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  • 1.
    Carvajal, Liliana
    et al.
    Division of Data Analytics Planning and Monitoring, Data and Analytics Section, UNICEF, New York, New York; Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
    Ottman, Katherine
    Department of Psychiatry and Behavioral Sciences, George Washington University, Washington, District of Columbia.
    Åhs, Jill
    Swedish Red Cross University, Department of Health Sciences. Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.
    Li, Geffrey Nan
    UNICEF, Belize City, Belize.
    Simmons, Juliet
    Department of Mental Health, Ministry of Health and Wellness, Belize City, Belize.
    Chorpita, Bruce
    Department of Psychology, University of California, Los Angeles, Los Angeles, California.
    Requejo, Jennifer Harris
    Division of Data Analytics Planning and Monitoring, Data and Analytics Section, UNICEF, New York, New York.
    Kohrt, Brandon A
    Department of Psychiatry and Behavioral Sciences, George Washington University, Washington, District of Columbia.
    Translation and Adaptation of the Revised Children's Anxiety and Depression Scale: A Qualitative Study in Belize2023In: Journal of Adolescent Health, ISSN 1054-139X, E-ISSN 1879-1972, Vol. 72, no S1, p. S34-S39Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Adapting data collection instruments using transcultural translation and adaptation processes is essential to ensure that respondents comprehend the items and the original meaning is retained across languages and contexts. This approach is central to UNICEF's efforts to expand the use of standard data collection tools across settings and close the global data gap on adolescent mental health.

    METHODS: We conducted transcultural translation and adaptation processes in Belize using the Revised Children's Anxiety and Depression Scale (RCADS). Items from the original scale were translated into Belizean English and Kriol, reviewed by local mental health experts, and discussed in focus groups. Cognitive interviews were conducted with adolescents and parents. The information collected was analyzed with cultural equivalence domains: comprehensibility, acceptability, relevance, completeness, and technical equivalence. Bilingual discussions of findings informed the final item wordings, and the adapted tool was back-translated.

    RESULTS: Adaptation of terms and specific expressions were done to improve comprehensibility and to ensure the appropriate clinical meaning. For example, the expression 'feeling scared' was perceived to imply immaturity or threaten masculinity and was adapted to 'feeling afraid.' Expressions like "shaky" were modified to "trimble" in Kriol. Statements were reworded as questions to enhance acceptability and comprehensibility.

    DISCUSSION: A culturally adapted version of the RCADS was developed for use among adolescents in Belize in Belizean English and Kriol. The transcultural translation and adaptation procedure can be applied for other settings or tools to design contextual adaptations of mental health instruments prior to their validation or use in new settings.

  • 2.
    Carvajal, Liliana
    et al.
    UNICEF, USA; Karolinska Institutet, Sweden.
    Åhs, Jill W.
    Swedish Red Cross University, Department of Health Sciences. Karolinska Institutet, Sweden.
    Requejo, Jennifer Harris
    UNICEF, USA.
    Kieling, Christian
    Hospital de Clínicas de Porto Alegre, Brazil; Universidade Federal do Rio Grande do Sul, Brazil.
    Lundin, Andreas
    Karolinska Institutet, Sweden.
    Kumar, Manasi
    University of Nairobi, Kenya.
    Luitel, Nagendra P.
    Transcultural Psychosocial Organization (TPO) Nepal, Nepal.
    Marlow, Marguerite
    Stellenbosch University, UK.
    Skeen, Sarah
    Stellenbosch University, UK.
    Tomlinson, Mark
    Stellenbosch University, UK; Queens University, UK.
    Kohrt, Brandon A.
    George Washington University, USA.
    Measurement of Mental Health Among Adolescents at the Population Level: A Multicountry Protocol for Adaptation and Validation of Mental Health Measures2023In: Journal of Adolescent Health, ISSN 1054-139X, E-ISSN 1879-1972, Vol. 72, no 1S, p. S27-S33Article in journal (Refereed)
    Abstract [en]

    Purpose: Mental disorders are among the leading causes of disability among adolescents aged 10-19 years. However, data on prevalence of mental health conditions are extremely sparse across low- and middle-income countries, even though most adolescents live in these settings. This data gap is further exacerbated because few brief instruments for adolescent mental health are validated in these settings, making population-level measurement of adolescent mental health especially cumbersome to carry out. In response, the UNICEF has undertaken the Measurement of Mental Health Among Adolescents at the Population Level (MMAP) initiative, validating open-access brief measures and encouraging data collection in this area.

    Methods: This protocol presents the MMAP mixed-methods approach for cultural adaptation and clinical validation of adolescent mental health data collection tools across settings. Qualitative activities include an initial translation and adaptation, review by mental health experts, focus-group discussions with adolescents, cognitive interviews, synthesis of findings, and back-translation. An enriched sample of adolescents with mental health problems is then interviewed with the adapted tool, followed by gold-standard semistructured diagnostic interviews.

    Results: The study protocol is being implemented in Belize, Kenya, Nepal, and South Africa and includes measures for anxiety, depression, functional limitations, suicidality, care-seeking, and connectedness. Analyses, including psychometrics, will be conducted individually by country and combined across settings to assess the MMAP methodological process.

    Discussion:This protocol contributes to closing the data gap on adolescent mental health conditions by providing a rigorous process of cross-cultural adaptation and validation of data collection approaches.

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  • 3.
    Carvajal-Velez, Liliana
    et al.
    Division of Data, Analytics, Planning and Monitoring, Data and Analytics Section, UNICEF, New York, New York; Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
    Harris Requejo, Jennifer
    Division of Data, Analytics, Planning and Monitoring, Data and Analytics Section, UNICEF, New York, New York.
    Åhs, Jill
    Swedish Red Cross University, Department of Health Sciences. Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.
    Idele, Priscilla
    UNICEF Office of Research-Innocenti, Florence, Italy.
    Adewuya, Abiodun
    Lagos State University College of Medicine, Lagos, Nigeria.
    Cappa, Claudia
    Division of Data, Analytics, Planning and Monitoring, Data and Analytics Section, UNICEF, New York, New York.
    Guthold, Regina
    Maternal, Newborn, Child and Adolescent Health and Ageing Department, World Health Organization, Geneva, Switzerland.
    Kapungu, Chisina
    WomenStrong International, Washington, District of Columbia.
    Kieling, Christian
    Department of Psychiatry, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; Child & Adolescent Psychiatry Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.
    Patel, Vikram
    Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Sangath, Goa, India.
    Patton, George
    University of Melbourne and Murdoch Children’s Research Institute, Melbourne, Victoria, Australia.
    Scott, James G.
    Child and Youth Mental Health Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.
    Servili, Chiara
    Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland.
    Wasserman, Danuta
    National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), Karolinska Institutet, Stockholm, Sweden.
    Kohrt, Brandon A.
    Department of Psychiatry and Behavioral Sciences, George Washington University, Washington, District of Columbia.
    Increasing Data and Understanding of Adolescent Mental Health Worldwide: UNICEF’s Measurement of Mental Health Among Adolescents at the Population Level Initiative2023In: Journal of Adolescent Health, ISSN 1054-139X, E-ISSN 1879-1972, Vol. 72, no S1, p. S12-S14Article in journal (Other academic)
  • 4.
    Carvajal-Velez, Liliana
    et al.
    UNICEF, USA; Karolinska Institutet, Sweden.
    Åhs, Jill W.
    Swedish Red Cross University, Department of Health Sciences. Karolinska Institutet, Sweden.
    Lundin, Andreas
    Karolinska Institutet, Sweden.
    van den Broek, Myrthe
    University of Amsterdam, Netherlands.
    Simmons, Juliet
    Ministry of Health and Wellness, Belize.
    Wade, Paulette
    UNICEF, Belize.
    Chorpita, Bruce
    University of California, USA.
    Requejo, Jennifer Harris
    UNICEF, USA.
    Kohrt, Brandon A.
    George Washington University, USA.
    Validation of the Kriol and Belizean English Adaptation of the Revised Children's Anxiety and Depression Scale for Use With Adolescents in Belize2023In: Journal of Adolescent Health, ISSN 1054-139X, E-ISSN 1879-1972, Vol. 72, no S1, p. S40-S51Article in journal (Refereed)
    Abstract [en]

    Purpose: To validate a culturally-adapted Kriol and Belizean English version of the Revised Children's Anxiety and Depression Scale (RCADS) through comparison with clinical diagnoses made using the Kiddie Schedule of Affective Disorders and Schizophrenia.

    Methods: Participants comprised of 256 adolescents aged 10-14 years and 15-19 years, who completed the adapted RCADS (10 depression items, 12 anxiety items) in one-on-one interviews, followed by a diagnostic assessment using Kiddie Schedule of Affective Disorders and Schizophrenia administered by trained clinicians. Sensitivity, specificity, positive predictive value, negative predictive value, diagnostic odds ratios, area under the curve (AUC), and Youden's Index were calculated for RCADS cutoffs and scores on the total scale and anxiety and depression subscales.

    Results: For adolescents aged 10-14 years (n = 161), the AUC was 0.72 for the full scale, 0.67 for anxiety subscale, and 0.76 for depression subscale. For adolescents aged 15-19 years (n = 95), the AUCs were 0.82, 0.77, and 0.83. Most depression items performed well in discriminating those with and without diagnoses. Separation anxiety items performed poorly. "Thoughts of death" were common even among adolescents not meeting diagnostic criteria. The RCADS depression subscale presented the strongest psychometric properties with adolescents aged 15-19 years (at cutoff of 13, sensitivity = 0.83, specificity = 0.77, positive predictive value = 0.47, negative predictive value = 0.95, odds ratio = 15.96).

    Conclusion: The adapted RCADS-22 had acceptable categorization for adolescents aged 10-14 years and excellent categorization for adolescents aged 15-19 years; therefore, the tool is recommended for use among the latter age group. Based on sensitivity and specificity values at different cutoffs, guidance is provided to select different thresholds to suit clinical, public health, or other uses to detect and quantify adolescent depression and anxiety in Belize.

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  • 5.
    Colvin, Christopher J
    et al.
    University of Cape Town.
    Smith, Helen J
    Liverpool School of Tropical Medicine.
    Swartz, Alison
    University of Cape Town.
    Åhs, Jill
    Duke University.
    de Heer, Jodie
    University of Cape Town.
    Opiyo, Newton
    KEMRI-Wellcome Trust Research Programme.
    Kim, Julia C
    UNICEF.
    Marraccini, Toni
    University of Cape Town.
    George, Asha
    Johns Hopkins University.
    Understanding careseeking for child illness in sub-Saharan Africa: a systematic review and conceptual framework based on qualitative research of household recognition and response to child diarrhoea, pneumonia and malaria2013In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 86, p. 66-78, article id S0277-9536(13)00113-5Article in journal (Refereed)
    Abstract [en]

    Diarrhoea, pneumonia and malaria are the largest contributors to childhood mortality in sub-Saharan Africa. While supply side efforts to deliver effective and affordable interventions are being scaled up, ensuring timely and appropriate use by caregivers remains a challenge. This systematic review synthesises qualitative evidence on the factors that underpin household recognition and response to child diarrhoea, pneumonia and malaria in sub-Saharan Africa. For this review, we searched six electronic databases, hand searched 12 journals from 1980 to 2010 using key search terms, and solicited expert review. We identified 5104 possible studies and included 112. Study quality was appraised using the Critical Appraisal Skills Program (CASP) tool. We followed a meta-ethnographic approach to synthesise findings according to three main themes: how households understand these illnesses, how social relationships affect recognition and response, and how households act to prevent and treat these illnesses. We synthesise these findings into a conceptual model for understanding household pathways to care and decision making. Factors that influence household careseeking include: cultural beliefs and illness perceptions; perceived illness severity and efficacy of treatment; rural location, gender, household income and cost of treatment. Several studies also emphasise the importance of experimentation, previous experience with health services and habit in shaping household choices. Moving beyond well-known barriers to careseeking and linear models of pathways to care, the review suggests that treatment decision making is a dynamic process characterised by uncertainty and debate, experimentation with multiple and simultaneous treatments, and shifting interpretations of the illness and treatment options, with household decision making hinging on social negotiations with a broad variety of actors and influenced by control over financial resources. The review concludes with research recommendations for tackling remaining gaps in knowledge.

  • 6. Dalman, Christina
    et al.
    Corman, Diana
    Dal, Henrik
    Hollander, Anna-Clara
    Jablonska, Beata
    Kosidou, Kyriaki
    Wicks, Susanne
    Åhs, Jill
    Fördjupning barn och unga –uppdrag psykisk hälsa2017Report (Other academic)
  • 7.
    Frans, Örjan
    et al.
    Uppsala universitet.
    Åhs, Jill
    Karolinska Institutet.
    Bihre, Eva
    Uppsala universitet.
    Åhs, Fredrik
    Uppsala universitet, Karolinska Institutet.
    Distance to threat and risk of acute and posttraumatic stress disorder following bank robbery: A longitudinal study2018In: Psychiatry Research, ISSN 0165-1781, E-ISSN 1872-7123, Vol. 267, p. 461-466Article in journal (Refereed)
    Abstract [en]

    Identifying pathways through which environmental risk factors influence PTSD is important for understanding PTSD etiology. Here, we hypothesized that the physical proximity to threat influences PTSD risk by increasing ASD following trauma. One hundred six bank employees who had experienced a bank robbery participated in the study. A longitudinal design assessing ASD at day 2 and PTSD at day 30 was used to test the hypothesis. Participants also indicated their location in the bank at the time of the robbery. ASD was identified in 40 (38%) and PTSD in 16 (15%) of the robbery victims. Distance to the robber had a strong effect on ASD (OR 3.51, 95% CI 1.94-6.34) and a somewhat lesser effect on PTSD (OR 2.15, 95% CI 1.04-4.46), indicating that the effect of proximity to threat on PTSD 1 month following trauma could be mediated by its effect on ASD 2 days following trauma. Using structural equation modeling, we confirmed that the effect of distance on PTSD was fully mediated by ASD. These findings suggest that proximity to threat may increase PTSD risk by enhancing the acute stress response following trauma.

  • 8.
    Hayes, J.
    et al.
    University College London, London, United Kingdom.
    Carvajal, L.
    UNICEF, New York, USA; Karolinska Instituetet, Sweden.
    Hijazi, Z.
    UNICEF HQ, New York, USA.
    Åhs, Jill Witney
    Swedish Red Cross University, Department of Health Sciences. Karolinska Institutet, Sweden.
    Doraiswamy, P. M.
    Duke University School of Medicine, Durham, North Carolina, USA.
    El Azzouzi, F. A.
    Global Shapers Community, Vancouver, British Columbia, Canada.
    Fox, C.
    World Economic Forum, San Francisco, California, USA.
    Herrman, H.
    University of Melbourne, Melbourne, Australia.
    Gornitzka, C. P.
    UNICEF HQ, New York, USA.
    Staglin, B.
    One Mind, Rutherford, California, USA.
    Wolpert, M.
    Wellcome Trust, London, United Kingdom; University College London, London, United Kingdom.
    You Can't Manage What You Do Not Measure - Why Adolescent Mental Health Monitoring Matters2023In: Journal of Adolescent Health, ISSN 1054-139X, E-ISSN 1879-1972, Vol. 72, no 1S, p. S8-S9Article in journal (Other academic)
  • 9.
    Lundin, Andreas
    et al.
    Karolinska Institutet / Stockholm County Council.
    Åhs, Jill
    Karolinska Institutet.
    Åsbring, Nina
    Stockholm County Council.
    Kosidou, Kyriaki
    Karolinska Institutet / Stockholm County Council.
    Dal, Henrik
    Karolinska Institutet / Stockholm County Council.
    Tinghög, Petter
    The Swedish Red Cross University College, Department of Health Sciences. Karolinska Institutet.
    Saboonchi, Fredrik
    The Swedish Red Cross University College, Department of Health Sciences. Karolinska Institutet.
    Dalman, Christina
    Karolinska Institutet / Stockholm County Council.
    Discriminant validity of the 12-item version of the general health questionnaire in a Swedish case-control study2017In: Nordic Journal of Psychiatry, ISSN 0803-9488, E-ISSN 1502-4725, Vol. 71, no 3, p. 171-179Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The 12-item version of the General Health Questionnaire (GHQ-12) is widely used as a proxy for Affective Disorders in public health surveys, although the cut-off points for distress vary considerably between studies. The agreement between the GHQ-12 score and having a clinical disorder in the study population is usually unknown.

    AIMS: This study aimed to assess the criterion validity and to determine the sensitivity and specificity of the GHQ-12 in the Swedish population.

    METHODS: This study used 556 patient cases surveyed in specialized psychiatric care outpatient age- and sex-matched with 556 controls from the Stockholm Health Survey. Criterion validity for two scoring methods of GHQ-12 was tested using Receiver Operating Characteristics (ROC) analyses with Area Under the Curve (AUC) as a measure of agreement. Reference standard was (1) specialized psychiatric care and (2) current depression, anxiety or adjustment disorder.

    RESULTS: Both the Likert and Standard GHQ-12 scoring method discriminated excellently between individuals using specialized psychiatric services and healthy controls (Likert index AUC = 0.86, GHQ index AUC = 0.83), and between individuals with current disorder from healthy controls (Likert index AUC = 0.90, GHQ index AUC = 0.88). The best cut-off point for the GHQ index was ≥4 (sensitivity = 81.7 and specificity = 85.4), and for the Likert index ≥14 (sensitivity = 85.5 and specificity = 83.2).

    CONCLUSIONS: The GHQ-12 has excellent discriminant validity and is well suited as a non-specific measure of affective disorders in public mental health surveys.

  • 10.
    Marlow, Marguerite
    et al.
    Stellenbosch University, South Africa.
    Skeen, Sarah
    Stellenbosch University, South Africa; University of Amsterdam, Netherlands.
    Grieve, Caitlin M
    Stellenbosch University, South Africa.
    Carvajal, Liliana
    UNICEF, USA; Karolinska Institutet, Sweden.
    Åhs, Jill W.
    Swedish Red Cross University, Department of Health Sciences. Karolinska Institutet, Sweden.
    Kohrt, Brandon A
    George Washington University, USA.
    Requejo, Jennifer
    UNICEF, USA.
    Stewart, Jaqueline
    University of Cape Town, South Africa.
    Henry, Junita
    Stellenbosch University, South Africa.
    Goldstone, Daniel
    Stellenbosch University, South Africa.
    Kara, Tashmira
    Stellenbosch University, South Africa.
    Tomlinson, Mark
    Stellenbosch University, South Africa; Queens University, UK.
    Detecting Depression and Anxiety Among Adolescents in South Africa: Validity of the isiXhosa Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7.2023In: Journal of Adolescent Health, ISSN 1054-139X, E-ISSN 1879-1972, Vol. 72, no S1, p. S52-S60Article in journal (Refereed)
    Abstract [en]

    PURPOSE: Screening tools such as the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7) could potentially be used in resource-limited settings to identify adolescents who need mental health support. We examined the criterion validity of the isiXhosa versions of the PHQ-9 and GAD-7 in detecting depression and anxiety among adolescents (10-19 years) in South Africa.

    METHODS: Adolescents were recruited from the general population and from nongovernmental organizations working with adolescents in need of mental health support. The PHQ-9 and GAD-7 were culturally adapted and translated into isiXhosa and administered to 302 adolescents (56.9% female). The Kiddie Schedule for Affective Disorders and Schizophrenia was administered by trained clinicians as the gold standard diagnostic measure for depression and anxiety.

    RESULTS: For the PHQ-9, the area under the curve was 0.88 for the full sample of adolescents (10-19 years old). A score of ≥10 had 91% sensitivity and 76% specificity for detecting adolescents with depression. For the GAD-7, the area under the curve was 0.78, and cutoff scores with an optimal sensitivity-specificity balance were low (≥6). A score of ≥6 had 67% sensitivity and 75% specificity for detecting adolescents with anxiety.

    DISCUSSION: The culturally adapted isiXhosa version of the PHQ-9 can be used as a valid measure for depression in adolescents. Further research on the GAD-7 for use with adolescents is recommended.

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  • 11.
    Maselko, Joanna
    et al.
    Duke University.
    Sebranek, Matthew
    Duke University.
    Mun, Mirna H
    Duke University.
    Perera, Bilesha
    University of Ruhuna, Galle, Sri Lanka.
    Åhs, Jill
    Duke University.
    Ostbye, Truls
    Duke University.
    Contribution of generative leisure activities to cognitive function in elderly Sri Lankan adults2014In: Journal of The American Geriatrics Society, ISSN 0002-8614, E-ISSN 1532-5415, Vol. 62, no 9, p. 1707-1713Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To examine the unique contribution of generative leisure activities, defined as activities motivated by a concern for others and a need to contribute something to the next generation.

    DESIGN: Cross-sectional survey.

    SETTING: Peri-urban and rural area in southern Sri Lanka.

    PARTICIPANTS: Community-dwelling adults aged 60 and older (N = 252).

    MEASUREMENTS: The main predictors were leisure activities, grouped into generative, social, or solitary. The main outcome was cognitive function, assessed using the Montreal Cognitive Assessment (MoCA) and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE).

    RESULTS: More-frequent engagement in generative leisure activities was associated with higher levels of cognitive function, independent of the effect of other social and solitary leisure activities. In a fully adjusted model combining all three leisure activities, generative activities independently predicted cognitive function as measured using the MoCA (β = 0.47, 95% confidence interval (CI) = 0.11-0.83) and the IQCODE (β = -0.81, 95% CI = -1.54 to -0.09). In this combined model, solitary activities were also independently associated with slower cognitive decline using the MoCA (β = 0.40, 95% CI = 0.16-0.64) but not the IQCODE (β = -0.38, 95% CI = -0.88-0.12); the association with social activities did not reach statistical significance with either measure. These associations did not differ meaningfully according to sex.

    CONCLUSION: Generative leisure activities are a promising area for the development of interventions aimed at reducing cognitive decline in elderly adults.

  • 12.
    Nyongesa, Vincent
    et al.
    University of Nairob, Kenya.
    Kathono, Joseph
    University of Nairob, Kenya; Nairobi Metropolitan Services, Kenya.
    Mwaniga, Shillah
    Nairobi Metropolitan Services, Kenya; Vrije University, the Netherlands.
    Yator, Obadia
    University of Nairobi, Kenya.
    Madeghe, Beatrice
    University of Nairobi, Kenya.
    Kanana, Sarah
    Nairobi Metropolitan Services, Kenya.
    Amugune, Beatrice
    University of Nairobi, Kenya.
    Anyango, Naomi
    Ministry of Health, Kenya.
    Nyamai, Darius
    Nairobi Metropolitan Services, Kenya.
    Wambua, Grace Nduku
    Vrije Universiteit Amsterdam, the Netherlands.
    Chorpita, Bruce
    University of California, USA.
    Kohrt, Brandon A.
    The George Washington University, USA.
    Åhs, Jill W.
    Swedish Red Cross University, Department of Health Sciences. Karolinska Institutet, Sweden.
    Idele, Priscilla
    UN Secretariat, USA.
    Carvajal, Liliana
    UNICEF, USA; Karolinska Institutet, Sweden.
    Kumar, Manasi
    Aga Khan University, Kenya.
    Cultural and contextual adaptation of mental health measures in Kenya: An adolescent-centered transcultural adaptation of measures study2022In: PLOS ONE, E-ISSN 1932-6203, Vol. 17, no 12, article id e0277619Article in journal (Refereed)
    Abstract [en]

    Introduction: There is paucity of culturally adapted tools for assessing depression and anxiety in children and adolescents in low-and middle-income countries. This hinders early detection, provision of appropriate and culturally acceptable interventions. In a partnership with the University of Nairobi, Nairobi County, Kenyatta National Hospital, and UNICEF, a rapid cultural adaptation of three adolescent mental health scales was done, i.e., Revised Children’s Anxiety and Depression Scale, Patient Health Questionnaire-9 and additional scales in the UNICEF mental health module for adolescents.

    Materials and methods: Using a qualitative approach, we explored adolescent participants’ views on cultural acceptability, comprehensibility, relevance, and completeness of specific items in these tools through an adolescent-centered approach to understand their psychosocial needs, focusing on gender and age-differentiated nuances around expression of distress. Forty-two adolescents and 20 caregivers participated in the study carried out in two primary care centers where we conducted cognitive interviews and focused group discussions assessing mental health knowledge, literacy, access to services, community, and family-level stigma.

    Results: We reflect on process and findings of adaptations of the tools, including systematic identification of words adolescents did not understand in English and Kiswahili translations of these scales. Some translated words could not be understood and were not used in routine conversations. Response options were changed to increase comprehensibility; some statements were qualified by adding extra words to avoid ambiguity. Participants suggested alternative words that replaced difficult ones and arrived at culturally adapted tools.

    Discussion: Study noted difficult words, phrases, dynamics in understanding words translated from one language to another, and differences in comprehension in adolescents ages 10–19 years. There is a critical need to consider cultural adaptation of depression and anxiety tools for adolescents.

    Conclusion: Results informed a set of culturally adapted scales. The process was community-driven and adhered to the principles of cultural adaptation for assessment tools.

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  • 13.
    Rudolph, Christiane E S
    et al.
    University of Lübeck, Karolinska Institutet.
    Lundin, Andreas
    Karolinska Institutet.
    Åhs, Jill W.
    Karolinska Institutet.
    Dalman, Christina
    Karolinska Institutet, Stockholm Läns Landsting.
    Kosidou, Kyriaki
    Karolinska Institutet, Stockholm Läns Landsting.
    Brief Report: Sexual Orientation in Individuals with Autistic Traits2018In: Journal of autism and developmental disorders, ISSN 0162-3257, E-ISSN 1573-3432, Vol. 48, no 2, p. 619-624Article in journal (Refereed)
    Abstract [en]

    We examined the association between autistic traits and sexual orientation in a general adult population (N = 47,356). Autistic traits were measured with the ten items Autistic Quotient questionnaire using a cut-off score of ≥ 6. Sexual orientation was assessed by self-report. Multinomial logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for sexual orientation categories. Participants with autistic traits were more likely to identify as bisexual (OR 1.73; 95% CI 1.01-2.9) and to feel that their sexual orientation could neither be described as hetero-, homo- nor bisexual (OR 3.05; 95% CI 2.56-3.63), compared to individuals without autistic traits. Autistic traits are associated with minority sexual orientation, and perhaps with uncertain self-identification and/or a defiance of traditional ways of categorizing sexual identity.

  • 14.
    Tele, Albert Kimtai
    et al.
    University of Nairobi, Kenya; Vrije Universiteit Amsterdam, The Netherlands.
    Carvajal, Liliana
    UNICEF, USA; Karolinska Institutet, Sweden.
    Nyongesa, Vincent
    University of Nairobi, Kenya.
    Åhs, Jill W.
    Swedish Red Cross University, Department of Health Sciences. Karolinska Institutet, Sweden.
    Mwaniga, Shillah
    Nairobi Metropolitan Services, Kenya.
    Kathono, Joseph
    Nairobi Metropolitan Services, Kenya.
    Yator, Obadia
    University of Nairobi, Kenya.
    Njuguna, Simon
    Kenyatta National Hospital, Kenya.
    Kanyanya, Ian
    Kenyatta National Hospital, Kenya.
    Amin, Nabila
    Mathare National Referral and Teaching Hospital, Kenya.
    Kohrt, Brandon
    George Washington University, USA.
    Wambua, Grace Nduku
    University of Nairobi, Kenya; Vrije Universiteit, the Netherlands.
    Kumar, Manasi
    University of Nairobi, Kenya; Aga Khan University, Kenya.
    Validation of the English and Swahili Adaptation of the Patient Health Questionnaire–9 for Use Among Adolescents in Kenya2023In: Journal of Adolescent Health, ISSN 1054-139X, E-ISSN 1879-1972, Vol. 72, no S1, p. S61-S70Article in journal (Refereed)
    Abstract [en]

    Purpose: Our study aimed to validate culturally adapted English and Swahili versions of the Patient Health Questionnaire-9 (PHQ-9) for use with adolescents in Kenya. Criterion validity was determined with clinician-administered diagnostic interviews using the Kiddie Schedule of Affective Disorders and Schizophrenia.

    Methods: A total of 250 adolescents comprising 148 (59.2%) females and 102 (40.8%) males aged 10-19 years (mean = 14.76; standard deviation = 2.78) were recruited. The PHQ-9 was administered to all respondents concurrently in English and Swahili. Adolescents were later interviewed by clinicians using Kiddie Schedule of Affective Disorders and Schizophrenia to determine the presence or absence of current symptoms of major depressive disorder. Sensitivity specificity, positive predictive value (PPV) and negative predictive value (NPV), and likelihood ratios for various cut-off scores for PHQ-9 were analyzed using receiver operating characteristic curves.

    Results: The internal consistency (Cronbach's α) for PHQ-9 was 0.862 for the English version and 0.834 for Swahili version. The area under the curve was 0.89 (95% confidence interval, 0.84-0.92) and 0.87 (95% confidence interval, 0.82-0.90) for English and Swahili version, respectively, on receiver operating characteristic analysis. A cut-off of ≥ 9 on the English-language version had a sensitivity of 95.0%, specificity of 73.0%, PPV of 0.23, and NPV of 0.99; a cut-off of ≥ 9 on the Swahili version yielded a sensitivity of 89.0%, specificity of 70.0%, PPV of 0.20, and NPV of 0.90.

    Discussion: Psychometric properties were comparable across both English-adapted and Swahili-adapted version of the PHQ-9, are reliable, and valid instrument to detect major depressive disorder among adolescents which can be used in resource-limited settings for early identification of adolescents in need of mental health support.

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  • 15.
    Åhs, Jill
    et al.
    Swedish Red Cross University, Department of Health Sciences. Karolinska Institutet, Sweden.
    Eriksson, Henrik
    University West, Sweden.
    Mazaheri, Monir
    Karolinska Institutet, Sweden; Sophiahemmet University, Sweden.
    Distant suffering: A concept analysis2024In: International Journal of Nursing Studies, ISSN 0020-7489, E-ISSN 1873-491X, Vol. 151Article, review/survey (Refereed)
    Abstract [en]

    Patients who are suffering may be commonly encountered in health care. The growing use of telehealth implies that encounters with patients who are suffering may increasingly take place at a distance. "Distant suffering" is a concept coined within sociology to describe the suffering of far-away others. It is conceptualized as a paradox, as distance changes the relation between the witness of suffering and the suffering encountered. Impacts may include a potential detriment to the sufferer and ethical implications for the witness. To explore the concept of distant suffering and any relevance, implications, or important avenues for potential research within the healthcare sciences. Rodgers' evolutionary concept analysis. Databases of Web of Science, Medline, CINAHL and PsycInfo were searched for the terms "distant suffering" or "mediated suffering". Attributes, surrogate or related terms, antecedents, consequences, and uses of the concept were extracted and synthesized. Thirty articles published within the past ten years were selected for review from the search results. "Distant suffering" was characterized as comprising 1) mediated far-away suffering, 2) a "recognizer" or witness, and 3) a potential role of a moderator. Antecedents include shared understandings and socially-influenced responses. Consequences include responses like empathy, compassion, pity, also indifference, cynicism and compassion fatigue. Further research to explore distant suffering from healthcare sciences' perspective could uncover valuable insights for those suffering, for healthcare workers, and any who are exposed to it. An improved understanding of how distant suffering is conveyed and moderated could enable targeted reduction of exposure or improve response to distant suffering. Such knowledge could help diminish negative consequences for those suffering, for healthcare workers who are caring at a distance for those suffering, or for others who encounter distant suffering in their occupations or in daily life via media, social media, or digital communications. New analysis finds that exposure to distant suffering may have important implications for health and health care.

  • 16.
    Åhs, Jill
    et al.
    The Swedish Red Cross University College, Department of Health Sciences.
    Eriksson, Henrik
    The Swedish Red Cross University College, Department of Health Sciences.
    Ranheim, Albertine
    Mazaheri, Monir
    The Swedish Red Cross University College, Department of Health Sciences.
    Distant Suffering in Modern Times2019Conference paper (Refereed)
  • 17.
    Åhs, Jill
    et al.
    Karolinska Institutet, Sweden.
    Kosidou, K.
    Karolinska Institutet, Sweden.
    Wicks, S.
    Stockholm County Council, Sweden.
    Lundin, A.
    Karolinska Institutet, Sweden.
    Dalman, C
    Karolinska Institutet, Sweden.
    Trends in Inpatient Psychiatric Diagnoses in Sweden 1997-20112017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no suppl_3, article id ckx186.239Article in journal (Refereed)
    Abstract [en]

    Background: Mental health service use has increased among the young.Trends in psychiatric hospitalizations might lend clues as to underlying causes influencing young peoples’ growing use ofpsychiatric services.

    Methods: We calculated population-adjusted rates for seven broadcategories of ICD-10 psychiatric diagnoses for Swedishinpatients discharged 1997- 2011. We computed rates forages 13-74 overall, as well as six age strata: 13-17, 18-24, 25-29,30-44, 45-64 and 65-74 years, utilizing data from nationalregisters.

    Results: The overall population-standardized rate of psychiatric hospitalizations did not change significantly over the 15-year period. Yet, children and young adults under age 30 sawnotable increases in inpatient psychiatric care, with ratesroughly doubling over the time period. Affective and anxietydisorders accounted for much of these increases, with curvi-linear increases in developmental and childhood behavioral disorders. Rates among older age groups were more stable,though all age groups saw increases in hospitalizations for anxiety disorders. Declines were seen for adults ages 30-44 for psychotic disorders. Adults ages 65-74 declined in hospitalizations for affective disorders while rising for all other age groupsduring this time.

    Conclusions: Young adults ages 18-29 years have become the age group withthe greatest proportion hospitalized for psychiatric care. Adolescents and young adults under age 30 saw rises in ratesof psychiatric inpatient care, while at the same time, older age groups did not. A large portion of this increase is due to affective and anxiety disorders, warranting investigation into changes in outpatient care practices, severity, or perceivedseverity of these disorders among this age group.

  • 18.
    Åhs, Jill
    et al.
    Swedish Red Cross University, Department of Health Sciences. Karolinska Institutet, Sweden.
    Lundin, A.
    Karolinska Institutet, Sweden.
    Carvajal Aguirre, L.
    UNICEF, USA.
    Stevanovic, D.
    Clinic for Neurology and Psychiatry for Children and Youth, Serbia.
    The Revised Children’s Anxiety and Depression Scale: Analyses for a Very Brief Scale Based on Multi-Country Data2019Conference paper (Other academic)
  • 19.
    Åhs, Jill
    et al.
    The Swedish Red Cross University College, Department of Health Sciences.
    Mazaheri, Monir
    The Swedish Red Cross University College, Department of Health Sciences.
    Eriksson, Henrik
    The Swedish Red Cross University College, Department of Health Sciences.
    Ranheim, Albertine
    Distant suffering in the Global Village2019Conference paper (Refereed)
  • 20.
    Åhs, Jill
    et al.
    Swedish Red Cross University, Department of Health Sciences.
    Ranheim, Albertine
    Karolinska Institutet, Sweden .
    Eriksson, Henrik
    University West, Sweden .
    Mazaheri, Monir
    Karolinska Institutet, Sweden; Sophiahemmet University, Sweden .
    Encountering suffering in digital care: a qualitative study of providers' experiences in telemental health care2023In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 23, no 1, article id 418Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Encountering patients who are suffering is common in health care, and particularly when providing mental health care. Telehealth technologies are increasingly used to provide mental health care, yet little is known about the experiences of providers when encountering patients who are suffering within remote care. The present study explored health care providers' lived experiences of encountering patient suffering during telemental health care.

    METHODS: A qualitative phenomenological approach was used to uncover participants' experiences. In-depth interviews were conducted with a purposive sample of physicians, psychologists, and therapists who used telemental health in varied clinical practices in Sweden. Data were analyzed using descriptive phenomenology.

    RESULTS: Telehealth care with patients who were suffering was experienced by providers as loose connections, both literally in compromised functioning of the technology and figuratively in a compromised ability connecting emotionally with patients. Providers' lived experiences were explicated into the following aspects: insecurity in digital practice, inaccessibility of the armamentarium, and conviction in the value of telehealth care. Interpersonal connection between patient and provider is necessary. Worry and guilt arose for providers with fears that technology would not work, patient status was deteriorated, or the care needed could not be delivered. Providers overcame barriers in telehealth encounters, and expressed they perceived that patients appreciated the care received, and through it found relief.

    CONCLUSIONS: This study brings an understanding of experiences in providing telemental care for patients who are suffering. Providers experience challenges in connecting with patients, and in accessing tools needed to enable reaching the goals of the caring encounter. Efforts to ensure functioning of technology, comfort with its use, and accessibility of tools might be some accommodations to support providers for successful and rewarding telehealth care encounters.

  • 21.
    Åhs, Jill
    et al.
    Swedish Red Cross University, Department of Health Sciences. Karolinska Institutet, Sweden.
    Ranheim, Albertine
    Karolinska Institutet, Sweden.
    Mattelin, Erica
    Linköping University, Sweden.
    Eriksson, Henrik
    University West, Sweden.
    Mazaheri, Monir
    Karolinska Institutet, Sweden; Sophiahemmet University, Sweden.
    Distance in Distant Care: Qualitative Content Analysis of Providers' Experiences in Tele-Mental Care2023In: Journal of Medical Internet Research, E-ISSN 1438-8871, Vol. 25, article id e38568Article in journal (Refereed)
  • 22.
    Åhs, Jill
    et al.
    Karolinska Institutet.
    Tao, Wenjing
    Karolinska Institutet.
    Löfgren, Jenny
    Karolinska Institutet.
    Forsberg, Birger
    Karolinska Institutet.
    Diarrheal Diseases in Low- and Middle-Income Countries: Incidence, Prevention and Management2010In: The Open Infectious Diseases Journal, ISSN 1874-2793, Vol. 4, p. 113-124Article in journal (Refereed)
    Abstract [en]

    Diarrheal diseases due to infection constitute a major burden of disease. Dehydration resulting from diarrhea can be fatal. It is the cause of approximately 1.8 million deaths every year. The vast majority of these deaths are of children under five years of age living in low- and middle- income countries. Interventions to prevent diarrhea include provision of safe water, hand washing, the use of sanitation facilities, exclusive breastfeeding of infants and rotavirus vaccination. Diagnosis is guided by symptoms into one of three categories: acute watery diarrhea, dysentery or bloody diarrhea, or persistent diarrhea of longer than 2 weeks in duration. Treatment of diarrhea in children includes oral rehydration with a pre-formulated solution or with fluids that can be prepared and administered in the home. Zinc supplementation is recommended. Only in certain circumstances are antibiotics advised and anti-motility agents are discouraged. The lives of many children could be saved with proper case management of diarrhea. With immediate and sustained actions to decrease both the incidence and mortality attributed to diarrhea, the burden of this prominent public health threat could be dramatically reduced.

  • 23.
    Åhs, Jill W.
    et al.
    Karolinska Institutet.
    Dhejne, Cecilia
    Karolinska Institutet.
    Magnusson, Cecilia
    Karolinska Institutet, Stockholms Läns Landsting.
    Dal, Henrik
    Karolinska Institutet, Stockholms Läns Landsting.
    Lundin, Andreas
    Karolinska Institutet.
    Arver, Stefan
    Karolinska Institutet.
    Dalman, Christina
    Karolinska Institutet, Stockholms Läns Landsting.
    Kosidou, Kyriaki
    Karolinska Institutet, Stockholms Läns Landsting.
    Proportion of adults in the general population of Stockholm County who want gender-affirming medical treatment2018In: PLOS ONE, E-ISSN 1932-6203, Vol. 13, no 10, article id e0204606Article in journal (Refereed)
    Abstract [en]

    The number of patients presenting for care at gender clinics is increasing, yet the proportion of adults in the general population who want gender-affirming medical treatment remains essentially unknown. We measured the wish for cross-sex hormones or gender-affirming surgery, as well as other aspects of gender incongruence, among the general adult population of Stockholm County, Sweden. A population-representative sample of 50,157 Stockholm County residents ages 22 and older comprise the Stockholm Public Health Cohort. They were enrolled in 2002, 2006, and 2010 and followed-up in roughly 4-year intervals, with questions on health, lifestyle and social characteristics. In 2014, participants received the item "I would like hormones or surgery to be more like someone of a different sex." Two additional items concerned other aspects of gender incongruence: "I feel like someone of a different sex", and "I would like to live as or be treated as someone of a different sex." Each item had four answer options ("Not at all correct", "Somewhat or occasionally correct", "Quite correct", and "Absolutely correct"). For each item, any of the three affirmative answer choices were considered as some level of agreement. Calibration weights were used to estimate population-representative rates with 95% confidence intervals. The desire for cross-sex hormones or surgery was reported by 0.5% (95% CI, 0.4%-0.7%) of participants. Feeling like someone of a different sex was reported by 2.3% (95% CI, 2.1%-2.6%). Wanting to live as or be treated as a person of another sex was reported by 2.8% (95% CI, 2.4%-3.1%). These findings greatly exceed estimates of the number of patients receiving gender-affirming medical care. Clinicians must be prepared to recognize and care for patients experiencing discomfort due to gender incongruence and those who would like gender-affirming medical treatment.

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