Mixed Method Synthesis of Cognitive interviews with Kenyan peripartum adolescents: Testing EPDS and PHQ questionnaires in Nairobi primary care settings

Background: Cognitive interviewing is a well-recognized methodology to identify clinical and commonsensical relevance of mental health questionnaire items by our research participants. Depression is amongst the most common condition impacting pregnant and parenting adolescents in sub-Saharan Africa (SSA). In Kenya, studies have reported depression prevalence estimates of 12-50% in peripartum adolescents. While young people prefer using English, there has not been enough data to point to how well they respond to Kiswahili translations of the commonly used tools.Method: Thirty-two participants between ages 14-18 years were approached and through informed consent for them to participate. We used Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire-9 (PHQ-9) in English and Kiswahili versions to carry out the interviews and were coded along four domains of comprehension, retrieval, judgement and patient response. Scores were tabulated for all participants and simple reliability analyses were offered. The interviews were discussed within the team and tables were shared between three raters for further consensus. The interview transcripts were analyzed manually using thematic analysis.Discussion: We found that adolescents had challenges in fully understanding items in both set of tools however, EPDS was better received than PHQ-9. Psychometrically, EPDS English version and Kiswahili versions fared better than the PHQ-9 English and Kiswahili versions. PHQ-9 presented considerable issues with regards to semantic clarity however had simpler response options in comparison to EPDS which was more experientially appropriate, but response options were not simple. On our thematic analysis we felt that the adolescents were significantly challenged by the new, unanticipated pregnancy or motherhood experience. Poverty, poor partner support, discord with parents and distress in the family, and traumatic end of supportive and helpful relationships were the notable problems.Conclusion: While sensitive cross-cultural translations for the commonly used open access depression tools is critical, it is also pertinent to understand whether these are developmentally appropriate. Our participants had multiple psychosocial and material challenges that necessitate measures sensitive to their age, social context and health experiences. Additionally, we felt that both the tools may not be suitable for self-administration and may need involvement of a case worker or community health worker.