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The methods of improving cultural sensitivity of depression scales for use among global indigenous populations: a systematic scoping review

Published online by Cambridge University Press:  23 November 2023

Liliana Gomez Cardona
Affiliation:
Douglas Mental Health University Institute, McGill University, Montreal, QC, Canada Department of Psychiatry, McGill University, Montreal, QC, Canada
Michelle Yang
Affiliation:
École interdisciplinaire des sciences de la santé/Interdisciplinary School of Health Sciences, Université d’Ottawa/University of Ottawa, Ottawa, ON, Canada
Quinta Seon
Affiliation:
Douglas Mental Health University Institute, McGill University, Montreal, QC, Canada Department of Psychiatry, McGill University, Montreal, QC, Canada
Maharshee Karia
Affiliation:
Douglas Mental Health University Institute, McGill University, Montreal, QC, Canada
Gajanan Velupillai
Affiliation:
Department of Psychiatry, McGill University, Montreal, QC, Canada
Valérie Noel
Affiliation:
Douglas Mental Health University Institute, McGill University, Montreal, QC, Canada ACCESS Open Minds, Douglas Mental Health University Institute, McGill University, Montreal, QC, Canada
Outi Linnaranta*
Affiliation:
Douglas Mental Health University Institute, McGill University, Montreal, QC, Canada Department of Psychiatry, McGill University, Montreal, QC, Canada Equality Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
*
Corresponding author: Outi Linnaranta; Email: [email protected]
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Abstract

Cultural adaptation of psychometric measures has become a process aimed at increasing acceptance, reliability, and validity among specific Indigenous populations. We present a systematic scoping review to: (1) identify the depression scales that have been culturally adapted for use among Indigenous populations worldwide, (2) globally report on the methods used in the cultural adaptation of those scales, and (3) describe the main features of those cultural adaptation methods. We included articles published from inception to April 2021, including 3 levels of search terms: Psychometrics, Indigenous, and Depression. The search was carried out in the Ovid Medline, PubMed, Embase, Global Health, PsycINFO, and CINAHL databases, following PRISMA guidelines. We identified 34 reports on processes of cultural adaptation that met the criteria. The scales were adapted for use among Indigenous populations from Africa, Australia, Asia, North America, and Latin America. The most common scales that underwent adaptation were the Patient Health Questionnaire (PHQ-9), the Center for Epidemiologic Studies Depression Scale (CES-D), and the Edinburgh Postnatal Depression Scale (EPDS). Methods of adaptation involved a revision of the measures’ cultural appropriateness, standard/transcultural translation, revision of the administration process, and inclusion of visual supports. Culturally safe administration of scales was reported in some studies. To come to a consensus on most appropriate methods of improving cultural safety of psychometric measurement, most studies utilized qualitative methods or mixed methods to understand the specific community’s needs. Revision of linguistic equivalence and cultural relevance of content, culturally safe administration procedures, qualitative methods, and participatory research were key features of developing safe culturally adapted measures for depressive symptoms among Indigenous populations. While for comparability, uniform scales would be ideal as mental health evaluations, an understanding of the cultural impact of measurements and local depression expressions would benefit the process of developing culturally sensitive psychometric scales. PROSPERO registration ID: CRD42023391439.

Type
Overview Review
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
Copyright
© The Author(s), 2023. Published by Cambridge University Press

Impact statement

Language, context, and methods of administrating psychiatric evaluations may hinder timely and accurate depression evaluation of Indigenous peoples, which may delay or prevent treatment. A potential strategy to close this gap is to develop new or culturally adapted scales that are more sensitive to detecting culturally specific expressions of mental health. While several structured instruments exist to describe methods and phases of adaptation, it remains open how commonly methods of adaptation are used and reported. In this research, we review original work representing all continents and report on the global evidence on the types of adapted scales for use with Indigenous peoples, their qualities, and their methods of adaptation. This is hoped to form a basis for future work in identifying suitable scales for adaptation, and in developing, adapting, and creating culturally sensitive psychometrics for treatment of major depression disorder. Given the need for equal access to safe mental health services for all population groups, it remains to be defined when a culturally safe administration of a standard scale is preferable, when there is a need to invest in a translation or a cultural adaptation of a scale, and to what extent visual supports can complement verbal measurement. This summary of findings on successfully adapted scales as well as acceptance of items in specific scales can support clinicians who need to choose a safe measure for assessing patients from different cultures. Moreover, the importance of inclusion of community members in the process of selecting and adapting the psychometric scales should be recognized in research and clinical work.

Introduction

Indigenous peoples have originally inhabited several geographical regions and formed values, languages, and strong links to these territories. Indigenous people number about 400 million worldwide, belonging to five thousand diverse groups living in more than 90 countries (Indigenous Peoples, 2023; United Nations, 2023). As a result of imperialism and colonialism, the health of Indigenous peoples worldwide is characterized by systematic inequities in health outcomes (Reid et al., Reference Reid, Cormack and Paine2019). They have experienced varying degrees of racial discrimination and social oppression, evident as health and social marginalization in regard to education, housing, employment, and access to adequate social and health services (Frohlich et al., Reference Frohlich, Ross and Richmond2006). It is an alarming fact that such health disparities are still predominant to this day. This is well illustrated by the higher prevalence and morbidity/mortality rate of mental health conditions and suicide among Indigenous people, up to 20 times higher than the general population (Hajizadeh et al., Reference Hajizadeh, Bombay and Asada2019). This emphasizes the need for providing efficient and accessible mental health care, among other procedures, to improve Indigenous populations’ resilience (Davy et al., Reference Davy, Harfield, McArthur, Munn and Brown2016), and calls for a decolonization of psychological practices (Smallwood et al., Reference Smallwood, Usher, Woods, Sampson and Jackson2023). Ensuring the equal accessibility of mental health services requires more than easy reach services; it requires examination of barriers and racist and colonial practices and then implementation of culturally appropriate mental health services (Davy et al., Reference Davy, Harfield, McArthur, Munn and Brown2016; National Collaborating Centre for Aboriginal Health, 2019).

Accessibility of medical care is traditionally dependent on formal diagnoses by conventional psychiatric professionals. Yet, the traumatic history of colonization has negatively impacted Indigenous populations’ help seeking behavior, trust, and acceptance of Western psychiatric treatment (Chachamovich et al., Reference Chachamovich, Kirmayer, Haggarty, Cargo, McCormick and Turecki2015). Unfortunately, delayed efforts and unfruitful cooperation are common in screening and treating mental health (Leung, Reference Leung2016). Furthermore, Indigenous people share values and historical experiences that influence their expression of symptoms of depression – cultural expressions not represented in the biomedical conceptualization of psychiatric disorders (Kleinman, Reference Kleinman1977; Kirmayer et al., Reference Kirmayer, Fletcher and Watt2008; Nichter, Reference Nichter2010). Use of colonializers’ language and structural barriers have hindered access to good quality mental health and social services (Montreal Urban Aboriginal Health Needs Assessment, 2012). Without adequate levels of cultural safety embedded in current psychiatric practice (e.g., cultural awareness, cultural sensitivity, and cultural competency), there is limited timely and effective response to depression among the Indigenous (Brascoupé and Waters, Reference Brascoupé and Waters2009; Darroch et al., Reference Darroch, Giles, Sanderson, Brooks-Cleator, Schwartz, Joseph and Nosker2017).

Access to psychiatric care is based on diagnostic categories; for example, severe depression is characterized by the symptoms that decrease the ability to function (Aboraya et al., Reference Aboraya, Nasrallah, Elswick, Ahmed, Estephan, Aboraya, Berzingi, Chumbers, Berzingi, Justice, Zafar and Dohar2018). The ‘gold-standard’ method of psychiatric diagnosis is clinical interviews, where the delivery is through human interaction. However, Indigenous communities, especially remote groups, typically have limited access to personnel with specialized skills (Boksa et al., Reference Boksa, Joober and Kirmayer2015). To overcome this barrier, screening for psychiatric disorders can be completed through psychometric measures in primary care to guide decision-making in treatment. In instances where psychiatric services are not easily accessible, psychometric measures may be used during follow-ups to detect relapse, and inform self-management and therapeutic interventions (Boksa et al., Reference Boksa, Joober and Kirmayer2015). The organizational and political need for accurate measurement of a population’s mental health increases when there is a need to allocate resources, plan service, or to improve quality of treatment.

If initial contact for mental health evaluation and treatment includes completing a psychometric screen, it is essential to confirm that this method of evaluation is culturally acceptable. Currently, most available instruments are based on the Diagnostic and Statistical Manual-5 (DSM-5), which was developed based on the literature and contribution of subject experts predominantly from Western societies. Additionally, as the DSM-5 was developed for use in the context of Western psychiatric practices, it does not capture the global expression of mental health conditions (Kleinman, Reference Kleinman1977; Haroz et al., Reference Haroz, Bass, Lee, Oo, Lin, Kohrt, Michalopolous, Nguyen and Bolton2017). Simultaneously, calls for cultural safety in health care education and services and concurrent adaptation of measures for assessing psychiatric symptoms in Indigenous populations have been made (Brascoupé and Waters, Reference Brascoupé and Waters2009; Baba, Reference Baba2013; Darroch et al., Reference Darroch, Giles, Sanderson, Brooks-Cleator, Schwartz, Joseph and Nosker2017).

The cultural adaptation of assessment tools has improved acceptance, response rate, and reliability of measures (Arafat et al., Reference Arafat, Chowdhury, Qusar and Hafez2016; Kral, Reference Kral2016; Hackett et al., Reference Hackett, Teixeira‐Pinto, Farnbach, Glozier, Skinner, Askew, Gee, Cass and Brown2019). There has been work on guidelines for the process of cross-cultural adaptations (Beaton et al., Reference Beaton, Bombardier, Guillemin and Ferraz2000; Chávez and Canino, Reference Chávez and Canino2005; Sousa and Rojjanasrirat, Reference Sousa and Rojjanasrirat2011; Arafat et al., Reference Arafat, Chowdhury, Qusar and Hafez2016). This process generally involves modifications of instruments with the aim of making them more suitable for a specific population (Wexler et al., Reference Wexler, McEachern, Difulvio, Smith, Graham and Dombrowski2017; Haroz et al., Reference Haroz, Bass, Lee, Oo, Lin, Kohrt, Michalopolous, Nguyen and Bolton2017; Wiltsey Stirman et al., Reference Wiltsey Stirman, Baumann and Miller2019). However, global consensus on guidelines and evaluation criteria for cultural adaptation is not available, and actually used methods remain open.

In this paper, we present a scoping review to synthesize the literature on cultural adaptations of depression measures among Indigenous populations. The rationale of this study is based specifically on a problem identified during the course of our participatory research with Indigenous populations – a critical Indigenous view on conventional, symptom-focused psychometrics (Gomez Cardona et al., Reference Gomez Cardona, Brown, McComber, Outerbridge, Parent-Racine, Phillips, Boyer, Martin, Splicer, Thompson, Yang, Velupillai, Laliberté, Haswell and Linnaranta2021). The main objectives of this review were to: (1) identify the depression scales that have been culturally adapted for use among Indigenous populations worldwide, (2) report the methods used in the cultural adaptation of those scales, and (3) describe the main features of used cultural adaptation methods.

Methods

Study design

We conducted a systematic scoping review, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews (PRISMA-ScR) guidelines for scoping reviews (Tricco et al., Reference Tricco, Lillie, Zarin, O’Brien, Colquhoun, Levac, Moher, Peters, Horsley, Weeks, Hempel, Akl, Chang, McGowan, Stewart, Hartling, Aldcroft, Wilson, Garritty, Lewin, Godfrey, Macdonald, Langlois, Soares-Weiser, Moriarty, Clifford, Tunçalp and Straus2018). The PRISMA-ScR checklist provides a systematic process for reporting title, abstract, introduction, methods, results, discussion, and funding (Tricco et al., Reference Tricco, Lillie, Zarin, O’Brien, Colquhoun, Levac, Moher, Peters, Horsley, Weeks, Hempel, Akl, Chang, McGowan, Stewart, Hartling, Aldcroft, Wilson, Garritty, Lewin, Godfrey, Macdonald, Langlois, Soares-Weiser, Moriarty, Clifford, Tunçalp and Straus2018). A systematic scoping review design was chosen as this allowed us to present an overview of a large and diverse body of literature pertaining to the broad topic of screening for Indigenous mental health, while carrying out a systematic approach to answering focused objectives.

Search strategy

We used three levels of search terms, which included terminology for depression, psychometrics, and Indigenous (Supplement 1). We searched Ovid Medline, PubMed, PsycINFO, Embase, CINAHL, and Global Health databases for original research articles published between inception of the databases to April 2021. Gray literature searches were complemented through hand-searching on Google Scholar, open access repositories and the reference lists of selected articles. Study researchers (MY, QS) and a librarian created the search strategy and conducted the search. Citations of the search results were uploaded to a citation manager, and the library of references was accessible to all co-authors. The original search was conducted in July 2019, and supplemented by an updated systematic search in April 2021, under the guidance of a McGill University librarian.

Operationalization of search terms

We operationalized the term Indigenous as the original habitants of colonized geographical regions (e.g., European colonization) who have cultural characteristics (e.g., values, languages, strong links to territories) distinct from the dominant societies, self-identify as Indigenous/Aboriginal peoples, and live in their country of origin (United Nations, 2023). However, where possible and to be respectful, we use the terms specified by the specific Nation. We considered cultural adaptation of scales in the form of questionnaires, surveys, or self-reports in culturally distinct populations. Cultural adaptation was operationalized as modifications to increase cultural sensitivity, not solely through – but including – the use of translation. Depression was operationalized in this study as psychological distress or clinical major depression. The search term psychometrics included rating scales, measures, questionnaires, indices, and other related terms and concepts. The final search was confirmed with a professional from the McGill University library.

Study selection

At least two researchers participated independently in each stage of article screening and full-text selection from which we calculated agreement coefficient (kappa = 0.71, substantial; McHugh, Reference McHugh2012). We included studies that adapted standard validated psychometric measures for depression. We searched for articles that were published in English, as this ensured that we included uniform descriptions of adaptation processes in order to synthesize findings. Articles were included if they (1) were a primary source study, (2) included depression measures, (3) described and/or mentioned the cultural adaptation or validation process of an adapted scale, and (4) had an Indigenous population as its target population. Articles were excluded if (1) they did not include information about the cultural adaptation of a scale, (2) they did not specify the Indigenous identity of the population, (3) they presented adapted scales for non-Indigenous populations, (4) adaptations were done to a scale focused on symptomology unrelated to depression, or (5) they were conference abstracts or poster submissions. The only exception is a protocol for an included adaptation study as it provided supportive information (e.g., cultural adaptation methods) and further context for the full study. The final inclusion and exclusion of full-text articles was confirmed by the first author (LGC).

Data collection process and data items

Authors systematically and blindly searched for and screened articles (MY, QS, MK, GV, VN, OL). The inclusion of articles followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews (PRISMA-ScR) guidelines (Tricco et al., Reference Tricco, Lillie, Zarin, O’Brien, Colquhoun, Levac, Moher, Peters, Horsley, Weeks, Hempel, Akl, Chang, McGowan, Stewart, Hartling, Aldcroft, Wilson, Garritty, Lewin, Godfrey, Macdonald, Langlois, Soares-Weiser, Moriarty, Clifford, Tunçalp and Straus2018) (Figure 1). Data from the selected articles were extracted and summarized by authors (MY, QS, MK, GV, VN) in two tables. Table 1 includes author(s), publication year, study objectives, setting and location of the research, study methods, language in which the scale was presented, population, sample size, and ethnic identity. Table 2 includes methods of cultural adaptation and the main modifications made to the scales. Following a comprehensive data extraction, we conducted a qualitative and narrative synthesis of the themes by collating, summarizing, and reporting on prominent ideas and concepts from the literature data (Arksey and O’Malley, Reference Arksey and O’Malley2005).

Figure 1. Flowchart of search and screening process.

Table 1. Characteristics of studies

1 Beck Depression Inventory-II (BDI-II), and Hopkins Symptom Check List (HSCL).

2 Center for Epidemiologic Studies Depression Scale – 20 items (CES-D-20).

3 Center for Epidemiologic Studies Depression Scale – 10 items (CES-D-10).

4 Center for Epidemiologic Studies Depression Scale– 12 items (CES-D-12) and Center for Epidemiologic Studies Depression Scale– 20 items (CES-D-20).

5 Center for Epidemiologic Studies Depression Scale – 10 items (CES-D-10).

6 Center for Epidemiologic Studies Depression Scale – 19 items (CES-D-19).

7 Center for Epidemiologic Studies Depression Scale (CES-D).

8 Center for Epidemiologic Studies Depression Scale for Children (CES-DC).

9 Coping Questionnaire (CQ), Symptom Rating Test (SRT), and Depression Scale Center for Epidemiological Studies (CES-D).

10 Dar-es-Salaam Symptom Questionnaire (DSQ).

11 Edinburgh Postnatal Depression Scale (EPDS).

12 Edinburgh Postnatal Depression Scale (EPDS).

13 Edinburgh Postnatal Depression Scale (EPDSc).

14 Edinburgh Postnatal Depression Scale (EPDS), Kessler Psychological Distress Scale (K-10).

15 Edinburgh Postnatal Depression Scale (EPDS), Hopkins Symptom Checklist (HSCL-D).

16 Functioning Assessment Instrument (FAI), World Health Organization’s Disability Assessment Schedule (WHODAS).

17 Hindi version of the Geriatric Depression Scale (GDS-H).

18 Geriatric Depression Scale – 15 items (GDS-15).

19 Hopkins Symptom Checklist Depression Scale (HSCL-25).

20 International Depression Symptom Scale-general (IDSS-G).

21 Kessler Psychological Distress Scale – 10 items (K-10).

22 Kessler Psychological Distress Scale – 6 items (K-6).

23 Kessler Psychological Distress Scale – 5 items (K-5).

24 Kimberley Indigenous Cognitive Assessment of Depression (KICA-dep).

25 Kimberley Mum’s Mood Scale (KMMS).

26 Ndetei–Othieno–Kathuku Scale (NOK).

27 Patient Health Questionnaire – 9 items (PHQ-9).

28 Patient Health Questionnaire – 16 items (PHQ-16).

29 Patient Health Questionnaire – 10 items (PHQ-10).

30 Patient Health Questionnaire – 8 items (PHQ-8).

31 Patient Health Questionnaire – 9 items (PHQ-9).

32 Patient Health Questionnaire – 9 items (PHQ-9).

33 Patient Health Questionnaire – 9 items (PHQ-9).

34 Patient Health Questionnaire – 2 items (PHQ-2).

Table 2. Process of cultural adaptation

1 Beck Depression Inventory-II (BDI-II), and Hopkins Symptom Check List (HSCL).

2 Center for Epidemiologic Studies Depression Scale– 20 items (CES-D-20).

3 Center for Epidemiologic Studies Depression Scale – 10 items (CES-D-10).

4 Center for Epidemiologic Studies Depression Scale– 12 items (CES-D-12) and Center for Epidemiologic Studies Depression Scale– 20 items (CES-D-20).

5 Center for Epidemiologic Studies Depression Scale – 10 items (CES-D-10).

6 Center for Epidemiologic Studies Depression Scale – 19 items (CES-D-19).

7 Center for Epidemiologic Studies Depression Scale (CES-D).

8 Center for Epidemiologic Studies Depression Scale for Children (CES-DC).

9 Coping Questionnaire (CQ), Symptom Rating Test (SRT), and Depression Scale Center for Epidemiological Studies (CES-D).

10 Dar-es-Salaam Symptom Questionnaire (DSQ).

11 Edinburgh Postnatal Depression Scale (EPDS).

12 Edinburgh Postnatal Depression Scale (EPDS).

13 Edinburgh Postnatal Depression Scale (EPDS).

14 Edinburgh Postnatal Depression Scale (EPDS), Kessler Psychological Distress Scale (K-10).

15 Edinburgh Postnatal Depression Scale (EPDS), Hopkins Symptom Checklist (HSCL-D).

16 Functioning Assessment Instrument (FAI), World Health Organization’s Disability Assessment Schedule (WHODAS).

17 Hindi version of the Geriatric Depression Scale (GDS-H).

18 Geriatric Depression Scale – 15 items (GDS-15).

19 Hopkins Symptom Checklist Depression Scale (HSCL-25).

20 International Depression Symptom Scale- General (IDSS-G).

21 Kessler Psychological Distress Scale – 10 items (K-10).

22 Kessler Psychological Distress Scale – 6 items (K-6).

23 Kessler Psychological Distress Scale – 5 items (K-5).

24 Kimberley Indigenous Cognitive Assessment of Depression (KICA-dep).

25 Kimberley Mum’s Mood Scale (KMMS).

26 Ndetei–Othieno–Kathuku Scale (NOK).

27 Patient Health Questionnaire – 9 items (PHQ-9).

28 Patient Health Questionnaire – 16 items (PHQ-16).

29 Patient Health Questionnaire – 10 items (PHQ-10).

30 Patient Health Questionnaire – 8 items (PHQ-8).

31 Patient Health Questionnaire – 9 items (PHQ-9).

32 Patient Health Questionnaire – 9 items (PHQ-9).

33 Patient Health Questionnaire – 9 items (PHQ-9).

34 Patient Health Questionnaire – 2 items (PHQ-2).

Results

Selection of sources of evidence

We identified 3,845 unique articles from the search (following de-duplication) and screened for their titles/abstracts in the first phase. Then, we identified 183 full texts and assessed for eligibility; of these, 37 articles met our inclusion criteria (Chapleski et al., Reference Chapleski, Lamphere, Kaczynski, Lichtenberg and Dwyer1997; Ganguli et al., Reference Ganguli, Dube, Johnston, Pandav, Chandra and Dodge1999; Bowen and Muhajarine, Reference Bowen and Muhajarine2006; Husain et al., Reference Husain, Gater, Tomenson and Creed2006; Esler et al., Reference Esler, Johnston and Thomas2007, Reference Esler, Johnston, Thomas and Davis2008; Tiburcio Sainz and Natera Rey, Reference Tiburcio Sainz and Natera Rey2007; Bass et al., Reference Bass, Ryder, Lammers, Mukaba and Bolton2008; Campbell et al., Reference Campbell, Hayes and Buckby2008; Kaaya et al., Reference Kaaya, Lee, Mbwambo, Smith-Fawzi and Leshabari2008; Australian Institute of Health and Welfare, 2009; Fernandes et al., Reference Fernandes, Srinivasan, Stein, Menezes, Sumithra and Ramchandani2011; Mitchell and Beals, Reference Mitchell and Beals2011; Ekeroma et al., Reference Ekeroma, Ikenasio-Thorpe, Weeks, Kokaua, Puniani, Stone and Foliaki2012; Brown et al., Reference Brown, Mentha, Rowley, Skinner, Davy and O’Dea2013; Gelaye et al., Reference Gelaye, Williams, Lemma, Deyessa, Bahretibeb, Shibre, Wondimagegn, Lemenhe, Fann, Vander Stoep and Andrew Zhou2013; Almeida et al., Reference Almeida, Flicker, Fenner, Smith, Hyde, Atkinson, Skeaf, Malay and LoGiudice2014; Armenta et al., Reference Armenta, Sittner Hartshorn, Whitbeck, Crawford and Hoyt2014; Haroz et al., Reference Haroz, Bass, Lee, Murray, Robinson and Bolton2014, Reference Haroz, Bass, Lee, Oo, Lin, Kohrt, Michalopolous, Nguyen and Bolton2017; McNamara et al., Reference McNamara, Banks, Gubhaju, Williamson, Joshy, Raphael and Eades2014; Andersen et al., Reference Andersen, Kagee, O’Cleirigh, Safren and Joska2015; Sarkar et al., Reference Sarkar, Kattimani, Roy, Premarajan and Sarkar2015; Schneider et al., Reference Schneider, Baron, Davies, Bass and Lund2015; Bougie et al., Reference Bougie, Arim, Kohen and Findlay2016; Hackett et al., Reference Hackett, Farnbach, Glozier, Skinner, Teixeira-Pinto, Askew, Gee, Cass and Brown2016, Reference Hackett, Teixeira‐Pinto, Farnbach, Glozier, Skinner, Askew, Gee, Cass and Brown2019; Baron et al., Reference Baron, Davies and Lund2017; Denckla et al., Reference Denckla, Ndetei, Mutiso, Musyimi, Musau, Nandoya, Anderson, Milanovic, Henderson and McKenzie2017; Marley et al., Reference Marley, Kotz, Engelke, Williams, Stephen, Coutinho and Trust2017; Schantz et al., Reference Schantz, Reighard, Aikens, Aruquipa, Pinto, Valverde and Piette2017; Gallis et al., Reference Gallis, Maselko, O’Donnell, Song, Saqib, Turner and Sikander2018; Harry and Crea, Reference Harry and Crea2018; Kilburn et al., Reference Kilburn, Prencipe, Hjelm, Peterman, Handa and Palermo2018; Ashaba et al., Reference Ashaba, Cooper-Vince, Vořechovská, Maling, Rukundo, Akena and Tsai2019; Chapla et al., Reference Chapla, Prabhakaran, Ganjiwale, Nimbalkar and Kharod2019; Caneo et al., Reference Caneo, Toro and Ferreccio2020). Finally, there were 3 cases where the same research team produced two manuscripts detailing adaptation processes; this yielded 34 original reports of cultural adaptation processes included in this review.

Characteristics of the scale measures with a cultural adaptation (Table 1)

In a total of 34 reports of cultural adaptation processes, there were 41 different depression scales adapted (Table 1). The Indigenous groups of the studies were native to Canada or the United States (6/34), Latin America (3/34), Asia (8/34), Africa (9/34), and Australia or New Zealand (8/34). The most commonly adapted scales included the Patient Health Questionnaire (PHQ-9), the Center for Epidemiologic Studies Depression Scale (CES-D), and the Edinburgh Postnatal Depression Scale (EPDS).

Methods of scale modifications

Revision of cultural relevance and transcultural translation

The cultural relevance of the measurement scales, in addition to the linguistic equivalence (language translation), was verified in 19/34 cultural adaptations (Table 2). An example of such a process was asking Indigenous women about the most relevant tasks and activities related to taking care of themselves, their families, and taking care of and participating in the community. The researchers subsequently translated the mentioned categories and constructed a new instrument with items based off the need to cover sufficient domains of functioning.

Some studies spoke more explicitly about transcultural translation, which was described as a process of understanding the meaning of phrases and ensuring that translation maintains cultural nuances. In all these cases, the researchers used qualitative methods to gain insight into the questions and responses presented in the tools and their relevance from the sociocultural point of view of the target population. Participatory qualitative methods were another common characteristic of adaptation processes. This was done in all studies, including through consultations with the Indigenous community focus groups (4/34), qualitative interviews with key community informants (11/34), and or a participatory action research process (1/34) (Table 2). Furthermore, three studies used mixed methods, combining the use of surveys with interviews.

A trend shown by the studies was that significant engagement between researchers/practitioners and Indigenous community members is needed in the process of revising cultural relevance of depression scales. For example, in the cultural adaptation of the Patient Health Questionnaire (PHQ-9) with Indigenous Australian people, focus groups were conducted (Brown et al., Reference Brown, Mentha, Rowley, Skinner, Davy and O’Dea2013). This required the interplay of feedback from bilingual experts and acceptance testing through discussions with community members. The translators, research team members, and Indigenous members discussed the translations to provide linguistic and conceptual equivalences of the adapted scale items, reviewed the difficult items, and identified ways to achieve semantic and cultural equivalence. This process resulted in a modification of words and phrases, as well as division of one initial question into two items that were more precise (e.g., psychomotor changes and appetite changes). Also, seven key features of depression not covered by the standard PHQ-9 but relevant for the local population were identified and added: anger, homesickness, irritability, excessive worry, weakened spirit, drug/alcohol use, and rumination.

Following the involvement of experts and the community to identify needs, different depression scales were adapted in a variety of ways to increase acceptance of their content and use by the Indigenous group, which improves cultural safety. In studies where items were added, the goal was often to incorporate local idioms of distress or of functioning. For example, the most common somatic symptoms (e.g., ‘fatigue’) or positive affect concepts (e.g., ‘hopefulness’) items were added (Baron et al., Reference Baron, Davies and Lund2017; Kilburn et al., Reference Kilburn, Prencipe, Hjelm, Peterman, Handa and Palermo2018). Research teams also used a deletion method to remove items perceived as culturally inappropriate or irrelevant to the local constructs of depression. For example, older Australian Aboriginal people perceived the question on the original Kessler Psychological Distress Scale (K-5) concerning feelings of worthlessness as offensive (McNamara et al., Reference McNamara, Banks, Gubhaju, Williamson, Joshy, Raphael and Eades2014). Accordingly, some items about suicidal ideation were subsequently excluded to respect the local sociocultural codes (Gelaye et al., Reference Gelaye, Williams, Lemma, Deyessa, Bahretibeb, Shibre, Wondimagegn, Lemenhe, Fann, Vander Stoep and Andrew Zhou2013; Schantz et al., Reference Schantz, Reighard, Aikens, Aruquipa, Pinto, Valverde and Piette2017). Similarly, the suicidal ideation item was separated into two questions in another study: Have you had thoughts that you would be better off dead? and Have you thought of hurting yourself? (Almeida et al., Reference Almeida, Flicker, Fenner, Smith, Hyde, Atkinson, Skeaf, Malay and LoGiudice2014). Thus, the desire of the community was most important when considering including questions about suicide in depression measures.

Other than through sole use of qualitative methods, some studies adapted scales using quantitative methods. Following interviews with mothers, Bass et al. (Reference Bass, Ryder, Lammers, Mukaba and Bolton2008) compiled a list of identified postpartum symptoms and statistically regressed them on mental health constructs that comprised the measure (Bass et al., Reference Bass, Ryder, Lammers, Mukaba and Bolton2008). Through this, the authors identified relevant depression-like problems that were meaningful based on both phenomenological insight and objective validation. Subsequently, they reviewed standard post-partum depression screens to identify those that best reflected the local descriptions. Based on this work, they selected, translated, and adapted the EPDS and the Hopkins Symptom Checklist depression section (HSCL-D). This involved adding new questions associated with signs and symptoms that were not part of the original screens but were described by the interviewees.

Language translation

Translation to the respective Indigenous language was completed in 14/34 scales (Table 2). In general, these translations followed a rigorous protocol, informed by guidelines and examples set forth by experts in psychiatry or experts in the field of linguistics (Ganguli et al., Reference Ganguli, Dube, Johnston, Pandav, Chandra and Dodge1999; Brown et al., Reference Brown, Mentha, Rowley, Skinner, Davy and O’Dea2013; Almeida et al., Reference Almeida, Flicker, Fenner, Smith, Hyde, Atkinson, Skeaf, Malay and LoGiudice2014). Most translations were done by professional translators with recognized experience in psychiatry; in two cases, non-native translators were fluent in both the original scale language and the Indigenous language (Easton et al., Reference Easton, Safadi, Wang and Hasson2017; Schantz et al., Reference Schantz, Reighard, Aikens, Aruquipa, Pinto, Valverde and Piette2017). Additionally, the first translated version of certain tools was completed in a blinded manner and through back-translation (14/14). When discrepancies arose, the researchers turned to mental health experts to define the most accurate translation (9/14).

Following a direct transcultural translation, some scale items needed to be rewritten for grammatic purposes. This necessitated reformulation of items (2/14), addition of items (2/14), removal of items (2/14), changes to the order of questions (1/14), and recommendations regarding the wording of items (5/14). To assist in this, some studies compiled a list of Indigenous symptoms or expressions of distress that could be useful for screening for depression. This information was collected through qualitative methods including interviews (4/14) and use of interpreters (1/14). An example of a language translation process is reported by Ganguli et al. (Reference Ganguli, Dube, Johnston, Pandav, Chandra and Dodge1999). They translated the Geriatric Depression Scale (GDS), originally written in English, into the local Haryanvi dialect of Hindi through a standard approach of iterative back-translation by bilingual clinicians (Ganguli et al., Reference Ganguli, Dube, Johnston, Pandav, Chandra and Dodge1999). The researchers also made minimal modifications to the content of the tool to improve cultural appropriateness. The question regarding whether the person found life to be ‘exciting’ was modified to ‘very enjoyable’, as the concept of older people feeling ‘excited’ was found to not be appropriate in rural India. The adapted scale was named the Geriatric Depression Scale-Hindi version (GDS-H).

Visual scales

One study developed a visual scale to accompany the original numerical Likert scale (Marley et al., Reference Marley, Kotz, Engelke, Williams, Stephen, Coutinho and Trust2017). In this study, the Kimberley Mum’s Mood Scale (KMMS) was adapted to fit the needs of pregnant and postpartum Indigenous women in Australia. The qualitative methodology relied on multiple focus groups for input on appropriate visual representations, wording, and a protocol for administration of the tool. The resulting visual scale included a water glass pictorial to distinguish different multiple-choice responses, pictographs, and a visual analogue scale comprised of degrees of facial expression indicating valence and magnitude of emotions.

Scale administration

Increasing cultural safety and sensitivity at administration of the scale was often the aim of the studies’ adaptation processes. The context of use as well as the scale administration process were considered by three studies (Table 2). Some authors tried to improve the acceptability, reliability, and utility of the scales, and explored impact of the administration process on this. Increasing acceptability of the tool by the Indigenous community was described as being the process whereby adapted tools were considered sufficiently culturally safe, non-judgmental, and could provide providers with valuable insights into participants’ lived experiences and social, emotional, and cultural well-being. Increasing acceptability also supports the validity of the scale, which is the accuracy of the tool for measuring constructs of depression that align with the Indigenous’ conceptualizations of it.

Esler et al. (Reference Esler, Johnston and Thomas2007) investigated attitudes toward depression screening and the components of the PHQ-9 among members of an urban Indigenous community in Australia (Esler et al., Reference Esler, Johnston and Thomas2007). Some focus group participants suggested that involving a family member in the assessment process may improve the accuracy of the screening while other participants shared the opposite point of view. Most participants stated they would prefer an Indigenous health worker as interviewer. Equally, familiarity with the Indigenous community-controlled health service was considered to contribute to the acceptance of the administration of the tool. The need for an initial trusting relationship between the patient and the tool administrator was noted as being particularly important.

In Marley et al.’s (Reference Marley, Kotz, Engelke, Williams, Stephen, Coutinho and Trust2017) adaptation of the KMMS, the study team created a culturally safe space to conduct the screen with the Indigenous women (Marley et al., Reference Marley, Kotz, Engelke, Williams, Stephen, Coutinho and Trust2017). They incorporated a guided questionnaire that allowed the women participants to describe their history in detail, making it easier for researchers and clinicians to identify protective and vulnerability factors. The authors also developed culturally safe training modules for staff administering the tool. Resultingly, the majority of participants reported that completing the KMMS was highly useful and better than the standard instrument (EPDS), as it increased mutual respect, trust, and understanding between the personnel and the participants.

Discussion

We identified 34 reports on cultural adaptation processes including 41 different depression scales. The most commonly adapted scales included the Patient Health Questionnaire (PHQ-9), the Center for Epidemiologic Studies Depression Scale (CES-D), and the EPDS. The review found that cultural adaptation of depression scales is more of an exception than a rule; only 34 reported cultural adaptations were identified, yet the estimated global number of Indigenous groups is over 5,000 (United Nations, 2023). Geographically, the cultural adaptations were mostly conducted in Africa, Australia, and Asia. This finding is consistent with the geographic dispersion of Indigenous populations, as approximately 70% of Indigenous populations live in Asia and the Pacific, 16.3% in Africa, 11.5% in Latin America and the Caribbean, 1.6% in North America, and 0.1% in Europe and Central Asia (Jamil Asilia Centre, 2021). This shows a heightened need for attention to recognizing importance of cultural safety in mental health care for Indigenous populations of these areas.

Four main processes of utilized cultural adaptation of depression scales were identified. The most commonly used non-exclusive methods were revision of cultural appropriateness or transcultural psychiatry, language translation, modifications of the administration process, and complementary visual scales. Most importantly, the approach chosen depended on the context of administration and the specific clinical or research issues to address. Cultural adaptations to scales could increase cultural safety and response rate of psychometrics; however, it remains open when it is appropriate to consider conducting a translation or further cultural adaptation. A careful, shared needs assessment is important before cultural adaptations, given the intensive use of Indigenous resources in the adaptation process.

Importance of cross-cultural translation

Studies found that a rigorous translation of the tool into the native language was important, since the language is a significant identity marker for the community members. As compared to literal equivalence in traditional translation, the main challenges in cultural translation are the complexity of local semantics and the need to guarantee conceptual equivalence, criterion equivalence, and content equivalence (Ghimire et al., Reference Ghimire, Chardoul, Kessler, Axinn and Adhikari2013). The success of translation processes necessitates several steps and good resources: (1) establishment of a bilingual group of experts, (2) examination of conceptual composition by the experts, (3) translation by an expert, (4) examination of the translation by the experts, (5) examination of the translation by a group representative of the population, (6) blind back-translation by another expert, (7) examination of the blind back-translation by the experts and adjustment of discrepancies, (8) a pilot study to test the tool among the population, and (9) adjustments based on pilot study results (Sartorius and Janca, Reference Sartorius and Janca1996; Beaton et al., Reference Beaton, Bombardier, Guillemin and Ferraz2000; Sousa and Rojjanasrirat, Reference Sousa and Rojjanasrirat2011; Arafat et al., Reference Arafat, Chowdhury, Qusar and Hafez2016). This process can last up to several months and constitutes the most simple and economical form of adaptation processes.

Importance of qualitative methods

Confirming that a cultural adaptation process is successful and useful to the population is important to support its use (Wiltsey Stirman et al., Reference Wiltsey Stirman, Baumann and Miller2019). In quantitative data collection, completion rates for individual items can provide indirect evidence for the acceptance of a tool. While quantitative research provides a rapid insight into scale-user satisfaction, these methods do not provide concrete information for improvement of cultural sensitivity (Ingersoll-Dayton, Reference Ingersoll-Dayton2011). For instance, if items are deemed unclear, researchers must understand culturally relevant ways to modify them. To do this, qualitative methods are necessary, as is following-up on user experiences (Ingersoll-Dayton, Reference Ingersoll-Dayton2011). Iterative focus groups, fieldwork, qualitative interviews, and feedback collection with community members and clinicians (among other methods) are appropriate methods to review and improve different iterations of a scale until a final, culturally accepted tool is disseminated for community use (Ingersoll-Dayton, Reference Ingersoll-Dayton2011; Brown et al., Reference Brown, Mentha, Rowley, Skinner, Davy and O’Dea2013).

Response options

Colonization, repeated systemic discrimination, and unsafe schools have limited access to resources and conditions necessary to maximize socioeconomic status for many Indigenous groups (Reading and Wien, Reference Reading and Wien2009; Davy et al., Reference Davy, Harfield, McArthur, Munn and Brown2016; Gall et al., Reference Gall, Anderson, Howard, Diaz, King, Willing, Connolly, Lindsay and Garvey2021). This disadvantage can be manifested in lower rates of educational attainment, literacy, and familiarity of colonizers’ language, which limit reliability of responses to scales and influence the accuracy of depression screening instruments (Akena et al., Reference Akena, Joska, Obuku, Amos, Musisi and Stein2012). As an example, high rates of missing data on Likert response options have challenged defining the diagnosis (Bell et al., Reference Bell, Smith, Arcury, Snively, Stafford and Quandt2005). Conversely, participants’ openness to respond can be compromised when the native language is not used (Borsa et al., Reference Borsa, Damasio and Bandeira2012; Ghimire et al., Reference Ghimire, Chardoul, Kessler, Axinn and Adhikari2013; Arafat et al., Reference Arafat, Chowdhury, Qusar and Hafez2016). Thus, translation, audio recordings of the questions, or administration of the tool verbally can improve reliability.

Indigenous co-leadership in scale development

Seeking Indigenous knowledge to inform decision-making on selection, cultural adaptations, and administration of scales, implies that Indigenous peoples are stakeholders in their own mental health (Latulippe and Klenk, Reference Latulippe and Klenk2020). Reconciliation is about the genuine restructuring and transformation of the relationships between Indigenous and settler people (Hoicka et al., Reference Hoicka, Savic and Campney2021). Reconciliation can take place in cultural adaptation processes that use Indigenous knowledge as ‘expert’ knowledge. In fact, through qualitative interviews to learn about experiences with culturally adapted tools, Indigenous people reported that adapted tools ‘mean something to them’, and that these scales can make Indigenous ‘identify with their own person within’ (Marley et al., Reference Marley, Kotz, Engelke, Williams, Stephen, Coutinho and Trust2017).

Prior to cultural adaptation, Indigenous peoples in the studies reported that the original scales created “distrust and questions before you get started, and that confidence is really hard to get back” (Marley et al., Reference Marley, Kotz, Engelke, Williams, Stephen, Coutinho and Trust2017). In contrast, inviting Indigenous people in the leadership of their own tools supported trust and mutual respect of researchers/practitioners and Indigenous groups, which allows for confidence in and readiness for cultural adaptations. In this way, the studies illustrated how Indigenous co-leadership in scale development was a determinant of the success of other adaptation methods. This is because this process facilitated collaboration in translation and revision of cultural relevance, as well as established a trusting relationship when Indigenous peoples were invited to focus group discussions, key informant interviews, or consultations.

Indigenous co-leadership in adapting scales requires time and resources from both researchers and the Indigenous community. This is stressing the importance of shared needs assessment before the process of cultural adaptation. The needs assessment has to start from the overall idea of using symptom measures. For symptom measures to be useful, cultural safety cannot compromise utility for the medical approach in evaluation and treatment, necessary to inform mental health services.

Holistic constructs of mental well-being

Some tools were developed to be complementary to the symptom measure scales, considering Indigenous conceptualizations of well-being and honoring the self-determination of the Indigenous group. For example, this was the case of the Functional Assessment Instrument (FAI), developed through free-listing interviews – a particular technique that explores how a group thinks about and defines health domains through engaging communities to identify their shared priorities from the perspective of their own ideologies (Schneider et al., Reference Schneider, Baron, Davies, Bass and Lund2015). The researchers adapted this scale to identify tasks and activities that women performed during the perinatal period, which they expressed was more relevant to them than clinical features of post-partum assessments and were more meaningful for healing.

Several Indigenous groups reported feeling that alternatives to symptom measures were more consistent with Indigenous visions of health. This aligns with the literature sharing that Indigenous ideologies embrace a holistic concept of health that reflects physical, spiritual, emotional, and mental dimensions (Reading and Wien, Reference Reading and Wien2009). Accordingly, other than symptom scales adapted by studies included in the review, there exists tools to evaluate distress while considering factors specific to the sociocultural reality of the community and their worldviews (Kinzie et al., Reference Kinzie, Manson, Vinh, Tolan, Anh and Pho1982). For example, the Native American Cultural Values and Beliefs Scale assesses whether the individual experiences any distress based on their lack of participation in important Dakota, Nakota, and Lakota values and beliefs (Reynolds et al., Reference Reynolds, Quevillon, Boyd and Mackey2006). Other instruments have moved toward the assessment of more general factors that promote or hinder mental health in a broader sense (e.g., emotional wellness and empowerment) rather than standard clinical measures (Haswell et al., Reference Haswell, Kavanagh, Tsey, Reilly, Cadet-James, Laliberte, Wilson and Doran2010). Moreover, some scales for Indigenous groups have moved away from assessing negative constructs of mental illness, and toward strengths and resources associated with resilience, healing, and recovery (Gee et al., Reference Gee, Hulbert, Kennedy and Paradies2023).

Inclusion of local cultural expressions can be particularly important in depression, which is a psychological and experiential phenomenon whose meanings are closely shaped by the sociocultural context. Moreover, measurement scales for Western populations may contain behaviors or experiences considered normal or irrelevant to the local culture of the Indigenous population.

Western symptom measures have been developed based on an individual view of health; cultural adaptation of measures cannot change this fact if the focus is still on symptomology. In contrast, if a screen is to be truly aligned with the local Indigenous concept of health, it is possible that it is developed less as a screen of symptomology but rather developed holistically, recognizing that health is interrelated with and interconnected to their families, community, and lands.

Cultural safety during the adaptation and use of the scale

Researchers have emphasized the importance of an ethnographic approach when assessing global mental health and providing care. The incorporation of qualitative and ethnographic methods in developing assessment tools and interventions is well established and recognized (Campbell et al., Reference Campbell, Fitzpatrick, Haines, Kinmonth, Sandercock, Spiegelhalter and Tyrer2000; Moreau et al., Reference Moreau, Hassan, Rousseau and Chenguiti2009; Onwuegbuzie et al., Reference Onwuegbuzie, Bustamante and Nelson2010). Collaborative-participatory research, commitment of Indigenous peoples, and a relationship of trust and respect with the community are crucial methods for a successful process of cultural adaptation. The ethical principles that regulate the research with Indigenous populations must be respected by the research team. Respecting the national standards as well as the specific standards of the target Indigenous group is necessary and essential to confirm further use of adapted depression screens.

Increasing cultural safety starts in the planning stage for conducting research or developing programs for Indigenous peoples, and inclusion of the target population is essential from the early stages of needs assessment and planning (Kirmayer et al., Reference Kirmayer, Simpson and Cargo2003; Darroch et al., Reference Darroch, Giles, Sanderson, Brooks-Cleator, Schwartz, Joseph and Nosker2017; Yaphe et al., Reference Yaphe, Richer and Martin2019). For example, it is recommended to have research members or service providers of the same ethnic origin as the respondents available to establish a safe space (Rait et al., Reference Rait, Burns, Baldwin, Morley, Chew-Graham, St Leger and Abas1999; Kaiser et al., Reference Kaiser, Kohrt, Keys, Khoury and Brewster2013; Billan et al., Reference Billan, Starblanket, Anderson, Legare, Hagel, Oakes, Jardine, Boehme, Dubois, Spencer, Hotomani, McKenna and Bourassa2020). When this is not possible, the administrators of the tools may undergo training in cultural competency through workshops, educational programs, or continuing education to create a culturally sensitive space which correspondingly facilitates communication (Billan et al., Reference Billan, Starblanket, Anderson, Legare, Hagel, Oakes, Jardine, Boehme, Dubois, Spencer, Hotomani, McKenna and Bourassa2020). Finally, it is essential to consider institutional discrimination and possible stigma of psychiatric diagnoses in the administration of scales. In cultural adaptation processes, minding the local principles are important as it addresses the ownership of data of adapted scale, as well as the patient’s definition of what safe care means (Baba, Reference Baba2013).

Unanswered questions and future research

While the final version of a culturally adapted depression psychometric remains specific for the target community, scientifically reporting the process of scale cultural adaptation makes it possible to evaluate methods and make conclusions about culturally specific factors that promote or threaten mental health. Reports also enable accumulation of knowledge on suitable methods not only for culturally sensitive measurement but also to inform treatment.

Deleting unsafe items can also have limitations. The lack of inclusion of ‘idioms of distress’ or ‘cultural concepts of distress’ in the diagnoses developed by the biomedical approach can result in low levels of reliability in the information communicated by people. This can potentially interfere with appropriate diagnoses and securing appropriate mental health services or support (Nichter, Reference Nichter2010; Kohrt et al., Reference Kohrt, Luitel, Acharya and Jordans2016; Kidron and Kirmayer, Reference Kidron and Kirmayer2019; Lewis-Fernández and Kirmayer, Reference Lewis-Fernández and Kirmayer2019). Thus, it should be noted that adaptations that seem necessary to increase acceptability might compromise other psychometric characteristics and thus, confirming validity, comparability, and clinical utility remains an equally important but separate line of development, where normal guidelines for psychometric evaluation apply.

Currently, selection of populations for cultural adaptation seems to have been arbitrary, dependent on motivation of researchers and community members. Future work may include a needs assessment before devoting external and community resources to a cultural adaptation. A rigorous process of cultural adaptation is challenging and necessitates time and resources. Recognizing the populations where measurement will not be possible without a translation or a more profound cultural adaptation as well as prioritizing populations for adaptation based on a needs assessment might be necessary. Alternatively, focus on culturally safe administration of standard scales might be an option.

Greater focus on including supporting visuals (e.g., pictographs) and auditory materials would extend the accessibility of these tools to low literacy or small populations. Sometimes, valid scales could be modified to avoid the most culturally contradictory items. Research should optimally compare acceptability and validity of pure translations to cultural adaptation of the same scales in the same population and calculate the resources vs. benefit of the process.

Use of cultural knowledge to complement mental health interventions is an interesting approach that should be explored. The process of cultural adaptation, and knowledge about local concepts in mental health and the culture specific resilience, can also indirectly increase cultural safety and respect of minorities.

Strengths and limitations

To our knowledge, this is the first systematic scoping review on methods used for culturally adapting depression measures with Indigenous peoples. Broadly, our analysis contributes to the field of cross-cultural studies and to cultural psychiatry providing well established practices that can guide the process of cultural adaptation of measurement tools, as proposed recently (Arafat et al., Reference Arafat, Chowdhury, Qusar and Hafez2016). The findings of this review may facilitate further research and more equitable exchanges of knowledge on culturally sensitive measures for not only psychiatry but also resilience and supporting factors. The latter remains a generally unmet need; reports have shown that many psychometric scales can be experienced as unsafe and that empowering approaches to mental health assessment are preferred by several Indigenous groups (Gomez Cardona et al., Reference Gomez Cardona, Brown, McComber, Outerbridge, Parent-Racine, Phillips, Boyer, Martin, Splicer, Thompson, Yang, Velupillai, Laliberté, Haswell and Linnaranta2021).

Our search was limited to articles in English. We discarded several articles due to the complexity of the definition of Indigenous peoples and the way this was addressed in the research. In fact, the definition of Indigenous is problematic since the auto-definition of individuals as such is not always rigorously considered by all studies, especially those published before the 2000s. In several cases, Indigenous identity was not specified in the studies or was not used as an inclusion criterion. For consistency, we intentionally excluded studies where the Indigenous community was not living in their country of origin, such as when cultural adaptation was done for immigrants or refugees in another country. In future research, these factors could be considered – particularly, the geographical distribution of Indigenous peoples in identified studies. Moreover, since there are many undertakings of research with Indigenous on mental health assessment, updated searches should be done to support new innovation in culturally safe tools.

Conclusion

Revision of linguistic equivalence and cultural relevance of items, culturally safe administration procedures, and participatory research were key features of improving cultural sensitivity of psychometric measures for depressive symptoms among global Indigenous populations. Participatory qualitative research and methods are appropriate for conducting cultural adaptation of instruments most suitable for the community, but a careful, shared needs assessment is necessary to prioritize resources. Across all studies, increasing cultural safety by translation, changes to content, or modes of administration protocol were found to be empowering and healing. Indigenous reported that the most acceptable scales were culturally safe and able to be integrated into their health services. Use of visual scales and auditory materials are promising in terms of acceptability of the measurement. Finally, empowerment – focused approaches and tools as alternatives to symptom measures should actively be sought for provision of high-quality and culturally sensitive mental health services.

Open peer review

To view the open peer review materials for this article, please visit http://doi.org/10.1017/gmh.2023.75.

Supplementary material

The supplementary material for this article can be found at https://doi.org/10.1017/gmh.2023.75.

Data availability statement

All additional data is available upon request from authors.

Acknowledgements

We would like to thank Ms. Andrea Quaiattini from the McGill University Library for her assistance with our comprehensive systematic search procedure. We also express our gratitude for Indigenous co-authors in other publications and some other community members in Montreal and Kahnawà:ke for introducing us to some basic concepts of their view of health and wellbeing as opposed to symptom measurement.

Author contribution

L.G.C., V.N. and O.L. were involved in the conceptualization of the review. Project management was the responsibility of L.G.C. and O.L. Data screening and data analysis were conducted by all authors. All findings were validated by L.G.C. The original draft of the manuscript was written by L.G.C., M.Y., Q.S., and O.L. was reviewed and edited by L.G.C., M.Y., O.L. All co-authors reviewed the final version of the article. Funding was acquired by L.G.C. and O.L.

Financial support

O.L. was funded by grants from FSISSS (#8400958), CIHR (#426678), FRSQ (#252872 and #265693O), the Réseau Québécois sur le suicide, les troubles de l’humeur et les troubles associés, and the Strategic Research Council (SRC) established within the Academy of Finland (#352700). L.G.C. had financial support from the Réseau universitaire intégré de santé et services sociaux (RUISSS) McGill and CIHR grant #430331. Q.S. had funding from McGill University’s Healthy Brains Healthy Lives fellowship (Q.S.). The funders had no role in study design or in later collection and data analysis.

Competing interest

The authors declare none.

Footnotes

L.G.C. and M.Y. shared co-first authorship.

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Figure 0

Figure 1. Flowchart of search and screening process.

Figure 1

Table 1. Characteristics of studies

Figure 2

Table 2. Process of cultural adaptation

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Author comment: The methods of improving cultural sensitivity of depression scales for use among global indigenous populations: a systematic scoping review — R0/PR1

Comments

Please find attached our review “The methods of improving cultural sensitivity of depression scales for use among Indigenous populations - A systematic scoping review” for consideration in the journal Global Mental Health. Culturally competent care is needed to address major depression amongst Indigenous communities, as rates of depression and suicide have commonly been found to be significantly higher amongst Indigenous in comparison to the general population. We present a systematic scoping review of processes where standard depression scales that have been culturally adapted for use among Indigenous populations worldwide. Here, we aimed to describe the processes and main features of adaptation methods and approaches.

Review: The methods of improving cultural sensitivity of depression scales for use among global indigenous populations: a systematic scoping review — R0/PR2

Conflict of interest statement

Nil

Comments

Thank you for asking me to read this interesting scoping review examining methods to improve the cultural sensitivity of Indigenous populations. This is important work as draws together the range of approaches used to adapt scales for use by Indigenous people, a practice which is increasing in focus by researchers and necessary to prepare health services to deliver care to Indigenous people. I believe this to be a potentially important paper, however, I provide some comments for your consideration.

Introduction

1. Some of these claims could be strengthened with references, for instance:

- Sentence three, can we be specific about examples of marginalisation? (starting “As a result of colonization…) and back it up by literature.

- Final sentence para 1, (starting “access and quality is commonly not equal…), can we define and reference this statement?

Aims

2. There is some inconsistency in the aims as reported throughout the paper, e.g., between the impact statement ( stated as “describing the concepts and methods use), abstract (“process and features of methods) and article (“availability of measures, target pops and geographic distribution of the scales, methods and process of adaptations). I suggest reviewing these for consistency to clarify the purpose for the reader.

3. I suggest reviewing the aims in the paper. From reading the results it appears that aim 1 (availability) is addressed in section 3.2. I’m not clear the difference between aims 1 (availability) and 2 (target populations and geo distribution). Perhaps these could be revised and simplified. The bulk of the results appear to be focused on aim 3 (“methods), section 3.3 onwards. (More closely linking the aims with the results will enhance compliance with PRISMA item 18).

Methods

4. The search is now over 2 years out of date. Perhaps the authors could consider updating this search or justifying why this is appropriate.

5. The authors have appropriately reported using the PRISMA ScR guidelines for the review. I was unable to review the search strategy (as is included in the guideline) as it was not provided with the manuscript, however it was noted that it would be provided as a supp table.

Results

6. I suggest considering the framing of communities to recognise their skills and strengths throughout the paper. For instance, Pg 9 line 120 identifies ‘the community and experts’, which could be interpreted to indicate the community are not experts, whereas the community holds a range of skills and knowledge that the research experts lack. In this instance, re-framing the ‘experts’ as ‘university based researchers or clinicians’ (as is accurate) may address this issue. This should be considered throughout.

7. PHQ-16 (ref 28) and PHQ-9 (ref 27) are the same tool, i.e., the PHQ-9 was adapted in ref 27, resulting in the aPHQ-9, which was then tested for validity, etc in ref 28. I suggest reviewing the representation of the results table to reflect this process.

Discussion

8. 4.4 I find it unusual to include additional results in the discussion that are not responding to an aim or result (sentence starting “Beyond the main objective of this review, we also identified some complementary projects..). When considering my comments above about the aims, I suggest considering including this information in the aim, result.

9. 4.4 Additional referencing in this section would improve clarity – currently, it is not clear to the reader which paper are been illuded to in this section and specific information about this idea.

10. As it currently reads, I found it difficult to follow how these conclusions were drawn. How did we ascertain if co-produced tools minimised stigma? (section: The studies showed that co-produced tools can minimize stigma associated with mental illness, increase acceptability of measurement among the population, have higher sensitivity to local emotional experiences, and improve identification and treatment of distress). How was this shown? By linking the aim, method with this idea may clarify this point.

11. 4.5 Consider reviewing and including a reference to demonstrate which literature the paper is referring to (line 284-5). I also wondered if the authors were aware of the Australian “Aboriginal Resilience and Recovery Questionnaire (ARRQ)”, by Graham Gee as this work may have relevance to this section.

Review: The methods of improving cultural sensitivity of depression scales for use among global indigenous populations: a systematic scoping review — R0/PR3

Conflict of interest statement

Reviewer declares none.

Comments

Thank you for the opportunity to review the manuscript The Methods of Improving Cultural Sensitivity of Depression Scales for Use Among Indigenous Populations – A Systematic Scoping Review.‘’ In this systematic scoping review, the authors seek to expand the literature on the strategies used in the cultural adaptation of standard depression scales for Indigenous populations worldwide.

Reviewer’s Comments:

Strengths

The manuscript will significantly contribute to the field with a high impact.

The manuscript is original and fills a gap in the literature.

The manuscript covers global content, including research inclusion, presentation of results, and discussion.

The findings will contribute to advancing knowledge in the field of psychometrics, psychiatry, and Indigenous mental health.

The authors convey their ideas and present their results in an organized and structured manner.

Areas for Improvement

Global content in the impact statement could be expanded.

Describing the reasons for the exclusion of the 3662 articles would be informative.

Review: The methods of improving cultural sensitivity of depression scales for use among global indigenous populations: a systematic scoping review — R0/PR4

Conflict of interest statement

Reviewer declares none.

Comments

Response to Question 1

For global reviews, how well does the review cover global content in the inclusion of research, presentation of results, and/or in the discussion and implications? And how could this be improved/expanded?

This scoping review investigates an important issue that is relevant to practitioners working with Indigenous populations and researchers investigating the prevalence of Western conceptualisation of depression and/or the impact of interventions. In doing this the manuscript contributes to a growing body of work that highlights the issues related to the use of screening tools that are designed using the Western biomedical paradigm and associated conceptualisation of depression.

However, in my view, in its current version the manuscript has several issues that should be attended to. Initially, the framing of the ‘problem’ does not take a strengths-based approach. Rather than focusing on Indigenous peoples as the problem, the authors should consider the benefits of framing the issue of cultural adaptation of tools developed using the Western biomedical paradigm as a recognition that the worldviews of Indigenous peoples globally are holistic being interrelated with and interconnected to their families, community, and lands. Consequently, they are different from the individualistic Western biomedical paradigm on which the screening tools examined in this scoping review are based on.

Second, the authors do not explicitly identify the root of the issue which is that Indigenous worldviews are different and therefore ‘dis-ease’ and the means of screening it/them need to be aligned with those worldviews.

Third, while the authors identified that they followed Tricco et al., (2018) scoping review checklist they did not report using an acceptable and repeatable method for their review. This scoping review would have been significantly enhanced using a published method. For example, Joanna Briggs Institute (https://jbi.global/scoping-review-network/resources) or Peters MD, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. JBI Evidence Implementation. 2015 Sep 1;13(3):141-6, which includes using the framework Population, Concept Context (PCC) to frame inclusion criteria. Additionally, the Tricco et al., (2018) checklist (item number 4) identifies the need for “an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g. population or participants, concepts and context) (p. 471).

Fourth, the review would be significantly enhanced if the authors systematically and explicitly defined the parameters of their subject of interest. For example, what do the authors mean by cultural relevance, linguistic equivalence, acceptability?

Fifth, the authors should review their discussion about Hackett et al., 2019 (beginning line 120). Hackett and colleagues (2019) (The Getting it Right Study) was a validation of Brown and colleagues previous work (2012, 2013, 2016) done to adapt the PHQ-9 with Australian Aboriginal people from the Central Desert area.

Lines 123 – 131 in the manuscript is taken from Hackett et al., 2019 (p. 24). As cited in the manuscript it misrepresents what the validation did. Here the authors should be referring to the work of Brown (2013).

Relevant references that support this adaptation are listed below.

Brown, A., Scales, U., Beever, W., Rickards, B., Rowley, K., & O’Dea, K. (2012). Exploring the expression of depression and distress in aboriginal men in central Australia: a qualitative study. BMC psychiatry, 12, 1-13.

Brown, A. D., Mentha, R., Rowley, K. G., Skinner, T., Davy, C., & O’Dea, K. (2013). Depression in Aboriginal men in central Australia: adaptation of the Patient Health Questionnaire 9. BMC psychiatry, 13, 1-10.

Brown, A., Mentha, R., Howard, M., Rowley, K., Reilly, R., Paquet, C., & O’Dea, K. (2016). Men, hearts and minds: developing and piloting culturally specific psychometric tools assessing psychosocial stress and depression in central Australian Aboriginal men. Social Psychiatry and Psychiatric Epidemiology, 51, 211-223.

Sixth, the inclusion of the word ‘global’ in the title would alert the reader to the fact that this scoping review included publications from across the globe.

Finally, the manuscript needs significant editing.

Recommendation – major revision

The following addresses specific aspects of the manuscript

Abstract

Both reliability and validity are necessary for all scales including adapted scales. Consequently, the sentence beginning “Therefore, cultural adaptation….” should include relevant validity, not just acceptability (face validity) and reliability.

The objective needs editing as the current sentence is fragmented. Perhaps it should read “…present findings of systematic review of ‘processes’ used to cross-culturally adapt depression scales for use with Indigenous peoples worldwide?”

Methods:

For standard translation do you mean language translation?

Conclusion:

Sentence reading “While for comparability, ….” also consider health equity.

Access to culturally safe measures that reflect local idioms and lexicon support equitable access to appropriate care and treatment.

Introduction.

Line 19 – also consider bias and equivalence of tools developed using the Western biomedical paradigm.

Lines 35 – 36 Why is the development of instruments based on DSM-5 important? What is different about Western and Indigenous expressions of low mood? Why does this matter?

Line 41 - The sentence beginning “While no consensus….” is true. However, Beaton and colleagues (2000), (Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine. 2000; 25(24): 3186-91) (cited by 12494 according to Google Scholar; Arafat et al., (2016) (Arafat SMY, Chowdhury HR, Qusar M, Hafez MA. Cross cultural adaptation & psychometric validation of research instruments: A methodological review. J Behav Health. 2016; 5(3): 129-36) (cited by 259); and Sousa & Rojjansrirat (2011) (Sousa VD, Rojjanasrirat W. Translation, adaptation and validation of instruments or scales for use in cross‐cultural health care research: a clear and user‐friendly guideline. J Eval Clin Pract. 2011; 17(2): 268-74) (cited by 2291) have all published relevant guidelines (guides) that should be cited here as acknowledgment of the work that has already been done in this area.

Line 51 – The sentence beginning “The main objectives ….” Should be past tense.

Objective 1 – what do you mean by “track”?

Line 53 – are methods and process the same thing?

What are the research questions guiding this scoping review and what is its rationale?

The authors indicated that they had a problem in their study but are not explicit about what that problem was. The authors indicated that they are following the Tricco et al., 2018 scoping review checklist which identifies that a rationale (number 3 on the checklist) for the scoping review must be included.

Methods

The method contains insufficient information about ho the data was managed. Were citations uploaded to a citation manager? How did co-authors access the data?

Lines 67- 71 This needs a reference

Line 79 – Authors indicate that they calculated Kappa coefficients, but they are not reported in the manuscript.

Line 82 – inclusion criteria indicates that the authors included primary source studies. However, they included at least one protocol (Hackett et al., 2016) which is not a study.

Line 84 – Inclusion criteria 5 indicates that the authors included peer review articles. Why was peer review important? According to Munn et al., (2018) the purpose of a scoping review is “to identify knowledge gaps, scope a body of literature, clarify concepts or to investigate research conduct.” (p. 1). Scoping reviews map broad and available evidence which includes that provided in grey literature. Consequently, the authors need to justify why they have limited their inclusion criteria to peer-reviewed articles and indicate why a systematic review (which uses empirical evidence) was not a more appropriate method for their study.

Results:

Line 100 – 3845 articles is different to that recorded in the PRISMA flow chart (Fig 1).

Line 106 – Sentence beginning The Indigenous group …….”. Can the authors clarify what they mean by “scales were native to”?

Line 118 – Sentence beginning with “Further, three studies….”. The authors use the word methodology when it should be methods.

Lines 122- 123 The First Nations peoples of Australia are Aboriginal and Torres Strait Islanders. They are two culturally distinct groups. Torres Strait Islander people are of Melanesian descent.

Line 123 – Should Hackett et al., 2016 be included in the analysis? It is a protocol not a study.

Line 133 – What do the authors mean by “increase acceptance” and how does acceptance relate to the scale’s validity?

Lines 134 – 135 Relevant citations of articles that reported these characteristics would be helpful for the reader.

Lines 136 – 137 More information needed here including authors, location, relevant Indigenous population, and related scale.

Line 139 – is this just about comprehension (understanding)? Is it also about acceptability?

Line 140 – Refer to comment for Lines 122-23 for correct terminology for Australian First Nations peoples.

Line 159 – Citations needed here

Discussion

Line 211 – 212 I suggest that this information should be presented in the results section as it relates to Objective 1 (tracking)? In which countries are these scales most used?

Line 239 – There are more recent publications associated with the language translation of scales that should have been cited here. See comment for Line 41.

Line 242 – This sentence may be contrary to a previous comment made by the authors (Line 41) indicating that there are no guides or evaluation criteria.

Lines 241 –251 (Section 4.2) This section would benefit from citing relevant literature.

Lines 257 – Consider whether “high illiteracy rates” takes a strength-based approach (see first general comment). The use of deficit language such as this reinforces continuing impact of colonisation where use of dominant language is promoted above Indigenous languages.

Lines 264 - 277 (Section 4.4)

If this very important aspect about cross-cultural adaptation of scales is to be included in the manuscript. It needs to be included as a research question and objective of the scoping review as well as reported in the results section.

Line 269 – To assist the reader relevant studies should be cited here.

Line 309 – Is there a more recent reference than 1999?

Line 318 – Do you mean Indigenous peoples?

Line 322 – How do the review findings facilitate further research and equitable exchange of knowledge for resilience and supporting factors? This is very important when utilising a strengths-based approach that values the importance of connection to culture as supporting resilience.

References

Line 533 – Review journal name.

Recommendation: The methods of improving cultural sensitivity of depression scales for use among global indigenous populations: a systematic scoping review — R0/PR5

Comments

No accompanying comment.

Decision: The methods of improving cultural sensitivity of depression scales for use among global indigenous populations: a systematic scoping review — R0/PR6

Comments

No accompanying comment.

Author comment: The methods of improving cultural sensitivity of depression scales for use among global indigenous populations: a systematic scoping review — R1/PR7

Comments

Please find attached the revised article “The Methods of Improving Cultural Sensitivity of Depression Scales for Use Among Global Indigenous Populations - A Systematic Scoping Review”, which we kindly resubmitted for consideration in Cambridge Prisms: Global Mental Health. We feel very grateful for the comments from referees and believe edits have improved the scope of the review.

Yours,

Outi Linnaranta, MD, PhD

Finnish Institute for Health and Welfare, Finland

McGill University, QC, Canada

Review: The methods of improving cultural sensitivity of depression scales for use among global indigenous populations: a systematic scoping review — R1/PR8

Conflict of interest statement

none

Comments

Review of “The Methods of Improving Cultural Sensitivity of Depression

Scales for Use Among Global Indigenous Populations – A Systematic Scoping Review”

General comments

The authors have significantly strengthened this manuscript by incorporating reviewer feedback which is to be commended. However, there are opportunities to further strengthen thins manuscript by positing ‘up front’ the key reason why scales developed using the Western biomedical paradigm are inappropriate for Indigenous peoples globally. This issue is germane to the need for this scoping review. In my opinion positioning is not strong enough in the Introduction. Suggestions for strengthening this out outlined below.

In addition, there is an opportunity to use a strengths-based approach to your discussion about Indigenous peoples’ literacy levels.

It is also noted that all your examples come from the Canadian context (p. 13 line 262 – 263; p. 15 Lines 309 – 321). Given the global scope of this review this aspect could be further strengthened and more inclusive by including additional citations from other countries.

Finally, please note recommendations below in relation to Table 1. Specifically how you refer to the First Nations peoples of Australia and correctly reporting the work of Hackett and colleagues (2016; 2019) in relation to the validation of the aPHQ-9.

Specific comments

Pg 3 line 6 – 8 Review for written expression. What do you mean by roots?

Pg 3 line 10 – amongst Indigenous peoples?

Pg3 12 – 15 – This sentence would be strengthened by including decolonising psychology (Dudgeon et al., 2017; Dudgeon, 2020; Gone, 2021)as an approach to supporting the mental health of Indigenous peoples.

Line 18 – biased in what way? This point could be strengthened by including considerations of Indigenous worldviews of health and wellbeing. For example, Indigenous peoples holistic worldviews (Dudgeon et al., 2017; Gall et al., 2021; Weaver, 2002) that are inclusive of their connections to community and their lands which also makes screening tools developed using the individualistic Western bio-medical paradigm inappropriate. If this point was strengthened then it would link nicely with your additions related to tool acceptability (p10 -11) where, in line 205 (p.11) you speak to “insights into participants’ lived experiences and social, emotional and cultural wellbeing.”

P11. Line209 – Esler et al., (2007) reference is not needed twice.

P 13 line 262 – 263 Is there a more recent publication than Reading and Wien (2006)? Noting that Reading and Wein report Canadian information, it would also be good to include citations from other countries that are represented in your scoping review.

P13 line 263 – 266 This section does not take a strengths-based approach. Perhaps consider that Indigenous language traditions are mainly oral not written (Struthers & Peden-McAlpine, 2005) and the coloniser’s language is often a second or third language (+) of an Indigenous person and how that might impact their responses to questionnaires.

P15 Lines 309 – 321 Your inclusion of this section has strengthened your discussion. However, as this is a global scoping review perhaps use your Canadian reference as an example of the deleterious impact of colonisation. Other Indigenous peoples across the globe have experienced a variety of policies by their colonisers that have impacted their communities in similar ways. To be more inclusive, perhaps this point should also be noted.

P 18 lines 398- 99. Consider adopting a strength-based approach to literacy in line with suggestions above (p. 13 lines 263- 266)

Page 28 – 32 across Table one

Is ethnic group the most appropriate title for column 9? Perhaps Indigenous group would be more appropriate.

It is noted that you refer to Australian Indigenous and Torres Strait Islanders separately and inconsistently across Table 1. For example, EPDSb, K5; KMMS etc.

Torres Strait Islanders are one of the two groups of First Nations peoples of Australia. Therefore, using the term Australian Indigenous is inclusive of Torres Strait Islanders. If you need to differentiate it is suggested that you use Australian Aboriginal and Torres Strait Islander Peoples. Please review https://aiatsis.gov.au/explore/australias-first-peoples

Page 31 line 24 aPHQ-9 (amended) column six should be amended to describe what the study (Hackett et al., 2019) did, not the intention of the protocol. For example, focus groups were not conducted with participants only questionnaires (the aPHQ-9 and acceptability) were administered. Phone interviews were only conducted with participants if face-to-face interviews to establish the criterion validity of the aPHQ-9 using the MINI were not available.

Interviews were conducted to determine the feasibility of administering the aPHQ-9 and staff perceptions of participating in the study. However, these findings are reported in a separate publication (Farnbach et al., 2019).

This is an example were the inclusion of a protocol which is not a research study becomes issue in a systematic review as the intentions outlined in a protocol may not eventuate in the actual study as is the case with here.

References

Dudgeon, P., Bray, A., D’Costa, B., & Walker, R. (2017). Decolonising psychology: Validating social and emotional wellbeing. Australian Psychologist, 52(4), 316-325.

Dudgeon, P., Darlaston-Jones, D.; Alexi, J. (2020). Decolonising psychology: Self-determination and social and emotional well-being 1. In Routledge handbook of critical indigenous studies (pp. 100-113). Routledge.

Farnbach, S., Gee, G., Eades, A.-M., Evans, J. R., Fernando, J., Hammond, B., Simms, M., DeMasi, K., Glozier, N., Brown, A., Hackett, M. L., & Getting it Right, I. (2019). Process evaluation of the Getting it Right study and acceptability and feasibility of screening for depression with the aPHQ-9. BMC PUBLIC HEALTH, 19(1), 1270. https://doi.org/https://dx.doi.org/10.1186/s12889-019-7569-4

Gall, A., Anderson, K., Howard, K., Diaz, A., King, A., Willing, E., Connolly, M., Lindsay, D., & Garvey, G. (2021). Wellbeing of Indigenous Peoples in Canada, Aotearoa (New Zealand) and the United States: A Systematic Review. International Journal of Environmental Research and Public Health, 18(11). https://doi.org/10.3390/ijerph18115832

Gone, J. P. (2021). Decolonization as methodological innovation in counseling psychology: Method, power, and process in reclaiming American Indian therapeutic traditions. Journal of Counseling Psychology, 68(3), 259.

Struthers, R., & Peden-McAlpine, C. (2005). Phenomenological research among Canadian and United States Indigenous populations: Oral tradition and quintessence of time. Qualitative Health Research, 15(9), 1264-1276.

Weaver, H. N. (2002). Perspectives on wellness: Journeys on the red road. J. Soc. & Soc. Welfare, 29, 5.

Review: The methods of improving cultural sensitivity of depression scales for use among global indigenous populations: a systematic scoping review — R1/PR9

Conflict of interest statement

Reviewer declares none.

Comments

I have carefully reviewed the revised manuscript titled “The Methods of Improving Cultural Sensitivity of Depression Scales for the Use Among Global Indigenous Populations - A Systematic Scoping Review” that you submitted for consideration in Global Mental Health. I would like to commend you and your co-authors for the thorough revisions made in response to the previous feedback. The changes have significantly improved the clarity, quality, and overall scientific rigor of the manuscript. Thank you for the opportunity to review your work, and I look forward to seeing this valuable contribution published in the near future.

Recommendation: The methods of improving cultural sensitivity of depression scales for use among global indigenous populations: a systematic scoping review — R1/PR10

Comments

No accompanying comment.

Decision: The methods of improving cultural sensitivity of depression scales for use among global indigenous populations: a systematic scoping review — R1/PR11

Comments

No accompanying comment.

Author comment: The methods of improving cultural sensitivity of depression scales for use among global indigenous populations: a systematic scoping review — R2/PR12

Comments

Please find attached a second revision of our article “The Methods of Improving Cultural Sensitivity of Depression Scales for Use Among Global Indigenous Populations - A Systematic Scoping Review”, which we respectfully resubmit for consideration.

Yours,

Outi Linnaranta

Medical Director, Mental Health Strategy, Finnish Institute for Health and Welfare, Helsinki, Finland

Recommendation: The methods of improving cultural sensitivity of depression scales for use among global indigenous populations: a systematic scoping review — R2/PR13

Comments

No accompanying comment.

Decision: The methods of improving cultural sensitivity of depression scales for use among global indigenous populations: a systematic scoping review — R2/PR14

Comments

No accompanying comment.