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Displacement and Isolation: Insights from a Mental Stress Survey of Syrian Refugees in Houston, Texas, USA. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19052547. [PMID: 35270240 PMCID: PMC8909545 DOI: 10.3390/ijerph19052547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/10/2022] [Accepted: 02/17/2022] [Indexed: 12/10/2022]
Abstract
(1) Background: Syrians are the largest forcibly displaced population in the world. Approximately 20,000 Syrian refugees have resettled in the United States (US) since the civil war in Syria began in 2011, with an estimated 130 families resettling in Houston, Texas. We conducted a pilot study with the objective of examining the physical and mental well-being of the Houston Syrian refugee population. (2) Methods: Online surveys were conducted using psychometrically valid instruments including Afghan Symptom Checklist (ASC), Refugee Post-Migration Stress Scale (RPMSS), Perceived Stress Scale (PSS), and Self-Report Questionnaire (SRQ) (3) Results: According to independent t-tests, Syrian refugee females scored higher than males on ASC (37.78 vs. 31.64, p = 0.0446), particularly in the subscales of sadness with social withdrawal (28.89 vs. 24.31, p = 0.0495), and stress-induced reactivity (6.56 vs. 4.86, p = 0.0004). Similarly, females scored higher than males in RPMSS (60.54 vs. 45.15, p = 0.0022), including the social strain domain (8.08 vs. 5.18, p = 0.0204). In PSS and SRQ, Syrian refugee females reported comparable stress and distress scores as males. (4) Conclusions: Syrian refugee females reported higher stress and distress than males. Displacement from their home country and social strain were the major sources of stress in Syrian refugee females, as indicated in RPMSS.
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The mental health of youth and young adults during the transition to adulthood in Egypt. DEMOGRAPHIC RESEARCH 2017; 36:1721-1758. [PMID: 29242707 PMCID: PMC5726610 DOI: 10.4054/demres.2017.36.56] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND There has been growing interest in the stalled transition to adulthood in the Middle East and North Africa (MENA) and its consequences for young people’s socioeconomic outcomes. However, little is known about how important life transitions relate to youth psychosocial well-being in the region. OBJECTIVE Drawing on a life course framework, we estimate the associations between making transitions in education, employment, and marriage with changes in mental health among young people in Egypt. METHODS We descriptively analyze mental health scores, measured via the Self-Reporting Questionnaire-20 and disaggregated by gender, for a panel of young people first surveyed in 2009 at ages 13–29 and followed up in late 2013 and early 2014. We regress change in mental health scores against indicators of making different transitions. RESULTS Young women experience worse mental health than young men overall. Lower school achievement was associated with poorer mental health; being out of the labor force was an additional risk factor for young men. While average mental health scores improved over time, over a quarter of the sample experienced worsening mental health, related to failure to marry and find a job among older men, and failure to finish schooling among younger women. CONCLUSIONS Mental health is an important but often overlooked component of youth well-being during the transition to adulthood in MENA, and potentially other low- and middle-income countries. CONTRIBUTION This is the first paper to empirically examine the relationship between psychosocial well-being and achieving important socioeconomic milestones among a nationally representative cohort of young people in MENA.
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Santos KOB, Carvalho FM, de Araújo TM. Internal consistency of the self-reporting questionnaire-20 in occupational groups. Rev Saude Publica 2016; 50:6. [PMID: 27007682 PMCID: PMC4794769 DOI: 10.1590/s1518-8787.2016050006100] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 05/21/2015] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To assess the internal consistency of the measurements of the Self-Reporting Questionnaire (SRQ-20) in different occupational groups. METHODS A validation study was conducted with data from four surveys with groups of workers, using similar methods. A total of 9,959 workers were studied. In all surveys, the common mental disorders were assessed via SRQ-20. The internal consistency considered the items belonging to dimensions extracted by tetrachoric factor analysis for each study. Item homogeneity assessment compared estimates of Cronbach’s alpha (KD-20), the alpha applied to a tetrachoric correlation matrix and stratified Cronbach’s alpha. RESULTS The SRQ-20 dimensions showed adequate values, considering the reference parameters. The internal consistency of the instrument items, assessed by stratified Cronbach’s alpha, was high (> 0.80) in the four studies. CONCLUSIONS The SRQ-20 showed good internal consistency in the professional categories evaluated. However, there is still a need for studies using alternative methods and additional information able to refine the accuracy of latent variable measurement instruments, as in the case of common mental disorders.
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Affiliation(s)
| | | | - Tânia Maria de Araújo
- Departamento de Saúde, Universidade Estadual de Feira de Santana, Feira de Santana, BA, Brasil
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Kootbodien T, Becker P, Naicker N, Mathee A. Gender invariance of the Self-Reporting Questionnaire (SRQ-20). SOUTH AFRICAN JOURNAL OF PSYCHOLOGY 2015. [DOI: 10.1177/0081246315572500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The World Health Organization 20-item Self-Reporting Questionnaire is a quick, low-cost screening instrument for measuring common mental disorders and has been applied in community-based health surveys in developing countries. It was originally designed as a general single factor tool for assessing mental distress associated with several common mental disorders. However, studies have also examined alternate multi-factor solutions for the Self-Reporting Questionnaire–20 across diverse study populations. A cross-sectional household survey was conducted in August and September 2009 among adults living in five urban communities in Johannesburg, South Africa ( n = 360). The Self-Reporting Questionnaire–20 was used to assess common mental disorders in the past month. Confirmatory factor analysis was applied to compare three competing models (one-, two-, and three-factor models). All three models fit the data well. Gender invariance was tested on the one-factor model based on its extensive application in clinical and research settings. Our findings did not support gender invariance. The differences in factor loadings between male and female subgroups suggest that the application of the Self-Reporting Questionnaire–20 may be more suited to women and therefore should be used cautiously for the assessment of common mental disorders in South Africa urban populations.
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Affiliation(s)
- Tahira Kootbodien
- Environment and Health Research Unit, South African Medical Research Council, University of Johannesburg, South Africa
| | - Piet Becker
- Biostatistics Unit, South African Medical Research Council, South Africa
| | - Nisha Naicker
- Environment and Health Research Unit, South African Medical Research Council, University of Johannesburg, South Africa
| | - Angela Mathee
- Environment and Health Research Unit, South African Medical Research Council, University of Johannesburg, South Africa
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Does poverty reduce mental health? An instrumental variable analysis. Soc Sci Med 2014; 113:59-67. [PMID: 24836844 DOI: 10.1016/j.socscimed.2014.05.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 04/15/2014] [Accepted: 05/04/2014] [Indexed: 11/20/2022]
Abstract
That poverty and mental health are negatively associated in developing countries is well known among epidemiologists. Whether the relationship is causal or associational, however, remains an open question. This paper aims to estimate the causal effect of poverty on mental health by exploiting a natural experiment induced by weather variability across 440 districts in Indonesia (N = 577,548). Precipitation anomaly in two climatological seasons is used as an instrument for poverty status, which is measured using per capita household consumption expenditure. Results of an instrumental variable estimation suggest that poverty causes poor mental health: halving one's consumption expenditure raises the probability of suffering mental illness by 0.06 point; in terms of elasticity, a 1% decrease in consumption brings about 0.62% more symptoms of common mental disorders. This poverty effect is approximately five times stronger than that obtained prior to instrumenting and is robust to alternative distributional assumption, model specification, sample stratification and estimation technique. An individual's mental health is also negatively correlated with district income inequality, suggesting that income distribution may have a significant influence upon mental health over and above the effect of poverty. The findings imply that mental health can be improved not only by influencing individuals' health knowledge and behaviour but also by implementing a more equitable economic policy.
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Evaluation of the psychometric properties of the Self-Reporting Questionnaire (SRQ-20) in a sample of Vietnamese adults. Compr Psychiatry 2013; 54:398-405. [PMID: 23228466 DOI: 10.1016/j.comppsych.2012.10.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Revised: 08/17/2012] [Accepted: 10/21/2012] [Indexed: 11/23/2022] Open
Abstract
PURPOSE There are significant gaps in the literature on the prevalence of mental health problems and associated needs in Vietnam. A thorough understanding of culture-specific expressions of psychiatric distress is vital for the identification of the mental health needs of a community, and more research on the development and evaluation of culturally-sensitive mental health assessments is warranted. This study aims to evaluate the psychometric properties of the World Health Organization 20-item Self-Reporting Questionnaire (SRQ-20) in an epidemiologic study of Vietnamese adults. METHODS A latent variable modeling approach investigated the underlying factor structure of the SRQ-20 items. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted on SRQ-20 item-level data gathered from 4980 participants. RESULTS Based on scree plots and EFA results, two latent structures were deemed plausible and were subsequently subjected to further modeling. A bi-factor model (BFM) and a correlated three-factor model solution (Negative Affect, Somatic Complaints, and Hopelessness) provided reasonable fits. The BFM specifies a single dominant General Distress factor (all SRQ-20 items) with orthogonal group factors for the subsets of items: Negative Affect (9 items), Somatic Complaints (8 items), and Hopelessness (3 items). This model fit the data as well or better than the three-factor model. Results also showed differences in endorsement rates of SRQ-20 items among males and females. CONCLUSIONS Study results provide an evaluation of the psychometric properties of a commonly used screening tool and offer insight into the presentation of mental distress in a representative sample of Vietnamese adults.
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Friborg O, Martinussen M, Kaiser S, Overgård KT, Rosenvinge JH. Comorbidity of personality disorders in anxiety disorders: a meta-analysis of 30 years of research. J Affect Disord 2013; 145:143-55. [PMID: 22999891 DOI: 10.1016/j.jad.2012.07.004] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Revised: 07/02/2012] [Accepted: 07/05/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND A comprehensive meta-analysis to identify the proportions of comorbid personality disorders (PD) across the major subtypes of anxiety disorders (AD) has not previously been published. METHODS A literature search identified 125 empirical papers from the period 1980-2010 on patients with panic disorders, social phobia, generalised anxiety, obsessive-compulsive (OCD) and post-traumatic stress disorder (PTSD). Several moderators were coded. RESULTS The rate of any comorbid PD was high across all ADs, ranging from .35 for PTSD to .52 for OCD. Cluster C PDs occurred more than twice as often as cluster A or B PDs. Within cluster C the avoidant PD occurred most frequently, followed by the obsessive-compulsive and the dependent PD. PTSD showed the most heterogeneous clinical picture and social phobia was highly comorbid with avoidant PD. A range of moderators were examined, but most were non-significant or of small effects, except an early age of onset, which in social phobia increased the risk of an avoidant PD considerably. Gender or duration of an AD was not related to variation in PD comorbidity. LIMITATIONS Blind rating of diagnoses was recorded from the papers as an indication of diagnostic validity. However, as too few studies reported it the validity of the comorbid estimates of PD was less strong. CONCLUSIONS The findings provided support to several of the proposed changes in the forthcoming DSM-5. Further comorbidity studies are needed in view of the substantial changes in how PDs will be diagnosed in the DSM-5.
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Affiliation(s)
- Oddgeir Friborg
- Faculty of Health Sciences, Department of Psychology, University of Tromsø, Norway.
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Scholte WF, Verduin F, van Lammeren A, Rutayisire T, Kamperman AM. Psychometric properties and longitudinal validation of the self-reporting questionnaire (SRQ-20) in a Rwandan community setting: a validation study. BMC Med Res Methodol 2011; 11:116. [PMID: 21846391 PMCID: PMC3173390 DOI: 10.1186/1471-2288-11-116] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Accepted: 08/16/2011] [Indexed: 11/10/2022] Open
Abstract
Background This study took place to enable the measurement of the effects on mental health of a psychosocial intervention in Rwanda. It aimed to establish the capacities of the Self-Reporting Questionnaire (SRQ-20) to screen for mental disorder and to assess symptom change over time in a Rwandan community setting. Methods The SRQ-20 was translated into Kinyarwanda in a process of forward and back-translation. SRQ-20 data were collected in a Rwandan setting on 418 respondents; a random subsample of 230 respondents was assessed a second time with a three month time interval. Internal reliability was tested using Cronbach's alpha. The optimal cut-off point was determined by calculating Receiver Operating Curves, using semi-structured clinical interviews as standard in a random subsample of 99 respondents. Subsequently, predictive value, likelihood ratio, and interrater agreement were calculated. The factor structure of the SRQ-20 was determined through exploratory factor analysis. Factorial invariance over time was tested in a multigroup confirmatory factor analysis. Results The reliability of the SRQ-20 in women (α = 0.85) and men (α = 0.81) could be considered good. The instrument performed moderately well in detecting common mental disorders, with an area under the curve (AUC) of 0.76 for women and 0.74 for men. Cut-off scores were different for women (10) and men (8). Factor analysis yielded five factors, explaining 38% of the total variance. The factor structure proved to be time invariant. Conclusions The SRQ-20 can be used as a screener to detect mental disorder in a Rwandan community setting, but cut-off scores need to be adjusted for women and men separately. The instrument also shows longitudinal factorial invariance, which is an important prerequisite for assessing changes in symptom severity. This is a significant finding as in non-western post-conflict settings the relevance of diagnostic categories is questionable. The use of the SRQ-20 can be considered an alternative option for measuring the effect of a psychosocial intervention on mental health. Trial registration Nederlands Trial Register NTR1120.
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Affiliation(s)
- Willem F Scholte
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Netherlands.
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Khan NZ, Muslima H, Bhattacharya M, Parvin R, Begum N, Jahan M, Begum D, Akhtar S, Ahmed ASMNU, Darmstadt GL. Stress in mothers of preterm infants in Bangladesh: associations with family, child and maternal factors and children's neuro-development. Child Care Health Dev 2008; 34:657-64. [PMID: 18796057 DOI: 10.1111/j.1365-2214.2008.00873.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of this paper was to ascertain stress experienced by mothers of prospectively followed up preterm infants, and associations with family, child and maternal factors and children's neuro-development. METHODS Within a follow-up study of preterm infants<33 weeks gestational age at a Child Development Center in Dhaka Shishu Hospital, mothers were interviewed with the Self-Report Questionnaire (SRQ) at each visit. Association between SRQ scores and child, family and maternal variables at first and final visit and children's neuro-developmental outcomes was determined. RESULTS Low income mothers were more compliant (54%) compared with the defaulters (31%) (P=0.0001) among the 159 mothers enrolled. Of the 88 mothers who were followed up until a mean age of 22 months of their child, 29.3% were at high risk for psychiatric morbidity at first visit compared with 23.9% on their last visit. Use of abortifacients (P=0.026) and higher maternal age (P=0.040) were significantly associated with maternal stress at first visit; while at last follow-up, total number of visits had the most significant association (P=0.041). Twenty-five per cent and 19% of mothers were at risk for psychiatric morbidity in children developing normally and those with neuro-developmental impairments respectively. CONCLUSIONS Mothers at risk for psychiatric morbidity can be helped through follow-up support within public hospitals close to their homes, which is most availed by low income families. Neuro-developmental monitoring of high-risk infants closer to homes may be more feasible in resource poor countries than reliance on hospital visits, which increase stress. Biological markers of stress and coping strategies need further research.
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Affiliation(s)
- N Z Khan
- Child Development and Neurology Unit, Dhaka Shishu Hospital, Dhaka, Bangladesh.
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Bhargava D, Al-Abri R, Rizvi SGA, Al Okbi MH, Bhargava K, Al-Adawi S. Phenomenology and outcome of factitious disorders in otolaryngology clinic in Oman. Int J Psychiatry Med 2007; 37:229-40. [PMID: 17953239 DOI: 10.2190/3175-282h-11u4-1u07] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The phenomenology of factitious disorders from the Arab part of the world has been lacking in the medical literature and few reports have emerged from otolaryngology. Using an observational prospective case series study (n = 19) with long-term follow-up (two to six years), the present study reports the magnitude and mode of clinical profile of factitious disorders in a tertiary care hospital in Oman, an Arab-Islamic country. The outcome was operationalized as prognosis following culturally sensitive intervention akin to confrontation technique. The present observation suggests the prevalence of factitious disorders in the otolaryngology tertiary care setting was 0.2%. Approximately 42.1% (n = 8) had hemorrhagic factitious disorders, 15.8% (n = 3) were those who feigned for multiple surgical interventions. Approximately 15.8% (n = 3) presented neurological factitious disorders while the remaining 26.3% (n = 5) clinical profile suggested minor feigned illnesses. Objective "evidence factitia" was present in 68.4% (n = 13) of the cases. On subsequent follow-up, nine patients with chronic forms became asymptomatic, three patients had fewer episodes, four patients were unchanged, and three patients were lost to follow-up. The prognosis was good in patients who did not have associated psychiatric illnesses as compared to those with psychiatric disorders. Factitious disorders are often incorrectly diagnosed, with all consequences in terms of adverse sequels. The observed good prognostic outcomes are discussed in the context of socio-cultural patterning and the factors that may shape the presentation of factitious disorders in Oman.
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Zurayk H, Myntti C, Salem MT, Kaddour A, El-Kak F, Jabbour S. Beyond Reproductive Health: Listening to Women About Their Health in Disadvantaged Beirut Neighborhoods. Health Care Women Int 2007; 28:614-37. [PMID: 17668356 DOI: 10.1080/07399330701462017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In this article, we aim to contextualize gynecological problems within a broader health and social context, expanding the lens beyond reproductive health. Questionnaires were administered to 1,869 ever-married women aged 15 to 59 that included questions on living, general health, and gynecological problems. These questions were open-ended, allowing women to respond in their own words. Women reported a multitude of health problems, indicating competing priorities. Musculoskeletal complaints emerged as the most prevalent and most important health problem. One in four women reported a gynecological problem, mainly reproductive tract infections (RTIs), when asked directly. Selected quotes provide clues about the complex relationship between women's lives and health.
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Affiliation(s)
- Huda Zurayk
- American University of Beirut, Beirut, Lebanon.
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Tsutsumi A, Izutsu T, Islam AM, Maksuda AN, Kato H, Wakai S. The quality of life, mental health, and perceived stigma of leprosy patients in Bangladesh. Soc Sci Med 2007; 64:2443-53. [PMID: 17382441 DOI: 10.1016/j.socscimed.2007.02.014] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2006] [Indexed: 10/23/2022]
Abstract
The present study aims to determine the quality of life (QOL) and general mental health of leprosy patients compared with the general population, and evaluate contributing factors such as socio-economic characteristics and perceived stigma. A total of 189 patients (160 outpatients, 29 inpatients) and 200 controls without leprosy or other chronic diseases were selected from Dhaka district, Bangladesh, using stratified random sampling. A Bangladeshi version of a structured questionnaire including socio-demographic characteristics-the Bangla version of the World Health Organization Quality of Life Assessment BREF (WHOQOL-BREF)-was used to assess QOL; a Self-Reporting Questionnaire (SRQ) was used to evaluate general mental health; the Barthel Index to control activities of daily living (ADL); and the authors' Perceived Stigma Questionnaire was used to assess perceived stigma of patients with leprosy. Medical records were examined to evaluate disability grades and impairment. QOL and general mental health scores of leprosy patients were worse than those of the general population. Multiple regression analysis revealed that factors potentially contributing to the deteriorated QOL of leprosy patients were the presence of perceived stigma, fewer years of education, the presence of deformities, and a lower annual income. Perceived stigma showed the greatest association with adverse QOL. We conclude that there is an urgent need for interventions sensitive to the effects of perceived stigma, gender, and medical conditions to improve the QOL and mental health of Bangladeshi leprosy patients.
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Giang KB, Allebeck P, Kullgren G, Tuan NV. The Vietnamese version of the Self Reporting Questionnaire 20 (SRQ-20) in detecting mental disorders in rural Vietnam: a validation study. Int J Soc Psychiatry 2006; 52:175-84. [PMID: 16615249 DOI: 10.1177/0020764006061251] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is a need to develop instruments to measure mental disorders in developing countries because mental disorders are increasingly being recognised as a major public health problem. There has been no previous study in Vietnam validating screening instruments for mental health problems. AIM To adapt and to validate the Self Reporting Questionnaire-20 (SRQ-20) in the Vietnamese community. METHODS A Vietnamese version of the SRQ-20 was developed and tested in 52 persons in a district hospital sample and 485 persons in a community sample. The psychiatrists' diagnoses were taken as the validity criterion. Receiver Operating Characteristic (ROC) analysis was performed to identify the optimal cut-off value. The area under the ROC curve (AUC) was calculated to assess the performance of SRQ in different sociodemographic groups. RESULTS In the district hospital sample, the optimal cut-off score was 5/6 with a sensitivity of 85%, a specificity of 46% and an AUC of 0.74 (95% CI: 0.59-0.89). In the community sample, it was 6/7 with a sensitivity of 85%, a specificity of 61% and AUC of 0.86 (95% CI: 0.81-0.93). In terms of AUC, SRQ performed significantly better in the age group 18-24 years as compared with other ages and with single persons as compared with widowed or divorced people. CONCLUSION The SRQ-20 was found feasible to use and adapt to the Vietnamese setting. We confirmed the value of this instrument for use in developing countries, but the optimal cut-off limit has to be assessed and determined according to local conditions.
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Affiliation(s)
- Kim Bao Giang
- Faculty of Public Health, Hanoi Medical University, Vietnam.
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