ABSTRACT

Objective

. To translate and culturally adapt the Patient Health Questionnaire (PHQ-9) to three varieties of Quechua and analyse their validity, reliability, and measurement invariance.

Materials and methods

. 1) Cultural adaptation phase: the PHQ-9 was translated from English into three variants of Quechua (Central, Chanca, Cuzco-Collao) and translated again into English. Then, experts and focus groups allowed the translations to be culturally adapted. 2) Psychometric phase: the unidimensionality of the adapted PHQ-9 was evaluated by using Confirmatory Factor Analysis (CFA), reliability was evaluated by internal consistency (Alpha and Omega), and measurement invariance according to Quechua varieties and sociodemographic variables was evaluated by using CFA, multigroups and MIMIC models (Multiple Indicator Multiple Cause).

Results

. Each of the adaptations of the PHQ-9 to the three Quechua varieties reported clear and culturally equivalent items. Subsequently, data from 970 Quechua-speaking adult men and women were analyzed. The general one-dimensional model reported an adequate fit (Comparative fit index = 0.990, Tucker-Lewis index = 0.987, Standardized root mean squared residual= 0.048, Root mean squared error of approximation=0.071); each of the Quechua varieties also showed an adequate fit. Reliability was high for all varieties (α = 0.865 - 0.915; ω = 0.833 - 0.881). The results of the multigroup CFA and MIMIC models confirmed measurement invariance according to Quechua variant, sex, residence, age, marital status and educational level.

Conclusions

. The PHQ-9 adaptations to Central Quechua, Chanca and Cuzco-Collao offer a valid, reliable and invariant measurement, confirming that comparisons can be made between the evaluated groups. Its use will benefit mental health research and care for Quechua-speaking populations.

Keywords:
Patient Health Questionnaire; depression; Indigenous Peoples; Psychometrics

KEY MESSAGES

1. Motivation for the study. Peru is the country with the largest Quechua-speaking population in South America, but it does not have an instrument to assess depression culturally adapted to Quechua populations.
2. Main findings. A valid and reliable version of the PHQ-9 was obtained for use in Quechua-speaking populations of the Central, Chanca and Cuzco-Collao varieties.
3. Implications. This new version could be implemented in national health surveys and community mental health centers for screening and evaluation of depressive symptoms.

Keywords:
Patient Health Questionnaire; depression; Indigenous Peoples; Psychometrics

INTRODUCTION

Depression is a frequent mental disorder, and is caused by complex interactions between social, psychological and biological factors ¹1. Villarreal-Zegarra D, Copez-Lonzoy A, Bernabé-Ortiz A, Melendez-Torres GJ, Bazo-Alvarez JC. Valid group comparisons can be made with the Patient Health Questionnaire (PHQ-9): A measurement invariance study across groups by demographic characteristics. PLOS ONE. 2019;14(9):e0221717. doi: 10.1371/journal.pone.0221717.
https://doi.org/10.1371/journal.pone.022... . According to the World Health Organization, more than 5% of the world population had depression in 2021 ²2. World Health Organization. Depression [Internet]. Geneva: WHO; 2021 [citado el 5 de julio de 2022]. Disponible en: https://www.who.int/health-topics/depression.
https://www.who.int/health-topics/depres... , increasing by 25% during the COVID-19 pandemic ³3. World Health Organization. COVID-19 pandemic triggers 25% increase in prevalence of anxiety and depression worldwide [Internet]. Geneva: WHO; 2022 [citado el 5 de julio de 2022]. Disponible en: https://www.who.int/news/item/02-03-2022-covid-19-pandemic-triggers-25-increase-in-prevalence-of-anxiety-and-depression-worldwide.
https://www.who.int/news/item/02-03-2022... . In Peru, of 57,446 respondents, 60.1% of 9383 persons with a mental health diagnosis living in the Peruvian highlands and coast, with the exception of Metropolitan Lima, had depressive symptoms during the pandemic ⁴4. Antiporta DA, Cutipé YL, Mendoza M, Celentano DD, Stuart EA, Bruni A. Depressive symptoms among Peruvian adult residents amidst a National Lockdown during the COVID-19 pandemic. BMC Psychiatry. 2021;21(1):111. doi: 10.1186/s12888-021-03107-3.
https://doi.org/10.1186/s12888-021-03107... . Another Peruvian study, that evaluated 31,996 participants, found that living in the highland region was an important factor for the increase in clinically relevant depressive symptoms, reporting 9.0% of moderate to severe cases, compared with 5.8% in other regions ⁵5. Hernández-Vásquez A, Vargas-Fernández R, Bendezu-Quispe G, Grendas LN. Depression in the Peruvian population and its associated factors: analysis of a national health survey. J Affect Disord. 2020;273(1):291-7. doi: 10.1016/j.jad.2020.03.100.
https://doi.org/10.1016/j.jad.2020.03.10... .

The Patient Health Questionnaire (PHQ-9) is a psychometric instrument designed to assess depressive symptoms according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders - IV ⁶6. American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders, Fouth Edition, Text Revision (DSM-4) [Internet]. 2013 [citado el 13 de julio de 2022]. Disponible en: https://psychiatry.org:443/psychiatrists/practice/dsm
https://psychiatry.org:443/psychiatrists... . Originally written in English with a single factor ⁷7. Kroenke K, Spitzer RL, Williams JBW. The PHQ-9 Validity of a Brief Depression Severity Measure. J Gen Intern Med. 2001;16(9):606-13. doi: https://doi.org/10.1046/j.1525-1497.2001.016009606.x.
https://doi.org/https://doi.org/10.1046/... , it is widely used in clinical practice and research internationally ⁸8. Obbarius A, van Maasakkers L, Baer L, Clark DM, Crocker AG, de Beurs E, et al. Standardization of health outcomes assessment for depression and anxiety: recommendations from the ICHOM Depression and Anxiety Working Group. Qual Life Res. 2017;26(12):3211-25. doi: 10.1007/s11136-017-1659-5.
https://doi.org/10.1007/s11136-017-1659-... . It has been adapted to more than 18 languages in 24 countries ⁹9. El-Den S, Chen TF, Gan YL, Wong E, O'Reilly CL. The psychometric properties of depression screening tools in primary healthcare settings: A systematic review. J Affect Disord. 2018;225(1):503-22. doi: 10.1016/j.jad.2017.08.060.
https://doi.org/10.1016/j.jad.2017.08.06... , such as French ¹⁰10. Arthurs E, Steele RJ, Hudson M, Baron M, Thombs BD, Group (CSRG) Canadian Scleroderma Research. Are Scores on English and French Versions of the PHQ-9 Comparable? An Assessment of Differential Item Functioning. PLOS ONE. 2012;7(12):e52028. doi: 10.1371/journal.pone.0052028.
https://doi.org/10.1371/journal.pone.005... , Mandarin Chinese ¹¹11. Leung D, Wah Y, Leung SF, Chiang V, Yuen A. Measurement invariances of the PHQ-9 across gender and age groups in Chinese adolescents. Asia-Pacific Psychiatry. 2020;12(e12381). doi: https://doi.org/10.1111/appy.12381.
https://doi.org/10.1111/appy.12381... , Spanish ¹²12. Muñoz-Navarro R, Cano-Vindel A, Medrano LA, Schmitz F, Ruiz-Rodríguez P, Abellán-Maeso C, et al. Utility of the PHQ-9 to identify major depressive disorder in adult patients in Spanish primary care centres. BMC Psychiatry. 2017;17(1):291. doi: 10.1186/s12888-017-1450-8.
https://doi.org/10.1186/s12888-017-1450-... , Russian ¹³13. Pogosova NV, Dovzhenko TV, Babin AG, Kursakov AA, Vygodin VA. Russian version of PHQ-2and 9 questionnaires: Sensitivity and specificity in detection of depression in outpatient general medical practice. Cardiovascular Therapy and Prevention. 2014;13(3):18-24. Disponible en: https://cardiovascular.elpub.ru/jour/article/view/51.
https://cardiovascular.elpub.ru/jour/art... , German ¹⁴14. Reich H, Rief W, Brähler E, Mewes R. Cross-cultural validation of the German and Turkish versions of the PHQ-9: an IRT approach. BMC Psychology. 2018;6(1):26. doi: 10.1186/s40359-018-0238-z.
https://doi.org/10.1186/s40359-018-0238-... , Norwegian ¹⁵15. Wisting L, Johnson SU, Bulik CM, Andreassen OA, Rø Ø, Bang L. Psychometric properties of the Norwegian version of the Patient Health Questionnaire-9 (PHQ-9) in a large female sample of adults with and without eating disorders. BMC Psychiatry. 2021;21(1):6. doi: 10.1186/s12888-020-03013-0.
https://doi.org/10.1186/s12888-020-03013... , Farsi ¹⁶16. Maroufizadeh S, Omani-Samani R, Almasi-Hashiani A, Amini P, Sepidarkish M. The reliability and validity of the Patient Health Questionnaire-9 (PHQ-9) and PHQ-2 in patients with infertility. Reprod Health. 2019;137(16):e. doi: https://doi.org/10.1186/s12978-019-0802-x.
https://doi.org/https://doi.org/10.1186/... , Lithuanian ¹⁷17. Pranckeviciene A, Saudargienne A, Gecaite-Stonciene J, Liaugaudaite V, Griskova-Bulanova I, Simkute D, et al. Validation of the patient health questionnaire-9 and the generalized anxiety disorder-7 in Lithuanian student sample. Plos One. 2022;27(1):e0263027. doi: 10.1371/journal.pone.0263027.
https://doi.org/10.1371/journal.pone.026... ⁾ and even Kinyarwanda ¹⁸18. Sebera F, Nickenig JR, Umwiringirwa J, Teuwen D, Boon P, Dedeken P. Validity, reliability and cut-offs of the Patient Health Questionnaire-9 as a screening tool for depression among patients living with epilepsy in Rwanda. Plos One. 2020 ;12(6):e0234095. doi: 10.1371/journal.pone.0234095.
https://doi.org/10.1371/journal.pone.023... . The Spanish version of this instrument has shown good properties among Spanish speakers in Peru ¹1. Villarreal-Zegarra D, Copez-Lonzoy A, Bernabé-Ortiz A, Melendez-Torres GJ, Bazo-Alvarez JC. Valid group comparisons can be made with the Patient Health Questionnaire (PHQ-9): A measurement invariance study across groups by demographic characteristics. PLOS ONE. 2019;14(9):e0221717. doi: 10.1371/journal.pone.0221717.
https://doi.org/10.1371/journal.pone.022... .

In a previous study on the Peruvian version of the PHQ-9 (in Spanish) ¹1. Villarreal-Zegarra D, Copez-Lonzoy A, Bernabé-Ortiz A, Melendez-Torres GJ, Bazo-Alvarez JC. Valid group comparisons can be made with the Patient Health Questionnaire (PHQ-9): A measurement invariance study across groups by demographic characteristics. PLOS ONE. 2019;14(9):e0221717. doi: 10.1371/journal.pone.0221717.
https://doi.org/10.1371/journal.pone.022... , we reported evidence of measurement invariance according to socio-demographic variables: sex, age, educational level, socioeconomic status, marital status and area of residence (rural/urban). Such evidence allows comparisons between different groups (according to the categories of these variables), ensuring that PHQ-9 results indicate a similar underlying experience of depressive symptoms across these groups (e.g., men and women) ¹⁹19. Baas KD, Cramer AOJ, Koeter MWJ, van de Lisdonk EH, van Weert HC, Schene AH. Measurement invariance with respect to ethnicity of the Patient Health Questionnaire-9 (PHQ-9). J Affect Disord. 2011;129(1):229-35. doi: doi.org/10.1016/j.jad.2010.08.026.
https://doi.org/doi.org/10.1016/j.jad.20... . This invariance assessment has not been applied to any version of the PHQ-9 in Quechua yet. Without invariance analysis, there is no guarantee that the PHQ-9 measures depression in the same way in all Quechua-speaking groups, hence its necessity ²⁰20. Putnick DL, Bornstein MH. Measurement Invariance Conventions and Reporting: The State of the Art and Future Directions for Psychological Research. Dev Rev. 2016;41:71-90. doi: 10.1016/j.dr.2016.06.004.
https://doi.org/10.1016/j.dr.2016.06.004... .

However, there is still no Quechua version of the PHQ-9 for the Peruvian population. Peru has 3,799,780 inhabitants who have Quechua as their first language, representing 13.6% of the census population in 2017 ²¹21. Andrade L. Diez noticias sobre el quechua en el último censo peruano. Letras (Lima). 2019;90(132):41-70. doi: 10.30920/letras.90.132.2.
https://doi.org/10.30920/letras.90.132.2... . People ethnically self-identified as Quechua may perceive and express depressive symptoms differently than a Spanish speaker, which makes it difficult to use the PHQ-9 in Spanish. On the other hand, Quechua is a family of languages and presents much dialectal variation ²²22. Luykx A, Rivera FG, Julca F. Communicative strategies across Quechua languages. International Journal of the Sociology of Language. 2016 ;2016(240):159-91. doi: 10.1515/ijsl-2016-0018.
https://doi.org/10.1515/ijsl-2016-0018... . The main varieties by number of speakers and geographical extension are: Central Quechua (CQ), Ayacucho-Chanka Quechua (ACQ) and Cuzco-Collao Quechua (CCQ), which present many differences ²³23. Julca F. Quechua ancashino. Una mirada actual. Lexis. 2011;35(2):430. Disponible en: https://repositorio.pucp.edu.pe/index/handle/123456789/183128.
https://repositorio.pucp.edu.pe/index/ha... ^,2424. Cerrón-Palomino R. Lingüística quechua. Vol. 2. Lima: Centro de Estudios Rurales Andinos "Bartolomé de las Casas"; 1987. 434 p. Disponible en: https://cbc.org.pe/producto/linguistica-quechua-2/.
https://cbc.org.pe/producto/linguistica-... . Phonologically, CQ has 24 phonemes, ACQ has 19 phonemes and CCQ has 28 phonemes. Morphologically, for example, the progressive action and the first person “I am going”; in QC is marked with -yka and -V (aywa-yka-a), in ACQ it is marked with -chka and -ni (ri-chka-ni) and in CCQ it is marked with -sha and -ni (ri-sha-ni). Likewise, lexically, the translation of the words “yellow” and “accelerate” is qallwash and wip in CQ, hillu and utqay in ACQ and q’illu and utqhay in CCQ, respectively ²⁴24. Cerrón-Palomino R. Lingüística quechua. Vol. 2. Lima: Centro de Estudios Rurales Andinos "Bartolomé de las Casas"; 1987. 434 p. Disponible en: https://cbc.org.pe/producto/linguistica-quechua-2/.
https://cbc.org.pe/producto/linguistica-... . Thus, the linguistic variation is wide and; consequently, mutual intercomprehension among speakers of the various variants of Quechua is very difficult and almost impossible; therefore, a single survey could not be conducted using only one of the varieties. The ad hoc solution typically adopted by local users is to have a third bilingual person “translate” the questions and answers to the questionnaire (e.g., a younger family member with a different worldview than the person being assessed). However, this practice is not recommended because it introduces noise into the assessment ²⁵25. American Educational Research Association, American Psychological Association, National Council on Measurement in Education. Estándares para Pruebas Educativas y Psicológicas [Internet]. 2nd ed. Estados Unidos: American Educational Research Association; 2018. Disponible en: https://www.testingstandards.net/uploads/7/6/6/4/76643089/spanish_standards_pdf.pdf.
https://www.testingstandards.net/uploads... . In Peru, most health personnel are not fluent in Quechua as a first or second language, as mentioned by Montesinos-Segura et al. ²⁶26. Montesinos-Segura R, Maticorena-Quevedo J, Chung-Delgado K, Pereyra-Elías R, Taype-Rondan A, Mayta-Tristán P. Place of origin associated with depressive symptoms in health professionals performing social health service in Ancash, Peru, 2015. Rural Remote Health. 2018;18(2):4331. doi: 10.22605/RRH4331.
https://doi.org/10.22605/RRH4331... in the discussion of their study. In this sense, an appropriate assessment of depressive symptoms by health personnel in the general Quechua-speaking population is very difficult at present, given this inherent language limitation.

Therefore, the aim of our study was to translate and culturally adapt the PHQ-9 to three varieties of Quechua, and to analyze the internal structure validity, reliability and measurement invariance (by Quechua variants and sociodemographic variables) of the adapted instrument.

MATERIAL AND METHODS

Design and context

Instrumental study ²⁷27. Hambleton R, Merenda M, Spielberger C. Adapting Educational and Psychological Tests for Cross-Cultural Assessment [Internet]. Vol. 1. Psychology Press; 2005 [citado el 21 de mayo de 2021]. Disponible en: https://www.routledge.com/Adapting-Educational-and-Psychological-Tests-for-Cross-Cultural-Assessment/Hambleton-Merenda-Spielberger/p/book/9780805861761.
https://www.routledge.com/Adapting-Educa... , carried out in four departments of Peru (Ancash, Ayacucho, Puno and Cuzco) according to the variety of Quechua. We selected adults from the departments of Puno and Cuzco, located in southwestern Peru in order to evaluate the Cuzco-Collao variety. Puno has 538,127 (57.0%) and Cuzco has 709,892 (74.7%) Quechua speakers ²⁸28. Instituto Nacional de Estadística e Informática. Perú: Perfil sociodemográfico Informe nacional - Censos nacionales 2017: XII de Población, VII de Vivienda y III de Comunidades Indígenas [Internet]. Lima: INEI; 2018. Disponible en: https://www.inei.gob.pe/media/MenuRecursivo/publicaciones_digitales/Est/Lib1539/libro.pdf.
https://www.inei.gob.pe/media/MenuRecurs... ; both departments are characterized by commercial activities, livestock farming and tourism due to their richness in historical and archaeological sites. To evaluate the variety of Quechua Chanca, we selected inhabitants of the department of Ayacucho, which has 389,045 (81.2%) Quechua speakers, mostly dedicated to commerce, livestock farming and agriculture ²⁸28. Instituto Nacional de Estadística e Informática. Perú: Perfil sociodemográfico Informe nacional - Censos nacionales 2017: XII de Población, VII de Vivienda y III de Comunidades Indígenas [Internet]. Lima: INEI; 2018. Disponible en: https://www.inei.gob.pe/media/MenuRecursivo/publicaciones_digitales/Est/Lib1539/libro.pdf.
https://www.inei.gob.pe/media/MenuRecurs... . In order to evaluate the variety of Central Quechua, we selected inhabitants of the department of Ancash, which has 289,172 (34.0%) Quechua speakers, mostly engaged in commerce, agriculture and tourism ²⁸28. Instituto Nacional de Estadística e Informática. Perú: Perfil sociodemográfico Informe nacional - Censos nacionales 2017: XII de Población, VII de Vivienda y III de Comunidades Indígenas [Internet]. Lima: INEI; 2018. Disponible en: https://www.inei.gob.pe/media/MenuRecursivo/publicaciones_digitales/Est/Lib1539/libro.pdf.
https://www.inei.gob.pe/media/MenuRecurs... .

Cultural adaptation phase

Translation

We used the forward translation and back translation methods during the translation process ²⁷27. Hambleton R, Merenda M, Spielberger C. Adapting Educational and Psychological Tests for Cross-Cultural Assessment [Internet]. Vol. 1. Psychology Press; 2005 [citado el 21 de mayo de 2021]. Disponible en: https://www.routledge.com/Adapting-Educational-and-Psychological-Tests-for-Cross-Cultural-Assessment/Hambleton-Merenda-Spielberger/p/book/9780805861761.
https://www.routledge.com/Adapting-Educa... . The original version of the PHQ-9 (English) was translated directly into each variety of Quechua (Central, Cuzco-Collao, Chanca) by two independent translators, who are native Quechua speakers of each variety and with advanced knowledge of English. Once the translation for each variety was completed, the two translators and two native Quechua-speaking researchers met to discuss the differences in the translations. Once the discrepancies were resolved and the translations unified, we proceeded with the back translation (Quechua to English) of the three Quechua variants of the PHQ-9. This process was carried out by two translators who had English as their native language and advanced knowledge of Quechua for each variant. Once the back translations were completed, the translators for each variant met with two study researchers to verify the back translation along with the first translation, fine-tuning details and giving their approval to the final version for the three languages.

Cultural adaptation to Quechua contexts

By applying the Delphi method, we created a cultural adaptation form, which can be found at: https://doi.org/10.5281/zenodo.8312191. This form included some open questions for uncommon words in Quechua such as “depression” or “without hope”. We also sought to consult on the change of “reading newspaper” to “listening to radio”, this change involves the PHQ-9 response categories and the relationship between the PHQ-9 in Quechua with the DSM-V for the diagnosis of major depression. The Central Quechua version of the PHQ-9 was reviewed by two Quechua-speaking psychologists, who had at least three years of experience in the care of Quechua-speaking patients with depression in the provinces of Ancash; one of them had a master’s degree and the other a bachelor’s degree in psychology. The Cuzco-Collao Quechua version was evaluated by five Quechua-speaking psychologists, all with professional degrees and at least one year of experience in the care of Quechua-speaking patients with depression in Puno or Cuzco. The Chanca Quechua version was evaluated by two psychologists with professional degrees and at least one year of experience in the care of Quechua-speaking patients with depression in the provinces of Ayacucho. The interaction between each expert and the research team took place in two (Central) and four rounds (Cuzco-Collao and Chanca) of mailings. In addition, we assessed the improvements (based on the recommendations of the experts) using indicators of relevance, representativeness, clarity and cultural equivalence on a scale of 0 to 3 (where 3 was the best rating). Once all the experts rated the improvements in all indicators with a score of 3, we held a virtual meeting with the research team to evaluate the suggestions and reach a consensus.

Subsequently, a focus group (via Zoom) was organized for each variety of Quechua. The moderator for each variety was a Quechua-speaking psychologist proficient in qualitative methods. The meetings lasted approximately 60 minutes. First, we asked participants to answer the PHQ-9 in Quechua through an online version shared via Google Forms. Then, the moderator invited the participants to provide their opinion on the clarity and comprehension of the items in a language that was common and simple for Quechua speakers. Five Quechua speakers participated (three women and two men) in the focus group for the Cuzco-Collao variety; four people participated (two women and two men) for the Quechua Chanca variety; and four adults participated (three men and one woman) in the focus group for the Central Quechua variety. We considered, for the three varieties of Quechua, that the participants be bilingual (speak Quechua and Spanish) and over 18 years of age (Figure 1). The focus group participants provided a favorable opinion regarding the clarity and comprehension of the PHQ-9 in the three variants of Quechua, confirming that this adaptation is clear and in accordance with their cultural context.

Psychometric analysis phase

Participants

The final version of the instrument, obtained after the previous phase, was applied to a sample of 970 adults selected by non-probabilistic convenience sampling, ensuring that for each variety of Quechua we had no less than 200 participants. This number is even higher than the recommended standard for factor analyses (20 participants per item and considering that there are 9 items, the minimum size would be 180 participants) and reported as adequate in simulation studies ²⁹29. Kyriazos TA. Applied Psychometrics: Sample Size and Sample Power Considerations in Factor Analysis (EFA, CFA) and SEM in General. Psychology. 2018;09(08):2207. doi: 10.4236/psych.2018.98126.
https://doi.org/10.4236/psych.2018.98126... . It also complies with the minimum size calculated for factor analysis (n=218, see: https://doi.org/10.5281/zenodo.8312191). Six surveyors participated in the data collection, they presented the study to the participants, and once informed consent was obtained, they requested the participants to complete the survey via Google Forms. The collection was carried out in those towns and cities with the greatest Quechua presence. Men and women, over 18 years of age, living in urban and rural settings, located in three regions (according to Quechua variant) were included. We included inhabitants of the departments of Puno and Cusco (n=525) to evaluate the Cuzco-Collao variant, inhabitants of Ayacucho (n=226) to evaluate the Chanca variant, and inhabitants of the department of Ancash (n=219) to analyze the Central Quechua variant. All participants were bilingual Quechua speakers (Quechua and Spanish), with sufficient academic background to read Quechua (at least incomplete primary school). Those who spoke a variety of Quechua other than the three studied were excluded.

Instrument

The PHQ-9 consists of 9 items corresponding to DSM-IV depressive symptoms ⁶6. American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders, Fouth Edition, Text Revision (DSM-4) [Internet]. 2013 [citado el 13 de julio de 2022]. Disponible en: https://psychiatry.org:443/psychiatrists/practice/dsm
https://psychiatry.org:443/psychiatrists... . The response options evoke the frequency of occurrence of such symptoms in the last two weeks, considering the following Likert-type scale: 0 = not at all, 1 = several days (1-6 days), 2 = most days (7-11 days), 3 = almost every day (12 days or more). The Spanish version of the PHQ-9 has demonstrated validity (e.g., goodness of fit as a unidimensional measure: CFI [comparative fit index] = 0.936; RMSEA [root mean square error of approximation] = 0.089; SRMR [standardized root mean square residual] = 0.039), as well as adequate reliability (α = ω = 0.87) in the Spanish-speaking Peruvian population ¹1. Villarreal-Zegarra D, Copez-Lonzoy A, Bernabé-Ortiz A, Melendez-Torres GJ, Bazo-Alvarez JC. Valid group comparisons can be made with the Patient Health Questionnaire (PHQ-9): A measurement invariance study across groups by demographic characteristics. PLOS ONE. 2019;14(9):e0221717. doi: 10.1371/journal.pone.0221717.
https://doi.org/10.1371/journal.pone.022... .

Covariates

They were used to characterize the population, as well as to study the measurement invariance of the unidimensional model according to age (in years), sex (female, male), education (incomplete primary, complete primary, incomplete secondary, complete secondary, incomplete higher, complete higher), marital status (single, married/cohabiting, divorced/separated, widowed) and place of residence (rural/urban).

Procedure

For data collection, one interviewer for the Central Quechua variety, two interviewers for the Chanca Quechua variety, and three interviewers for the Cuzco-Collao Quechua variety were trained in the use and application of the instrument. All interviewers were third- or fourth-year psychology students. The interviewers identified WhatsApp groups of parents from educational institutions, Christian churches and groups of peasant community associations to whom they presented the survey in Google Forms format. Data collection began in February and ended in June 2022.

Statistical analysis

Relative and absolute frequencies were used during descriptive analysis ³⁰30. Widaman KF, Reise SP. Exploring the measurement invariance of psychological instruments: Applications in the substance use domain. En: The science of prevention: Methodological advances from alcohol and substance abuse research. Washington, DC, US: American Psychological Association; 1997. p. 281-324.. Subsequently, we conducted a Confirmatory Factor Analysis (CFA) of the unidimensional model (its unidimensionality was verified in Peru in a representative sample of 30,449 individuals: https://doi.org/10.5281/zenodo.8312191) using a WLSMV estimator (weighted robust squares with adjusted mean and variance), as we did previously ¹1. Villarreal-Zegarra D, Copez-Lonzoy A, Bernabé-Ortiz A, Melendez-Torres GJ, Bazo-Alvarez JC. Valid group comparisons can be made with the Patient Health Questionnaire (PHQ-9): A measurement invariance study across groups by demographic characteristics. PLOS ONE. 2019;14(9):e0221717. doi: 10.1371/journal.pone.0221717.
https://doi.org/10.1371/journal.pone.022... . In addition, the WLSMV is an unbiased estimator for items with ordinal responses and non-normal distribution ³¹31. Brauer K, Ranger J, Ziegler M. Confirmatory Factor Analyses in Psychological Test Adaptation and Development. Psychological Test Adaptation and Development. 2023;4(1):4-12. doi: 10.1027/2698-1866/a000034.
https://doi.org/10.1027/2698-1866/a00003... . We report the standardized betas of the model and standard goodness-of-fit measures: the chi-square (X²) for the model versus baseline, considering values <3 as acceptable; the CFI, which is adequate when >0.90; the TLI (Tucker-Lewis index), which is acceptable with values >0.90. Likewise, the SRMR and RMSEA, were considered adequate with values ≤ 0.08 ³²32. Cheung GW, Rensvold RB. Evaluating Goodness-of-Fit Indexes for Testing Measurement Invariance. Structural Equation Modeling: A Multidisciplinary Journal. 2002;9(2):233-55. doi: https://doi.org/10.1207/S15328007SEM0902_5.
https://doi.org/https://doi.org/10.1207/... .

We assessed measurement invariance across groups defined by Quechua variants, sex and location using a multigroup CFA. The change in CFI (ΔCFI) and RMSEA (ΔRMSEA) was used as the main criterion to compare models with more constraints versus models with fewer constraints. Models first assumed configurational invariance (i.e., similar factor structure across groups) as the base model, moving up to metric invariance (i.e., similar factor loadings and factor structure across groups), strong invariance (i.e., similar thresholds, factor loadings, and factor structure across groups), and strict invariance (i.e., similar residual variances of items, thresholds, factor loadings, and factor structure across groups). Between each model, we examined whether ΔCFI < 0.01 or ΔRMSEA < 0.01 in order to establish whether the more restricted model was appropriate ³⁰30. Widaman KF, Reise SP. Exploring the measurement invariance of psychological instruments: Applications in the substance use domain. En: The science of prevention: Methodological advances from alcohol and substance abuse research. Washington, DC, US: American Psychological Association; 1997. p. 281-324..

Alternatively, MIMIC (Multiple Indicators and Multiple Causes) models were adjusted for the evaluation of measurement invariance according to age, marital status and educational level (variables for which the multigroup CFA was not feasible). We assessed the invariance of indicator intercepts and mean differences of latent dimensions, all across groups according to these covariates. We preferred to use ∆CFI rather than ΔX² because the former is not affected by sample size or model complexity ³²32. Cheung GW, Rensvold RB. Evaluating Goodness-of-Fit Indexes for Testing Measurement Invariance. Structural Equation Modeling: A Multidisciplinary Journal. 2002;9(2):233-55. doi: https://doi.org/10.1207/S15328007SEM0902_5.
https://doi.org/https://doi.org/10.1207/... . For multigroup CFA, we performed a sensitivity analysis using the method recommended by Yoon and Lai ³³33. Yoon M, Lai MHC. Testing Factorial Invariance With Unbalanced Samples. Structural Equation Modeling: A Multidisciplinary Journal. 2018 ;25(2):201-13. doi: 10.1080/10705511.2017.1387859.
https://doi.org/10.1080/10705511.2017.13... for dissimilar sample sizes. In fact, each covariate was evaluated separately, comparing two types of models for each of them: 1) a saturated version where the covariate explains all the observed items, but not the latent dimensions, and 2) a version of the invariant intercept model where the covariate explains all the latent dimensions, but not the items. Similarly, the above fit indices are reported and interpreted.

Finally, reliability was determined using Cronbach’s Alpha ³⁴34. Domínguez-Lara SA, Merino-Soto C. ¿Por qué es importante reportar los intervalos de confianza del coeficiente alfa de Cronbach? Revista Latinoamericana de Ciencias Sociales, Niñez y Juventud [Internet]. 2015;13(2):4. Disponible en: https://www.redalyc.org/pdf/773/77340728053.pdf.
https://www.redalyc.org/pdf/773/77340728... ⁾ and McDonald’s Omega ³⁵35. McDonald R. Test Theory : A Unified Treatment [Internet]. Psychology Press; 1999 [citado el 1 de julio de 2022]. Disponible en: https://www.taylorfrancis.com/books/mono/10.4324/9781410601087/test-theory-roderick-mcdonald.
https://www.taylorfrancis.com/books/mono... ⁾ coefficients. To ensure reproducibility, the main codes of the analysis can be found at: https://github.com/JCBAZO/R-PHQ9-Quechua. All analyses were performed in R Studio version 4.0.4, with the packages “lavaan” ³⁶36. Rosseel Y. lavaan: An R Package for Structural Equation Modeling. Journal of Statistical Software, 2012;48(2):1-36. doi: 10.18637/jss.v048.i02.
https://doi.org/10.18637/jss.v048.i02... , “lavaan.survey” ³⁷37. Oberski D. lavaan.survey: An R Package for Complex Survey Analysis of Structural Equation Models. Journal of Statistical Software. 2014;57:1-27. doi:10.18637/jss.v057.i01.
https://doi.org/10.18637/jss.v057.i01... “semTools” ³⁸38. Terrence DJ. Useful Tools for Structural Equation Modeling [Internet]. 2022. Disponible en: https://cran.r-project.org/web/packages/semTools/semTools.pdf.
https://cran.r-project.org/web/packages/... , “semPlot” ³⁹39. Epskamp S. semPlot: Unified Visualizations of Structural Equation Models. Structural Equation Modeling: A Multidisciplinary Journal. 2015 ;22(3):474-83. doi:10.1080/10705511.2014.937847.
https://doi.org/10.1080/10705511.2014.93... ⁾ and “Psych” ⁴⁰40. Komperda R. Likert-Type Survey Data Analysis with R and RStudio. En: Computer-Aided Data Analysis in Chemical Education Research (CADACER): Advances and Avenues. American Chemical Society; 2017. p. 91-116. (ACS Symposium Series; vol. 1260). doi: 10.1021/bk-2017-1260.ch007.
https://doi.org/10.1021/bk-2017-1260.ch0... .

Ethical Considerations

This study was evaluated and approved by the Ethics Committee of the Faculty of Health Sciences of the Universidad Peruana Unión with report number 2022-CE-FCS-UPeU-059. The instrument was applied as a self-report in virtual format (Google Forms), designed to present the informed consent first, so only those who agreed to participate in the study accessed the survey. Authorization was requested from the copyright owner of the original instrument (Pfizer) via e-mail, who authorized its use and adaptation.

RESULTS

Cultural adaptation phase

The experts and the research team interacted until achieving the highest rating of appropriateness for each item with respect to its cultural adaptation (3 on a range of 0 to 3), highlighting its relevance, representativeness, clarity and cultural equivalence. Additionally, they provided valuable suggestions which are mentioned below.

Some recommendations contributed to improve the adaptation of the word “depression”, which was initially translated as “llaqui”. Experts suggested to add “sinchi”, which gives a greater intensity, leaving “sinchi llakisqa” (a lot sadness) as the best understanding of depression (item 2). Regarding the expression “without hope”, the experts recommended implementing the question as “manañan q’anchay karqanchu kausayñiykipi / yanqallañan kausaranki” (item 2). For contextual reasons, the daily activity “reading the newspaper” was changed to “listening to the radio”, because the latter is the most used media in the three regions (item 7).

The response options (Likert-type) of the translated PHQ-9 also required special attention on the part of the judges and focus group participants. In particular, the category “almost every day” presented problems of clarity in its translation. The team’s final recommendation was to use the expressions “Mana hayk’aqpas”, “Wakin p’unchawkunalla”, “Ashka p’unchawkuna”, “Yaqa llapa p’unchawkuna”, representing the Spanish equivalent of “Never”, “Some days”, “Several days”, “Almost every day”.

Psychometric analysis phase

Characterization data

Of the 970 bilingual participants, 560 (57.7%) were female, 580 (59.8%) were between 18 and 30 years old, 621 (64%) reported being currently at or having completed college, 577 (59.5%) were single, and 614 (63.3%) lived in an urban area (Table 1).

Validity of internal structure

The three final instruments (one for each variety of Quechua) were validated independently. The single-factor model reported adequate goodness-of-fit values for the three varieties of Quechua (Central, Chanca and Cuzco-Collao), as well as for the total sample (CFI= 0.990; TLI= 0.987; SRMR=0.048; RMSEA= 0.071) (Table 2). On the other hand, the sensitivity analysis for the multigroup CFA reported results similar to those shown here. The only latent factor of the measurement model (depression) loaded a minimum of λ = 0.57 and a maximum of λ = 0.79 to the PHQ-9 items (Figure 2).

Reliability

The PHQ-9 reported good reliability for all Quechua varieties, with Cronbach’s Alpha values between 0.865 and 0.915, and with Omega values between 0.833 and 0.881 (Table 2).

Measurement invariance

The results of the multigroup CFA confirm the invariance of measurement according to Quechua variants, sex and place of residence (Table 3). The configural model showed good fit to the data (CFI = 0.935) for the three Quechua variants. After confirming configural invariance, metric invariance was proven with ΔCFI = 0.001 and ΔRMSEA=0.007 (both <0.01). Then, the values of ΔCFI=0.018 and ΔRMSEA=0.005 demonstrated strong invariance, with at least the latter being <0.01. Finally, strict invariance was confirmed with ΔCFI=0.009 and ΔRMSEA=0.001. The results and interpretation were similar for the invariance models according to sex and residence (Table 3).

The results of the MIMIC models confirmed the invariance by age, marital status and educational level (Table 4). The CFI and TLI values were >0.98 for all the variables, while the SRMR and RMSEA values were <0.08. Likewise, the absolute values of ΔCFI, ΔTLI and ΔRMSEA were <0.01.

DISCUSSION

This is the first study on the cultural adaptation to Quechua of the PHQ-9, a standardized instrument used internationally to assess depressive symptoms. After completing a back-and-forth translation (English-Quechua-English) for the three variants of Quechua, we carried out the cultural adaptation with the help of expert judges and members of the target population, all Quechua speakers. The adapted version offers a unidimensional, reliable and invariant measurement across groups according to Quechua variant, gender, residence, age, marital status and educational level. This invariance confirms that comparisons can be made with the PHQ-9 Quechua measurements across the aforementioned groups. The final instruments can be found in the Supplementary Material.

This cultural adaptation opens new possibilities for the assessment of depression in the Peruvian Quechua-speaking population, both for research and clinical purposes. Previously, a narrative review that searched Pubmed, Web of Science and Scopus, included studies in English and/or Spanish, found seven studies that assessed depression in Quechua-speaking populations ⁴¹41. Cjuno J, Figueroa-Quiñones J, Marca-Dueñas GG, Esteban RFC. Producción científica sobre depresión en poblaciones quechua hablantes: una revisión narrativa. Terapia Psicológica. 2021 ;163-74. doi: 10.4067/s0718-48082021000200163.
https://doi.org/10.4067/s0718-4808202100... . Only two of these studies used an instrument translated and adapted into Quechua, the Hopkins Symptoms Checklist (HSCL-25); however, this adaptation only considered one variant: Ayacuchan Quechua ⁴²42. Tremblay J, Pedersen D, Errazuriz C. Assessing Mental Health Outcomes of Political Violence and Civil Unrest in Peru. Int J Soc Psychiatry. 2009 ;55(5):449-63. doi: 10.1177/0020764009103214.
https://doi.org/10.1177/0020764009103214... . The distinction of variants is essential to be able to cover larger groups of people in the different regions of Peru, otherwise, the problem of having to resort to a third person to translate or interpret the questions and answers at the time of application persists. The PHQ-9 adapted to three versions of Quechua reduces the need for such support, facilitating assessment both in research (e.g., DHS-type health surveys) and in clinical settings (e.g., standardized instrument required according to DSM-V diagnostic criteria).

The adapted instruments have psychometric properties similar to those of the original PHQ-9 and the one validated for Spanish-speaking Peruvians. In both cases, the internal structure of the PHQ-9 was determined to be unidimensional, i.e., a single latent representing depression and expressed through each of the nine symptoms assessed by the instrument ¹1. Villarreal-Zegarra D, Copez-Lonzoy A, Bernabé-Ortiz A, Melendez-Torres GJ, Bazo-Alvarez JC. Valid group comparisons can be made with the Patient Health Questionnaire (PHQ-9): A measurement invariance study across groups by demographic characteristics. PLOS ONE. 2019;14(9):e0221717. doi: 10.1371/journal.pone.0221717.
https://doi.org/10.1371/journal.pone.022... ^,77. Kroenke K, Spitzer RL, Williams JBW. The PHQ-9 Validity of a Brief Depression Severity Measure. J Gen Intern Med. 2001;16(9):606-13. doi: https://doi.org/10.1046/j.1525-1497.2001.016009606.x.
https://doi.org/https://doi.org/10.1046/... . Internationally, recent systematic evidence supports the unidimensional model across cultures ⁴³43. Lamela D, Soreira C, Matos P, Morais A. Systematic review of the factor structure and measurement invariance of the Patient Health Questionnaire-9 (PHQ-9) and validation of the Portuguese version in community settings. J Affect Disord. 2020;276:220-33. doi: 10.1016/j.jad.2020.06.066.
https://doi.org/10.1016/j.jad.2020.06.06... , with such acceptance that the debate is now focused on defining the most accurate cut-off points for a single measure of the PHQ-9 when used, for example, to screen for depression ⁴⁴44. Negeri ZF, Levis B, Sun Y, He C, Krishnan A, Wu Y, et al. Accuracy of the Patient Health Questionnaire-9 for screening to detect major depression: updated systematic review and individual participant data meta-analysis. BMJ. 2021;375:n2183. doi: 10.1136/bmj.n2183.
https://doi.org/10.1136/bmj.n2183... . Likewise, the good reliability of the PHQ-9 in Quechua is in agreement with the findings of the study in Spanish-speaking Peruvians ¹1. Villarreal-Zegarra D, Copez-Lonzoy A, Bernabé-Ortiz A, Melendez-Torres GJ, Bazo-Alvarez JC. Valid group comparisons can be made with the Patient Health Questionnaire (PHQ-9): A measurement invariance study across groups by demographic characteristics. PLOS ONE. 2019;14(9):e0221717. doi: 10.1371/journal.pone.0221717.
https://doi.org/10.1371/journal.pone.022... , and with what has been observed in countries with a similar sociocultural context such as Chile (α=0.891 and ω=0.896) ⁴⁵45. Saldivia S, Aslan J, Cova F, Vicente B, Inostroza C, Rincón P, et al. Propiedades psicométricas del PHQ-9 (Patient Health Questionnaire) en centros de atención primaria de Chile. Rev Med Chil. 2019;147(1):53-60. doi: 10.4067/S0034-98872019000100053.
https://doi.org/10.4067/S0034-9887201900... , even in other very different sociocultural contexts such as Kenya (α=0.840 and ω=0.840) ⁴⁶46. Mwangi P, Nyongesa M, Koot H, Cuijpers P, Newton C, Abubakar A. Validation of a Swahili version of the 9-item Patient Health Questionnaire (PHQ-9) among adults living with HIV compared to a community sample from Kilifi, Kenya. J Affect Disord Rep. 2020 ;1. doi: 10.1016/j.jadr.2020.100013.
https://doi.org/10.1016/j.jadr.2020.1000... .

The PHQ-9 in the three varieties of Quechua have shown measurement invariance, similar to the version for Peruvian Spanish speakers and other versions of the PHQ-9 internationally. In China, invariance was reported according to age and sex groups, as well as strict invariance ¹¹11. Leung D, Wah Y, Leung SF, Chiang V, Yuen A. Measurement invariances of the PHQ-9 across gender and age groups in Chinese adolescents. Asia-Pacific Psychiatry. 2020;12(e12381). doi: https://doi.org/10.1111/appy.12381.
https://doi.org/10.1111/appy.12381... . In Kenya, configurational, metric and scalar invariance of the model was determined according to the presence of HIV infection, sex and age groups ⁴⁶46. Mwangi P, Nyongesa M, Koot H, Cuijpers P, Newton C, Abubakar A. Validation of a Swahili version of the 9-item Patient Health Questionnaire (PHQ-9) among adults living with HIV compared to a community sample from Kilifi, Kenya. J Affect Disord Rep. 2020 ;1. doi: 10.1016/j.jadr.2020.100013.
https://doi.org/10.1016/j.jadr.2020.1000... . In the United States, the instrument showed configurational, metric and scalar measurement invariance when comparing English-speaking and Spanish-speaking women ⁴⁷47. Merz EL, Malcarne VL, Roesch SC, Riley N, Sadler GR. A Multigroup Confirmatory Factor Analysis of the Patient Health Questionnaire-9 among English- and Spanish-speaking Latinas. Cultur Divers Ethnic Minor Psychol. 2011;17(3):309-16. doi: 10.1037/a0023883.
https://doi.org/10.1037/a0023883... , as well as when comparing college students by age group and race ⁴⁸48. Keum BT, Miller MJ, Inkelas KK. Testing the factor structure and measurement invariance of the PHQ-9 across racially diverse U.S. college students. Psychological Assessment. 2018;30(8):1096-106. doi: 10.1037/pas0000550.
https://doi.org/10.1037/pas0000550... . A Norwegian study reported invariance according to the presence or absence of eating disorders in the female population ¹⁵15. Wisting L, Johnson SU, Bulik CM, Andreassen OA, Rø Ø, Bang L. Psychometric properties of the Norwegian version of the Patient Health Questionnaire-9 (PHQ-9) in a large female sample of adults with and without eating disorders. BMC Psychiatry. 2021;21(1):6. doi: 10.1186/s12888-020-03013-0.
https://doi.org/10.1186/s12888-020-03013... . A recent systematic review confirmed measurement invariance in at least 18 groups, including those determined by the sociodemographic variables included in this study ⁴³43. Lamela D, Soreira C, Matos P, Morais A. Systematic review of the factor structure and measurement invariance of the Patient Health Questionnaire-9 (PHQ-9) and validation of the Portuguese version in community settings. J Affect Disord. 2020;276:220-33. doi: 10.1016/j.jad.2020.06.066.
https://doi.org/10.1016/j.jad.2020.06.06... .

The present study demonstrates configurational, metrical, scalar and strict invariance according to Quechua variants, gender and place of residence. Thus, our findings suggest that it is possible to make comparisons between Peruvians who speak different Quechua variants, as well as comparisons between men and women and between urban and rural residents. In the same sense, the PHQ-9 in Quechua showed measurement invariance according to age, marital status and educational level, with similar practical implications.

We recognize some strengths and limitations of the present study that should be highlighted. This is the first study of cultural adaptation to Quechua of the PHQ-9, a tool widely used internationally for the assessment of depressive symptoms. This research was carried out in three different regions of Peru, which are usually neglected in the study and care of their mental health. However, since this was a written version, participants were required to have a minimum level of schooling, which is not always possible to find in the target population. Future studies should overcome this barrier in order to reach Quechua speakers who do not yet know how to read or write. Also, although our study adhered to international standards in order to achieve the best possible cultural adaptation, we understand that there are subtle aspects specific to each Quechua-speaking culture that we have not been able to assess regarding their experiences related to the symptoms that universally define depression. Therefore, it is possible that the adapted instrument may not be able to measure some of the depressive symptoms in a completely correct and/or accurate way in regions of Peru where the Spanish-speaking culture still has very little presence. On the other hand, altitude may be associated with the presence of certain depressive symptoms, and therefore its inclusion may be informative (e.g., in an invariance analysis). Unfortunately, we were unable to assess altitude for logistic reasons, so it would be useful for future studies to include this variable. Also, unlike the multigroup CFA, the MIMIC models can only evaluate the invariant intercept models and factorial means. Therefore, for the variables where we applied MIMIC, we assume that the rest of the structural and measurement parameters (e.g., factor loadings, variance/covariance error, variance/covariance factor) are the same across all levels of these variables. Another limitation is related to the change made in item 7, from “reading newspaper” to “listening to radio”. Although this change is intended to improve the cultural adaptation of the instrument, it is possible that it could cause variations in the measurement of symptoms compared to the Spanish version of the PHQ-9. These variations could be caused by the different cultural characteristics of each Quechua-speaking society. Also, the number of participants was different for each department/variety, and the sampling was non-probabilistic, which formally affects the external validity of the estimates. Nevertheless, this is the best estimate of validity/reliability of the PHQ-9 in Quechua available to date.

In terms of public health, this is an important first step towards knowledge and attention to the mental health of historically underserved populations. The three versions of the PHQ-9 in Quechua can be gradually incorporated into national health surveys (e.g. ENDES), and can also be used by community mental health centers in the different regions of the country as a valid and reliable screening tool.

In conclusion, the PHQ-9 adapted to three variants of Quechua (Central, Chanca and Cuzco-Collao) offers a valid, reliable and invariant unidimensional measurement across groups according to Quechua variant, sex, residence (rural/urban), age, marital status and educational level. This invariance confirms that comparisons can be made with the measurements of the three Quechua versions of the PHQ-9 across the aforementioned groups.

References

Publication Dates

History