Preliminary communicationCross-cultural validity of the Spanish version of PHQ-9 among pregnant Peruvian women: A Rasch item response theory analysis
Introduction
The patient health questionnaire-9 (PHQ-9) is a very brief, easy to administer and interpret depression screening instrument (Kroenke et al., 2001). Because of its brevity and demonstrated good reliability and validity (Kroenke et al., 2001), the PHQ-9 is one of the most widely used depression screening instruments in primary care settings among racially and ethnically diverse populations. The PHQ-9 has generally been validated under the framework of classic test theory (CTT) or traditional psychometric approaches. However, these traditional techniques often provide inaccurate diagnosis and hide the heterogeneity that exists in each specific item (Hobart et al., 2007, Packham and Macdermid, 2013). These methods are now being complemented and, in some cases replaced, by item response theory (IRT) approaches and particularly by the application of the Rasch models.
Rasch IRT models are considered the most appropriate and robust methods to examine the measurement properties of rating scales such as the PHQ-9 (Hobart et al., 2007). Specifically, application of Rasch IRT models for analysis of the PHQ-9 provides an opportunity to identify and subsequently reduce the potential bias that may exist when using the depression screening instruments in new cultural settings. Consequently, results from analyses of Rasch models can be used to increase the validity and utility of depression screening when the PHQ-9 is used in culturally diverse settings.
To date, only five studies have evaluated the properties of the PHQ-9 using Rasch IRT models (Gelaye et al., 2013, Williams et al., 2009, Smith et al., 2008, Smith et al., 2009, Lamoureux et al., 2009) and none included the Spanish language version of PHQ-9. Although the PHQ has been used in studies of pregnant women (Melville et al., 2010, Spitzer et al., 2000) its validity has not been confirmed using Rasch models. Given the high prevalence of depression in this population (World Health Organization, 2008), it is important to evaluate the validity and utility of PHQ-9. In addition, symptomology characteristics of pregnant women are different from those of non-pregnant women (Yawn et al., 2009, Yonkers et al., 2009, Ross et al., 2003). Significant potential benefit will be gained to the mother and fetus/infant if depression is detected and managed (Adewuya et al., 2006). Therefore the aim of this study is to validate the Spanish language version of the PHQ-9 among pregnant Peruvian women using Rasch IRT models, and to examine the appropriateness of the response formats, psychometric validity and potential bias of items by age, education attainment and employment status. Clinically, the PHQ-9 can be used as a time-effective screening instrument to potentially identify pregnant women at risk for depression in resource limited clinical settings.
Section snippets
Study population
This cross-sectional investigation was a part of pregnancy outcomes, maternal and infant study (PrOMIS) Cohort. The PrOMIS Cohort is an ongoing prospective study of pregnant women enrolled in prenatal care clinics at the Instituto Nacional Materno Perinatal (INMP) in Lima, Peru. The INMP is the main reference establishment for maternal and perinatal care operated by the Ministry of Health of the Peruvian government. Women who attended the INMP for their first prenatal care visit from February
Participant characteristics
Participants׳ socio-demographic and reproductive characteristics are summarized in Table 1. Briefly, the mean age of participants was 28.0 years (standard deviation=6.2 years). The majority of participants were Mestizo (75.5%), with at least 7 years of education (95.5%), and multigravida (68.2%). On average, participants were interviewed at a gestational age of 9.8 weeks (standard deviation=3.4 weeks). More than half of study participants were not employed (56.5%), and reported that the current
Discussion
The Spanish language version of PHQ-9 demonstrated unidimensionality, local independence, adequate fit for the Rasch IRT model and moderate reliability. However, we detected disordered response categories for the original four response categories (“not at all,” “several days,” “more than half the days,” and “nearly every day”). After collapsing the latter two categories, the response categories ordered properly and the PHQ-9 fit the Rasch IRT model. As it intended, the Spanish language version
Role of funding source
This research was supported by an award from the National Institutes of Health (NIH), the Eunice Kennedy Shriver Institute of Child Health and Human Development (R01-HD-059835). The NIH had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.
Conflict of interest
The authors have no competing interests to declare.
Acknowledgment
The authors wish to thank the dedicated staff members of Asociacion Civil Proyectos en Salud (PROESA), Peru and Instituto Especializado Materno Perinatal, Peru for their expert technical assistance with this research.
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