Factorial validity of the Twi versions of five measures of mental health and well-being in Ghana

Internal Structure of the Patient Health Questionnaire-9: A Systematic Review and Meta-analysis

PURPOSE

This review aimed to evaluate the internal structure (structural validity, internal consistency, and measurement invariance) of the Patient Health Questionnaire-9 (PHQ-9), which is one of the most widely used self-administered instruments for assessing and screening depression.

METHODS

The updated COnsensus-based Standards for the selection of health Measurement Instruments methodology for a systematic review of self-reported instruments was used. PubMed, Embase, CINAHL, PsycINFO, and the Cochrane Library databases were searched from their inception up to February 28, 2023.

RESULTS

This study reviewed 98 psychometric studies reported on in 90 reports conducted in 40 countries. Various versions of the PHQ-9 were identified: one-factor structures (8 types), two-factor structures (10 types), bifactor structures (4 types), three-factor structure (1 type), and second-order three-factor structure (1 type). There was sufficient high-quality evidence for structural validity of the one-factor structure with nine items scored using a four-point Likert scale based on confirmatory factor analysis, for internal consistency with a quantitatively pooled Cronbach α of .85, and for measurement invariance across sex, age, education level, marital status, and income groups. There was sufficient high-quality evidence for structural validity, internal consistency (Cronbach's α = .76- .92, ω = 0.83- .92), and measurement invariance across sex for the PHQ-8 (which excluded item 9: "suicidality or self-harm thoughts").

CONCLUSION

The one-factor PHQ-9 and PHQ-8 (excluding item 9) scored using a four-point Likert scale have the best internal structure based on the current evidence. The one-factor PHQ-9 and PHQ-8 justify the use of aggregated total scores in both practice and research. The total score of the PHQ-9 using a four-point Likert scale can be used to compare depression levels across sex, age, education level, marital status, and income groups due to the availability of sufficient evidence for measurement invariance across these demographic groups.

A bibliometric review of positive psychology and well-being research in Africa

Positive Psychology rapidly developed into an influential field of study and intervention, initially situated in Psychology, and later becoming multidisciplinary. Research interest in the study of (psychological) well-being has gained global popularity, with increasing salience in Africa. Although the global trends of these developments are relatively well-known, a bibliometric analysis of positive psychology research in Africa was necessary to shed light on the present hotspots and trends and future trajectories in this region of the world. The data source of the present bibliometric analysis study was Scopus, from which Positive Psychology and well-being research literature from Africa between 1983 and 2023 were searched. Using biblioshiny and VOSviewer, the 622 extracted articles were analysed, from which findings about the current condition, research hotspots, and thematic developmental patterns could be made. Africa experienced an initial slow growth period from 1983 until 2005, after which a rapid growth in research productivity, relevance and impact was experienced. In this regard, the results show that the focal point of scientific productivity is South Africa, with the dominance of South African institutions, particularly the North-West University, from where most positive psychology research is produced and cited. Even with potential access to international journal, African researchers seem to prefer to place their publications in the regional journals such as Journal of Psychology in Africa and South African Journal of Psychology. The research reviewed tends to be characterised by more dominant thematic clusters of positive psychology, psychological well-being, and subjective well-being, with a focus on human individuals. An increasing concern for contextual factors and potential antecedents and dynamics of well-being is also observed. The findings provide a good map from which identification of future research priorities can be deduced. As such, we speculate that future positive psychology research in Africa ought to be concerned with the following: greater distribution and intercountry collaborations across the continent, questions of conceptual clarity of terms, better understanding of contextual factors which influence well-being, and well-being research embracing the complexity of bio-psycho-social-ecological well-being, and science concerned with health-promotion interventions.

Confirmatory factor analysis of latent constructs for measuring social well-being in African migrant samples

The present study contributes to psychology and well-being literature by investigating social well-being in minority contexts. The factor structure of the Keyes' long format 33-item social well-being measure was investigated among African migrant samples. A cross-sectional survey methodology was used to collect data from a total of 404 African migrants living in South Africa (n = 146), Uganda (n = 158) and Kenya (n = 100). They were 202 (50%) males, 195 (48.3%) females, and 7 (1.7%) of the samples did not disclose their gender. They were aged from 14 to 70 with a Mean age of 32.21 (standard deviation = 7.696). Data collected were analysed using CFA in AMOS (version 29). We found an unstable four-factor emic solution for African migrants in Sub-Sahara Africa. We could not replicate the theoretical social well-being model of Keyes (1998) among African migrant samples in Sub-Saharan Africa. Insights from the study will be critical to designing culturally appropriate indigenous measures that accurately reflect the social realities and well-being constructs of African migrants. Our findings will also help policymakers and service providers to identify areas of need, develop appropriate socio-cultural programmes, and allocate resources more effectively to support the integration and well-being of migrants within African societies.

Psychometric properties of the Harmony in Life Scale in South African and Ghanaian samples

Harmony is regarded as important for well-being in many cultures. However, (cultural) differences in the meanings and manifestations of harmony may impact the equivalence of measures of harmony in life, as well as the associations between harmony and other well-being constructs. This study aimed to investigate the factorial, convergent and divergent validity, and measurement invariance of the Harmony in Life Scale (HILS) in South African and Ghanaian samples. Confirmatory factor analysis was applied to data from three South African samples (two multicultural samples completed the HILS in English; and a Setswana-speaking sample completed the HILS in Setswana) and one Ghanaian sample (completed the HILS in English). Sample sizes ranged between n = 400 and n = 427. Good fit indices were obtained for all samples, except for the Setswana-speaking sample from South Africa. In all instances the HILS showed good internal consistency reliability and convergent and divergent validity. Full scalar invariance was supported for the two multicultural South African samples, but only partial scalar invariance when data from the Ghanaian sample were added to the analysis. The HILS shows potential for future use in all samples, except the Setswana-speaking sample. Findings emphasise the importance of considering cultural and/or contextual and linguistic differences and how these may influence the measurement of psychological constructs. Future research should qualitatively explore the meanings and manifestations of harmony in various African and other global contexts in local languages.Contribution: This study is the first to investigate the psychometric properties of the original English version of the HILS in South African and Ghanaian samples, as well as a Setswana translation of the scale. The study contributes to the understanding of harmony in life and the measurement thereof in diverse contexts, in this case specifically focused on African samples, and may, in turn, inform interventions and evaluation of interventions. 

Depression and Quality of Life of People Accused of Witchcraft and Living in Alleged Witches’ Camps in Northern Ghana

In Northern and Northeast Ghana, women accused of witchcraft are banished from society to live in special locations designated “witches camps.” The processes leading to their banishment, admission, and living in the camps may affect their psychological wellbeing and quality of life. This study was conducted to determine the prevalence of depression and assess the quality of life of 277 alleged witches in four camps located in these two regions in Ghana. A structured questionnaire was developed and administered using the open data collection kit (ODK). The Patient Health Questionnaire-8 (PHQ-8) and the World Health Organisation Quality of Life (WHOQOL) questionnaires were adopted to measure depression and health-related quality of life, respectively. The data were analysed using STATA version 16. The prevalence of depression among the alleged witches was 52.7%. Out of this, 37.2% had moderate depression, 7.2% had moderate or severe depression whilst 2.9% had severe depression. The sociodemographic factors that have a statistically significant association with depression included gender, marital status, being widowed or separated, and not having biological children. Over 97% of alleged witches have a low or extremely low quality of life. In conclusion, the majority of the people accused of witchcraft have a low or extremely low quality of life with high-probable depression.

Bifactor exploratory structural equation modeling: A meta-analytic review of model fit

Multivariate behavioral research often focuses on latent constructs-such as motivation, self-concept, or wellbeing-that cannot be directly observed. Typically, these latent constructs are measured with items in standardized instruments. To test the factorial structure and multidimensionality of latent constructs in educational and psychological research, Morin et al. (2016a) proposed bifactor exploratory structural equation modeling (B-ESEM). This meta-analytic review (158 studies, k = 308, N = 778,624) aimed to estimate the extent to which B-ESEM model fit differs from other model representations, including confirmatory factor analysis (CFA), exploratory structural equation modeling (ESEM), hierarchical CFA, hierarchical ESEM, and bifactor-CFA. The study domains included learning and instruction, motivation and emotion, self and identity, depression and wellbeing, and interpersonal relations. The meta-analyzed fit indices were the χ2 /df ratio, the comparative fit index (CFI), the Tucker-Lewis index (TLI), the root mean square error of approximation (RMSEA), and the standardized root mean squared residual (SRMR). The findings of this meta-analytic review indicate that the B-ESEM model fit is superior to the fit of reference models. Furthermore, the results suggest that model fit is sensitive to sample size, item number, and the number of specific and general factors in a model.

Context matters: Sociocultural considerations in the design and implementation of community-based positive psychology interventions in sub-Saharan Africa

Scholars conducting cross-cultural research in mental health often import intervention programs found to be efficacious in one social context (e.g., Western) and directly implement them in other contexts (e.g., African and Asian) without recourse to the sociocultural disparities between the target populations and the theoretical foundations of the constructs and principles underpinning the intervention programs. Such efforts mistakenly assume that positive psychology interventions (PPIs), most of which were developed from Western perspectives and assumed individualistic cultural orientation and value systems, operate equally across all contexts. Drawing on the extant literature and on insights from designing, implementing, and evaluating group-based (mental) health behavior change intervention programs across several communities in Ghana, we discuss some sociocultural, theoretical, and methodological issues that can significantly constrain the design, uptake, and effectiveness of PPIs in the rural, low literate, socioeconomically disadvantaged, highly collectivistic context of Ghana, and sub-Saharan Africa more generally. In all illustrations, we offer suggestions to guide the design and implementation processes to ensure culturally appropriate, highly acceptable, and potentially effective intervention programs. We argue that PPIs can be potentially fructuous in the sub-region when adapted to, or embedded in, the cultural values of the target population and tailored to the needs, capacities, and circumstances of participants.

Measuring Positive Mental Health and Depression in Africa: A Variable-Based and Person-Centred Analysis of the Dual-Continua Model

The dual-continua model of mental health provides a contemporary framework for conceptualising and operationalising mental health. According to this model, mental health is distinct from but related to mental illness, and not the opposite or merely the absence of psychopathology symptoms. To examine the validity of the dual-continua model, previous studies have either applied variable-based analysis such as confirmatory factor analysis (CFA), or used predetermined cut-off points for subgroup division. The present study extends this contribution by subjecting data from an African sample to both CFA and latent class analysis (LCA) to test the dual-continua model in Africa. We applied CFA separately for the Mental Health Continuum—Short Form (MHC-SF) and Patient Health Questionnaire—9 (PHQ-9); and LCA on combined item responses. College students (N = 892; average age = 22.74, SD = 4.92; female = 58%) from Ghana (n = 309), Kenya (n = 262), Mozambique (n = 232), and South Africa (n = 89) completed the MHC-SF and PHQ-9. With minor modifications to the measurement models, the CFA results of this study confirm the three-factor structure of the MHC-SF, and a unidimensional solution for the PHQ-9. LCA results show the presence of three distinct latent classes: languishing with moderate endorsement of depressive symptoms (25.9%), flourishing with low endorsement of depressive symptoms (63.7%), and moderate mental health with high endorsement of depressive symptoms (10.4%). These findings further contribute to affirming the evidence for the dual-continua model of mental health, with implications for the assessment of mental health, to inform policy, practise, and future research in community and clinical settings in Africa.

The Inspired Life Program: Development of a multicomponent positive psychology intervention for rural adults in Ghana

Although several theories and studies have explored human strengths and mental well-being at the global level, these insights are rarely tested and translated into practice in sub-Saharan Africa. This study aims to describe the development of a 10-session multicomponent positive psychology intervention, the Inspired Life Program (ILP), designed to promote mental health and reduce symptoms of depression and negative affect in rural adults in Ghana. Guided by the Medical Research Council's framework for developing complex interventions, a seven-step iterative community-based participatory research approach was adopted to develop the ILP, based on constructs and principles of positive psychology and cognitive-behavioral model. The final intervention components included a 10-session, two-hourly, once-weekly manualized program designed to promote meaningful and purposeful living, self-acceptance, personal growth, goal-setting and problem-solving skills, and positive thinking through group discussion and activity sessions. We describe the program theory and implementation strategy of the final intervention, and reflect on the challenges and lessons learned from applying this framework in the study context. The development of strengths-based interventions and practicality of methods to promote positive mental health in rural adults are feasible, and have important policy implications for mental health and social care in sub-Saharan Africa.

Participants' experiences and impressions of a group-based positive psychology intervention programme for rural adults in Ghana

Introduction: There is growing evidence that group-based mental health intervention programmes can encourage the development of peer support, psychosocial skills, and collaborative therapeutic relationships with longer lasting effects. This study explored participants' experiences of, perceived benefits of, and recommendations to improve a 10-session group-based multicomponent positive psychology intervention (mPPI)-the Inspired Life Programme (ILP)-designed to promote positive mental health and reduce symptoms of depression and negative affect in a sample of rural Ghanaian adults.Method: Face-to-face semi-structured individual interviews were conducted with 18 randomly selected programme participants three months after their participation in the ILP. Data were analysed thematically with an inductive approach.Results: Participants described their experience of the ILP as a forum for growth that granted them the opportunity to introspect, practicalise and situate everyday life challenges, connect with others, and to develop a sense of mutual accountability. Results indicate that the ILP  led participants to develop a stronger sense of positivity and well-being, fructify their ideas, and to cultivate stronger social networks and relationships that led to increased vocational productiveness. Participants recommended that researchers include facets of physical health promotion in the programme and invite close relations of participants to participate in the programme.Conclusion: This study provides the first insight into participants' experiences of a group-based mPPI in Ghana. These findings may provide useful information to inform the design of context-appropriate community-based mental health interventions to fit participants' specific needs, capacities, and circumstances.

Gurus and Griots: Revisiting the research informed consent process in rural African contexts

BACKGROUND

Researchers conducting community-based participatory action research (CBPAR) in highly collectivistic and socioeconomically disadvantaged community settings in sub-Saharan Africa are confronted with the distinctive challenge of balancing universal ethical standards with local standards, where traditional customs or beliefs may conflict with regulatory requirements and ethical guidelines underlying the informed consent (IC) process. The unique ethnic, socioeconomic, and cultural diversities in these settings have important implications for the IC process, such as individual decisional autonomy, beneficence, confidentiality, and signing the IC document.

MAIN TEXT

Drawing on insights and field observations from conducting CBPARs across several rural, highly communal, low literate, and low-income communities in Ghana, we discuss some theoretical, ethico-cultural, and methodological challenges associated with applying the universal, Western individualistic cultural value-laden IC process in sub-Saharan Africa. By citing field situations, we discuss how local cultural customs and the socioeconomic adversities prevalent in these settings can influence (and disrupt) the information disclosure process, individual decisional authority for consent, and voluntariness. We review the theoretical assumptions of the Declaration of Helsinki's statement on IC and discuss its limitations as an ultimate guide for the conduct of social science research in the highly communal African context. We argue that the IC process in these settings should include strategies directed at preventing deception and coercion, in addition to ensuring respect for individual autonomy. We urge Universities, research institutions, and institutional review boards in Africa to design and promote the use of context-appropriate ethical IC guidelines that take into consideration both the local customs and traditional practices of the people as well as the scientific principles underpinning the universal IC standards.

CONCLUSION

We recommend that, rather than adopt a universal one-size-fits-all IC approach, researchers working in the rural, highly collectivistic, low literate, socioeconomically disadvantaged settings of sub-Saharan Africa should deeply consider the roles and influence of cultural values and traditional practices on the IC and the research process. We encourage researchers to collaborate with target communities and stakeholders in the design and implementation of context-appropriate IC to prevent ethics dumping and safeguard the integrity of the research process.

Prevalence of positive mental health and functioning among adults with sickle cell disease in Ghana

Objectives

With increasing survival rates of children with sickle cell disease (SCD) reaching adulthood, there has been a growing interest in the quality of life and mental health functioning of affected individuals. Positive mental health is recognised as a significant dimension of human health that plays an important role in advancing well-being. This study explored the prevalence of positive mental health and functioning among a sample of Ghanaian adults with SCD.

Methods

A quantitative cross-sectional survey design was implemented for data-gathering. A random sample of 62 adult SCD patients (21 to 56 years; mean age of 29 years) receiving treatment at the Sickle Cell Clinic of the Ghana Institute of Clinical Genetics at the Korle-Bu Teaching Hospital completed the Mental Health Continuum-Short Form (MHC-SF). Descriptive statistics and reliability indices were estimated for the MHC-SF. We implemented Keyes's criteria for the assessment and categorisation of levels of mental health to determine the prevalence of positive mental health and functioning.

Results

We found a high level of positive mental health (66% flourishing; 26% moderately mentally healthy; 8% languishing) and functioning, with no significant difference between the genders. A total of 34% of the participants were functioning at suboptimal levels and were at risk of psychopathology.

Conclusion

This study gives the first overview of the prevalence of positive mental health and functioning in a clinical population in Ghana. Although the majority of participants were flourishing, contextually appropriate positive psychological interventions are needed to promote the mental health of SCD patients who are functioning at suboptimal levels, which would, inherently, also buffer against psychopathology.

Funding

Self-funded.

Community-based participatory research in rural African contexts: Ethico-cultural considerations and lessons from Ghana

Researchers conducting community-based participatory research (CBPR) with vulnerable populations in rural African settings are confronted with distinctive ethical and cultural challenges due to the community context of their research, their methods of investigation, and the implications of their findings for populations. Ethical considerations such as informed consent, the protection of privacy and confidentiality, and relationships between researchers and participants take on greater complexity and have implications beyond the individual research participant. Drawing on careful reflections of experiences from conducting mental health promotion intervention research using the CBPR approach and multi-methods in resource-poor rural communities in Ghana, we examine a range of ethico-cultural issues associated with community-based group intervention research in rural remote settings of Ghana. We offer suggestions to help researchers to envision and manage these complexities in a more appropriate way. Approaches aimed to promote relationships, fairness, respect, and cultural harmony between researchers and study participants are outlined. We urge prospective researchers to carefully explore and respect the cultural values and practices of community members and observe locally-defined ethical values and principles when conducting CBPRs in rural African settings to minimise ethics dumping and safeguard the integrity of their research.

Association of Internet Addiction with Family Functionality, Depression, Self-Efficacy and Self-Esteem among Early Adolescents

Early adolescents usually have worse self-control and poor time management abilities. They are a higher-risk group for Internet addiction than older adolescents or adults. This study aims to explore the prevalence of Internet addiction and associated factors in early adolescents. Participants included 451 fifth and sixth-grade students in Central Taiwan. This study adopted a cross-sectional design and a structured questionnaire that consisted of demographics, Young's Internet Addiction Test, the Centre for Epidemiological Studies-Depression scale, the General Self-Efficacy Scale and the Rosenberg Self-Esteem Scale. The participants were 50.8% male, and the mean age was 11.35, with a range of 10.33-12.92 years. A total of 33.7% of all participants were prone to Internet addiction. The results showed that participants who were male and had high money allowance, poor family atmosphere, parents who did not limit Internet usage time, high depression, low self-efficacy and low self-esteem were more prone to Internet addiction. A multiple logistic regression analysis revealed that being male, having parents who did not limit Internet usage time and higher degrees of depression were the associated factors of Internet addiction in early adolescents. The phenomenon of Internet addiction among early adolescents seems to be increasing. Improving family functionality and individual mental health may be effective ways to reduce Internet addiction.

Integrated mental health screening for obstetric fistula patients in Mali: From evidence to policy

BACKGROUND

Obstetric fistula significantly impacts women's mental health and well-being. Routine screening for mental health in fistula repair programs can be a gateway to link patients to services, and can produce routine data to inform programmatic investments. This study observed the integration of a mental health screening program into an obstetric fistula repair program in Mali, with two specific objectives: 1) to describe the social and mental health well-being of women presenting with obstetric fistulas in Mali, and 2) to document the impact of the mental health screening pilot on policy change in Mali.

METHODS

Seven fistula repair campaigns were conducted between June 2016 and May 2017. All individuals presenting for fistula repair completed a mental health assessment at intake, including a depression screener (PHQ-9) and an assessment of psycho-social impacts of fistula. The depression screener was repeated three months following inpatient discharge. Findings were shared with stakeholders in Mali and impacts on policy were documented.

RESULTS

Of 207 women who presented for fistula repair, 167 patients completed the mental health assessment at surgical intake, and 130 patients repeated the screener at 3-month follow-up. At intake, 36.5% of women had moderate or severe depression, decreasing to 16.9% at follow-up. The mean depression score differed significantly by timepoint (9.14 vs. 6.72, p <0.001). Results were shared in a report with stakeholders, and consultations with the Mali Ministry of Health. As a result of advocacy, mental health was a key component of Mali's National Fistula Prevention and Treatment Strategy (2018-2022).

CONCLUSION

The high prevalence of depression in Malian fistula patients underscores a need for more robust mental health support for patients after surgery. Data on mental health from routine screening informs community reintegration strategies for individual patients, elevates the overall quality of care of fistula repair programs by addressing patients' holistic health needs, and contributes to evidence-informed decision-making and data-driven policy change within the larger health system.