Bonnie N. Kaiser

Code Saturation Versus Meaning Saturation How Many Interviews Are Enough

Saturation is a core guiding principle to determine sample sizes in qualitative research, yet little methodological research exists on parameters that influence saturation. Our study compared two approaches to assessing saturation: code saturation and meaning saturation. We examined sample sizes needed to reach saturation in each approach, what saturation meant, and how to assess saturation. Examining 25 in-depth interviews, we found that code saturation was reached at nine interviews, whereby the range of thematic issues was identified. However, 16 to 24 interviews were needed to reach meaning saturation where we developed a richly textured understanding of issues. Thus, code saturation may indicate when researchers have “heard it all,” but meaning saturation is needed to “understand it all.” We used our results to develop parameters that influence saturation, which may be used to estimate sample sizes for qualitative research proposals or to document in publications the grounds on which saturation was achieved.

Cultural concepts of distress and psychiatric disorders: literature review and research recommendations for global mental health epidemiology

BACKGROUND Burgeoning global mental health endeavors have renewed debates about cultural applicability of psychiatric categories. This studys goal is to review strengths and limitations of literature comparing psychiatric categories with cultural concepts of distress (CCD) such as cultural syndromes, culture-bound syndromes, and idioms of distress. METHODS The Systematic Assessment of Quality in Observational Research (SAQOR) was adapted based on cultural psychiatry principles to develop a Cultural Psychiatry Epidemiology version (SAQOR-CPE), which was used to rate quality of quantitative studies comparing CCD and psychiatric categories. A meta-analysis was performed for each psychiatric category. RESULTS Forty-five studies met inclusion criteria, with 18 782 unique participants. Primary objectives of the studies included comparing CCD and psychiatric disorders (51%), assessing risk factors for CCD (18%) and instrument validation (16%). Only 27% of studies met SAQOR-CPE criteria for medium quality, with the remainder low or very low quality. Only 29% of studies employed representative samples, 53% used validated outcome measures, 44% included function assessments and 44% controlled for confounding. Meta-analyses for anxiety, depression, PTSD and somatization revealed high heterogeneity (I(2) > 75%). Only general psychological distress had low heterogeneity (I(2) = 8%) with a summary effect odds ratio of 5.39 (95% CI 4.71-6.17). Associations between CCD and psychiatric disorders were influenced by methodological issues, such as validation designs (β = 16.27, 95%CI 12.75-19.79) and use of CCD multi-item checklists (β = 6.10, 95%CI 1.89-10.31). Higher quality studies demonstrated weaker associations of CCD and psychiatric disorders. CONCLUSIONS Cultural concepts of distress are not inherently unamenable to epidemiological study. However, poor study quality impedes conceptual advancement and service application. With improved study design and reporting using guidelines such as the SAQOR-CPE, CCD research can enhance detection of mental health problems, reduce cultural biases in diagnostic criteria and increase cultural salience of intervention trial outcomes.

Idioms of distress, ethnopsychology, and the clinical encounter in Haiti's central plateau.

Haitis 2010 earthquake mobilized mental health and psychosocial interventions from across the globe. However, failure to understand how psychological distress is communicated between lay persons and health workers in rural clinics, where most Haitians access care, has been a major limitation in providing mental health services. The goal of this study was to map idioms of distress onto Haitian ethnopsychologies in a way that promotes improved communication between lay persons and clinicians in rural Haiti. In Haitis Central Plateau, an ethnographic study was conducted in May and June 2010, utilizing participant observation in rural clinics, 31 key informant interviews, 11 focus groups, and four case studies. Key informants included biomedical practitioners, traditional healers, community leaders, and municipal and religious figures. Deductive and inductive themes were coded using content analysis (inter-rater reliability > 0.70). Forty-four terms for psychological distress were identified. Head (tèt) or heart (kè) terms comprise 55% of all qualitative text segments coded for idioms of distress. Twenty-eight of 142 observed patient-clinician contacts involved persons presenting with tèt terms, while 29 of the 142 contacts were presentations with kè terms. Thus, 40% of chief complaints were conveyed in either head or heart terms. Interpretations of these terms differed between lay and clinical groups. Lay respondents had broad and heterogeneous interpretations, whereas clinicians focused on biomedical concepts and excluded discussion of mental health concerns. This paper outlines preliminary evidence regarding the psychosocial dimensions of tèt and kè-based idioms of distress and calls for further exploration. Holistic approaches to mental healthcare in Haitis Central Plateau should incorporate local ethnopsychological frameworks alongside biomedical models of healthcare.

Explanatory models and mental health treatment: Is vodou an obstacle to psychiatric treatment in rural Haiti?

Vodou as an explanatory framework for illness has been considered an impediment to biomedical psychiatric treatment in rural Haiti by some scholars and Haitian professionals. According to this perspective, attribution of mental illness to supernatural possession drives individuals to seek care from houngan-s (Vodou priests) and other folk practitioners, rather than physicians, psychologists, or psychiatrists. This study investigates whether explanatory models of mental illness invoking supernatural causation result in care-seeking from folk practitioners and resistance to biomedical treatment. The study comprised 31 semi-structured interviews with community leaders, traditional healers, religious leaders, and biomedical providers, 10 focus group discussions with community members, community health workers, health promoters, community leaders, and church members; and four in-depth case studies of individuals exhibiting mental illness symptoms conducted in Haiti’s Central Plateau. Respondents invoked multiple explanatory models for mental illness and expressed willingness to receive treatment from both traditional and biomedical practitioners. Folk practitioners expressed a desire to collaborate with biomedical providers and often referred patients to hospitals. At the same time, respondents perceived the biomedical system as largely ineffective for treating mental health problems. Explanatory models rooted in Vodou ethnopsychology were not primary barriers to pursuing psychiatric treatment. Rather, structural factors including scarcity of treatment resources and lack of psychiatric training among health practitioners created the greatest impediments to biomedical care for mental health concerns in rural Haiti.

Depression, suicidal ideation, and associated factors: a cross-sectional study in rural Haiti

BackgroundSince the 2010 earthquake in Haiti, there has been increased international attention to mental health needs throughout the country. The present study represents one of the first epidemiologic studies of depression symptomatology, suicidal ideation, and associated factors in Haiti’s Central Plateau.MethodsWe conducted a cross-sectional, zone-stratified household survey of 408 adults in Haiti’s Central Plateau. Depression symptomatology was assessed with a culturally-adapted Kreyòl version of the Beck Depression Inventory (BDI). Multivariable linear and logistic regression models were built using backward elimination, with the outcomes being continuous BDI scores and endorsing suicidal ideation, respectively.ResultsThe mean BDI score was 20.4 (95% confidence interval [CI]: 19.3-21.5), and 6.13% (N = 25) of participants endorsed current suicidal ideation. Factors associated with BDI scores were: continuous age (adjusted beta [aβ]: 0.14, CI: 0.06-0.22), female gender (aβ: 2.1, CI: 0.18-4.0), suicidal ideation (aβ: 11.1, CI: 7.3-14.9), death in family (aβ: 2.7, CI: 0.57-4.9), and prior life-threatening illness (aβ: 2.6, CI: 0.77-4.5). Education was a risk factor for depression among women but not among men, and employment was a risk factor for both genders. Factors associated with endorsing suicidal ideation were: BDI score (ten point change) (adjusted odds ratio [aOR]: 2.5, CI: 1.7-3.6), lack of care if sick (aOR: 5.5, CI: 1.1-28.6), alcohol use (aOR: 3.3, CI: 1.3-8.2), and ever having been to a Vodou priest (aOR: 3.2, CI: 1.1-9.5).ConclusionsA large proportion of Haiti’s Central Plateau may be experiencing high levels of depression symptomatology and/or current suicidal ideation. Screening could be conducted in biomedical, religious, and Vodou healing contexts. For prevention, poverty reduction and improved healthcare access are key elements. For treatment, general psychiatric services, psychosocial services for the medically ill and their families, and substance abuse interventions should be explored. Paradoxical associations related to education and employment require further exploration.

Development and validation of a Haitian Creole screening instrument for depression

Developing mental health care capacity in postearthquake Haiti is hampered by the lack of assessments that include culturally bound idioms Haitians use when discussing emotional distress. The current paper describes a novel emic-etic approach to developing a depression screening for Partners in Health/Zanmi Lasante. In Study 1 Haitian key informants were asked to classify symptoms and describe categories within a pool of symptoms of common mental disorders. Study 2 tested the symptom set that best approximated depression in a sample of depressed and not depressed Haitians in order to select items for the screening tool. The resulting 13-item instrument produced scores with high internal reliability that were sensitive to culturally informed diagnoses, and interpretations with construct and concurrent validity (vis-à-vis functional impairment). Discussion focuses on the appropriate use of this tool and integrating emic perspectives into developing psychological assessments globally. The screening tool is provided as an Appendix.

Determinants of Care Seeking for Mental Health Problems in Rural Haiti: Culture, Cost, or Competency

OBJECTIVE This study examined patterns, determinants, and costs of seeking care for mild to moderate psychiatric distress in order to determine optimal approaches for expanding mental health care in rural Haiti. METHODS A cross-sectional, zone-stratified household survey of 408 adults was conducted in Haitis Central Plateau. Multivariable logistic regression models were built to assess determinants of first-choice and lifetime health service use by provider type. RESULTS Thirty-two percent of respondents endorsed God as their first choice for care if suffering from mental distress, and 29% of respondents endorsed clinics and hospitals as their first choice. Forty-seven percent of respondents chose potential providers on the basis of anticipated efficacy. Suicidal individuals were 7.6 times (95% confidence interval [CI]=1.4-42.0) as likely to prefer community-based providers (herbal healer, church priest or pastor, or Vodou priest) over hospitals or clinics. Depression severity was associated with increased odds (adjusted odds ratio [AOR]=1.8, CI=1.5-2.3) of ever having been to an herbal healer. Having a household member with mental health problems was associated with increased odds of ever having been to church pastors or priests (AOR=5.8, CI=2.8-12.0) and decreased odds of ever having been to hospitals or clinics (AOR=.3, CI=.1-.8). Median actual service costs were US

Perceived discrimination, humiliation, and mental health: a mixed-methods study among Haitian migrants in the Dominican Republic

1 for hospitals or clinics,

Reflechi twòp—Thinking Too Much: Description of a Cultural Syndrome in Haiti’s Central Plateau

6 for herbal healers, and

Authorship in Global Mental Health Research: Recommendations for Collaborative Approaches to Writing and Publishing

120 for Vodou priests. CONCLUSIONS Three out of four rural Haitians said they would seek community resources over clinical care if suffering from mental distress. Therefore, isolated clinical interventions may have limited impact because of less frequent use. Efforts to expand mental health care should consider differential provider costs when selecting community resources for task shifting.