M e d i c i n e J o u r n a l f o r p u b l i c a t i o n . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ P r o f . Q . M T e m a n e P r o f . M . P W i s s i n g S u p e r v i s o r C o - S u p e r v i s o r
5 . M A N U S C R I P T
V a l i d a t i o n o f t h e P a t i e n t H e a l t h Q u e s t i o n n a i r e ( P H Q - 9 ) i n a n A f r i c a n c o n t e x t
5 . 1 I n s t r u c t i o n s t o a u t h o r s : S o c i a l S c i e n c e & M e d i c i n e J o u r n a l Social Science & Medicine: Guide for authors
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Adkins, L. (2002). Revisions: Gender and sexuality in late modernity. Buckingham: Open University Press.
Macintyre, S., & Ellaway, A. (2000). Ecological approaches: Rediscovering the role of the physical and social environment. In L. F. Berkman, & I. Kawachi (Eds.), Social epidemiology (pp. 332-348). New York: Oxford University Press.
Glenton, C. (2003). Chronic back pain sufferers-striving for the sick role. Social Science & Medicine, 57, 2243-2252.
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V a l i d a t i o n o f t h e P a t i e n t H e a l t h Q u e s t i o n n a i r e ( P H Q - 9 ) i n a n A f r i c a n c o n t e x t M a r g u e r i t e N . B o t h a * , Q . M i c h a e l T e m a n e , M a r i e P . W i s s i n g S c h o o l f o r P s y c h o s o c i a l B e h a v i o u r a l S c i e n c e s , N o r t h - W e s t U n i v e r s i t y ( P o t c h e f s t r o o m C a m p u s ) , S o u t h A f r i c a * C o r r e s p o n d e n c e t o : M a r g u e r i t e N . B o t h a P / a P r o f . Q . M . T e m a n e S c h o o l f o r P s y c h o s o c i a l B e h a v i o u r a l S c i e n c e s N o r t h - W e s t U n i v e r s i t y ( P o t c h e f s t r o o m C a m p u s ) P r i v a t e B a g X 6 0 0 1 P o t c h e f s t r o o m 2 5 2 0 S o u t h A f r i c a M a r g u e r i t e . B o t h a @ g m a i l . c o m M i c h a e l . T e m a n e @ n w u . a c . z a T e l : + 2 7 1 8 2 9 9 1 7 2 1 F a x : + 2 7 1 8 2 9 9 1 7 3 0
A b s t r a c t K e y w o r d s : P a t i e n t H e a l t h Q u e s t i o n n a i r e ( P H Q - 9 ) ; d e p r e s s i o n ; r e l i a b i l i t y ; v a l i d i t y ; f a c t o r a n a l y s i s ; p s y c h o m e t r i c p r o p e r t i e s ; S o u t h A f r i c a T h e a i m o f t h i s s t u d y w a s t o v a l i d a t e t h e P H Q - 9 s c a l e i n a n A f r i c a n c o n t e x t . T h e P H Q - 9 ( K r o e n k e , S p i t z e r & W i l l i a m s , 2 0 0 1 ) a n d o t h e r m e a s u r e s o f w e l l - b e i n g w e r e a d m i n i s t e r e d t o a c o n v e n i e n c e s a m p l e o f 2 2 1 4 p a r t i c i p a n t s f r o m F E T c o l l e g e s a n d o t h e r o r g a n i s a t i o n s i n t h e N o r t h - W e s t P r o v i n c e o f S o u t h A f r i c a ( n1= 1 4 8 0 , n2= 5 5 9 , n3= 1 8 5 ) . T h e s a m p l e c o m p r i s e d o f t h r e e s u b - g r o u p s i n c l u d i n g a d u l t s a n d a d o l e s c e n t s , b o t h m a l e a n d f e m a l e f r o m u r b a n a n d r u r a l a r e a s w h o c o m p l e t e d t h e P H Q - 9 a n d o t h e r i n s t r u m e n t s u s e d f o r c r i t e r i o n v a l i d i t y ( G e n e r a l H e a l t h Q u e s t i o n n a i r e - 2 8 , M e n t a l H e a l t h C o n t i n u u m - S F , C o l l e c t i v e S e l f - e f f i c a c y S c a l e a n d t h e N e w G e n e r a l i s e d S e l f - e f f i c a c y S c a l e ) . T h e s c a l e y i e l d e d g o o d r e l i a b i l i t y a c r o s s t h e t h r e e g r o u p s . S i g n i f i c a n t c o r r e l a t i o n s b e t w e e n t h e P H Q - 9 a n d o t h e r m e a s u r e s o f d e p r e s s i o n i n d i c a t e d g o o d c r i t e r i o n – r e l a t e d v a l i d i t y . C o n s t r u c t v a l i d i t y i n d i c a t e d t h a t t h e P H Q - 9 h a s g o o d v a l i d i t y i n t w o o f t h e t h r e e g r o u p s o f p a r t i c i p a n t s .
V a l i d a t i o n o f t h e P a t i e n t H e a l t h Q u e s t i o n n a i r e ( P H Q - 9 ) i n a n A f r i c a n c o n t e x t D e p r e s s i v e d i s o r d e r s a r e a s s o c i a t e d w i t h h i g h l e v e l s o f p e r s o n a l s u f f e r i n g , i n c r e a s e d d i s a b i l i t y d a y s , a n d e l e v a t e d r i s k s o f c a r d i o v a s c u l a r m o r t a l i t y a n d s u i c i d e ( P e n n i n x , B e e k m a n , H o n i g , D e e g , S c h o e v e r s , v a n E i j k , & V a n T i l b u r g , 2 0 0 1 ) . T h e r e i s s c a n t e m p i r i c a l i n f o r m a t i o n o n p r e v a l e n c e , i n c i d e n c e a n d d u r a t i o n o f p s y c h i a t r i c d i s o r d e r s i n S o u t h A f r i c a n p o p u l a t i o n s ( K a g e e , 2 0 0 8 ) . L a r g e p a t i e n t n u m b e r s , o v e r w o r k e d n u r s i n g s t a f f , a n d g e n e r a l l a c k o f i n f r a s t r u c t u r e a n d r e s o u r c e s i n p r i m a r y h e a l t h c a r e c l i n i c s o f S o u t h A f r i c a m a y p o s s i b l y r e s u l t i n p a t i e n t s n o t r e c e i v i n g t r e a t m e n t f o r t h e s y m p t o m s o f d e p r e s s i o n a n d a n x i e t y . V a l i d a t e d i n s t r u m e n t s t o m e a s u r e d e p r e s s i o n m a y t h u s g o a l o n g w a y i n h e l p i n g t o d e t e c t s y m p t o m s o f d e p r e s s i o n i n a n A f r i c a n c o n t e x t . T h e a i m o f t h i s s t u d y w a s t o e x a m i n e t h e p o s s i b l e v a l i d i t y o f t h e P H Q - 9 i n a n A f r i c a n c o n t e x t . I t h a s b e e n d e m o n s t r a t e d t h a t s c r e e n i n g c o s t s o f d e p r e s s i o n c a n b e l o w a n d c o n s e q u e n t e f f e c t i v e t r e a t m e n t s c a n b e a d m i n i s t e r e d ( V a l e n s t e i n , B i j a n , Z e b e r , B o e h m , & B u t t a r , 2 0 0 1 ) f o l l o w i n g s u c h s c r e e n i n g . S c r e e n i n g q u e s t i o n n a i r e s t h a t g u a r a n t e e l o w s c r e e n i n g c o s t s a r e e n t i r e l y s e l f - a d m i n i s t e r e d , a n d o n l y r e q u i r e a f e w m i n u t e s
f o r p a t i e n t s t o c o m p l e t e a n d p h y s i c i a n s t o r e v i e w ( L o w e e t a l . , 2 0 0 4 ) a n d t h u s a s s u m e a l e v e l o f r e a d i n g a b i l i t y a n d l i t e r a c y . A s c a l e t h a t i s a s b r i e f a s t h e P H Q - 9 m a y h e l p b o t h p s y c h o l o g i s t s a n d p s y c h i a t r i s t s s c r e e n c l i e n t s a n d p a t i e n t s f o r d e p r e s s i o n i n a s e f f i c i e n t a m a n n e r a s p o s s i b l e , e s p e c i a l l y a s i t i s b a s e d o n D S M - I V c r i t e r i a . S e c o n d l y , a l t h o u g h m a n y d i f f e r e n t i n s t r u m e n t s h a v e b e e n u s e d t o s t u d y a n d m e a s u r e d e p r e s s i o n f e w i f a n y , h a v e b e e n v a l i d a t e d f o r u s e i n t h e A f r i c a n c o n t e x t . T h e a i m o f t h i s s t u d y w a s t h e r e f o r e t o v a l i d a t e t h e P H Q - 9 i n a s a m p l e o f u r b a n a n d r u r a l S o u t h A f r i c a n p a r t i c i p a n t s . T h e P a t i e n t H e a l t h Q u e s t i o n n a i r e i s t h e f i r s t s e l f - r e p o r t q u e s t i o n n a i r e d e s i g n e d f o r u s e i n p r i m a r y c a r e t h a t a c t u a l l y d i a g n o s e s p e c i f i c d i s o r d e r s ( K r o e n k e , S p i t z e r , & W i l l i a m s , 2 0 0 1 ) . I t s n i n e - i t e m d e p r e s s i o n m o d u l e , t h e P H Q - 9 , i s i n c r e a s i n g l y b e i n g u s e d a s a b r i e f d i a g n o s t i c a n d s e v e r i t y m e a s u r e i n r e s e a r c h a n d c l i n i c a l p r a c t i c e ( K r o e n k e , S p i t z e r , & W i l l i a m s , 2 0 0 1 ) . T h e P H Q - 9 h a s t h e p o t e n t i a l o f b e i n g a d u a l - p u r p o s e i n s t r u m e n t t h a t , w i t h t h e s a m e 9 i t e m s , c a n e s t a b l i s h d e p r e s s i v e d i s o r d e r d i a g n o s e s a s w e l l a s g r a d e d e p r e s s i v e s y m p t o m s e v e r i t y ( K r o e n k e e t a l . , 2 0 0 1 ) . M e a s u r i n g i n s t r u m e n t s f o r u s e i n d e p r e s s i o n a m o n g s t t h e S e t s w a n a -s p e a k i n g p o p u l a t i o n i -s n o t k n o w n . T h e r e f o r e v a l i d a t i n g t h e P H Q - 9 i s e v e n m o r e i m p o r t a n t f o r t h i s p o p u l a t i o n .
T h e s u p e r i o r c r i t e r i o n v a l i d i t y o f t h e P H Q - 9 c o m p a r e d t o t w o o t h e r e s t a b l i s h e d d e p r e s s i o n s c r e e n i n g q u e s t i o n n a i r e s h a s r e c e n t l y b e e n d e m o n s t r a t e d w i t h r e s p e c t t o t h e d i a g n o s i s o f ‘ m a j o r d e p r e s s i v e d i s o r d e r ’ m a d e b y a s t a n d a r d i n t e r v i e w i n a s s e s s i n g p s y c h o t i c d i s o r d e r s ( L o w e e t a l . , 2 0 0 4 ) i n o t h e r s o c i a l c o n t e x t s e x c l u d i n g t h e S o u t h A f r i c a n c o n t e x t . T h e d i a g n o s t i c v a l i d i t y o f t h e P H Q - 9 h a s b e e n e s t a b l i s h e d i n 2 s t u d i e s i n v o l v i n g 3 , 0 0 0 p a t i e n t s i n 8 p r i m a r y c a r e c l i n i c s a n d 3 , 0 0 0 p a t i e n t s i n 7 o b s t e t r i c s - g y n a e c o l o g y c l i n i c s ( K r o e n k e , S p i t z e r , W i l l i a m s , 2 0 0 1 ) . T h e f o r e g o i n g s u g g e s t s t h a t t h e u t i l i t y o f t h e P H Q - 9 i s c l e a r l y a t t e s t e d b y t h e a v a i l a b l e e m p i r i c a l e v i d e n c e . A s i n d i c a t e d , i n t h i s s t u d y a n a t t e m p t w a s m a d e t o t e s t i t s v a l i d i t y i n r u r a l a n d u r b a n S o u t h A f r i c a n p a r t i c i p a n t s . O n l y s c a n t e m p i r i c a l i n f o r m a t i o n ( m a i n l y f r o m t h e n i n e t i e s ) i s a v a i l a b l e o n m e n t a l h e a l t h i s s u e s i n S u b - S a h a r a n A f r i c a . R u m b l e , S w a r t z , P a r r y , & Z w a r e n s t e i n ( 1 9 9 6 ) f o u n d t h a t t h e r e w a s a p r e v a l e n c e r a t e o f 1 8 p e r c e n t o f d e p r e s s i v e s y m p t o m a t o l o g y i n a r u r a l S o u t h A f r i c a n v i l l a g e , w h i l e R u m b l e ( 1 9 9 4 ) a n d G i l l i s , W e l m a n , K o c h , & J o y i ( 1 9 9 1 ) f o u n d a p r e v a l e n c e r a t e o f 2 7 p e r c e n t . I n a s t u d y b y R o g e r s ( 1 9 9 2 ) i t w a s f o u n d t h a t o v e r h a l f o f a n u n s e l e c t e d g r o u p o f p e o p l e i n a S o u t h A f r i c a n v i l l a g e s u f f e r e d f r o m “ t h e n e r v e s ” , c h a r a c t e r i s e d b y s y m p t o m s o f b o d i l y d i s o r d e r s , p a i n ,
t e n s i o n , s a d n e s s , w e e p i n g , a n x i e t y a n d f e e l i n g h y s t e r i c a l . P o o r e c o n o m i c c o n d i t i o n s , w o r r i e s , b a d f e e l i n g s a n d i n t e r p e r s o n a l c o n f l i c t r e s u l t e d i n “ n e r v e s ” , a n d t h e s e f i n d i n g s a r e s i m i l a r t o f i n d i n g s i n m a n y o t h e r p a r t s o f t h e w o r l d . I t i s t h u s i m p o r t a n t t o f i n d o u t h o w a b r i e f i n s t r u m e n t s u c h a s t h e P H Q - 9 , b a s e d o n i t s v a l i d i t y , c o u l d p o s s i b l y h e l p i n t h e S o u t h A f r i c a n c o n t e x t t o s c r e e n f o r d e p r e s s i o n , e s p e c i a l l y i n c o n t e x t s c h a r a c t e r i s e d b y p o o r a c c e s s t o m e n t a l h e a l t h s e r v i c e s . M o r e f r e q u e n t l y , d e p r e s s i o n g o e s u n d e t e c t e d a n d s o r e m a i n s u n t r e a t e d ( G e l e n b e r g , 1 9 9 9 ) . U n f o r t u n a t e l y , p h y s i c i a n s o n l y d e t e c t 3 0 - 5 0 % o f p a t i e n t s w i t h d e p r e s s i o n i n p r i m a r y c a r e ( W i l l i a m s e t a l . , 1 9 9 9 ; H a n s e n e t a l . , 2 0 0 1 ) . D e p r e s s i o n i s , h o w e v e r , s e e n a s o n e o f t h e m o s t p r e v a l e n t a n d t r e a t a b l e m e n t a l d i s o r d e r s a n d i s r e g u l a r l y s e e n b y a w i d e s p e c t r u m o f c a r e p r o v i d e r s . T h e f o r e g o i n g s u p p o r t s t h e v a l i d a t i o n o f t h e P a t i e n t H e a l t h Q u e s t i o n n a i r e i n t h i s s t u d y a s t h e r a t e s o f d e t e c t i o n ( o r l a c k t h e r e o f ) i n t h i r d w o r l d c o u n t r i e s a r e g e n e r a l l y u n k n o w n c o m p a r e d t o f i r s t w o r l d c o u n t r i e s . M a j o r a n d m i n o r d e p r e s s i v e d i s o r d e r s r e s p o n d w e l l t o p s y c h o t h e r a p y a n d / o r t r e a t m e n t w i t h a n t i - d e p r e s s a n t s ( W i l l i a m s e t a l . , 1 9 9 9 ; J a r r e t t e t a l . , 2 0 0 1 ) , t h u s e m p h a s i s i n g t h e n e e d t o i m p r o v e d e t e c t i o n b y c l i n i c i a n s ( L o w e e t a l . , 2 0 0 4 ) . A s i n d i c a t e d p r e v i o u s l y , t h e v a l i d a t i o n o f a
s c a l e s u c h a s t h e P H Q - 9 i n a n A f r i c a n c o n t e x t w i l l h e l p i n t h e e n d t o s c r e e n f o r d e p r e s s i o n i f i t i s f o u n d t o b e a v a l i d i n s t r u m e n t . A l t h o u g h t h e B e c k D e p r e s s i o n I n v e n t o r y ( B D I : B e c k , S t e e r , B a l l , & R a m i e r i , 1 9 9 6 ) h a s b e e n u s e d i n n u m e r o u s s t u d i e s , t h e P H Q - 9 i s m u c h p r e f e r r e d f o r t h i s s t u d y . F i r s t l y , t h e d i f f e r e n c e s b e t w e e n t h e t w o s c a l e s i s t h e i r l e n g t h ( w i t h t h e B D I h a v i n g 2 1 i t e m s a n d t h e P H Q o n l y 9 ) . S e c o n d l y , t h e P H Q ’ s c o r r e s p o n d e n c e t o D S M - I V c r i t e r i a m a y h e l p w i t h p r e l i m i n a r y d i a g n o s e s o f d e p r e s s i o n a n d t h e i d e n t i f y i n g t h e s e v e r i t y o f t h e s y m p t o m s . T h u s u s i n g t h e P H Q , t h i s s t u d y w i l l s e r v e a s a n i m p o r t a n t c o n t r i b u t i o n i n t e r m s o f m a k i n g i t p o s s i b l e t o m e a s u r e d e p r e s s i o n w i t h a b r i e f i n s t r u m e n t v a l i d a t e d i n a n A f r i c a n c o n t e x t . I n l i n e w i t h t h e s u g g e s t i o n m a d e b y P a u n o n e n a n d A s h t o n ( 1 9 9 8 ) r e g a r d i n g v a l i d a t i o n p r o c e s s e s , t h e f o l l o w i n g s t a t i s t i c a l p r o c e s s e s w i l l b e e x p l o r e d : r e l i a b i l i t y i n d i c e s ( e . g . , C r o n b a c h a l p h a a n d i n t e r n a l h o m o g e n e i t y ) a n d v a l i d i t y i n d i c e s ( s u c h a s c o n s t r u c t a n d c r i t e r i o n - r e l a t e d v a l i d i t y ) . T h u s , t h e a i m o f t h i s s t u d y i s t o v a l i d a t e t h e P H Q - 9 t h a t p o t e n t i a l l y c o u l d b e u s e d i n e p i d e m i o l o g i c a l s t u d i e s t o a s s e s s a n d m e a s u r e d e p r e s s i o n i n a s a m p l e o f S o u t h A f r i c a n p a r t i c i p a n t s f r o m r u r a l a n d u r b a n a r e a s .
M E T H O D D e s i g n A c r o s s - s e c t i o n a l s u r v e y w a s i m p l e m e n t e d t o s t u d y t h e m a i n a i m o f t h e p r e s e n t s t u d y . P a r t i c i p a n t s A c o n v e n i e n c e s a m p l e o f 2 2 1 4 p a r t i c i p a n t s f r o m F u r t h e r E d u c a t i o n T r a i n i n g ( F E T ) c o l l e g e s a n d o t h e r o r g a n i s a t i o n s i n t h e N o r t h - W e s t P r o v i n c e o f S o u t h A f r i c a p a r t i c i p a t e d i n t h i s s t u d y . T h e s a m p l e c o m p r i s e d o f t h r e e s u b - g r o u p s i n c l u d i n g b o t h m a l e a n d f e m a l e p a r t i c i p a n t s s o a s t o b e l a r g e e n o u g h t o p e r f o r m a l l n e c e s s a r y a n a l y s i s f o r v a l i d a t i o n p u r p o s e s . G r o u p o n e c o n s i s t e d o f 1 4 8 0 F E T -s t u d e n t -s b e t w e e n t h e a g e -s o f 1 6 a n d 2 1 . G r o u p t w o c o n -s i -s t e d o f a n o t h e r s a m p l e o f 5 4 9 F E T - s t u d e n t s b e t w e e n t h e a g e s o f 1 6 a n d 2 1 , w h i l e g r o u p t h r e e w a s m a d e u p o f a n a v a i l a b i l i t y s a m p l e o f a d u l t s ( N = 1 8 5 ) M e a s u r i n g I n s t r u m e n t s P a t i e n t H e a l t h Q u e s t i o n n a i r e : D e p r e s s i o n S y m p t o m s ( P H Q - 9 ) ( K r o e n k e , S p i t z e r & W i l l i a m s , 2 0 0 1 ) . T h i s 9 - i t e m , s e l f - a d m i n i s t e r e d s c a l e i s u s e d t o m e a s u r e d e p r e s s i o n s e v e r i t y , w h i c h s c o r e s e a c h o f
t h e D S M - I V c r i t e r i a a s 0 ( ‘ N o t a t a l l ’ ) t o 3 ( ‘ N e a r l y e v e r y d a y ’ ) . I n d i v i d u a l s a r e a s k e d t o r a t e h o w o f t e n t h e y h a v e b e e n b o t h e r e d b y a n y o f t h e f o l l o w i n g p r o b l e m s o v e r t h e l a s t 2 w e e k s , f o r e x a m p l e : ‘ L i t t l e i n t e r e s t / p l e a s u r e i n d o i n g t h i n g s ’ a n d ‘ T h o u g h t s t h a t y o u w o u l d b e b e t t e r o f f d e a d / o f h u r t i n g y o u r s e l f i n s o m e w a y ’ . O n c e t h e s c a l e h a d b e e n c o m p l e t e d , p a r t i c i p a n t s w e r e a s k e d t o i n d i c a t e h o w d i f f i c u l t t h e s e p r o b l e m s , i f t i c k e d o f f , h a v e m a d e i t f o r t h e m t o d o t h e i r w o r k , t a k e c a r e o f t h i n g s a t h o m e o r g e t a l o n g w i t h o t h e r p e o p l e . K r o e n k e e t a l . ( 2 0 0 1 ) f o u n d e x c e l l e n t t e s t - r e t e s t r e l i a b i l i t y a s w e l l a s i n t e r n a l r e l i a b i l i t y o f t h e P H Q - 9 w i t h a C r o n b a c h a l p h a o f 0 . 8 6 . R e l i a b i l i t i e s f o r t h e p r e s e n t s t u d y o n t h i s s c a l e a r e r e p o r t e d i n T a b l e 1 . G e n e r a l H e a l t h Q u e s t i o n n a i r e ( G H Q ) ( G o l d b e r g & H i l l i e r , 1 9 7 9 ) . T h e G H Q i s a 2 8 - i t e m s c a l e d e s i g n e d w i t h t h e a i m o f d e t e c t i n g s y m p t o m s o f m e n t a l d i s o r d e r . T h i s s c a l e c o n s i s t s o f 4 s u b - s c a l e s i n c l u d i n g S o m a t i c S y m p t o m s ( S S ) , A n x i e t y a n d I n s o m n i a ( A I ) , S o c i a l D y s f u n c t i o n ( S D ) a n d S e v e r e D e p r e s s i o n ( D S ) . R a t i n g s a r e d o n e o n a 4 - p o i n t s c a l e w h e r e a n c h o r s i n d i c a t e 1 ( ‘ N o t a t a l l ’ ) , 2 ( ‘ N o m o r e t h a n u s u a l ’ ) , 3 ( ‘ R a t h e r m o r e t h a n u s u a l ’ ) a n d 4 ( ‘ M u c h m o r e t h a n u s u a l ’ ) , a l t h o u g h t h e s e f l u c t u a t e t h r o u g h o u t t h e m e a s u r e . I n d i v i d u a l s a r e a s k e d ‘ H a v e y o u r e c e n t l y ? ’ f o l l o w e d b y , f o r e x a m p l e : ‘ B e e n f e e l i n g p e r f e c t l y w e l l a n d i n g o o d h e a l t h ? ’ .
G o l d b e r g a n d H i l l i e r ( 1 9 7 9 ) r e p o r t e d C r o n b a c h a l p h a s f r o m 0 . 8 2 t o 0 . 8 6 . W i s s i n g e t a l . ( 1 9 9 9 ) n o t e d t h e a p p l i c a b i l i t y o f t h e G H Q i n a S o u t h A f r i c a n c o n t e x t b y r e p o r t i n g a C r o n b a c h a l p h a o f 0 . 9 1 f o r t h e t o t a l s c a l e . C o p i n g S e l f - E f f i c a c y S c a l e ( C S E ) ( C h e s n e y , N e i l a n d s , C h a m b e r s , T a y l o r & F o l k m a n , 2 0 0 6 ) . T h e C S E c o m p r i s e s o f 2 6 i t e m s a n d i s a m e a s u r e o f a p e r s o n ’ s c o n f i d e n c e o r p e r c e i v e d s e l f - e f f i c a c y i n p e r f o r m i n g c o p i n g b e h a v i o u r s w h e n f a c i n g c h a l l e n g e s o r t h r e a t s i n l i f e a n d c a n a l s o b e u s e d t o a s s e s s c h a n g e s i n c o p i n g s e l f - e f f i c a c y o v e r t i m e ( C h e s n e y e t a l . , 2 0 0 6 ) . R e s p o n d e n t s a r e a s k e d ‘ W h e n t h i n g s a r e n ’ t g o i n g w e l l f o r y o u , o r w h e n y o u ’ r e h a v i n g p r o b l e m s , h o w c o n f i d e n t a r e y o u t h a t y o u c a n d o t h e f o l l o w i n g : ’ a t w h i c h t h e y a r e r e q u i r e d t o r a t e t h e e x t e n t t o w h i c h t h e y b e l i e v e t h e y w i l l b e a b l e t o p e r f o r m b e h a v i o u r s i m p o r t a n t t o a d a p t i v e c o p i n g s u c h a s ‘ K e e p f r o m g e t t i n g d o w n i n t h e d u m p s ’ , ‘ T a k e y o u r m i n d o f f u n p l e a s a n t t h o u g h t s ’ a n d ‘ G e t f r i e n d s t o h e l p y o u w i t h t h e t h i n g s y o u n e e d ’ . T h e a n c h o r s o f t h e 1 1 - p o i n t s c a l e a r e 0 ( ‘ C a n n o t d o i t a t a l l ’ ) , 5 ( ‘ M o d e r a t e l y c e r t a i n c a n d o ’ ) a n d 1 0 ( ‘ C e r t a i n c a n d o ’ ) . T h e t o t a l C S E s c o r e i s d e t e r m i n e d b y s u m m i n g t h e i t e m r a t i n g s ( C h e s n e y e t . a l . , 2 0 0 6 ) . C h e s n e y e t a l . ( 2 0 0 6 ) d e v e l o p e d a 1 3 - i t e m r e d u c e d f o r m o f t h e C S E w i t h t h r e e f a c t o r s : U s e p r o b l e m - f o c u s e d c o p i n g ( 6 i t e m s , α = . 9 1 ) , S t o p u n p l e a s a n t e m o t i o n s a n d t h o u g h t s ( 4 i t e m s , α =
. 8 0 ) . F o r a l l t h r e e f a c t o r s t h e i n t e r n a l c o n s i s t e n c y a n d t e s t - r e t e s t r e l i a b i l i t y w a s f o u n d t o b e s t r o n g ( C h e s n e y e t a l . , 2 0 0 6 ) . N e w G e n e r a l S e l f - E f f i c a c y S c a l e ( N G S E ) ( C h e n , G u l l y & E d e n , 2 0 0 1 ) . T h e N G S E , a n 8 - i t e m s c a l e , w a s d e v e l o p e d t o m e a s u r e a n i n d i v i d u a l ’ s t e n d e n c y t o v i e w t h e s e l f a s c a p a b l e o f m e e t i n g t a s k d e m a n d s i n v a r i o u s c o n t e x t s . V a r i o u s v a l i d a t i o n s t u d i e s h a v e s h o w n t h a t t h e N G S E m e a s u r e s a c o n s t r u c t t h a t i s r e l a t e d t o , b u t d i s t i n c t f r o m b o t h s e l f - e s t e e m a n d s i t u a t i o n a l s e l f - e f f i c a c y ( C h e n , G u l l y & E d e n , 2 0 0 1 ) . T h e 8 - i t e m m e a s u r e i s r a t e d o n a 5 - p o i n t s c a l e r a n g i n g f r o m 1 ( ‘ S t r o n g l y d i s a g r e e ) t o 5 ( ‘ S t r o n g l y a g r e e ’ ) . C h e n e t a l . ( 2 0 0 1 ) r e p o r t s s t a b i l i t y c o e f f i c i e n t s r a n g i n g f r o m r = 0 . 6 2 t o r = 0 . 6 5 a s w e l l a s a n u n d i m e n s i o n a l f a c t o r s t r u c t u r e . M e n t a l H e a l t h C o n t i n u u m – S h o r t F o r m f o r a d u l t s ( M H C _ S F ) ( K e y e s , 2 0 0 6 ) . T h e M H C _ S F i s a 1 4 - i t e m s c a l e a n d m e a s u r e s t h e u p p e r e n d o f t h e m e n t a l h e a l t h c o n t i n u u m . R e s p o n d e n t s s p e c i f y h o w f r e q u e n t l y d u r i n g t h e p r e c e d i n g m o n t h t h e y h a v e e x p e r i e n c e d f o u r t e e n f e e l i n g s – “ n e v e r ” , “ o n c e o r t w i c e ” , “ a b o u t o n c e a w e e k ” , 2 o r 3 t i m e s a w e e k ” , “ a l m o s t e v e r y d a y ” o r “ e v e r y d a y ” . T h e s c a l e c o m p r i s e s o f t h r e e s u b - s c a l e s , n a m e l y E m o t i o n a l w e l l b e i n g ( s a t i s f a c t i o n w i t h l i f e , p r e s e n c e o f p o s i t i v e a f f e c t a n d t h e a b s e n c e o f n e g a t i v e a f f e c t ) , P s y c h o l o g i c a l / P e r s o n a l w e l l b e i n g ( s e l f -
a c c e p t a n c e , p u r p o s e i n l i f e , p e r s o n a l g r o w t h , p o s i t i v e r e l a t i o n s w i t h o t h e r s , e n v i r o n m e n t a l m a s t e r y a n d a u t o n o m y ) a n d S o c i a l w e l l b e i n g ( s o c i a l i n t e g r a t i o n , s o c i a l c o h e r e n c e , s o c i a l a c t u a l i z a t i o n , s o c i a l c o n t r i b u t i o n a n d s o c i a l a c c e p t a n c e ) . K e y e s ( 2 0 0 6 ) a t t e s t s t o t h e r e l i a b i l i t y a n d v a l i d i t y o f t h i s s c a l e a n d m o d e l i n a S e t s w a n a s p e a k i n g A f r i c a n g r o u p . T h e C r o n b a c h a l p h a r e l i a b i l i t y w a s 0 . 7 7 f o r t h e t o t a l s c a l e . P r o c e d u r e T h i s s t u d y f o r m e d p a r t o f t h e l a r g e r p r o j e c t o n P s y c h o s o c i a l H e a l t h a n d B i o m a r k e r s i n a n A f r i c a n c o n t e x t ( F O R T 3 : W i s s i n g , 2 0 0 8 ) . T h e m a j o r i t y o f c r i t e r i o n r e l a t e d q u e s t i o n n a i r e s t h a t w e r e u s e d f o r t h e a n a l y s e s f o r m p a r t o f t h e F O R T 3 p r o j e c t a n d h a d a l r e a d y b e e n v a l i d a t e d i n o t h e r s t u d i e s l i n k e d t o t h i s p r o j e c t . T h e f i r s t s t e p i n t h e p r o c e d u r e w a s t o o b t a i n c o n s e n t f r o m t h e d i f f e r e n t i n s t i t u t i o n s i n w h i c h d a t a w e r e c o l l e c t e d a s w e l l a s p a r t i c i p a n t s t o e n s u r e t h e i r w i l l i n g n e s s t o p a r t i c i p a t e i n t h e s t u d y v o l u n t a r i l y . S e c o n d l y , t h e q u e s t i o n n a i r e s w e r e f i l l e d i n b y t h e d i f f e r e n t g r o u p s u n d e r t h e s u p e r v i s i o n o f i n d i v i d u a l s w h o h a d b e e n t r a i n e d i n t h e a d m i n i s t r a t i o n o f t h e t e s t b a t t e r y . T h e t e s t a d m i n i s t r a t o r s w e r e i n t u r n s u p e r v i s e d b y p s y c h o l o g i s t s r e g i s t e r e d w i t h t h e H e a l t h P r o f e s s i o n s C o u n c i l o f S o u t h A f r i c a ( H P C S A ) a n d
a r e e t h i c a l l y b o u n d b y a c o d e o f c o n d u c t t o p r o t e c t t h e i n t e r e s t s o f p a r t i c i p a n t s . E t h i c a l A p p r o v a l I n f o r m e d c o n s e n t w a s o b t a i n e d f r o m e a c h p a r t i c i p a n t w h o s h o w e d t h e w i l l i n g n e s s t o p a r t i c i p a t e a n d w h o u n d e r s t o o d t h a t p a r t i c i p a t i o n w a s v o l u n t a r y . T h e e t h i c s c o m m i t t e e o f t h e N o r t h W e s t U n i v e r s i t y a p p r o v e d t h i s s t u d y ( A p p r o v a l n u m b e r : N W U - 0 0 0 0 2 - 0 7 - A 2 ) . D a t a A n a l y s i s S P S S ( v e r . 1 6 ) w a s u s e d t o d e t e r m i n e t h e v a r i o u s d e s c r i p t i v e s t a t i s t i c s ( m e a n s a n d s t a n d a r d d e v i a t i o n s ) . C r o n b a c h a l p h a c o e f f i c i e n t s a n d i n t e r - i t e m c o r r e l a t i o n c o e f f i c i e n t s w e r e u s e d t o a s s e s s t h e r e l i a b i l i t y o f t h e P H Q - 9 ( C l a r k & W a t s o n , 1 9 9 5 ; F i e l d , 2 0 0 5 ) . A c c o r d i n g t o C l a r k a n d W a t s o n ( 1 9 9 5 ) c o n t e m p o r a r y r e s e a r c h e r s c l a s s i f y r e l i a b i l i t i e s b e t w e e n 0 . 6 0 a n d 0 . 7 0 a s a d e q u a t e , w h e r e a s N u n n a l l y a n d B e r n s t e i n ( 1 9 9 4 ) s u g g e s t e d a r e l i a b i l i t y o f 0 . 7 0 a s s u f f i c i e n t i n c o n s t r u c t v a l i d a t i o n r e s e a r c h . F i e l d ( 2 0 0 5 ) i n d i c a t e s t h a t a C r o n b a c h v a l u e o f 0 . 8 o r 0 . 9 f o r a b i l i t y t e s t s a r e g o o d . I n t e r - i t e m c o r r e l a t i o n s p r o v i d e a n i n d i c a t i o n o f t h e d e g r e e t o w h i c h t h e i t e m s i n t h e s c a l e m e a s u r e a s i n g l e c o n s t r u c t o r f a c t o r ( S m i t h & M c C a r t h y , 1 9 9 5 ) , f o r a b r o a d c o n s t r u c t , t h e s e c o r r e l a t i o n s s h o u l d f a l l b e t w e e n 0 . 1 5 a n d 0 . 5 0 ( C l a r k & W a t s o n , 1 9 9 5 ) .
C r i t e r i o n - r e l a t e d v a l i d i t y w a s d e t e r m i n e d b y c o r r e l a t i n g t h e P H Q - 9 w i t h o t h e r s c a l e s m e a s u r i n g d e p r e s s i o n a n d p s y c h o l o g i c a l w e l l -b e i n g . C o n s t r u c t v a l i d i t y o n t h e o t h e r h a n d , w a s e s t a -b l i s h e d f i r s t l y b y c o n d u c t i n g c o n f i r m a t o r y f a c t o r a n a l y s i s u s i n g s t r u c t u r a l e q u a t i o n m o d e l l i n g o n t h e P H Q - 9 t o a s s e s s t h e n u m b e r o f f a c t o r s ( a c c o r d i n g t o t h e o r y ) a n d m o d e l f i t . M o d e l f i t a n d a s s o c i a t e d i n d i c e s ( s u c h a s R M S E A a n d G F I ) w e r e e s t a b l i s h e d b a s e d o n t h e o u t p u t o f s t r u c t u r a l e q u a t i o n m o d e l l i n g . R M S E A i n d i c a t e s a m o u n t o f e r r o r i n t h e h y p o t h e s i s e d m o d e l - d a t a f i t c o m p a r a t i v e t o t h e n u m b e r o f e s t i m a t e d p a r a m e t e r s o r t h e c o m p l e x i t y o f t h e m o d e l a r e i n d i c a t e d b y t h e R M S E A . B r o w n e a n d C u d e c k ( 1 9 9 3 ) s t a t e a v a l u e o f 0 . 0 5 o r l e s s i n d i c a t e s a g o o d f i t . O t h e r m e a s u r e s o f f i t s u c h a s t h e G F I w e r e u s e d . T h e G F I s h o w s t h e r e l a t i v e a m o u n t o f v a r i a n c e a n d c o -v a r i a n c e f o u n d i n t h e s a m p l e p r e d i c t e d b y e s t i m a t e s o f t h e p o p u l a t i o n . A n a l y s e s w e r e c o n d u c t e d o n t h e t o t a l s a m p l e , a s t h e d e s c r i p t i v e s t a t i s t i c s u s e d t o e x p l o r e t h e d a t a f r o m t h e s u b g r o u p s w e r e c o m p a r a b l e . E x p l o r a t o r y f a c t o r a n a l y s i s w a s u s e d t o e s t a b l i s h t h e n u m b e r o f f a c t o r s y i e l d e d b y t h e P H Q - 9 .
R E S U L T S D e s c r i p t i v e s t a t i s t i c s o f m e a s u r e s u s e d i n t h e s t u d y D e s c r i p t i v e s t a t i s t i c s o f t h e P H Q - 9 a n d i n t e r n a l c o n s i s t e n c y i n d i c e s a r e r e p o r t e d i n T a b l e 1 . C r o n b a c h a l p h a r e l i a b i l i t i e s f o r t h e 3 s u b -g r o u p s r a n -g e d b e t w e e n 0 . 7 6 a n d 0 . 7 8 w i t h s p e c i f i c a l l y t h e f o l l o w i n -g r e l i a b i l i t i e s 0 . 7 7 f o r g r o u p 1 , 0 . 7 8 f o r g r o u p 2 a n d 0 . 7 6 f o r g r o u p 3 . I n t e r - i t e m c o r r e l a t i o n s , w h i c h s e r v e a s i n d i c a t o r s o f i n t e r n a l c o n s i s t e n c y ( C l a r k & W a t s o n , 1 9 9 5 ) , y i e l d e d v a l u e s r a n g i n g f r o m 0 . 2 8 a n d 0 . 5 6 . C l a r k a n d W a t s o n ( 1 9 9 5 ) i n d i c a t e d t h a t v a l u e s b e t w e e n 0 . 1 5 a n d 0 . 5 0 f a l l w i t h i n t h e d e s i r a b l e r a n g e f o r i n t e r - i t e m c o r r e l a t i o n s . I n t e r - i t e m c o r r e l a t i o n s f o r t h e v a r i o u s P H Q - 9 s u b g r o u p s r a n g e b e t w e e n 0 . 2 6 a n d 0 . 2 8 . T h u s , i t c a n b e c o n c l u d e d t h a t i n t e r n a l c o n s i s t e n c y o f t h e P H Q - 9 i n t h e 3 s u b - g r o u p s i s s a t i s f a c t o r y . [ I n s e r t T a b l e 1 a p p r o x i m a t e l y h e r e ] C r i t e r i o n - r e l a t e d v a l i d i t y o f t h e P H Q - 9 C o r r e l a t i o n s o f t h e P H Q - 9 w i t h o t h e r s c a l e s m e a s u r i n g v a r i o u s d i m e n s i o n s o f w e l l b e i n g w e r e u s e d t o d e t e r m i n e c r i t e r i o n - r e l a t e d v a l i d i t y . R e s u l t s a r e r e p o r t e d i n T a b l e 2 . A l l t h e c o r r e l a t i o n s a r e
s t a t i s t i c a l l y s i g n i f i c a n t . T h e h i g h e s t p r a c t i c a l s i g n i f i c a n c e w a s o b t a i n e d f o r t h e c o r r e l a t i o n b e t w e e n t h e G H Q a n d t h e P H Q - 9 w i t h a v a l u e o f 0 . 6 3 * * w h i c h c a n b e i n t e r p r e t e d a s a l a r g e e f f e c t ( s e e F i e l d , 2 0 0 5 ) . T h i s c o r r e l a t i o n w o u l d e x p l a i n 3 9 . 6 9 % o f t h e v a r i a n c e . [ I n s e r t T a b l e 2 a p p r o x i m a t e l y h e r e ] C o n f i r m a t o r y F a c t o r A n a l y s i s o f t h e P H Q - 9 C o n f i r m a t o r y f a c t o r a n a l y s i s f o r t h e P H Q - 9 y i e l d e d a o n e - f a c t o r s o l u t i o n i n a l l g r o u p s . T h e p e r c e n t a g e v a r i a n c e e x p l a i n e d r a n g e d b e t w e e n 3 4 . 7 1 % a n d 4 6 . 6 2 % . T a b l e 3 s u m m a r i s e s t h e r e s u l t s o f t h e c o n f i r m a t o r y f a c t o r a n a l y s i s . [ I n s e r t T a b l e 3 a p p r o x i m a t e l y h e r e ] E x p l o r a t o r y f a c t o r a n a l y s i s E x p l o r a t o r y f a c t o r a n a l y s i s w a s c o n d u c t e d u s i n g t h e m a x i m u m l i k e l i h o o d m e t h o d o f f a c t o r e x t r a c t i o n w i t h o b l i q u e r o t a t i o n o n t h e P H Q - 9 . A s m a x i m u m l i k e l i h o o d i s t h e p r e f e r r e d m e t h o d o f f a c t o r e x t r a c t i o n w h e n d a t a i s r e l a t i v e l y n o r m a l l y d i s t r i b u t e d ( F a b r i g a r , W e g e n e r , M a c C u l l u m , & S t r a h a n , 1 9 9 9 ) , i t w a s u s e d a s e x t r a c t i o n m e t h o d i n t h i s s t u d y . A t w o - f a c t o r s o l u t i o n w a s y i e l d e d f o r a l l t h e
g r o u p s . T h e s e c o n d f a c t o r i n a l l s u b g r o u p s c o m p r i s e d o f o n l y t w o i t e m s a n d w a s t h u s c o n s i d e r e d a m i n o r f a c t o r a n d c o n s e q u e n t l y d i s c a r d e d . R e s u l t s a r e a l s o r e p o r t e d i n T a b l e 3 . C o n s t r u c t V a l i d i t y o f t h e P H Q - 9 T h e c o n s t r u c t v a l i d i t y o b t a i n e d i n t h i s r e s e a r c h i n d i c a t e t h a t t h e P H Q - 9 i s a r e l a t i v e l y v a l i d m e a s u r e o f i d e n t i f y i n g d e p r e s s i o n f o r o n l y t w o o u t o f t h r e e s u b g r o u p s u s e d i n t h e s t u d y ( R M S E A = 0 . 0 8 i n g r o u p 1 ; 0 . 1 1 i n g r o u p 2 ; 0 . 0 7 i n g r o u p 3 ) . A c c o r d i n g t o B r o w n e a n d C u d e c k ( 1 9 9 3 ) R M S E A s h o u l d b e 0 . 0 5 o r l e s s t o i n d i c a t e g o o d f i t a n d R M S E A v a l u e s r a n g i n g b e t w e e n 0 . 0 8 a n d 0 . 1 0 w o u l d t h e n i n d i c a t e a m e d i o c r e f i t . T h u s o n l y t h e r e s u l t s f o r g r o u p 2 i n d i c a t e d a p o o r f i t o f t h e d a t a t o t h e m o d e l . F i t i n d i c e s s u c h a s G F I w e r e a l s o c o n s i s t e n t w i t h g o o d i n d i c a t i o n o f f i t a s t h e y w e r e a b o v e 0 . 9 i n g r o u p s 1 a n d 3 ( Y u , 2 0 0 2 ) i n c l u d i n g i t s a l t e r n a t i v e t h e A k a i k e I n f o r m a t i o n C r i t e r i o n ( A I C ) t h a t m u s t b e s m a l l t o i n d i c a t e t h e b e s t f i t i f d i f f e r e n t m o d e l s a r e c o m p a r e d . T h e A I C f o r g r o u p 3 m o d e l s i s r e l a t i v e l y t h e s m a l l e s t a s i n d i c a t e d i n T a b l e 4 . [ I n s e r t T a b l e 4 a p p r o x i m a t e l y h e r e ] O v e r a l l , t h e r e s u l t s i n d i c a t e t h a t t h e P H Q - 9 i s r e l a t i v e l y v a l i d f o r u s e i n t h e t w o g r o u p s s e l e c t e d f o r t h i s s t u d y a n d h a s a n a c c e p t a b l e
r e l i a b i l i t y i n a l l g r o u p s . T h e r e s u l t s f u r t h e r s h o w t h a t t h e P H Q - 9 i s r e l a t e d t o o t h e r m e a s u r e s o f d e p r e s s i o n a n d m e n t a l h e a l t h . D I S C U S S I O N T h e a i m o f t h i s s t u d y w a s t o e x p l o r e t h e v a l i d i t y o f t h e P a t i e n t H e a l t h Q u e s t i o n n a i r e ( P H Q - 9 ) i n a n A f r i c a n c o n t e x t . B a s e d o n c o n s t r u c t v a l i d i t y r e s u l t s y i e l d e d b y t h e f i n d i n g s , t h e P H Q - 9 i s r e l a t i v e l y v a l i d f o r t h e s a m p l e u s e d i n t h i s s t u d y b a s e d o n g o o d n e s s o f f i t i n d i c e s . P r e v i o u s r e s e a r c h f i n d i n g s o n t h i s i n s t r u m e n t i n d i f f e r e n t c o n t e x t s h a v e a l s o i n d i c a t e d s i m i l a r f i n d i n g s ( L o w e e t a l . , 2 0 0 4 ; S p i t z e r , K r o e n k e , W i l l i a m s , 2 0 0 1 ) . T h e r e s u l t s a l s o s h o w e d g o o d c r i t e r i o n r e l a t e d v a l i d i t y f o r t h e P H Q 9 . A l l c o r r e l a t i o n s o f t h e P H Q 9 w i t h o t h e r s c a l e s m e a s u r i n g w e l l -b e i n g w e r e s t a t i s t i c a l l y s i g n i f i c a n t . T h e h i g h c o r r e l a t i o n s -b e t w e e n t h e G H Q a n d t h e P H Q - 9 c o u l d b e e x p e c t e d s i n c e t h e G H Q m e a s u r e s s y m p t o m s o f d e p r e s s i o n a n d p s y c h o l o g i c a l f u n c t i o n i n g . M e a s u r e s o f c o n s i s t e n c y f o r t h e P H Q - 9 i n d i c a t e d t h a t i t w a s r e l i a b l e f o r u s e w i t h t h e g r o u p s s e l e c t e d f o r t h i s s t u d y . E s t a b l i s h i n g r e l i a b i l i t y i s o f c o u r s e o n e o f t h e f i r s t s t e p i n d e m o n s t r a t i n g t h a t a p a r t i c u l a r i n s t r u m e n t i s s u i t a b l e f o r a c e r t a i n c o n t e x t ( F i e l d , 2 0 0 5 ) .
T h e C r o n b a c h a l p h a f o r t h e t o t a l P H Q - 9 o f 0 . 7 7 c a n b e r e g a r d e d a s a d e q u a t e e s p e c i a l l y a s i t g i v e s a n i n d i c a t i o n o f t h e p r e s e n c e o f d e p r e s s i o n t h r o u g h t h e i t e m s u s e d i n t h e s c a l e . T h i s r e s u l t i s c o m p a r a b l e t o t h e C r o n b a c h a l p h a i n d i c a t e d f o r t h e G H Q o f 0 . 9 1 ( W i s s i n g e t a l . , 1 9 9 9 ) . I n t e r - i t e m c o r r e l a t i o n s w e r e g e n e r a l l y s a t i s f a c t o r y i n d i c a t i n g t h a t o v e r a l l , r e l i a b i l i t y o f t h e P H Q - 9 i s a c c e p t a b l e a s i n d i c a t e d b y t h e C r o n b a c h a l p h a , a n d i n t e r - i t e m c o r r e l a t i o n . I t i s c l e a r t h a t i n t e r - i t e m c o r r e l a t i o n s a m o n g t h e g r o u p s a r e w i t h i n s i m i l a r r a n g e s l e a d i n g t o h i g h e r h o m o g e n e i t y i n i t e m s . E x p l o r a t o r y f a c t o r a n a l y s i s y i e l d e d 2 f a c t o r s i n t w o o u t o f t h r e e g r o u p s . T h e s e c o n d f a c t o r w a s h o w e v e r a m i n o r f a c t o r w i t h l e s s t h a n t h r e e i t e m s . E s s e n t i a l l y , i t c a n b e c o n c l u d e d t h a t t h e e x p l o r a t o r y f a c t o r a n a l y s i s y i e l d e d o n l y o n e f a c t o r . T h e s e f a c t o r s r e l a t e t o a s e n s e o f c o p i n g w i t h e v e r y d a y l i f e a n d m e n t a l w e l l n e s s . B a s e d o n t h e p r i n c i p l e s o f t h e P H Q - 9 , r e s p o n d e n t s r a t e h o w o f t e n t h e y h a v e b e e n b o t h e r e d b y v a r i o u s p r o b l e m s w h i c h c o u l d i n d i c a t e l e v e l s o f m e n t a l w e l l n e s s o r d e p r e s s i o n . T h e R M S E A v a l u e o f t h i s s c a l e w a s a g o o d f i t i n a l l g r o u p s ( B r o w n e & C u d e c k , 1 9 9 3 ) . F i t i n d i c e s s u c h a s G F I w e r e a l s o c o n s i s t e n t w i t h g o o d f i t a s t h e y w e r e a b o v e 0 . 9 i n g r o u p s 1 a n d 3 ( Y u , 2 0 0 2 ) . I t c a n t h e r e f o r e b e c o n c l u d e d t h a t t h e P H Q - 9 p r e s e n t e d a g o o d m o d e l f i t
f o r t w o o f t h e g r o u p s s e l e c t e d i n t h i s s t u d y . A s d e s c r i b e d i n t h e i n t r o d u c t i o n o f t h i s a r t i c l e , e f f i c i e n t c o p i n g w i t h l i f e ’ s c h a l l e n g e s i s i m p o r t a n t f o r p s y c h o l o g i c a l w e l l - b e i n g w h i c h e m p h a s i z e s t h e i m p o r t a n c e o f t h e P H Q - 9 t o m e a s u r e d e p r e s s i o n i n a g r o u p o f S o u t h A f r i c a n y o u t h . C O N C L U S I O N A N D R E C O M M E N D A T I O N I t c a n b e c o n c l u d e d t h a t t h e P H Q - 9 , a s h o r t - i t e m s c a l e t h a t m e a s u r e s d e p r e s s i o n i s t h e r e f o r e v a l i d t o u s e a s a m e a s u r e m e n t o f d e p r e s s i o n i n a n A f r i c a n c o n t e x t . F u t u r e s t u d i e s c a n e x p l o r e t h e v a l i d i t y o f t h e P H Q - 9 i n o t h e r c u l t u r a l c o n t e x t s t o c o m p a r e i t s c r o s s - c u l t u r a l u s e f u l n e s s i n t h e v a r i o u s c o m m u n i t i e s o f S o u t h A f r i c a w h o a r e b a s e d i n b o t h r u r a l a n d u r b a n a r e a s . T h e v a l i d i t y o f t h i s s c a l e c o u l d f u r t h e r b e e n h a n c e d b y i n c l u d i n g d a t a a n a l y s i s a c r o s s d i f f e r e n t d e m o g r a p h i c , c u l t u r a l a n d l a n g u a g e g r o u p s . F u t u r e w o r k s h o u l d i n v e s t i g a t e v a l i d i t y a n d r e l i a b i l i t y i n v a r i o u s e t h n i c a n d g e n d e r s u b g r o u p s m o r e c o m p r e h e n s i v e l y . C o n s t r u c t e q u i v a l e n c e a n d b i a s c a n a l s o b e m e a s u r e d i n t h e s e e t h n i c a n d g e n d e r s u b g r o u p s .
