Complementing standard western measures of depression with locally co-developed instruments: A cross-cultural study on the experience of depression among the Luo in Kenya
Restricted accessResearch articleFirst published online August, 2021
Complementing standard western measures of depression with locally co-developed instruments: A cross-cultural study on the experience of depression among the Luo in Kenya
Our present understanding of depression relies on a Western nosology that might not be generalizable across diverse cultures around the world. As a consequence, current clinical research and practice may not capture culturally salient features of depression. Expanded cross-cultural research that uses ethnographic methods and local instruments may yield information of clinical utility to enhance culturally sensitive research and practice. In this mixed methods study, we used ethno-semantic interview procedures based on the DSM-5’s cultural formulation process to elicit a broad range of depression features reported by the Luo people of western Kenya. We identified how the Luo conceptualize depression, including idioms of depressive distress, moods associated with persistent negative affect, and other features including context, stressors and support systems. This information informed the co-development of a Luo Depression Questionnaire (LDQ-17). We used the LDQ-17 in a cross-sectional community survey (N = 116) to investigate its association with a standard Western instrument (Patient Health Questionnaire-9; PHQ-9). Factor analysis revealed a one-factor model for the PHQ-9 but not the LDQ-17 for which exploratory factor analysis suggested a three-factor model including cognitive, affective, and physical symptoms. Psychological, environmental/social, and even supernatural causes (i.e., ancestors, God and devil) of these symptoms were identified, as were support systems. Finally, visualizations through multidimensional scaling approaches showed some overlap between the LDQ-17 and the PHQ-9, but the local LDQ-17 identified salient features the Luo associated with depression that the PHQ-9 missed. Our findings illustrate how simple ethnographic procedures may guide the development of local instruments to complement current standardized instruments, potentially enhancing cultural relevance.
AnthonyJ.SartoriusN.JablenskyA.FentonF. R. (1985). Cross-cultural studies of depressive disorders: An overview. In KleinmanA.GoodB. (Eds.), Culture and depression: Studies in the anthropology and cross-cultural psychiatry of affect and disorder (pp. 299–324).
University of California Press.
BaxterA. J.ScottK. M.FerrariA. J.NormanR. E.VosT.WhitefordH. A. (2014).
Challenging the myth of an “epidemic” of common mental disorders: Trends in the global prevalence of anxiety and depression between 1990 and 2010. Depression and Anxiety,
31(6), 506–516. https://doi.org/10.1002/da.22230
CalhounL. G.CheneyT.DawesA. S. (1974).
Locus of control, self-reported depression, and perceived causes of depression. Journal of Consulting and Clinical Psychology,
42(5), 736–736. https://doi.org/10.1037/h0037048
7.
CaplanS.ParisM.WhittemoreR.DesaiM.DixonJ.AlvidrezJ.EscobarJ.ScahillL. (2011).
Correlates of religious, supernatural and psychosocial causal beliefs about depression among Latino immigrants in primary care. Mental Health, Religion & Culture,
14(6), 589–611. https://doi.org/10.1080/13674676.2010.497810
8.
ChangM. X.-L.JettenJ.CruwysT.HaslamC. (2017).
Cultural identity and the expression of depression: A social identity perspective. Journal of Community & Applied Social Psychology,
27(1), 16–34. https://doi.org/10.1002/casp.2291
9.
ChangW. C. (1985).
A cross-cultural study of depressive symptomology. Culture, Medicine and Psychiatry,
9(3), 295–317. https://doi.org/10.1007/BF00048503
10.
ChisholmD.SweenyK.SheehanP.RasmussenB.SmitF.CuijpersP.SaxenaS. (2016).
Scaling-up treatment of depression and anxiety: A global return on investment analysis. The Lancet Psychiatry,
3(5), 415–424. https://doi.org/10.1016/S2215-0366(16)30024-4
11.
ChoiN. G.RansomS.WyllieR. J. (2008).
Depression in older nursing home residents: The influence of nursing home environmental stressors, coping, and acceptance of group and individual therapy. Aging & Mental Health,
12(5), 536–547. https://doi.org/10.1080/1360786080234 3001
12.
de LeeuwJ. (1984).
Differentiability of Kruskal’s stress at a local minimum. Psychometrika,
49(1), 111–113.
13.
de LeeuwJ.MairP. (2009).
Multidimensional scaling using majorization: SMACOF in R. Journal of Statistical Software,
31(3). https://doi.org/10.18637/jss.v031.i03
FerrariA. J.CharlsonF. J.NormanR. E.PattenS. B.FreedmanG.MurrayC. J. L.VosT.WhitefordH. A. (2013).
Burden of depressive disorders by country, sex, age, and year: Findings from the global burden of disease study 2010. PLoS Medicine,
10(11), e1001547. https://doi.org/10.1371/journal.pmed.1001547
16.
GelayeB.WilliamsM. A.LemmaS.DeyessaN.BahretibebY.ShibreT.WondimagegnD.LemenheA.FannJ. R.Vander StoepA.Andrew ZhouX.-H. (2013).
Validity of the Patient Health Questionnaire-9 for depression screening and diagnosis in East Africa. Psychiatry Research,
210(2), 653–661. https://doi.org/10.1016/j.psychres.2013.07.015
17.
GetandaE. M.PapadopoulosC.EvansH. (2015).
The mental health, quality of life and life satisfaction of internally displaced persons living in Nakuru County, Kenya. BMC Public Health,
15(1), Article 755. https://doi.org/10.1186/s12889-015-2085-7
18.
HarozE. E.RitcheyM.BassJ. K.KohrtB. A.AugustinaviciusJ.MichalopoulosL.BurkeyM. D.BoltonP. (2017).
How is depression experienced around the world? A systematic review of qualitative literature. Social Science & Medicine,
183, 151–162. https://doi.org/10.1016/j.socscimed.2016.12.030
HuL.BentlerP. M. (1999).
Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling: A Multidisciplinary Journal,
6(1), 1–55.
21.
JormA. F.KortenA. E.JacombP. A.ChristensenH.RodgersB.PollittP. (1997).
Public beliefs about causes and risk factors for depression and schizophrenia. Social Psychiatry and Psychiatric Epidemiology,
32(3), 143–148. https://doi.org/10.1007/BF00794613
22.
KawaS.GiordanoJ. (2012).
A brief historicity of the Diagnostic and Statistical Manual of Mental Disorders: Issues and implications for the future of psychiatric canon and practice. Philosophy, Ethics, and Humanities in Medicine,
7(1), Article 2. https://doi.org/10.1186/1747-5341-7-2
KirmayerL. J.Gomez-CarrilloA.VeissièreS. (2017).
Culture and depression in global mental health: An ecosocial approach to the phenomenology of psychiatric disorders. Social Science & Medicine,
183, 163–168. https://doi.org/10.1016/j.socscimed.2017.04.034
26.
KirmayerL. J.JarvisG. E. (2006). Depression across cultures. In SteinD. J.KupferD. J.SchatzbergA. F. (Eds.), The American Psychiatric Publishing Textbook of Mood Disorders (pp. 699–715).
American Psychiatric Press.
27.
KleinmanA. (1977).
Depression, somatization and the “new cross-cultural psychiatry”. Social Science & Medicine (1967),
11(1), 3–9.
28.
KleinmanA. (1982).
Neurasthenia and depression: A study of somatization and culture in China. Culture, Medicine and Psychiatry,
6(2), 117–190. https://doi.org/10.1007/BF00051427
KleinmanA. (2008). Rethinking psychiatry: From cultural category to personal experience.
The Free Press. (Original work published 1988)
31.
KleinmanA.GoodB. (Eds.). (1985). Culture and depression: Studies in the anthropology and cross-cultural psychiatry of affect and disorder.
University of California Press.
32.
KokanovicR.DowrickC.ButlerE.HerrmanH.GunnJ. (2008).
Lay accounts of depression amongst Anglo-Australian residents and East African refugees. Social Science & Medicine,
66(2), 454–466.
KroenkeK.SpitzerR. L.WilliamsJ. B. W. (2001).
The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine,
16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x
35.
KruskalJ. B. (1964).
Multidimensional scaling by optimizing goodness of fit to a nonmetric hypothesis. Psychometrika,
29(1), 1–27.
Lewis-FernándezR.AggarwalN. K.BäärnhielmS.RohlofH.KirmayerL. J.WeissM. G.JadhavS.HintonL.AlarcónR. D.BhugraD.GroenS.van DijkR.QureshiA.CollazosF.RousseauC.CaballeroL.RamosM.LuF. (2014).
Culture and psychiatric evaluation: Operationalizing cultural formulation for DSM-5. Psychiatry: Interpersonal and Biological Processes,
77(2), 130–154. https://doi.org/10.1521/psyc.2014.77.2.130
38.
Lewis-FernándezR.Krishan AggarwalN. (2013). Culture and psychiatric diagnosis. In AlarcónR. D. (Ed.), Advances in psychosomatic medicine (Vol.
33, pp. 15–30).
Karger. https://doi.org/10.1159/000348725
39.
MansonS. M.ShoreJ. H.BloomJ. D. (1985). The depression experience in American Indian communities: A challenge for psychiatric theory and diagnosis. In KleinmanA.GoodB. (Eds.), Culture and depression: Studies in the anthropology and cross-cultural psychiatry of affect and disorder (pp. 331–368).
University of California Press.
40.
NdeteiD. M.MutisoV.MarajA.AndersonK. K.MusyimiC.McKenzieK. (2016).
Stigmatizing attitudes toward mental illness among primary school children in Kenya. Social Psychiatry and Psychiatric Epidemiology,
51(1), 73–80. https://doi.org/10.1007/s00127-015-1090-6
41.
NunnallyJ. C. (1978). Psychometric theory.
McGraw-Hill.
42.
Ocholla-AyayoA. B. C. (1980). The Luo culture: A reconstruction of the material culture patterns of a traditional African Society.
Steiner.
43.
OjwangB. O. (2018).
Linguistic conceptualizations of disease among the Luo of Kenya. Qualitative Health Research,
28(3), 433–445. https://doi.org/10.1177/1049732317747875
44.
OmoroS. A. O.FannJ. R.WeymullerE. A.MacHariaI. M.YuehB. (2006).
Swahili translation and validation of the Patient Health Questionnaire-9 depression scale in the Kenyan head and neck cancer patient population. The International Journal of Psychiatry in Medicine,
36(3), 367–381. https://doi.org/10.2190/8W7Y-0TPM-JVGV-QW6M
45.
OsbornT. L.Venturo-ConerlyK. E.WasilA. R.SchleiderJ. L.WeiszJ. R. (2020).
Depression and anxiety symptoms, social support, and demographic factors among Kenyan high school students. Journal of Child and Family Studies,
29(5), 1432–1443. https://doi.org/10.1007/s10826-019-01646-8
46.
OsbornT. L.RodriguezM.WasilA. R.Venturo-ConerlyK. E.GanJ.AlemuR. G.RoeE.ArangoG.OtienoB. H.WasangaC. M.ShingletonR.WeiszJ. R. (2020).
Single-session digital intervention for adolescent depression, anxiety and well-being: Outcomes of a randomized controlled trial with Kenyan adolescents. Journal of Consulting and Clinical Psychology,
88(7), 657–668. https://doi.org/10.1037/ccp0000505
47.
OsbornT. L.WasilA. R.Venturo-ConerlyK. E.SchleiderJ. L.WeiszJ. R. (2020).
Group intervention for adolescent anxiety and depression: Outcomes of a randomized trial with adolescents in Kenya. Behavior Therapy,
51(4), 601–615. https://doi.org/10.1016/j.beth.2019.09.005
PatelV.ChisholmD.ParikhR.CharlsonF. J.DegenhardtL.DuaT.FerrariA. J.HymanS.LaxminarayanR.LevinC.LundC.Medina MoraM. E.PetersenI.ScottJ.ShidhayeR.VijayakumarL.ThornicroftG.WhitefordH. (2016).
Addressing the burden of mental, neurological, and substance use disorders: Key messages from Disease Control Priorities, 3rd edition. The Lancet,
387(10028), 1672–1685. https://doi.org/10.1016/S0140-6736(15)00390-6
50.
RazaliS. M.KhanU. A.HasanahC. I. (1996).
Belief in supernatural causes of mental illness among Malay patients: Impact on treatment. Acta Psychiatrica Scandinavica,
94(4), 229–233. https://doi.org/10.1111/j.1600-0447.1996.tb09854.x
51.
Rehm, J., & Shield, K. D. (2019). Global burden of disease and the impact of mental and addictive disorders. Current psychiatry reports, 21(2), 1–7.
52.
RosseelY. (2012).
Lavaan: An R package for structural equation modeling and more. Version 0.5–12 (BETA). Journal of Statistical Software,
48(2), 1–36.
53.
SpitzerR. L.KroenkeK.WilliamsJ. B. W.LöweB. (2006).
A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine,
166(10), 1092–1097. https://doi.org/10.1001/archinte.166.10.1092
54.
SteelZ.MarnaneC.IranpourC.CheyT.JacksonJ. W.PatelV.SiloveD. (2014).
The global prevalence of common mental disorders: A systematic review and meta-analysis 1980–2013. International Journal of Epidemiology,
43(2), 476–493. https://doi.org/10.1093/ije/dyu038
55.
WallinM. I.DahlinM.NevonenL.BäärnhielmS. (2020).
Patients’ and clinicians’ experiences of the DSM-5 Cultural Formulation Interview: A mixed method study in a Swedish outpatient setting.Transcultural Psychiatry. Advance online publication. https://doi.org/10.1177/1363461520938917
YuX.TamW. W. S.WongP. T. K.LamT. H.StewartS. M. (2012).
The Patient Health Questionnaire-9 for measuring depressive symptoms among the general population in Hong Kong. Comprehensive Psychiatry,
53(1), 95–102. https://doi.org/10.1016/j.comppsych.2010.11.002
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