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Introduction There is paucity of culturally adapted tools for assessing depression and anxiety in children and adolescents in low-and middle-income countries. This hinders early detection, provision of appropriate and culturally acceptable interventions. In a partnership with the University of Nairobi, Nairobi County, Kenyatta National Hospital, and UNICEF, a rapid cultural adaptation of three adolescent mental health scales was done, i.e., Revised Children’s Anxiety and Depression Scale, Patient Health Questionnaire-9 and additional scales in the UNICEF mental health module for adolescents. Materials and methods Using a qualitative approach, we explored adolescent participants’ views on cultural acceptability, comprehensibility, relevance, and completeness of specific items in these tools through an adolescent-centered approach to understand their psychosocial needs, focusing on gender and age-differentiated nuances around expression of distress. Forty-two adolescents and 20 caregivers participated in the study carried out in two primary care centers where we conducted cognitive interviews and focused group discussions assessing mental health knowledge, literacy, access to services, community, and family-level stigma. Results We reflect on process and findings of adaptations of the tools, including systematic identification of words adolescents did not understand in English and Kiswahili translations of these scales. Some translated words could not be understood and were not used in routine conversations. Response options were changed to increase comprehensibility; some statements were qualified by adding extra words to avoid ambiguity. Participants suggested alternative words that replaced difficult ones and arrived at culturally adapted tools. Discussion Study noted difficult words, phrases, dynamics in understanding words translated from one language to another, and differences in comprehension in adolescents ages 10-19 years. There is a critical need to consider cultural adaptation of depression and anxiety tools for adolescents. Conclusion Results informed a set of culturally adapted scales. The process was community-driven and adhered to the principles of cultural adaptation for assessment tools.
The study was conducted in two government-owned urban-based health care facility sites (Kariobangi and Kangemi) [24]. These centers provide non-specialized primary health care services, including Maternal Child Health Care, and are operated by a limited number of Nurses and clinicians. Both health care centers are level three facilities under the Nairobi Metropolitan Services (formerly known as Nairobi County Health Services). Level three facilities include health centers, maternity homes, and sub-district hospitals. Kariobangi health center is in a low-income residential area in the northeastern part of Nairobi, Kenya. It consists of the lower middle class and informal settlements with approximately 18,903 residents [25]. On the other hand, Kangemi Health Center is located in an informal settlement in Nairobi City within a small valley on the city’s outskirts with approximately 116,710 residents [25]. The two study locations have similar characteristics: cosmopolitan, densely populated urban informal settlements. These areas have high drug abuse and crime levels coupled with youth unemployment and idleness. Other studies have demonstrated high prevalence of mental disorders in school-going children in Kenya [26], with substance abuse and depressive disorders being common [27]. These adolescent difficulties have been made worse by the COVID-19 pandemic [28,29]. In identifying the study participants, non-probability purposive sampling targeted adolescent boys and girls living in low-resource settings. These participants were mobilized by trained community health volunteers (CHVs), who administered consent and assent a few days before the focus group discussions (FGDs) and cognitive interviews (CIs). Six FGDs were conducted–This was a moderator-guided discussion that involved participants with similar characteristics and experiences who responded to questions exploring specific topics of interest. Sixteen CIs were also conducted–Individual interviews whereby the participant responded to questions asked by the interviewer to describe an experience or viewpoint on a topic of interest. These FGDs and CIs were carried out in November and December 2020 among 62 participants. This qualitative study explored the cultural acceptability, comprehensibility, relevance, and completeness of items in three adolescent mental health tools- RCADS, PHQ-9, and UNICEF mental health module. The design also reflected the TTA approaches, with qualitative data reported according to the COREQ checklist [30] (S1 Checklist). The TTA process uses a series of systematic steps to assess an array of cultural equivalence domains [31]. In TTA, the tools were translated by bilingual experts, then reviewed by mental health experts. FGDs followed this, then CIs, while adopting any suggested changes in the wording of the tools. Finally, a back-translation was done to check whether the tools retained their initial meaning [32–34]. The study was approved by the Kenyatta National Hospital/University of Nairobi ethical review committee (approval no. P694/09/2018). In addition, approval was received from Nairobi County Health no. CMO/NRB/OPR/VOL1/2019/04 and a permit from Kenyan National Commission for Science, Technology, and Innovation (NACOSTI/P/19/77705/28063) was obtained. We obtained assent from participants below 18 years old and consent from their parents or guardians. We conducted six focus group discussions (N = 46) among adolescents ages 10–19 years (n = 40) and caregivers to adolescents ages 10–14 years (n = 6) (See Table 1). A table showing categories of participants and numbers for the different FGDs. We also conducted cognitive interviews (n = 16) among twelve adolescents, including pregnant and parenting adolescents and four caregivers to adolescents ages 10–14 years. FGDs and Cis were the methods used to conduct transcultural translation and adaptation processes on an abbreviated version of the Revised Children’s Anxiety and Depression Scale (RCADS) items covering the subscales of major depressive disorder, generalized anxiety disorder, separation anxiety disorders, social phobia, and panic disorder [22]. The RCADS is a widely used instrument for collecting information on depression and anxiety symptoms in children and adolescents. We also used items from the Patient Health Questionnaire (PHQ-9) set, a brief and widely used screening measure of depressive symptomology [23]. The FGDs included activities like body mapping to acclimatize and elicit some of the feelings in the different parts of the body under circumstances of sadness or happiness. In addition, understanding free-listed mental health terms and some of the idioms or colloquial words used were also explored. Subsequently, the participants were taken through English and Kiswahili versions of the tools to discuss various aspects of each element, following the TTA methods [31] established in the MMAP protocol. These domains are comprehensibility, acceptability, relevance, completeness, and relevance [18]. The cognitive interviews focused on participants’ understanding of the specific wording of the tools. Each participant was either given an English tool or a Kiswahili tool and taken through each statement to gauge their comprehension and any problematic words identified and suggested alternative wordings provided by the participant. See Box 1, which provides vital information on domains covered during the FGDs and Cis [1]. The FGDs also looked at cultural practices, understanding of mental health problems, associated service availability, and caregiver and adolescent recommendations on needed services. Sociodemographic data was collected on the day when focus group discussion and cognitive interview were conducted. Permission was sought from all participants to record the interviews, and each participant was identified by a number during the discussion for anonymity. The study participants were taken through informed assent and consenting details to ensure they understood before signing the consent form. The consent highlighted the purpose of the study, benefits, risks, voluntary nature of participation, and withdrawal of consent at any stage of the study without being penalized. FGDs and Cis were facilitated by a team of 6 composed of female and male clinical psychologists and mental health researchers. All interviewers had prior training and field experience in conducting FGDs and Cis. Both the FGDs and Cis were carried out between November and December 2020 within the two health care facilities. Audio recordings were conducted following all protocols to ensure confidentiality and data protection. The recordings were transcribed verbatim, and group members collated transcriptions during the process. Qualitative data from the sixteen cognitive interviews and the six FGDs were uploaded and analyzed in Nvivo version 10 Qualitative Data Analysis software [35]. Thorough reading through the content and identifying the texts and patterns linked to each theme were done. During this thematic content analysis, emerging themes were identified both deductively and inductively. Cross-tabulation and queries were used in analysis to compare the respondents’ perspectives for each item in the PHQ-9 and RCAD tools. Participants transcribed responses to each statement, indicating if they understood or did not understand it. Therefore, this section was either coded ‘participant understood or not understood,’ which indicated comprehensibility during coding. Common patterns and discrepancies were identified during the process. In addition, adolescent experiences were also identified inductively and classified as independent themes. Working with adolescents and caregivers followed allCOVID-19 protocols set by the Kenyan Ministry of Health. A few facilitators were on the ground while others observed and participated via video conference using zoom or google meet set up for each FGD. In addition, we relied on our strong linkages with community health workers to make connections. During our data collection (November 2020- December 2020), Kenya experienced a strong first and second wave of COVID-19 infections surge. However, no participants or facilitators tested positive during this phase.
