individuals allows examination of the concordance of mental health outcomes among different members of the same household. Third, the comprehensive multipurpose nature of the surveys provide richer measures of socioeconomic characteristics, including expenditure or income-based measures of poverty, rather than more blunt indicators such as earning less than one-quarter the minimum wage, or the presence or absence of electricity and tap water (e.g. Patel and Kleinman, 2003). Finally, we also able to link mental health with behaviors in the labor and health care markets.

While the exact content of the mental health questionnaires vary across the different countries, they are similar in concept. Typical questions ask respondents the frequency in the last month of a similar range of internal states (e.g. “feeling sad or blue”, “feeling anxious or nervous”) or related behaviors (e.g. “difficulty falling asleep”, “distracted from everyday activities”). The frequency of such states or behaviors is recorded on a four-point scale that ranges from “never” or “almost never” to “very often”. In line with the standard analysis of the GHQ and MHI-5, we score the individual’s survey response by assigning a low ordinal value (1 point) to categorical responses of infrequency and high ordinal values (up to 4 points) to the most frequent categories.<sup>2</sup> The average response across all questions (with each question given equal weight) constitutes the respondent’s mental health score, often known as the Global Severity Index or GSI, which is higher for those reporting worse mental health.<sup>3</sup> In contrast to subjective measures of well-being such as life-satisfaction, mental health measures can be validated against well-defined objectives – in particular, whether or not answers to the questions are predictive of clinical diagnoses of depression, anxiety, and other mental health disorders. Both the GHQ and MHI-5 have been found to perform well in this regard. Attempts to validate the mental health modules with regards to the specific populations used in our studies were carried out for the India and BiH data. In BiH, a selected sample of individuals were administered the household survey module, and then examined by a psychiatrist for known psychiatric disorders. In India, survey teams administered the survey to 38 individuals seeking outpatient treatment at two psychiatric facilities and found the mental health scores to be significantly lower for the general population than for the selected sub-population known to suffer from psychiatric disorders. In BiH the validation relied on a sample of 184 patients who

> 2 The MHI-5 used in Tonga had a 5-point scale while the GHQ adapted in Indonesia had a 3-point scale. Both were standardized to a 1 to 4 range for Table 1.

> 3 In addition, for each country except Tonga there are three common questions, which ask whether the respondent has recently felt sad, felt anxious, and had trouble sleeping. An index formed using only these three questions has correlations of 0.84-0.90 with the overall index for each country, and similar results are obtained using this less comprehensive measure. In order to include Tonga in the analysis and use the indices most commonly employed in practice, we analyze the more comprehensive measures.

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