Cited by 239Psychometric Methodologies and TestingHealth Education and ValidationMental Health Treatment and Access

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Cross-Cultural Validity and Reliability Testing of a Standard Psychiatric Assessment Instrument without a Gold Standard

BOLTON, PAUL·2001·The Journal of Nervous and Mental Disease

DOI 10.1097/00005053-200104000-00005

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Abstract

The objective of this study was to assess the cross-culture validity and reliability of a standard psychiatric assessment instrument without the usual "gold standards." Normally criterion validity testing requires comparison with such a standard--usually another instrument or a professional diagnosis. Instead local informants identified persons with and without "agahinda gakabije" (a locally described grief syndrome) who were then asked if they thought they had this syndrome and also interviewed using the depression section of the Hopkins Symptom Checklist (DHSCL). To assess criterion validity, interviews where respondent and informant agreed on the presence or absence of agahinda gakabije were compared with depression diagnosis using the DHSCL. We also assessed construct validity (using factor analysis), internal reliability (Cronbach's alpha), and test-retest reliability using results from a subsequent community-based survey employing the DHSCL. We found a similar relationship between depression and agahinda gakabije as between depression and grief in western countries, which supports criterion validity. Construct validity and internal reliability were good (Cronbach's alpha = 0.87). Test-retest reliability of a DHSCL-based scale was less adequate (0.67). Although not replacing the usual gold standards for testing criterion validity, this approach may prove useful where these standards are unavailable. As this includes much of the developing world, this could result in more accurate mental health assessments among populations for whom this has hitherto not been possible.

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Self-citation
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Method
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Background
Depression and ART Initiation Among HIV Serodiscordant Couples in Kenya and Uganda
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“75 is considered high level of anxiety and depression symptoms [38].”
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Background
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MethodSelf-citation
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Background
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BackgroundInfluential
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“However, this practice runs the risk of producing flawed data and a biased estimate of participation since the initial context and purpose of the scale has changed and cultural adaptation can be challenging [47].”
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Background
The expression of perinatal depression in rural Ghana
Scorza, P., Owusu‐Agyei, S., Asampong, E., & Wainberg, M. L. (2015) · International Journal of Culture and Mental Health · doi:10.1080/17542863.2015.1037849 · Cited by 13
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“…criterion-related validity which is clearly established in this study, is generally considered adequate and the most concrete and 121 important dimension to establishing validity in theory testing and scale development (Anastasi, 1950; Bolton, 2001; Flannelly, Ellison, & Strock, 2004; Lewis 1999).”
Background
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Background
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Validation of a cross-cultural instrument for child behavior problems: the Disruptive Behavior International Scale – Nepal version
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“Internalizing problems were assessed with the Hopkins Symptom Checklist-25 (HSCL-25), a measure of depression/ anxiety symptoms that has been previously validated for use among adults in sub-Saharan Africa (Bolton, 2001) and adapted to Sierra Leone (Betancourt et al., 2011).”
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MethodSelf-citation
Adaptation and Validation of the Shame Questionnaire Among Ugandan Youth Living with HIV
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“First, the alternative method of exploring criterion validity, developed by Bolton (Bolton 2001) was utilized.”
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BackgroundMethod
Examining cognitive behavioral therapy interventions for unaccompanied minors: a systematic review and qualitative research synthesis.
Morroni, D., Konstantinou, P., Gkleka, C., Kassianos, A. P., & Karekla, M. (2025) · European Child & Adolescent Psychiatry · doi:10.1007/s00787-024-02500-z · Cited by 9
Nursing assessment of mental health issues in the general clinical environment: A descriptive study
Ngune, I., Ewens, B. A., Bell, S., Burns, B., Sutton, C., Creswell, C., & Middlewick, Y. (2024) · Journal of Advanced Nursing · doi:10.1111/jan.16214 · Cited by 10
“This may reduce the reliability and accuracy of the data collected (Boateng et al., 2018 ; Bolton, 2001 ).”
Humanitarian Crises: The Need for Cultural Competence and Local Capacity Building
Weissbecker, I., & Czincz, J. (2011) · Springer eBooks · doi:10.1007/978-1-4419-9742-5_5 · Cited by 8
Cultural Considerations in the Assessment of Survivors of Torture
Raghavan, S. S. (2018) · Journal of Immigrant and Minority Health · doi:10.1007/s10903-018-0787-5 · Cited by 8
Developing a Chinese PTSD Inventory (CPI) based on interviews with earthquake victims in Sichuan
Liu, Z., Liu, Y., Zhang, Y., Chen, Z., & Hannak, W. J. (2014) · PsyCh Journal · doi:10.1002/pchj.43 · Cited by 8
Preference of mHealth versus in-person treatment for depression and post-traumatic stress disorder in Kenya: demographic and clinical characteristics
Meffert, S. M., Mathai, M., Neylan, T. C., Mwai, D., Onyango, D., Rota, G., Otieno, A., Obura, R. R., Wangia, J., Opiyo, E., et al. (2024) · BMJ Open · doi:10.1136/bmjopen-2023-083094 · Cited by 8
Configural and scalar invariance of the center for epidemiologic studies depression scale in Egypt and Canada: Differential symptom emphasis across cultures and genders
Huang, V., Beshai, S., Korol, S., & Carleton, R. N. (2017) · Psychiatry Research · doi:10.1016/j.psychres.2017.01.079 · Cited by 7
Quality of mental health questionnaires in conflict-affected adult populations in low and middle income countries: A systematic review
Christy, S., Siriwardhana, C., Lohmann, J., Roberts, B., & Smith, S. C. (2021) · Journal of Migration and Health · doi:10.1016/j.jmh.2021.100068 · Cited by 7
“…depression (9 questionnaires) ( Getnet nd Alem, 2019 ; Farhood et al., 2015 ; Elsass et al., 2009 ; Tremblay t al., 2009 ; Ventevogel et al., 2007 ; Bolton, 2001 ; Jayawickreme et l., 2012 ; Fellmeth et al., 2018 ; Tay et al., 2015 ), then an anxiety or anic disorder (6 questionnaires) ( Elsass et…”
BackgroundMethodInfluential
Reliability and validity of a perinatal depression screening instrument in rural Mali
Lasater, M. E., Beebe, M., Warren, N., WINCH, P. J., Souko, F., Keita, M., Doumbia, S., & Murray, S. M. (2022) · SSM - Mental Health · doi:10.1016/j.ssmmh.2021.100059 · Cited by 8
“Given the scarcity of mental health providers in Mali and important differences between dusukasi, and a DSM diagnosis of depression, we felt the typical gold standard structured psychiatric interview was not an appropriate criterion (Bolton, 2001).”
BackgroundMethodInfluential
Transkulturelle Aspekte psychischer Erkrankungen
Machleidt, W., & Calliess, I. T. (2007) · Springer eBooks · doi:10.1007/978-3-540-33129-2_14 · Cited by 7
The Invisible Discrimination: Biases in the Clinical Approach Regarding Migrants: A Study to Help Ethnopsychology Services and Clinicians
Iudici, A., Colombo, L., Caravita, S. C. S., Cottone, P., & Neri, J. (2024) · Behavioral Sciences · doi:10.3390/bs14030155 · Cited by 6
“Other scholars have noted a lack of validity of related tests and assessment instruments [18,19], some errors of judgment made by mental health professionals [20–22] and bias based on bullying [23].”
Background
Prevalence of Mental Disorders in a German Kidney Transplant Population: Results of a KTx360°-Substudy
Birkefeld, K., Bauer-Hohmann, M., Klewitz, F., Tun, E.-M. K. T., Tegtbur, U., Pape, L., Schiffer, L. E., Schiffer, M., de Zwaan, M., & Nöhre, M. (2022) · Journal of Clinical Psychology in Medical Settings · doi:10.1007/s10880-022-09861-0 · Cited by 7
“However, the gold standard for identifying mental disorders is a diagnostic assessment by a mental health professional, ideally using structured diagnostic interviews (Ali et al., 2016; Bolton, 2001; Shabani et al., 2021).”
Background
Measuring culturally and contextually specific distress among Afghan, Iraqi, and Great Lakes African refugees.
Choe, R., Lardier, D. T., Hess, J. M., Blackwell, M. A., Amer, S., Ndayisenga, M., Deewa, S., Isakson, B. L., & Goodkind, J. R. (2024) · American Journal of Orthopsychiatry · doi:10.1037/ort0000718 · Cited by 6
Developing a Culturally Appropriate Assessment Tool: Reflections on Process Considerations
Weaver, H. N. (2016) · Journal of Ethnic & Cultural Diversity in Social Work · doi:10.1080/15313204.2016.1206495 · Cited by 5
“The studies conducted by Bolton (2001a, 2001b), Betancourt and colleagues (2009), Gladstone and colleagues (2010), and Hollifield and colleagues (2013) all support the importance of using assessment tools modified for use with specific refugee populations, as was done with this project.”
BackgroundMethodResultInfluential
The development of a contextually appropriate measure of psychological distress in Sierra Leone
Horn, R., Jailobaeva, K., Arakelyan, S., & Ager, A. (2021) · BMC Psychology · doi:10.1186/s40359-021-00610-w · Cited by 6
Ageing in West Africa
Aboderin, I. (2009) · Springer eBooks · doi:10.1007/978-1-4020-8356-3_12 · Cited by 4
Mental health screens used in U.S. corrections settings: evidence of fairness with Black and Latinx people
Louden, J. E., Adair, R., Romero, I., & Rioja, V. B. (2023) · Psychology Crime and Law · doi:10.1080/1068316x.2023.2206657 · Cited by 6
“For screening tools, this is typically assessed by comparing the results of an individual’s score on the screen (e.g. whether they scored above or below a prespecified cutoff) to a diagnostic interview conducted by a clinician (Bolton, 2001).”
Cross-cultural equivalence of the Kessler Psychological Distress Scale (K10) across four African countries in a multi-national study of adults
Ametaj, A., Denckla, C. A., Stevenson, A., Stroud, R. E., Hall, J., Ongeri, L., Milkias, B., Hoffman, J., Naisanga, M., Akena, D. H., et al. (2024) · SSM - Mental Health · doi:10.1016/j.ssmmh.2024.100300 · Cited by 5
Psychosocial Distress and Well-Being among Acholi Women in Northern Uganda
Horn, R. (2013) · doi:10.1596/17860
“Paul Bolton and his colleagues (Bass and others 2006) have frequently used freelisting and key informant interviews to develop locally relevant instruments to measure mental health problems (Bolton 2001b; Wilk and Bolton 2002).”
BackgroundMethod
Masculinity and mental health treatment initiation for former political prisoners in Yangon, Myanmar – a qualitative investigation
Lakin, D. P., Win, K. S., Aung, H., Soe, K. N. C., Kyi, B., Marcell, A. V., Tol, W. A., & Bass, J. K. (2021) · BMC Public Health · doi:10.1186/s12889-021-10249-2 · Cited by 7
Feasibility, Acceptability and Clinical Utility of the Bereavement and Grief Cultural Formulation Interview for Prolonged Grief Disorder
Killikelly, C., Christen, L.-M., Groen, S., Ogrodniczuk, J. S., Maercker, A. R. A., Smid, G. E., & Heim, E. (2025) · Culture Medicine and Psychiatry · doi:10.1007/s11013-025-09927-2 · Cited by 4
“In a similar manner, there is large cultural variation in symptoms of grief (Rosenblatt, 2008) and several research groups have identified CCD related to grief and bereavement, including culturally specific symptoms (Bolton, 2001; Tsutsui et al., 2014; Wikan, 1988; Xiu et al., 2016).”
Predominant approaches to measuring pregnancy-related anxiety in Sub-saharan Africa: a scoping review
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“Site-specific validated scales are needed to quantify the overall burden of pregnancy-related anxiety, evaluate individual patients in clinical environments, and accurately assess the efficacy and impact of mental health interventions [16].”
Background
Broadening the scope of social support, coping skills and resilience among caretakers of children with disabilities in Uganda: a sequential explanatory mixed-methods study
Namasaba, M., Kazembe, N., Seera, G., & Baguwemu, A. A. (2022) · BMC Public Health · doi:10.1186/s12889-022-13018-x · Cited by 4
“Divergence in the themes were also included in a summary draft reviewed and resolved by the principal investigator [72, 73].”
Background
Cross-culturally adapting the GHQ-12 for use with refugee populations: Opportunities, dilemmas, and challenges
Fennig, M. (2024) · Transcultural Psychiatry · doi:10.1177/13634615231223884 · Cited by 5
“…on trained mental health paraprofessionals — as opposed to clinical psychologists or psychiatrists — for the adaptation and validation of instruments is based on a procedure in previous studies in the context of limited availability of mental health experts (Bolton, 2001; Kohrt et al., 2011).”
Unmet medical care and sexual health counseling needs—: a cross-sectional study among university students in Uganda
Kyagaba, E., Asamoah, B. O., Emmelin, M., & Agardh, A. (2014) · Journal of Health Care for the Poor and Underserved · doi:10.1353/hpu.2014.0135 · Cited by 4
Making Moral Worlds: Individual and Social Processes of Meaning-Making in a Somali Diaspora
Jacobsen, A. (2011) · Open Scholarship Institutional Repository (Washington University in St. Louis) · doi:10.7936/k7th8jpg · Cited by 4
Cross-Cultural Measurement of Posttraumatic Stress Disorder in Post-Conflict Settings
Myers, S. J. (2011) · American Journal of Public Health · doi:10.2105/ajph.2010.300095 · Cited by 4
Okweraliikirira and Okwenyamira: Idioms of Psychological Distress Among People Living with HIV in Rakai, Uganda
West, N., Nakubulwa, R., Murray, S. M., Ddaaki, W. G., Mayambala, D., Nakyanjo, N., Nalugoda, F. K., Hutton, H. E., Surkan, P. J., & Kennedy, C. E. (2025) · Culture Medicine and Psychiatry · doi:10.1007/s11013-025-09912-9 · Cited by 5
“…Luganda adapted version of the Hopkins Symptom Checklist (HSCL) measure for depression does incorporate okweraliikirira as a term/symptom for the depression section of the checklist, and a translation of “thinking too much/too many thoughts” as part of a measure of quality of life (Bolton, 2001).”
They Will Surveil You to Death: Gangstalking as a Cultural Concept of Distress
Reed, J. C. (2024) · Culture Medicine and Psychiatry · doi:10.1007/s11013-024-09881-5 · Cited by 3
“Khyâl closely relates to anxiety and panic (Hinton & Lewis-Fernández, 2010), kut caraeun to PTSD (Hinton et al., 2015), kufungisisa kwe njodzi to stigma and trauma (Verhey et al., 2020), agahinda gakabije to grief and depression (Bolton, 2001).”
Ease of marital communication and depressive symptom severity among men and women in rural Uganda: cross-sectional, whole-population study
Jurinsky, J., Perkins, J. M., Kakuhikire, B., Nyakato, V. N., Baguma, C., Rasmussen, J. D., Satinsky, E. N., Ahereza, P., Kananura, J., Audet, C. M., et al. (2021) · Social Psychiatry and Psychiatric Epidemiology · doi:10.1007/s00127-021-02135-4 · Cited by 3
“Depression symptom severity was assessed via a modified version of the Hopkins Symptom Checklist for Depression (HSCL-D), which has been previously validated with participants in Uganda [49].”
Method
Adaptation of Two Family Therapy Training Instruments to Culturally Suit the Indian Context
Natrajan‐Tyagi, R., Karuppaswamy, N., Thomas, V. K., & Ramadoss, K. (2005) · Contemporary Family Therapy · doi:10.1007/s10591-005-6218-5 · Cited by 3
Culturally Sensitive PTSD Screening in Non-Western Youth: Reflections and Indications for Mental Health Practitioners
Perry, J. M., Modesti, C., Talamo, A., & Nicolais, G. (2019) · Journal of Refugee Studies · doi:10.1093/jrs/fez053 · Cited by 3
“Criterion validity is verified against the input of key informants within the local culture (Bolton 2001).”
BackgroundMethod
Transkulturelle Aspekte psychischer Erkrankungen
Machleidt, W., & Graef-Calliess, I. T. (2017) · Springer eBooks · doi:10.1007/978-3-662-49295-6_17 · Cited by 2
Measuring Psychosocial Wellbeing in Democratic Republic of Congo
Horn, R. (2014) · World Bank, Washington, DC eBooks · doi:10.1596/20059 · Cited by 2
“& Bolton,P. (2009) Assessing local instrument reliability and validity: a field-based example from northern Uganda Soc Psychiatry Psychiat Epidemiology DOI 10.”
BackgroundInfluential
Transkulturelle Aspekte psychischer Erkrankungen
Machleidt, W., & Calliess, I. T. (2011) · Springer eBooks · doi:10.1007/978-3-642-03637-8_15 · Cited by 2
International response to natural and manmade disasters
Weissbecker, I., & JONES, L. M. (2014) · Cambridge University Press eBooks · doi:10.1017/cbo9781139136341.037 · Cited by 2
Studies on affective disorders in rural Ethiopia
Fekadu, A. (2010) · KTH Publication Database DiVA (KTH Royal Institute of Technology) · Cited by 2
The Challenge of Simple Questions: Positioning Refugee Mental Health in the Global Health Agenda
Ager, A. (2005) · International Journal of Migration Health and Social Care · doi:10.1108/17479894200500002 · Cited by 2
Cognitive interviewing for understanding and adaptation of mental health screening instruments among people living with HIV in rakai, Uganda: the thinking a lot questionnaire, the patient health questionnaire 9 (PHQ-9), and the hopkins symptoms checklist (HSCL)
West, N., Namuganga, L. P., Isabirye, D., Nakubulwa, R., Ddaaki, W. G., Nakyanjo, N., Nalugoda, F. K., Murray, S. M., & Kennedy, C. E. (2025) · SSM - Mental Health · doi:10.1016/j.ssmmh.2025.100517 · Cited by 2
Validation of Shona Symptom Questionnaire (SSQ-14), Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorder scale (GAD-7) in Unguja Island, Zanzibar
Ceccolini, D., Dambi, J. M., Fatawi, H., Ali, S., Kühnert, S., Solera-Deuchar, L., James, J., Odhiambo, C. A., McGovern, P. G., Taiwo, W., et al. (2025) · BMC Psychology · doi:10.1186/s40359-025-03584-1 · Cited by 1
“On the other hand, the use of standardised diagnostic interviews conducted by qualified psychiatrists has been widely recommended for cross-cultural validations of screening tools [30, 63].”
Risk and protective factors of depression among caregivers of children with disabilities in rural Rwanda
Ahishakiye, A., Santo, L. D., Smith-Fawzi, M. C., Miller, A. C., Placencio‐Castro, M., Gilbert, H. N., Jensen, S. K. G., Wilson, K. A., Kirk, C. M., Sezibera, V., et al. (2026) · BMJ Global Health · doi:10.1136/bmjgh-2025-020491 · Cited by 1
The triple burden of trauma, uprooting and settlement
Lie, B. (2013) · Cited by 1
Needs assessment for psychotherapy training among family medicine physicians practicing at PSMMC, Riyadh, Saudi Arabia 2017-2018
AlNamlah, L. A., & Kofi, M. A. (2020) · International Journal of Advanced Research in Medicine · doi:10.22271/27069567.2020.v2.i2a.50 · Cited by 1
“We used a split-half association to test the correlation between the answers ([40]).”
Method
Reliability and Validity of Child Posttraumatic Stress-Revised Instrument in Malay Language among Malaysian Adolescents
Ghazali, Elklit, A., & Chen, Y. Y. (2015) · The Malaysian journal of psychiatry · Cited by 1

Authors: BOLTON, P.
Affiliations: Johns Hopkins University (US)
Corresponding author: BOLTON, PAUL
ORCID: BOLTON, PAUL
Venue: The Journal of Nervous and Mental Disease
Publisher: Ovid Technologies (Wolters Kluwer Health)
Published: 2001-04
Volume: 189
Issue: 4
Pages: 238-242
ISSN: 0022-3018 (ISSN-L)
DOI: 10.1097/00005053-200104000-00005
OpenAlex: W1987889140
Cited by: 239
References: 11
Citations by year: 2026: 2 · 2025: 5 · 2024: 13 · 2023: 3 · 2022: 12 · 2021: 20 · 2020: 10 · 2019: 13 · 2018: 10 · 2017: 13 · 2016: 5 · 2015: 14 · 2014: 22 · 2013: 13 · 2012: 8
FWCI: 5.12
Type: journal article
Language: en
Open access: closed
Locations: The Journal of Nervous and Mental Disease (publishedVersion)
PubMed (publishedVersion)
Topics: Social Sciences › Decision Sciences › Management Science and Operations Research › Psychometric Methodologies and Testing
Health Sciences › Nursing › Research and Theory › Health Education and Validation
Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
Keywords: cross-cultural validity, criterion validity, psychiatric assessment instruments, depression, Hopkins Symptom Checklist, local informants, test-retest reliability, construct validity, mental health assessment, developing countries
MeSH terms: Adult, Anthropology, Cultural, Cross-Cultural Comparison, Depressive Disorder, Factor Analysis, Statistical, Female, Health Services Needs and Demand, Homicide, Humans, Life Change Events, Male, Medicine, Traditional, Personality Inventory, Psychometrics, Rwanda, Sampling Studies, Sensitivity and Specificity, Sex Factors, Stress Disorders, Post-Traumatic, Reproducibility of Results

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Cross-Cultural Validity and Reliability Testing of a Standard Psychiatric Assessment Instrument without a Gold Standard

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