Functioning in people with severe mental disorders in rural Ethiopia: development, adaptation and validation of measures
Creators: name: Habtamu, Kassahun
Publisher: name: National Academic Digital Repository of Ethiopia
Year: 2015

description: Background: Restoring impaired functioning is one of the most difficult challenges in treating people with severe mental disorder (SMD). Significant improvement in interpersonal relations, role performance and community living skills usually lag behind symptomatic improvement, but are valued more by people with SMD. As a result of this, the assessment of functioning is gaining emphasis as an outcome in research and clinical practice. Though numerous instruments to assess functioning are in existence, most have been developed in high resource countries and may not be generalizable to other cultures as the definition of functional recovery differs with sociocultural context. Existing functioning measures are limited by questions that are culture bound; they do not take in to account role differences between men and women in rural African societies and fail to present specific tasks that are important to local people. Therefore, there is a pressing need to develop and/or adapt and validate measures of functioning that address the limitations of existing instruments and are appropriate for the socio-cultural context in Ethiopia. Objectives: The primary aim of this study wasto develop and validate a measure of functional impairment for people with SMD, which is socio-culturally appropriate for a rural, African lowincome country setting.A secondary aim was to evaluate the psychometric properties of the cross-cultural World Health Organization Disability Assessment Schedule (WHODAS- 2.0) and to compare performance with the newly developed, contextually-informed measure. Methods: A qualitative study (in-depth interviews and focus group discussions) was carried out to gain contextual understanding of day-to-day functioning in a rural Ethiopian setting and the functional impairments associated with SMD. Free listing and pile sorting exercises were conducted to identify key tasks that an adult person in the rural Ethiopian context is expected to accomplish, as well as to operationalize new scale items to measure functional impairment. Expert evaluation and cognitive interviewing were carried out for preliminary validation and initial reduction of items of the new scale, the Butajira Functioning Scale (the BFS). Pilot testing of the BFS was conducted with 200 people with SMD and their caregivers (n=200) in order to identify items that performed poorly and inform further item reduction. The psychometric properties (internal consistency, construct validity, convergent validity and sensitivity to change) of the finalized BFS were evaluated in an independent sample of people with SMD (n=150) and their caregivers (n=150) recruited in episode and a sub-sample of n=84 followed up for six viii weeks. Psychometric properties (internal consistency, convergent validity, construct validity and responsiveness to change) of the Amharic version of the World Health Organization Disability Assessment Scale (WHODAS-2.0) was carried out in the same sample to enable comparison with the BFS. Results: The qualitative study participants emphasized that functional impairment in people with SMD arose not only because of the symptoms associated with the illness, but also due to poverty, social exclusion and lack of social support. In this rural Ethiopian setting, the ability to work productively, engage in family life, maintain self-care and fulfill social obligations were the most highly valued domains of functioning. Gender differences were most apparent in the domains of work and family life. Impaired functioning was reported to have a critical immediate impact on survival as well as more far-reaching impacts on the lifetime opportunities of people with SMD, their caregivers and the younger generation within the family. The first draft of the BFS had 78 items in the women's scale and 84 items in the men's scale. Item reduction was carried out using expert evaluation, cognitive interviewing and pilot testing. The criteria considered for item reduction included understandability, relevance to the rural Ethiopian setting, whether or not the task is seasonal, insufficiently frequent, and specific to the locality, and psychometric properties of each item (e.g: item-item correlation, item-total correlation, test-retest reliability, factor loadings). The expert evaluation resulted in the BFS v2 with 69 items in the women's scale and 59 items in the men's scale. The cognitive interviewing brought the BFS v3, with 67 items in the women's scale and 50 items in the men's scale. The pilot study led to the finalized BFS comprising33 items, common to both men and women, and an additional eight items in the women's scale, with four domains: self-care, work, family and community participation. The BFS had excellent internal consistency (Cronbach's α=0.99), acceptable convergent validity (r= 0.88 with WHODAS-2.0 and r= 0.32 with the Brief Psychiatric Rating Scale [BPRS-E]) and was sensitive to change following treatment (effect size =0.50). The caregiver version of the BFS had similar psychometric properties but higher mean values for each item and better responsiveness to change. Exploratory factor analysis of the BFS provided evidence of construct validity, with four underlying dimensions: self-care, work (shared items), work (women only ix items) and social functioning. Internal consistency of the overall WHODAS-2.0 and each domain was either very good or excellent. Convergent validity was good (r= 0.88 with the BFS and r= 0.52 with the BPRS-E). The WHODAS-2.0 was found to be sensitive to treatment changes (effect size= 0.50). As hypothesized, the six domains highly loaded onto the general disability factor and each item loaded significantly onto their respective domains. The factor loadings of each item in the one factor model of the 12 item WHODAS were also high. However, the goodness of fit indices for both the 12- and 36-item WHODAS were close to, but not within, the acceptable ranges. Conclusions: The findings from the qualitative study indicate that, alongside medical treatment, there is a need to tackle social exclusion and poverty in order to improve functioning in people with SMD in this rural Ethiopian setting. An ecologically valid measure of functioning has been developed for people with SMD in a rural Ethiopian setting. The new scale (the BFS) is also likely to be applicable to similar rural African contexts. The BFS has acceptable psychometric properties, and is easy to administer, sensitive to changes following treatment and has content, construct and convergent validity. The BFS includes domains from existing measures, but has greater emphasis on social and occupational domains, which reflects priorities in the setting. The study showed that the WHODAS 2.0 has acceptable psychometric properties and can be used as a cross-cultural measure; however, the use of the scale in rural African settings requires careful and rigorous adaptation. Recommendations: On the basis of the findings and the conclusions made, the study recommends the following.  Mental health care providers need to involve family caregivers while providing treatment for people with SMD. This is because functional impairment in people with SMD has greater burden in family members and in turn, family members contribute to the functional impairment of people with SMD.  There is a need for further investigation to identify the effective type of psycho-social intervention to enhance the functioning of people with SMD in addition to treating illness symptoms. x  Clinicians are suggested to use the BFS in their routine clinical practice as it may have utility in clinical settings to ensure comprehensive assessment of functional status and track recovery.  Future research should explore whether or not a shorter version of the BFS is feasible; there is also need to test the feasibility and psychometric properties of the BFS in other rural African settings.  In mental health research, there is likely to be value in using both the BFS and the adapted version of the WHODAS-2.0 in order to both measure locally relevant functioning indicators to be able to compare across settings.