Volume 21, Issue 82 (11-2021)
refahj 2021, 21(82): 245-273 |
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Mahmoodi M H, Ahmadzad-Asl M, Rasoulian M. (2021). Mental Health Positive Knowledge Questionnaire: Translation and Cultural Adaptation and Psychometric Properties. refahj. 21(82), 245-273.
URL: http://refahj.uswr.ac.ir/article-1-3852-en.html
URL: http://refahj.uswr.ac.ir/article-1-3852-en.html
Keywords: questionnaire, positive mental health, validation, mental health literacy, positive mental health literacy
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Introduction: Mental health literacy (MHL) is a derivative of the known concept of health literacy. It is a modifiable factor that can affect a wide range of beliefs and behaviors related to mental health. In recent conceptualizations, four domains are suggested to construct MHL including 1) being familiar with mental disorders; 2) stigma against disorders and treatment; 3) help-seeking competency; and 4) understanding factors that keep and improve one’s mental health, which is known as positive mental health literacy (PMHL).
Many studies around the world have shown that higher MHL is related to desirable outcomes like higher help-seeking behavior, less stigma, better treatment compliance, and more effective communication with mental health providers. Most of these studies, however, have focused on disease-oriented MHL; i.e., have not investigated PMHL. This is not compatible with the World Health Organization (WHO)’s definition of health, which insisted that health is not just the absence of disease. This gap limits people’s and professional’s understanding of mental health to the medical model. Some researchers, therefore, have suggested including PMHL in MHL investigations in adults and adolescents.
Despite the high variability among MHL measures, most of them are disease-oriented. In recent years more attention has been paid to awareness of mental health maintenance and promotion, i.e., PMHL. The first PMHL questionnaire was introduced in 2017, and it was named Mental Health Positive Knowledge (MHPK). It is a single construct instrument with 10 brief questions in the English language. The average of all questions makes up the total score, which is from 0 to 5. The MHPK is tested in a population of Norwegian adolescents and the total score of 4 is considered as a preliminary cut-off of sufficient PMHL.
Using MHPK can fill the gap between the daily practice of mental health staff and standard definitions of health and mental health and extend our understanding of MHL beyond disease concepts. It can also be used to determine the efficacy of positive mental health educational interventions. Several studies have investigated positive mental health and its determinants in the Iranian population. No study, however, was found to explore PMHL, i.e., people’s awareness of positive mental health. There was also no instrument to measure PMHL in the Persian language according to the literature review. To use a valid instrument that is developed in another language and culture, it is necessary to ensure its compatibility with the target population. This study, therefore, aimed to translate MHPK into the Persian language with proper cultural adaptation along with checking its psychometric properties.
Method: The translation and cultural adaptation process was performed according to Beaton et al. It included two forward and two backward translated versions and an expert panel that resulted in a refined Persian MHPK with satisfactory face and content validity. This Persian version was used in the pretest, i.e., asking 30 participants from the target population to fill out the questionnaire and interviewing with them about its clarity and propriety. The final version and demographic questions were prepared as an online form so that it could be filled by any Iranian individual with a minimum age of 15, literacy for reading and writing, and basic internet skills. Answering all questions was necessary to submit the form; therefore, there were no missing data. Exploratory and confirmatory factor analyses were used to investigate the construct validity of Persian MHPK. The split-half method and measuring Cronbach’s alpha were used to investigate its reliability. Mean, standard deviation (SD), 95% confidence interval (95% CI), and frequency were used to describe data. SPSS Statistics for Windows, version 16 (SPSS Inc., Chicago, Ill., USA) and Mplus software version 7.4 were used. Participants were kept anonymous and the research protocol was approved by the ethics committee of Iran University of Medical Sciences. There was no conflict of interest for the authors.
Findings: Forward and backward translations were quite similar to each other and the original English questionnaire. Expert panel members discussed the accuracy and appropriateness of the Persian version and agreed easily on details. A brief explanation was added to some items in parentheses to be sure about the face and content validity. In the pretest, 30 individuals with a mean age of 27.9 participated in the study including 8 adolescents, and all of them found the instrument clear and without offensive content. Four of them, however, were not sure about the exact meaning of the item number 8 (“Setting limits for what is OK for you”). To investigate psychometric properties a total of 1606 individuals from different cities of the country were selected. The mean age was 29.9 (SD = 9.14) and ranged from 15 to 69; 176 participants were adolescents whose age was below 18. Most of the participants (71.9%) were female and 235 of them (15.2%) did not have any university degrees. The average MHPK score was 4.21 (SD = 0.72) with a 95% CI of 4.18 – 4.25. Near a quarter of participants (24.4%) scored below the preliminary cut-off and may be considered to have insufficient PMHL. Females and participants with Master’s or higher university degrees showed significantly higher MHPK scores (both p values < 0.001). Exploratory factor analysis showed sufficient sample size with Kaiser-Meyer-Olkin index of 0.887 and chi-square of 3980.85 in Bartlett’s test. Only one factor was extracted in exploratory factor analysis; therefore rotation techniques were not used. According to confirmatory factor analysis, the model with one factor showed satisfactory goodness of fit indices and provided further support for construct validity as well as convergent validity of the instrument. The Cronbach’s alpha of 0.81 was calculated as a measure of internal consistency and using the split-half method a Guttmann coefficient of 0.79 was calculated; these results showed good reliability of the instrument.
Discussion: In this study, the MHPK questionnaire which is a measure of positive mental health literacy (PMHL) was translated into Persian by using a standard method to ensure its validity and cultural adaptation. Afterward, its psychometric properties were investigated and showed good validity and reliability. Persian MHPK is a single factor instrument according to exploratory and confirmatory factor analyses; this is compatible with the construct of the original version. The average MHPK score evaluated in Norwegian adolescents by the original version has been 4.51 and less than 20% of them showed insufficient scores. These results are better than the findings of the current study with much more educated participants. The better results in the Norwegian sample may be due to the effects of the translation process on scores or may be another example of higher MHL in developed countries compared to developing nations, like Iran. Females showed higher PMHL both in the Norwegian sample and in the current study. A big sample size with considerable diversity and standard methodology were advantages of this study, but there are some limitations. All of the high school students who participated in this study were from Tehran, the capital of the country. Besides, all participants were capable of using the internet. Therefore, some psychometric properties may need to be tested before using the instrument in different communities. Validity and reliability could be inspected in more detail. Persian MHPK is the first Persian instrument to evaluate PMHL and is one of the few in the world. Using it, besides conventional disease-oriented MHL measures, can improve MHL evaluation in accordance with the WHO definition of health and mental health. Furthermore, adding PMHL concepts to mental health education interventions can make them applicable to all people regardless of being mentally healthy or ill. This study showed that Persian MHPK is a valid and reliable measure of PMHL for literate individuals with the age of 15 years old and higher.
Ethical Consideration
Authors’ contributions
Seyed Mohammad Hossein Mahmoodi contributed to the design of the work, data acquisition, analysis, and interpretation, and drafting of the manuscript. Masoud Ahmadzad-Asl and Maryam Rasoulian contributed to the conception and design, data interpretation, and revising the manuscript critically. The final version was approved by all authors.
Funding
No financial support is used in this research.
Conflicts of interest
The authors did not declare any competing interests.
Acknowledgments
This research was approved by the ethics committee of Iran University of Medical Sciences and the principles of the declaration of Helsinki were observed.
Introduction: Mental health literacy (MHL) is a derivative of the known concept of health literacy. It is a modifiable factor that can affect a wide range of beliefs and behaviors related to mental health. In recent conceptualizations, four domains are suggested to construct MHL including 1) being familiar with mental disorders; 2) stigma against disorders and treatment; 3) help-seeking competency; and 4) understanding factors that keep and improve one’s mental health, which is known as positive mental health literacy (PMHL).
Many studies around the world have shown that higher MHL is related to desirable outcomes like higher help-seeking behavior, less stigma, better treatment compliance, and more effective communication with mental health providers. Most of these studies, however, have focused on disease-oriented MHL; i.e., have not investigated PMHL. This is not compatible with the World Health Organization (WHO)’s definition of health, which insisted that health is not just the absence of disease. This gap limits people’s and professional’s understanding of mental health to the medical model. Some researchers, therefore, have suggested including PMHL in MHL investigations in adults and adolescents.
Despite the high variability among MHL measures, most of them are disease-oriented. In recent years more attention has been paid to awareness of mental health maintenance and promotion, i.e., PMHL. The first PMHL questionnaire was introduced in 2017, and it was named Mental Health Positive Knowledge (MHPK). It is a single construct instrument with 10 brief questions in the English language. The average of all questions makes up the total score, which is from 0 to 5. The MHPK is tested in a population of Norwegian adolescents and the total score of 4 is considered as a preliminary cut-off of sufficient PMHL.
Using MHPK can fill the gap between the daily practice of mental health staff and standard definitions of health and mental health and extend our understanding of MHL beyond disease concepts. It can also be used to determine the efficacy of positive mental health educational interventions. Several studies have investigated positive mental health and its determinants in the Iranian population. No study, however, was found to explore PMHL, i.e., people’s awareness of positive mental health. There was also no instrument to measure PMHL in the Persian language according to the literature review. To use a valid instrument that is developed in another language and culture, it is necessary to ensure its compatibility with the target population. This study, therefore, aimed to translate MHPK into the Persian language with proper cultural adaptation along with checking its psychometric properties.
Method: The translation and cultural adaptation process was performed according to Beaton et al. It included two forward and two backward translated versions and an expert panel that resulted in a refined Persian MHPK with satisfactory face and content validity. This Persian version was used in the pretest, i.e., asking 30 participants from the target population to fill out the questionnaire and interviewing with them about its clarity and propriety. The final version and demographic questions were prepared as an online form so that it could be filled by any Iranian individual with a minimum age of 15, literacy for reading and writing, and basic internet skills. Answering all questions was necessary to submit the form; therefore, there were no missing data. Exploratory and confirmatory factor analyses were used to investigate the construct validity of Persian MHPK. The split-half method and measuring Cronbach’s alpha were used to investigate its reliability. Mean, standard deviation (SD), 95% confidence interval (95% CI), and frequency were used to describe data. SPSS Statistics for Windows, version 16 (SPSS Inc., Chicago, Ill., USA) and Mplus software version 7.4 were used. Participants were kept anonymous and the research protocol was approved by the ethics committee of Iran University of Medical Sciences. There was no conflict of interest for the authors.
Findings: Forward and backward translations were quite similar to each other and the original English questionnaire. Expert panel members discussed the accuracy and appropriateness of the Persian version and agreed easily on details. A brief explanation was added to some items in parentheses to be sure about the face and content validity. In the pretest, 30 individuals with a mean age of 27.9 participated in the study including 8 adolescents, and all of them found the instrument clear and without offensive content. Four of them, however, were not sure about the exact meaning of the item number 8 (“Setting limits for what is OK for you”). To investigate psychometric properties a total of 1606 individuals from different cities of the country were selected. The mean age was 29.9 (SD = 9.14) and ranged from 15 to 69; 176 participants were adolescents whose age was below 18. Most of the participants (71.9%) were female and 235 of them (15.2%) did not have any university degrees. The average MHPK score was 4.21 (SD = 0.72) with a 95% CI of 4.18 – 4.25. Near a quarter of participants (24.4%) scored below the preliminary cut-off and may be considered to have insufficient PMHL. Females and participants with Master’s or higher university degrees showed significantly higher MHPK scores (both p values < 0.001). Exploratory factor analysis showed sufficient sample size with Kaiser-Meyer-Olkin index of 0.887 and chi-square of 3980.85 in Bartlett’s test. Only one factor was extracted in exploratory factor analysis; therefore rotation techniques were not used. According to confirmatory factor analysis, the model with one factor showed satisfactory goodness of fit indices and provided further support for construct validity as well as convergent validity of the instrument. The Cronbach’s alpha of 0.81 was calculated as a measure of internal consistency and using the split-half method a Guttmann coefficient of 0.79 was calculated; these results showed good reliability of the instrument.
Discussion: In this study, the MHPK questionnaire which is a measure of positive mental health literacy (PMHL) was translated into Persian by using a standard method to ensure its validity and cultural adaptation. Afterward, its psychometric properties were investigated and showed good validity and reliability. Persian MHPK is a single factor instrument according to exploratory and confirmatory factor analyses; this is compatible with the construct of the original version. The average MHPK score evaluated in Norwegian adolescents by the original version has been 4.51 and less than 20% of them showed insufficient scores. These results are better than the findings of the current study with much more educated participants. The better results in the Norwegian sample may be due to the effects of the translation process on scores or may be another example of higher MHL in developed countries compared to developing nations, like Iran. Females showed higher PMHL both in the Norwegian sample and in the current study. A big sample size with considerable diversity and standard methodology were advantages of this study, but there are some limitations. All of the high school students who participated in this study were from Tehran, the capital of the country. Besides, all participants were capable of using the internet. Therefore, some psychometric properties may need to be tested before using the instrument in different communities. Validity and reliability could be inspected in more detail. Persian MHPK is the first Persian instrument to evaluate PMHL and is one of the few in the world. Using it, besides conventional disease-oriented MHL measures, can improve MHL evaluation in accordance with the WHO definition of health and mental health. Furthermore, adding PMHL concepts to mental health education interventions can make them applicable to all people regardless of being mentally healthy or ill. This study showed that Persian MHPK is a valid and reliable measure of PMHL for literate individuals with the age of 15 years old and higher.
Ethical Consideration
Authors’ contributions
Seyed Mohammad Hossein Mahmoodi contributed to the design of the work, data acquisition, analysis, and interpretation, and drafting of the manuscript. Masoud Ahmadzad-Asl and Maryam Rasoulian contributed to the conception and design, data interpretation, and revising the manuscript critically. The final version was approved by all authors.
Funding
No financial support is used in this research.
Conflicts of interest
The authors did not declare any competing interests.
Acknowledgments
This research was approved by the ethics committee of Iran University of Medical Sciences and the principles of the declaration of Helsinki were observed.
Type of Study: orginal |
Received: 2021/02/19 | Accepted: 2021/10/20 | Published: 2021/11/23
Received: 2021/02/19 | Accepted: 2021/10/20 | Published: 2021/11/23
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