Background

Stress is defined as the loss of equipoise between evolving changes in an individual’s life and their capacity to adapt [1]. Although stress is a common phenomenon, its extent varies among people based on their perceptions and availability of appropriate coping strategies [2].

Assessing the burden of stress is not an easy task due to its subjectivity. As stress translates into many common mental disorders, the prevalence of mental disorders can serve as a relatively accurate measure for evaluating the effects of stress. Chronic stress may ultimately become the tipping point of common mental disorders such as depression, anxiety, mood disorders and suicide [3].

The Global Burden of Disease Survey conducted by World Health Organization (WHO) reports psychiatric illnesses along with stress-related disorders to be the second leading cause of disabilities by the year 2020 [4]. In 2010, depressive disorders had affected 40% of world’s population [5]. In Pakistan, studies from both rural and urban areas report prevalence of depression from 3.4% to 40% [6, 7].

Studies from Pakistan have reported tools that have been developed or adapted, translated and validated to measure stress [8]. These tools have been constructed for a specific condition e.g. anxiety or depression or for specific population for e.g. antenatal clinics, in-patient and out-patient psychiatric settings, adolescents and teachers (Table 1) [8,9,10,11,12,13,14,15,16]. There is a need for a generalizable tool to be used in community settings that can measure stress in the general population.

Table 1 Validated Stress Measurement Scales in Pakistan
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An important mediator of stress is the occurrence of repeated Stressful Life Events in the domains of home, health, work, environment and personal and social life. Rahe and Holmes developed a tool using these events so as to measure stress which is known as “Social Readjustment and Rating Scale (SRRS)”. However, SRRS had a limited item range which was reviewed periodically by these researchers and led to the development of another tool namely “Recent Life Changes Questionnaire (RLCQ)” in 1997 [17, 18]. RLCQ measures stress through life changing events occurring during a specified time frame (6 months or a year) and measures its consequences on health of an individual.

Pakistan is a developing country where daily life stressors have a major influence on mental health of people and no tools are available that measure stress in the general population in a relevant and contextually appropriate fashion. Hence, the aim of this study is to report the process of adaptation of the RLCQ with respect to the general population of urban Pakistan where the adapted tool becomes accurate and relevant.

Methods

Study design and setting

The study incorporated qualitative methodology following COREQ guidelines [19]. First, it followed a phenomenology study design as we aimed to explore stressors relevant to Pakistani context. We conducted serial in-depth interviews along with translating the tool and seeking expert’s opinion [19]. This was followed by community based scoring of each stressful item on the adapted tool (Fig. 1).

Fig. 1
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Study Flow Diagram

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Karachi best represents the multi-ethnicity of Pakistan due to its metropolitan nature and extreme diversity and thus was the ideal site for this study for reasons of external validity.

Populations for in-depth interviews and rating

Participants were recruited from the outpatient departments of Aga Khan University, Hospital (AKUH) which serves people from diverse socio-cultural backgrounds who visit for regular health checkups e.g. vaccination, eye checkups, employee assessment. They were invited and consented for in-depth interviews for theme identification of stressors that may not have been listed in the original RLCQ due to cultural differences.

Following these open ended in-depth interviews and theme identification, we proceeded to community scaling. From February to March 2015, we recruited adult participants from four communities in Karachi namely Kharadar, Dhorajee, Gulshan and Garden. These communities represent the various ethnic groups within Pakistan and ensure a better generalization (Fig. 2). Those who could understand Urdu and were willing to participate were invited to be part of the study however; individuals who had been taking medications prescribed for existing mental conditions were excluded because the use of medication may have altered their perception of severity of daily life stressors. These communities helped rate the scale of stressful life events that were identified in the open ended qualitative part of the study.

Fig. 2
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Community sites - Garden, Kharadar, Gulshan and Dhorajee

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Study procedures

Step I: In-depth interviews and adaptation steps

Qualitative interviews began in December 2014 from men and women aged ≥18 years who were able to understand Urdu and provided written informed consent. We excluded those participants who had cognitive, hearing or speech difficulties due to strokes or other organic impairments. There was no direct personal relationship with the participants prior to study commencement. However, the community trusts and has a good relationship with the institution. The purpose of these interviews was to explore the understanding of stress and to gain insight into stressful life events at the community level. Respondents were purposefully identified based on their willingness to give us an extended length of time and to ensure participation of a diverse population such as representativeness of both males and females and of different sociocultural backgrounds. Participants were approached face to face and were informed about the researcher’s credentials, personal goals and the purpose of the study while obtaining informed consent.

AA conducted all the interviews; she is a qualified nurse and has training experience in qualitative research methods courses as an academic program. In addition she is a Clinical Research Fellow and Masters in Epidemiology and Biostatistics.

From initial recruitment, we continued to interview participants until same stressful events were being reported and no new stressful event was discussed with the interviewer. Sample size was based on the data saturation. We continued to interview participants until 20 participants were interviewed and theme saturation was achieved. The interviews were conducted in separate rooms that were identified at each outpatient clinic. To ensure privacy of the participants, entry into the room was restricted to the interviewer and the participant only. People accompanying participants were accommodated in the waiting area of the clinic. A semi-structured interview guide was prepared for these interviews exploring stress phenomenon and inquiring about life events that predisposes participants to stress with open ended questions and appropriate prompts. This was pretested in the outpatient clinics where actual sample was to be conducted. Also, the original RLCQ was shared with the participants towards the end of the interview to reflect at the listed stressors. They were encouraged to express their views over events they thought were not stressful within the context of Pakistani community which were later incorporated in the first draft. Interviews were conducted once only and participants were encouraged to share with us as much as possible with the help of prompts. Audio recording was performed. Patient identity was kept confidential. Field notes were taken during interview and were reviewed with transcription. While concluding each interview, major points shared during the interview were summarized with the participants.

Transcriptions were done of these interviews and scripts were reviewed by the first authors along with its coding. These were discussed with all the research team who reached consensus with regards to data saturation and which culminated our first draft of the adapted RLCQ (Additional file 1). It comprised of newly identified stressful events along with removal of those that were perceived as not stressful. Translation and back translation of the tool was done to ensure face validity. Later, it was sent to experts for review which included a sociologist, a psychologist and two individuals belonging to the public health domain. The experts were identified based on formal completion of post-graduate education along with greater than 10 years of local experience in the field of stress and community work in the area. Qualitative research experts also reviewed the content and layout of the work. They provided written feedback on the language, understanding, content representativeness with respect to the construct and duration for completion which culminated our second draft. This draft was pre-tested in the communities which we planned to approach for scoring items on the questionnaire (Fig. 1).

Step II: Scoring of items on adapted RLCQ by communities

For each item on the adapted RLCQ, we needed a score that could represent the magnitude of stress perception numerically. Hence for scoring, we required 200 participants. The sample size was based on the recommendation by Kline as a requirement of principal component analysis that we were to apply for tool development [20]. As we had 83 events on the adapted RLCQ, item to responders’ ratio of 1:2 was suggested.

Systematic random sampling technique was used in each selected area. Households were selected based on the kth number that was determined from estimated population of these areas. As these communities were equally dense, we chose every eighth house based on kth number. One participant was chosen at random from each household fulfilling the entry criteria. These participants were not the same from whom in-depth interviews were conducted.

Participants were asked to rate each life event in the draft on a continuum of 0 to 100 where 0 represented no stress and 100 represented maximum stress that can be tolerated.

Human subjects approvals and registration

Ethical approval was sought from Ethical Review Committee, Aga Khan University which granted permission on 14th October 2014 with study registration ID as 3235-CHS-ERC-14. The study was registered as an observational study at Clinicaltrials.gov with the study ID NCT02356263.

Statistical analysis plan

For statistical analysis, STATA version 12 was used. We calculated means, medians and modes for the scores of all the events in the questionnaire. We kept mean as the score of an event. In case of events in which rated mean was different from median with ±5 points, we kept median as the score of those events. We applied exploratory factor analysis on the entire data so as to classify events in the adapted questionnaire into categories reflecting similar notion.

Results

Step I results: Qualitative stressful life events: Themes identified

We interviewed 20 participants, equal gender with equal number of men and women with an average age of 48 years (SD = 5.6 years). 12 individuals refused to participate as they had time constraints. However, those who gave consent continued the entire interview and there were no drop outs. The mean duration of these interviews was of 57 min. Transcriptions were read multiple times by the first authors and were verified for correctness with the audio recordings. Notes were made over experiences shared by the participants. Content analysis of the data began by identifying key words and phrases from the text and segregating it into smaller units. Upon further readings, the units indicating similar experiences were coded in all the transcripts. These codes were discussed by the research team and with agreement of all, were categorized and grouped into sub-themes. Out of these sub-themes, broader themes were extracted that became the newly identified stressful life events which with final consensus of the research team were included in the adapted RLCQ. Table 2 describes the sub-themes and themes that were derived from the data along with participant’s quotes. Transcription was typed in MS word 2010. Extraction of codes and revision were first done manually then updated electronically. These themes are in congruence with actual data. The qualitative interviews conducted from participants revealed a range of stressful events that stem from the socio-political environment within Pakistan. These events described difficulties that residents face in their daily lives such as lack of power, fuel and sanitation. In addition, social beliefs and values were causes of chronic stress such as such as having an unmarried middle aged daughter, prejudices of bearing a male child, harassment in public and lack of women empowerment within homes and at work. There were references to the political environment such as state sponsored brutality, missing job opportunity because of nepotism and lack of meritocracy, extortion of money by force and suicide bombings (Table 2).

Table 2 Themes and sub-themes describing stressful life events of urban adult population of Karachi
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Conversely, there was unanimous consensus among the participants to remove events such as promotion, lesser work responsibility, vacation, major increase in income, moderate purchase, major dental work, birth of a grandchild and major personal achievement. These events were regarded as “fortunate events” rather than stressful. Most participants felt that they did not have a place in the stressful life event category.

Step II results: Categorization of events of varying stress severity by communities

The original categories of the RLCQ focus on family, personal, social, health and financial circumstances of life. It did not have a structure to take these newly identified events into their existing framework as it has no representative category that could classify environment related life stressors. We tried to do an exploratory factor analysis where each event was dealt independently so that new possible categories could be formed for the structure of adapted RLCQ. Keeping a cut-off value of ≥1of Eigen values as selection criteria of factors, we assessed 10 emerging possibilities in which all the events on the adapted draft had been grouped.

When all the events were arranged into their respective categories, they appeared to have lost the meaning of the stressors as a group because they were non-representative with each other and seemed jumbled up. Hence, we decided to place all the events in the same order of groups as it was in the original RLCQ and introduced another group of stressors having all the new events calling it as “environmental factors” (Table 3).

Table 3 Final draft of RLCQ
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Out of 83, 23 events required median as event weightage whereas for others, means were closer to the median and hence we kept mean as their event weightage. At the end of this phase, we had our adapted RLCQ which was enriched with contextually relevant stressors through qualitative exploration, content validation via experts and face validity. Also, it depicts community’s perception upon severity of each event as the scores for the adapted tool were derived by community participation.

Discussion

The adapted RLCQ enumerates stressful life events that reflect stressors within an urban population of a multiethnic city in a Low-Middle Income Country (LMIC). These events influence daily life of individuals residing in these countries such as lack of basic living facilities, gender inequality, harassment and lack of social security and were different from the original RLCQ, hence a new category of ‘environment’ was formed to incorporate these events. Moreover, the relevant communities were involved in the entire process of rating which clarified the impact of these events in people’s life.

Stressful life events for adults living in Pakistan differ from developed countries because of poverty, lawlessness and political instability. The events of our adapted RLCQ are in congruence with those that were concluded in other adaptation studies of low middle income countries [21]. It depicts that theft, lack of basic living facilities, natural disasters, social discrimination and an insecure living environment prevails in these countries and hence has been included by them in the list [22, 23]. However, being a victim of suicide bombing and state sponsored brutalities has never been highlighted in any of the studies prior to our findings. These events are important mediators of population mental health and should be part of the systematic review of health within LMIC settings.

The adapted RLCQ is a simple tool and can be administered by community health workers. It was derived from qualitative exploration following COREQ guidelines that ensure rigor within this methodology. The adapted RLCQ mirrors stressful events in context of LMICs urban population. Through community participation during rating of events exercise, we were able to understand better the importance and impact of one life event as compared to other life events for e.g. death of a family member was given a higher score as compared to death of a close friend.

There are other approaches to measuring stressful life events such as the Brown and Harris approach where contextuality of the event is discussed in detail and gives further insight [24]. However, as an initial approach, without identifying even our basic life events, Brown and Harris’s contextual approach becomes challenging as it requires great deal of expertise and time to conduct such interviews with each individual where researchers could rate the severity of stressors without being influenced with the nature and timeliness of the circumstances being explored [24]. Furthermore, considering the Pakistani context where access to community mental health facilities is difficult, identifying stress using this approach in such resource scarce setting raises concerns to its applicability [24].

The aim of the current study was to develop a community based screening tool (adapted RLCQ) rather than a sophisticated tool to measure stress in the context of Pakistani population. We have a rich resource of community health workers that is now beginning to be trained for mental health work at very basic units. From the sustainability point of view, it is much easier for community health workers to screen and identify high risk individuals based on this adapted RLCQ that consumes less time and professional expertise.

This adaptation study has certain limitations. As we interviewed participants they may have more readily shared events that they feel less stigmatized to talk about from a socio-cultural perspective. This takes into account listing stressors that are socio-culturally acceptable to discuss openly. For events that are stigmatized, such as rape, drug abuse or other such events that are social taboos, stigma would have introduced a reporting bias. Having acknowledged that, we still have noted serious issues of extortion, suicide bombing, and harassment that were reported in this study. For any country with socio-political instability, it is highly likely that new stressful events would occur in a short time frame that would affect consistency of the tool when used over longer time frames to quantify stress. Minor themes have not been discussed in this paper, as our aim of the qualitative phase was to explore stressors that reflect Pakistani population majorly so that we could include these events in our adapted tool. The applicability of the adapted RLCQ to an overseas Pakistani community becomes limited with respect to the change in environmental circumstances. Essential sociocultural values that are nurtured at early stages of life of every individual may still be applicable to Pakistanis residing outside the country however, environmental and financial stressors may differ. For instance they may face social discrimination while they may not encounter problems due to unavailability of water or electricity. Overall, the applicability of adapted RLCQ depends on the nature of the research as it becomes limited with respect to the change in environmental circumstances Future research is planned to explore the validity of the adapted RLCQ in the study population and may additionally explore resilience and resilience boosting strategies at the community level.

Conclusions

Mental health in Pakistan needs integration in the existing infrastructure. This relevant tool can be utilized effectively in screening of individuals at the community level where effective interventions could be planned and performed for high risk groups. Initiatives such as identifying social support groups, behavioral therapies and resilience boosting strategies could help communities draw strength for coping.