Dr. Kathleen O’Connor University of Texas, El Paso School of Nursing

1. Ensuring Local Appropriateness of Spanish-Language Versions of Two Mental Health Survey Instruments: The World Mental Health/WHO Composite International Diagnostic Interview and the Harvard Trauma Questionnaire Dr. Kathleen O’Connor University of Texas, El Paso School of Nursing

2. Specific Aims • The project aimed to revise three mental health survey instruments that had been translated into Spanish in other geographical areas, into locally-appropriate Spanish for use at the Texas-Mexico border in the El Paso-Juárezbinational metropolitan area among low income Hispanics.

3. Harvard Trauma Questionnaire • Developed at Harvard a decade ago (funded by Mellon) to respond to human rights movement in health Mollica, Caspi-Yavin, Bollini, Truong, Tor, & Lavelle, 1992). • Designed to assess the degree and type of trauma suffered by civilian victims of mass violence, increasingly the major global health concern of this century.

4. HTQ • Originally developed in MA to measure trauma in Cambodian survivors of Pol Pot regime • Designed to ask about painful experiences that needed to be assessed with an instrument that was brief, thorough and empowering • Includes a qualitative section that elicits narrative: we audiorecord this section. • Simple scoring

5. HTQ Trauma Events Section 1 • Lack of shelter; Lack of food or water; Ill health without access to medical care; Confiscation or destruction of personal property; Combat situation (e.g. shelling and grenade attacks; Forced evacuation under dangerous conditions; Beating to the body; Rape; Other types of sexual abuse or sexual humiliation; Knifing or axing; Torture, i.e., while in captivity you received deliberate and systematic infliction of physical or mental suffering; Serious physical injury from combat situation or landmine; Imprisonment; Forced labor (like animal or slave); Extortion or robbery; Brainwashing; Forced to hide

6. HTQ Section 1 • Kidnapped; Other forced separation from family members; Forced to find and bury bodies; Enforced isolation from others; Someone was forced to betray you and place you at risk of death or injury; Prevented from burying someone; Forced to desecrate or destroy the bodies or graves of deceased persons; Forced to physically harm family member, or friend; Forced to physically harm someone who is not family or friend; Forced to destroy someone else's property or possessions

7. HTQ Section 1 • Forced to betray family member, or friend placing them at risk of death or injury; Forced to betray someone who is not family or friend placing them at risk of death or injury; Murder, or death due to violence, of spouse; Murder, or death due to violence, of child; Murder, or death due to violence, of other family member or friend; • Disappearance or kidnapping of spouse; Disappearance or kidnapping of child; Disappearance or kidnapping of other family member or friend; Serious physical injury of family member or friend due to combat situation or landmine;

8. HTQ Section 1 • Witness beatings to head or body; Witness torture; Witness killing/murder; Witness rape or sexual abuse; Another situation that was very frightening or in which you felt your life was in danger (Specify)

9. HTQ Section 2 - 3 • Section 2: Personal description of worst event in lifetime and worst event recently • Section 3: Beatings to the head, strangulation, drowning, and other types of head injuries, and loss of consiousness, if any. • Starvation: if yes, asks normal weight and weight after being starved

10. HTQ Section 4 • Asks about classic trauma symptoms: • Recurrent or intrusive thoughts and memories; nightmares; feeling as if the event was re-ocurring; emotional numbing; startle response; difficulty concentrating; trouble sleeping; hypervigilance; avoidance etc

11. Hopkins Symptom Checklist (HSCL-25). • Developed at Johns Hopkins Mollica, Wyshak, de Marneffe, Khuon, & Lavelle, 1987 • 15 items that identify depression • 10 items that aim to identify anxiety • Simple scoring

12. HTQ and HSCL • Both intended for screening, research, clinical assessment • Both are brief, readily adaptable, can be administered by non-clinicians • May have better psychometric properties than long complex clinical interviews (Mollica et al 2004)

13. Testing • We revised a Spanish version from Mexico City and tested our revisions on three groups: two groups of low income Mexican women in Juarez who suffered from domestic violence – living in a shelter and living at home in a colonia; and with college-age adults (ongoing).

14. Composite International Diagnostic Interview (CIDI) • Developed in 1990 by World Health Organization to address the cultural specificity of the Diagnostic Interview Schedule (DIS) and include ICD classifications for a more global perspective on diagnosis of mental health issues. • Developed for use by non-clinicians as well as clinicians

15. CIDI • In 1998 changes by international consortium were added to include risk factors; distress and impairment, clinical severity, subthreshold assessment, among others. • The PTSD section was greatly expanded in the belief that trauma exposure is a significant risk factor for comorbid and future mental health issues and that PTSD is rather more prevalent than previously believed. • Assesses 12-month, lifetime and worst PTSD episode or traumatic event.

16. CIDI • Assesses the sources of the trauma, providing choices and two further questions, events not mentioned, and events that the respondent is not comfortable talking about (the last is left undefined) • Depression was revised to include irritability and with depressive episodes as well as mixed episodes including reversed vegetative symptoms

17. CIDI • The interview begins with a screening section that is coded – the interviewer then skips to the sections for which the respondent reported having symptoms • Requires a 4-day training at U MI Ann Arbor and purchase of a license that provides access to the scoring algorithm • We revised the Screening, PTSD, Depression and Anxiety sections and tested our revisions on 14 student volunteers. We received IRB permission to offer extra credit as an incentive.

18. CIDI Trauma • GRUPO 1: Situaciones traumáticas personales • Experiencia de combate • Trabajador(a) de una organización humanitaria en zona de guerra • Civil en una zona de guerra • Civil en una zona de terror constante • Refugiado(a) • Secuestrado(a) • Estar expuesto(a) a sustancias químicas tóxicas • Accidente automovilístico • Otro accidente que puso su vida en peligro • Desastre natural • Desastre causado por el hombre • Enfermedad que puso su vida en peligro

19. CIDI Trauma • GRUPO 2: Violencia Personal • Golpeado(a) de niño(a) por quien lo/la cuidaba • Golpeado(a) por su esposo(a) o pareja • Golpeado(a) por alguien más • Robado(a) o amenazado(a) con un arma • Violado(a) • Atacado(a) sexualmente • Acosado(a) • Vio peleas físicas en su casa

20. CIDI Trauma • GRUPO 3: Eventos que afectaron a otros • Muerte inesperada de un ser querido • Enfermedad grave de un hijo • Experiencia traumática para un ser querido • Vio matar a alguien o vio un muerto o vio a alguien gravemente herido • Provocó accidentalmente heridas graves o la muerte a alguien • Hirió gravemente, torturó o mató a alguien a propósito • Vio atrocidades

21. Process • We made our revisions in the following steps: • 1- Tested the original with small focus groups whose members were of the same SES as our future participants. • 2- Made the revisions on the instruments • 3- Re-tested the revised instruments with focus groups whose members were of the same SES as our future participants, and back-translated in this step, comparing the the English versions to ensure that we captured the original meaning • 4-testing with participant cohorts with the revised and back-translated instruments.

22. Process • Currently analyzing data: • We have raw scores from HTQ/HSCL. • We will enter data into SPSSby item and rescore • Obtaining algorithm for CIDI

23. Immediate Future Directions • Adaptation of HTQ and HSCL for pediatric use • R21 submitted, under review, that looks at genetic and immunological links to risk for PTSD; uses these three instruments to establish a basline mental health profile • Questions? Thank you.