Reliability, Validity, and Factor Structure of the Hopkins Symptom Checklist-25: Population-Based Study of Persons Living with HIV in Rural Uganda
Depression and anxiety are highly comorbid among people living with HIV (PLHIV), but few instruments for screening or measurement have been validated for use in sub-Saharan Africa. The objective of this study was to determine the reliability, validity, and factor structure of the 25-item Hopkins Symptom Checklist (HSCL) in a population-based sample of PLHIV in rural Uganda. This study was nested within an ongoing population-based cohort of all residents living in Nyakabare Parish, Mbarara District, Uganda. All participants who identified as HIV-positive by self-report were included in this analysis. We performed parallel analysis on the scale items and estimated the internal consistency of the identified sub-scales using ordinal alpha. To assess construct validity we correlated the sub-scales with related constructs, including subjective well being (happiness), food insecurity, and health status. Of 1814 eligible adults in the population, 158 (8.7%) self-reported being HIV positive. The mean age was 41 years, and 68% were women. Mean HSCL-25 scores were higher among women compared with men (1.71 vs. 1.44; t = 3.6, P < 0.001). Parallel analysis revealed a three-factor structure that explained 83% of the variance: depression (7 items), anxiety (5 items), and somatic symptoms (7 items). The ordinal alpha statistics for the sub-scales ranged from 0.83 to 0.91. Depending on the sub-scale, between 27 and 41% of the sample met criteria for caseness. Strong evidence of construct validity was shown in the estimated correlations between sub-scale scores and happiness, food insecurity, and self-reported overall health. The HSCL-25 is a reliable and valid measure of mental health among PLHIV in rural Uganda. In cultural contexts where somatic complaints are commonly elicited when screening for symptoms of depression, it may be undesirable to exclude somatic items from depression symptom checklists administered to PLHIV.
KeywordsHIV Depression Anxiety Screening Case-finding Uganda Sub-Saharan Africa
We thank Peggy Bartek, Anna Baylor, Kate Bell, Ryan Carroll, Amy Q. McDonough, Nozmo F. B. Mukiibi, Rumbidzai Mushavi, and the HopeNet Study team, for their assistance with data collection, study administration, and infrastructure development; and Roger Hofmann of West Portal Software Corporation (San Francisco, California), for developing and customizing the Computer Assisted Survey Information Collection Builder software program. In addition to the named study authors, HopeNet Study team members who contributed to data collection and/or study administration during all or any part of the study were as follows: Phiona Ahereza, Owen Alleluya, Gwendoline Atuhiere, Patience Ayebare, Augustine Byamugisha, Patrick Gumisiriza, Clare Kamagara, Justus Kananura, Noel Kansiime, Allen Kiconco, Viola Kyokunda, Patrick Lukwago, Moran Mbabazi, Juliet Mercy, Elijah Musinguzi, Sarah Nabachwa, Elizabeth Namara, Immaculate Ninsiima, Mellon Tayebwa, and Specioza Twinamasiko.
The study was funded by Friends of a Healthy Uganda. The authors additionally acknowledge salary support through U.S. National Institutes of Health D43TW010128 (S.A.), T32MH093310 (C.E.C-V.), and K23MH096620 (A.C.T.). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Compliance with Ethical Standards
Conflict of interest
We have no conflicts of interest to disclose.
Ethical approval for all study procedures was obtained from the Partners Human Research Committee, Massachusetts General Hospital; and the Institutional Review Committee, Mbarara University of Science and Technology. Consistent with national guidelines, we received clearance for the study from the Uganda National Council for Science and Technology and from the Research Secretariat in the Office of the President.
Written informed consent to participate was obtained. Study participants who were unable to write were permitted to indicate consent with a thumbprint.
- 1.GBD 2015 DALYs and HALE Collaborators. Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388(10053):1603–58.CrossRefGoogle Scholar
- 5.Tsai AC, Weiser SD, Petersen ML, Ragland K, Kushel MB, Bangsberg DR. A marginal structural model to estimate the causal effect of antidepressant medication treatment on viral suppression among homeless and marginally housed persons with HIV. Arch Gen Psychiatry. 2010;67(12):1282–90.CrossRefPubMedPubMedCentralGoogle Scholar
- 20.National Statistical Office and ICF Macro. Malawi Demographic and Health Survey 2010. Calverton: ICF Macro; 2011.Google Scholar
- 22.Bolton P, Ndogoni L. Cross-cultural assessment of trauma-related mental illness (Phase II): a report of research conducted by World Vision Uganda and The Johns Hopkins University. 2001. http://www.certi.org/publications/policy/ugandafinalreport.htm. Accessed April 23, 2011.
- 32.Dinno A. Implementing Horn’s parallel analysis for principal component analysis and factor analysis. Stata J. 2009;9(2):192–298.Google Scholar
- 33.Gadermann AM, Guhn M, Zumbo BD. Estimating ordinal reliability for Likert-type and ordinal item response data: a conceptual, empirical, and practical guide. Pract Assess Res Eval. 2012;17(3):1–13.Google Scholar
- 37.Fisher RA. On the “probable error” of a coefficient of correlation deduced from a small sample. Metron. 1921;1(4):3–32.Google Scholar
- 38.Seed PT. sg159: confidence intervals for correlations. Stata Tech Bull. 2001;59(1):27–8.Google Scholar
- 47.Okello ES. Cultural explanatory models of depression in Uganda. Stockholm: Institutionen för Klinisk Neurovetenskap, Karolinska Institutet;2006. 9171408231.Google Scholar
- 49.Okello ES, Musisi S. Depression as a clan illness (eByekika): an indigenous model of psychotic depression among the Baganda of Uganda. World Cult Psych Res Rev. 2006;1(2):60–73.Google Scholar
- 56.Uganda Ministry of Health. Uganda AIDS Indicator Survey 2011. Kampala: Uganda Ministry of Health and Calverton: ICF International; 2012.Google Scholar