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. 2021 Apr:4:100121.
doi: 10.1016/j.jadr.2021.100121. Epub 2021 Feb 22.

Evaluating the Cross-Cultural Measurement Invariance of the PHQ-9 between American Indian/Alaska Native Adults and Diverse Racial and Ethnic Groups

Melissa L Harry  1 , R Yates Coley  2 , Stephen C Waring  1 , Gregory E Simon  2
Affiliations

Evaluating the Cross-Cultural Measurement Invariance of the PHQ-9 between American Indian/Alaska Native Adults and Diverse Racial and Ethnic Groups

Melissa L Harry et al. J Affect Disord Rep. 2021 Apr.

Abstract

Background: The Patient Health Questionnaire-9 (PHQ-9), a self-reported depression screening instrument for measurement-based care (MBC), may have cross-cultural measurement invariance (MI) with a regional group of American Indian/Alaska Native (AI/AN) and non-Hispanic White adults. However, to ensure health equity, research was needed on the cross-cultural MI of the PHQ-9 between other groups of AI/AN peoples and diverse populations.

Methods: We assessed the MI of the one-factor PHQ-9 model and five previously identified two-factor models between non-Hispanic AI/AN adults (ages 18-64) from healthcare systems A (n=1,759) and B (n=2,701) using secondary data and robust maximum likelihood estimation. We then tested either fully or partially invariant models for MI between either combined or separate AI/AN groups, respectively, and Hispanic (n=7,974), White (n=7,974), Asian (n=6,988), Black (n=6,213), and Native Hawaiian/Pacific Islander (n=1,370) adults from healthcare system B. All had mental health or substance use disorder diagnoses and were seen in behavioral health or primary care from 1/1/2009-9/30/2017.

Results: The one-factor PHQ-9 model was partially invariant, with two-factor models partially, or in one case fully, invariant between AI/AN groups. The one-factor model and three two-factor models were partially invariant between all seven groups, while a two-factor model was fully invariant and another partially invariant between a combined AI/AN group and other racial and ethnic groups.

Conclusions: Achieving health equity in MBC requires ensuring the cross-cultural validity of measurement tools. Before comparing mean scores, PHQ-9 models should be assessed for individual racial and ethnic group fit for adults with mental health or substance use disorders.

Keywords: American Indian/Alaska Native; Patient Health Questionnaire-9; cross-cultural; health equity; measurement equivalence; measurement invariance.

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Conflict of interest statement

Conflicts of interest: All authors declare that they have no conflicts of interest.

References

    1. Ahmedani BK, Simon GE, Stewart C, Beck A, Waitzfelder BE, Rossom R, Lynch F, Owen-Smith A, Hunkeler EM, Whiteside U, Operskalski BH, Coffey MJ, Solberg LI, 2014. Health care contacts in the year before suicide death. J. Gen. Intern. Med 29 (6), 870–877. 10.1007/s11606-014-2767-3. - DOI - PMC - PubMed
    1. Ahmedani BK, Westphal J, Autio K, Elsiss F, Peterson EL, Beck A, Waitzfelder BE, Rossom RC, Owen-Smith AA, Lynch F, Lu CY, Frank C, Prabhakar D, Braciszewski JM, Miller-Matero LR, Yeh HH, Hu Y, Doshi R, Waring SC, Simon GE, 2019. Variation in patterns of health care before suicide: A population case-control study. Prev. Med 127, 105796. 10.1016/j.ypmed.2019.105796. - DOI - PMC - PubMed
    1. Asdigian NL, Running Bear U, Beals J, Manson SM, Kaufman CE, 2018. Mental health burden in a national sample of American Indian and Alaska Native adults: differences between multiple-race and single-race subgroups. Soc. Psychiatry Psychiatr. Epidemiol 53, 521–530. 10.1007/s00127-018-1494-1 - DOI - PubMed
    1. Baas KD, Cramer AOJ, Koeter MWJ, van de Lisdonk EH, van Weert HC, Schene AH, 2011. Measurement invariance with respect to ethnicity of the Patient Health Questionnaire-9 (PHQ-9). J. Affect Disord 129, 229–235. 10.1016/j.jad.2010.08.026. - DOI - PubMed
    1. Boothroyd L, Dagnan D, Muncer S, 2019. PHQ-9: One factor or two? Psychiatry Res. 271, 532–534. 10.1016/j.psychres.2018.12.048 - DOI - PubMed