Journal of Personality Assessment
ISSN: 0022-3891 (Print) 1532-7752 (Online) Journal homepage: http://www.tandfonline.com/loi/hjpa20
A Hmong Adaptation of the Beck Depression Inventory Vang Leng Mouanoutoua , Lillian G. Brown , Gordon G. Cappelletty & Robert V. Levine To cite this article: Vang Leng Mouanoutoua , Lillian G. Brown , Gordon G. Cappelletty & Robert V. Levine (1991) A Hmong Adaptation of the Beck Depression Inventory, Journal of Personality Assessment, 57:2, 309-322, DOI: 10.1207/s15327752jpa5702_9 To link to this article: http://dx.doi.org/10.1207/s15327752jpa5702_9
Published online: 10 Jun 2010.
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JOURNAL OF PERSONALITY ASSESSMENT, 1991, 57(2), 309-322 Copyright o 1991, Lawrence Erlbaum Associates, Inc.
Hmong Adaptation of the Beck Depression Inventory Vang Leng Mouanoutoua and Lillian G. Brown California School of Professional Psychology-Fresno Downloaded by [Deakin University Library] at 00:47 07 November 2015
Gordon G. Cappelletty and Robert V. Levine California State University- Fresno
We developed the Hmong Adaptation of the Beck Depression Inventory (HABDI) and evaluated the instrument's psychometric characteristics. Also examined was the relationship between depression and demographic variables such as age, sex, length of stay in America, English-speakingability, and social support in Hmong refugees. One hundred twenty-three Hmong living in Fresno County, between the ages of 18 and 66, participated in the study. The new measure demonstrated a high coefficient alpha (.93), and test-retest reliability (.92), and a significant mean score difference between the nondepressed and the depressed groups. Individual items were distributed evenly and correlated highly with the total depression score. The HABDI correctly identified 94% of depressed and 78% of nondepiressed in the Hmong sample. The results suggest that quality of social support and years of education play important roles in buffering Hmong refugees against depression, whereas length of stay in America and number of social supports do not.
Depression is the most prevalent emotional problem among recent refugees, according t o a statewide survey conducted in California t o assess the mental health needs of Southeast Asian refugees (GongGuy, 1987). Hmong refugees manifest more depressive symptoms than Vietnamese, Kampuchean, Laotian, or Chinese-Vietnamese refugees. Recent studies consistently report widespread and profound multiple losses, traumatic escape journeys, and consequent acculturation problems among Hmong refugees (e.g., Cerhan, 1990; Westermeyer, 1987, 1988). T h e Hmong have experienced less favorable adjustment to U.S. culture (Nicassio, 1983); they have manifested more disorientation and fear than other Southeast Asian refugee groups (Aylesworth, 1983). Language barriers as well as cultural and traditional value differences between the host country and the Hmong have contributed t o their difficulties adjusting and
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acculturating (Camp, 1981). Overwhelming homesickness and sorrow related to losses of family members and familiar cultural traditions as well as family problems engendered by role reversals and other acculturation related issues have also taken a particular toll on the Hmong (Boehnlein, 1987; Kinzie, Tran, Breckenridge, & Bloom, 1980; Muecke, 1983). In a study examining continuing ethnic solidarity of the Hmong in San Diego, Scott (1982) concluded that their unmet basic needs were so great that Hmong were responding to the stress by interacting more with each other and less with outsiders, resulting in a vicious cycle of increased isolation from the dominant culture and consequently greater problems adjusting.
BACKGROUND The Hmong people, mountain dwellers from rural northern Laos, experienced minimal contact with Western culture prior to 1961 (Viviano, 1986). This lack of exposure to Western values and culture compounded by their experience of multiple traumata and losses exacerbate their difficulty adjusting effectively to the advanced technological society of the U.S. Research to date has identified English language proficiency, age, and length of stay in the U.S. to be related to adjustment in refugees. English language proficiency is inversely related to feelings of social isolation, hopelessness, despair, anxiety, and stress among Southeast Asian refugees (Nicassio, 1983). Psychiatric symptoms diminish over time as a function of English proficiency and employment (Westermeyer, Neider, & Vang, 1984). There is a striking need to develop psychometrically adequate and culturally sensitive assessment methods, enabling mental health professionals to identify and treat the depressive symptomatologyof Hmong refugees. To date, only the Zung (1965)Self Rating Depression Scale and the Depression scale of the 90-item Symptom Checklist (SCL-D; Derogatis, Lipman, & Covi, 1973) have been translated into Hmong (Westermeyer, 1986). Although the scales were significantly correlated with each other and predicted patients' clinical status, inspection of the data revealed several unexpected findings. Contrary to predictions, Zung scores did not correlate with treatment intensity, and the SCL-D scores were inversely related to treatment duration. These call the instruments' validity into question. Perhaps more unsettling were findings that nondepressed controls reported significantly higher symptom levels on two Zung and one SCL item. Finally, on 6 of 30 Zung and 3 of 13 SCL-D items there was no significant difference between depressed and nondepressed Hmong refugees. In an effort to create a more useful measure to assess depression, we adapted the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) into Hmong to investigate its utility for this population. The BDI was selected because of its well-established validity with American and
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cross-cultural samples (e.g., Comas-Diaz, 1981; Steer, Beck, & Garrison, 1986; Tarighati, 1980). It is important to note that we did not intend merely to translate BDI items from English to Hmong, however. Our intent was t~oadapt the BDI (both in content and format) to make it maximally useful as a predictor of depression in Hmong refugees-many of whom are illiterate. The adapted measure was standardized on two Hmong samples to determine its potential for differentiating depressed from nondepressed individuals. We also sought to investigate the relationships between depression/emotional distress and age, gender, length of stay in the U.S., English-speaking ability, and social support. Older persons, men, recent arrivals, non-English-speakingpersons, and those with limited sources of social support were hypothesized to displzy more depression than younger, female, early arrivals who spoke English and had more social support.
METHOD Subjects One hundred twenty-three Hmong refugees between 18 and 66 years old who left Laos after 1975 and who, through secondary or tertiary migration, were residing in Fresno County, California, participated in this study. Fifty individuals were classified as depressed, and 73 were classified as nondepressed (with a procedure described later). The nondepressed group was drawn from various community-based agencies (e.g., the Lao Family Community, Inc., the Department of Social Services, Adult Education) and from the community at large. Within the depressed group, 46 of 50 participants were active outpatient clients being treated for their depression. Another 4 individuals who were not mental health clients were found to meet the selection criteria for depression during the introduction phase (described later), so they were classified depressed. Among the 46 outpatient clients, only 13 carried major depression as the primary diagnosis. For the remaining 33 diagnosed participants, primary diagnosis involved somatic complaints with depressive features in 11 cases and other disorders (i.e., 7 posttraumatic stress disorder, 7 medical problems, 3 psychosis, 1 paranoid, 1 adjustment, 1 anxiety, 1 conversion, and 1 uncomplicated bereavement) for the remaining 22 clients. Despite the underrepresentation of depressive diagnoses, these clients were selected because review of clinical records revealed that in the course of treatment these refugees had reported events, symptoms, and facts related to their daily functioning that clearly qualified as criteria for depressive diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev. [DSM-Ill-R]; American Psychiatric Association, 1987). The failure of the diagnosing clinician to identify
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depression and PTSD in refugees is commonplace (Kinzie et al., 1990)for several reasons. Refugee victims of trauma underreport traumatic events spontaneously; shame or guilt contribute to their hesitance to discuss "personal" feelings with strangers; and disabling symptoms are frequently viewed not as "problemsn but as additional inconveniences in an already troubled life. Furthermore, client reports tend to emphasize somatic complaints (headaches, stomach aches, chronic back pain, poor sleep), which lead many clinicians to overlook the depressive symptoms that typically coexist with these physical problems.
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Instruments The BDI (Beck et al., 1961)of 21 depressive symptoms, each of which is rated on a scale ranging from not intense (0) to very intense (9,was translated into the Hmong language (Latinized script) by the first author. A number of changes were made in the Hmong version in order to achieve a culturally sensitive, more readily understood, simplified form. First, the scale indicating the severity of each symptom was changed to a 3-point frequency of occurrence scale. The shift from a severity to a frequency format occurred as a result of pretesting experiences which revealed that many Hmong became frustrated and did not respond to the subtle severity distinctions among the rating categories. This was especially true for the participants who required oral presentation of the HABDI. The oral presentation strains the memory and demands greater efforts (than written) to recall both the stem and the rating category. Especially for the depressed participants, this requirement put the task beyond reach. In contrast, the revised frequency format elicited no similar frustration and yielded clear responses from even the most severely depressed Hmong. Second, item Number 2 in the original version of the BDI, "I feel like the future is hopeless and cannot improve," was transformed into two separate items in the Hmong version because of difficulty translating the original item's connotation into Hmong. These items became: "I feel like the future is hopeless," and "I feel like things cannot improve." Scores on the adapted measure range from 22 to 66 instead of 0 to 63, as they do in the original BDI. The new instrument, the HABDI was back translated into English by four Hmong who spoke and read both English and Hmong. These translators were blind to the intent of the instrument and were instructed to make as accurate a translation as possible. Discrepancies in the choices of Hmong words were resolved by discussions among the translators. Particular difficulties arose with the BDI item Numbers 6 and 12, which refer to feeling "ashamed" and "irritated," respectively, as there are no corresponding terms for those concepts in the Hmong language. In these items, the Hmong words that have the closest meaning to those American concepts were substituted ("shy to oneself" and "trouble-hearted") in the HABDI.
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A demographic questionnaire constructed for this study elicited information about age, gender, and length of residence in the U.S. English-speaking ability, perceived social support, and satisfaction with life overall were also assessed using Likert scales. Observable depressive symptoms were rated by the first author in the initial interview (described next) to categorize subjects into depressed andl nondepressed groups. The ratings were derived from six depressive symptoms specified in the DSM-111-R: depressed mood, diminished interest in activities, weight loss or gain, psychomotor agitation or retardation, fatigability, and diminished ability to think or concentrate. Subjects observed to display more than three of these symptoms were classified as depressed. These ratings were obtained in addition to the demographic information just described. Procedure All participants were approached at their homes or offices by the first author and were asked to participate in the study. If they agreed, subjects then listened to an introductory description of the task and signed an informed consent form before they began to complete the questionnaires. It was during this initial contact with the subjects that the first author observed them and rated their level of depressive symptoms for classification as depressed or nondepressed. Participants then completed the demographic questionnaire and the HABDI. Nondepressed subjects were identified based on two criteria. First, during the interview, all nondepressed subjects displayed fewer than three of the six observable depressive symptoms. Second, they reported having at least "a little" satisfaction with their life overall on the demographic questionnaire. For all depressed subjects (n = 50) and for nondepressed subjects who couild not read Hmong (23 of 73), the instructions and the questionnaire items were read aloud and the principal investigator recorded their oral responses. The remaining subjects (50 nondepressed) were asked to read the instructions and complete the questionnaires themselves. Within 2 weeks of the initial interview, participants completed the questionnaires again to provide data for a test-retest analysis. The retest interview was conducted in the same manner as the initial interview. Immediately following the second interview, each subject was informed of the goal of the study. The participants were also encouraged to express their views regarding Hmong depression in order to provide qualitative information to the investigator for future research. Subjects were advised that anyone interested could call the principal investigator to find out the results of the study at a later date.
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RESULTS
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Characteristics of Subjects Subjects in this study were 76 men and 47 women who ranged in age from 18 to 66 years (M = 39; SD = 11.94). Their mean length of time in the U.S. was close to 7 years (SD = 5.10). The average number of people with whom they reported they could share their problems (their social support network) was approximately 7 (SD = 17.41). Four out of seven people identified to be social supports were relatives (SD = 7.23). Among the subjects, 94 (76.4%) were married, 3 (2.4%)were separated, 4 (3.3%)were divorced, 13 (10.6%)were widowed, and 9 (7.3%)were single. Most of the participants (67.5%)rated their English-speaking ability as "not good" (i.e., no English), 31 subjects (25.2%) believed they spoke English' "fairly well" (understand and speak some English), and only 9 subjects (7.3%)claimed to communicate in English "very well" (speak English fluently). A comparable pattern of the need to have an interpreter emerged when speaking to Americans. There were 83 subjects (67.5%)indicating "yes," 13 (10.6%)saying "sometimes," and 27 (22.0%) stating "no" to the need for an interpreter. A sizable number of the subjects (43.8%)stated that they were at least a little satisfied with their life overall, and the majority of them (56.1%) reported otherwise. Table 1 summarizes the frequencies and percentages for demographic variables.
Comparison of Depressed and Nondepressed Subjects Analysis of the mean differences on the HABDI between depressed and nondepressed individuals on each demographic variable revealed that age, education, English-speaking ability, and need for an interpreter significantly differentiated the two groups (see Table 2). Findings indicate that nondepressed subjects tended to be younger, to have more years of education, to speak better English, and to show less need for an interpreter than the depressed individuals. As indicated in Table 2, length of stay in the U.S. and social support did not differentiate the depressed and nondepressed groups significantly. Although in the initial categorization of subjects depression did not differentiate men and women (see Table 3), a significant gender difference emerged on the HABDI. Table 4 displays the mean depression scores, with women reporting significantly more depression than men.
Item Analysis The response frequency for each of the items of the HABDI was distributed relatively evenly throughout the three categories of response, with most of the responses clustering in the sometimes category. The only two items on which fewer than 20 people endorsed any one particular category of response were
HMONG ADAPTATION OF BDI
TABLE 1 Frequencies and Percentages for Demographic Variables
-
Variable
Category
Frequency
Pnzentage
Gender
Male Female Married Separated Divorced Widowed Never married Very well Fairly well Not well No Sometimes Yes Very satisfied Fairly satisfied A little satisfied A little dissatisfied Fairly dissatisfied Very dissatisfied Male Female Either sex Very satisfied Fairly satisfied A little satisfied A little dissatisfied Fairly dissatisfied Very dissatisfied
76 47 94 3 4 13 9 9 31 83 27 13 83 24 29 28 17 7 18 80 41 2 11 26 17 18 14 37
61.8 38.2 76.4 2.4 3.3 10.6 7.3 7.3 25.2 67.5 22.0 10.6 67.5 19.5 23.6 22.8 13.8 5.7 14.6 65.0 33.0 1.6 8.9 21.1 13.8 14.6 11.4 30.1
Marital status
English-speaking ability
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Need of interpreter
Satisfaction with social support
Gender of social support
Life satisfaction overall
-
sadness (Number 1) and pessimism (Number 2). On these two items, few people reported never experiencing sadness or pessimism about their future. Correlations were computed for each item to measure the relationship between the item and the total score with the item removed. Table 5 illustrates that most of the corrected item-total correlations range from moderate to high (r = .49 to .75). Expectation of punishment (r = .30), self-accusation (r =: .36), and weight loss (r = .38) yielded the lowest item-total correlations. Thus, no items were eliminated from the test.
Reliability Reliability was calculated by comparing the initial test scores with the 2-week retest scores. Test-retest reliability for all 123 subjects was .92. Internal consistency, evaluated by computing the alpha coefficient (Cronbach, 1951), was .93, suggesting good internal consistency for the HABDI.
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TABLE 2 Comparisons of Depressed a n d Nondepressed Subjects o n Demographic Variables
M Variable
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Age Length of stay in U.S. (years) Education ears) English-speaking ability (3-point scale) Need for interpreter (3-point scale) Social support (number of persons)
Depressed
Nondepressed
SD
t
43.90 7.26 2.30 2.45 1.24 3.30
34.89 6.53 6.47 2.82 1.75 9.12
11.93 3.89 5.10 .55 .83 17.41
4.41* 0.96 4.48* 3.34* 3.15 1.84
Note. N = 123. *p < .01.
TABLE 3 Initial Classification of Depressed Versus Nondepressed by Gender Depressed
Nondepressed
Gender
n
%
n
%
n
Male Female Total
37 31 68
49% 66%
39 16 55
51% 34%
76 47 123
Note. XZ(l,N = 123) = 3.51, ns.
TABLE 4 Mean Responses o n the HABDI for Male and Female Participants Depression Score Gender
M
SD
n
Male Female Note. t(l21) = -2.31, p < .05.
Validity The mean score of the nondepressed group (39.1 1; SD = 7.76), was significantly lower than the mean score of the depressed group (55.46; SD = 5.50; p < .001). The effect size (Howell, 1987) was 9.12, which has a power > .99. These results demonstrate that the HABDI is useful in discriminating between depressed and nondepressed Hmong individuals. To assess the hit rate of this measure, all subjects were assigned either to the depressed or the nondepressed group on the basis of their scores on the test. A cutoff score of 46 was selected, as this was
HMONG ADAPTATION OF BDI TABLE 5 Item-Total Correlations for the HABDI
-r
Item
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1 Sadness 2 Pessimism 3 Helplessness 4 Sense of failure 5 Dissatisfaction 6 Guilt 7 Expecration of punishment 8 Self-dislike 9 Self-accusation 10 Suicidal ideation I1 Crying 12 Irritability 13 Social withdrawal 14 Indecisiveness 15 Body image change 16 Work difficulty 17 Insomnia 18 Fatigue 19 Loss of appetite 20 Weight loss 21 Somaric preoccupation 22 Loss of libido
.70 .71 .70 .71 .49 .49 .30 .64 .36 .62 .59 .75 .59 .59 .72 .69 .53 .55 .57 .38 .63 .75
approximately 1 standard deviation above the mean for the nondepressed individuals. All subjects who obtained a score of 45 or below were classified as not depressed. All other subjects (i.e., with scores of 46 or above) were claljsified as depressed. Table 6 displays a sensitivity of 94% and a specificity of 78%, with 22% false positives and 6% false negatives. This results in an overall accuracy or hit rate of 85%, with 75% positive predictive power and 97% negative predictive power. TABLE 6 Classification of Depressed and Nondepressed Hmong With the HABDI p p
-
-
Actual Diagnosis Depressed
Nondepressed
Test Classificution
n
%
n
%
Total
Depressed Not depressed Total
47 3 73
94 6
16 57 50
22 78
63 60 123
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Demographic Factors and Depression Pearson product-moment correlations were computed to determine the associations of various demographic variables with HABDI scores. As predicted, age correlated significantly with depression score (r = .43, p < .001), indicating that younger Hmong tended to have fewer depressive symptoms than older Hmong. Education was also significantly (negatively) correlated with depression (r = - .51, p < .001), suggesting that as education in the U.S. increases, depressive symptoms in Hmong individuals tend to decrease. English-speaking ability (and need for an interpreter) were also significantly associated with depression ( r = - .47, and r = .50, respectively, both p < .001), as Hmong who did not speak English well and who needed interpreters tended to report more depression than those who had a better grasp of the English language. Hmong who felt satisfied with their social support systems tended to report less depression than those who were relatively dissatisfied with their social supports (r = .37, p < .001). On the other hand, length of stay in the U.S., the actual number of persons constituting social support, and the number of relatives considered social support were not found to be related to depression. The correlations between the HABDI scores and the demographic variables are displayed in Table 7. A simultaneous multiple regression of demographic characteristics (the effects of education, English-speaking ability, need for interpreter, gender, age, and time in the U.S.) on depression was computed. The beta weights af these variables were examined to determine the relative importance of each. This analysis revealed that (lack of) education contributed more to the prediction of depression than did either proficiency in English or the need for an interpreter. Higher levels of education appear to be associated with lower depression scores. The analysis further indicates that gender, age, and education ~redict37% of the total variance in depression scores, with the other variables contributing very little above this amount (see Table 8). TABLE 7
Correlations Between HABDI Scores and Demographic Variables Variables
As. Length of stay in US. Education (years) English-speakingability Need of interpreter Number of social support Gender of social support Relatives as social support Satisfaction with social support
r
HMONG ADAPTATION OF BDI TABLE 8 Multiple Regression of Demographic Variables on Depression Variables
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Gender Age Educatton Length of stay in the U.S. English-speaking ability Need for interpreter Constant
B
Standard Error of B
4.245 .202 - .699 .472 - 1.749 -1.148 29.406
1.627 .075 .255 .245 2.256 1.895 8.948
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-
Beta
T
.I95 .227 - .336 .I73 -.PO2 - .090
2.609* 2.667** -2.740** 1.922 .775 -0.606
-
Note. R = .633. F(6, 116) = 12.966, p < .001. R' = .370. *p < .05. **p < .01.
A second regression analysis of social support variables was conducted by entering level of social support, satisfaction with support, and gender of support in the regression analysis at the same time. Inspection of the beta weights for these variables indicated that the level of social support and the gender of social support were not significant predictor variables. On the other hand, satisfaction with social support rkrnained the best predictor for depression. As the beta weights remove the influence of the other variables in this analysis, this indicates that, among the social support variables, satisfaction is the most important predictor of level of depression even when the amount of social support is controlled. Satisfaction with social support accounted for 16% of the total variance in depression, whereas the other variables explained very little (see Table 9).
DISCUSSION Psychometric Properties The findings obtained in this study indicate that the HABDI is a highly reliable and useful instrument in assessing depression in Hmong individuals. The entire TABLE 9
Multiple Regression of Social Support on Depression Variables
B
Standard E m of B
Social support Satisfaction with support Gender of social support Constant
- .068 2.142 1.913 35.100
.052 .560 1.777 3.019
Note. R = .403. F(3, 199) = 7 . 6 7 9 , ~< .001. R2 = .162. *p < .001.
--
Beta
T
.I12 .332 .093
1.306 3.825* 1.076
-
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scale showed high test-retest reliability with a comparably high level of internal consistency. It also yielded an accuracy rate of 94% in identifying depressed Hmong individuals and of 78% in identifying nondepressed Hmong. The superiority of this instrument's sensitivity and specificity to depression relative to previously translated instruments in Hmong (Westermeyer, 1986) is attributable to the attention to format as well as content issues, which ensured it was readily understood by depressed and nondepressed Hmong. The expression of depressive symptoms differs across cultures (Marsella, 1978) and these differences (including relative priority of emotional, somatic, interpersonal, and energy related experiences) require careful attention to detail in wording and format to create effective assessment instruments. Analysis of the items suggested that subjects used the three response categories equally for most items. The exceptions were to items describing sadness, pessimism, and helplessness, which over 75% of the respondents indicated they experience "some" or "often." This is consistent with the history of losses, trauma, and difficulties acculturating that most Hmong exhibit (Cerhan, 1990). Despite the tendency toward severity in the distributions of the three symptoms just mentioned, the item-total correlations indicate that all of the items in the HABDI were measuring the same construct that the total score assessed.
Demographic Variables and Depression Age related significantly to the total depression score, consistent with earlier findings that older adult refugees have more depressive symptoms than their younger counterparts (Nicassio, 1983; Westermeyer, Vang, & Neider, 1983). As predicted, English-speaking ability and the need for an interpreter as well as education were all strongly related to depression. Our findings confirmed those of Krupinski and Burrows (1986) and Nicassio (1983), which indicated that Southeast Asian refugees who can speak English are less alienated and depressed than those who only communicate in their native languages. When Englishspeaking ability, need for an interpreter, and education were analyzed together, lack of education best accounted for the variance in depression. The factors required to pursue advanced educational goals are perhaps incompatible with depression-relatedsymptoms such as apathy, lethargy, low energy, and feelings of hopelessness and helplessness. Unexpectedly, length of stay in the U.S. was not a significant factor in predicting depression, suggesting that Hmong who came to the U.S. earlier tend to be as depressed as those who arrived recently. This finding may be related to Scott's (1982) study which described the formation of Hmong enclaved communities for maintaining their own customs and beliefs. This may inhibit their learning the mainstream's values and language, which may in turn create more isolation. These Hmong may be expected to continue to feel inadequate,
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underproductive, and uncertain about their future regardless of their length of time in the U.S. Total amount of social support and number of relatives used as social support also were not related significantly with depression, whereas satisfaction with social support was the best predictor of depression. This finding corroborates the results of other investigators (Golding & Burnam, 1990) who also found that perceived social support outweighs actual support in its buffering effect against the negative consequence of stress. The findings from this study suggest that service providers who work with Hmong refugees should take quality of social support into consideration as a significant buffer against depression. In conclusion, the HABDI is a useful screening tool for depression. Individuals who can read Hmong can complete the HABDI themselves; for those who cannot, an interpreter can administer the measure orally. Furthermore, apart from its clinical utility, the HABDI provides an excellent opportunity to explore the factor structure of Hmong versus Western (e.g., Euro-American) expression of depressive symptomatology. The way it was adapted to Hmong culture and language rather than being merely translated contributes to its usefulness. This study underscores the importance of attending to format as well as cont(ent issues when transforming existing instruments for use with other cultures.
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Kinzie, J. D., Boehnlein, M. D., Leung, P. K., Moore, L. J., Riley, C., & Smith, D. (1990). The prevalence of posttraumatic stress disorder and its clinical significance among Southeast Asian n of Psychiatry, 147, 913-917. refugees. A m m a c alournal Kinzie, J. D., Tran, K. A., Breckenridge, A., & Bloom, J. D. (1980). An Indochinese refugees' psychiatric clinic: Culturally accepted treatment approaches. American Journal of Psychiatry, 137, 1429-1432. Krupinski, J., & Burrows, G. (Eds.). (1986). The price of freedom: Young Indochinese refugees m Australia. Sydney: Pergamon. Marsella, A. J. (1978).Thoughts on cross cultural studies on the epidemiology of depression. Cultural Medical Psychiatry, 2, 343-357. Muecke, M. A. (1983). Caring for Southeast Asian refugee patients in the U.S.A. American Journal of Public Health, 73,431-438. Nicassio, P. (1983).Psychological correlates of alienation: Study of a sample of Indochinese refugees. Jwmal of Cross-Cultural Psychology, 14, 337-351. Scott, J. M. (1982). The Hmong community in San Diego: Theoretical and practical implications of its continuing ethnic solidarity. Anthropological Quarrerly, 55, 146-159. Steer, R. A., Beck, A. T., & Garrison, B. (1986). Application of the Beck Depression Inventory. In N. Sartorius & T. A. Ban (Eds.), Assessment of depression (pp. 123-142). New York: SpringerVerlag. Tarighati, S. (1980). An exploratory study on depression in Iranian addicts. International Journal of Soaal Psychiatry, 26, 196-199. Viviano, F. (1986, August). Strangers in the promised land. Image, pp. 15-38. Westermeyer, J. (1986). Two self-rating scales for depression in Hmong refugees: Assessment in clinical and non-clinical samples. Journal of Psychiatric Research, 20, 103-113. Westermeyer, J. (1987). Prevention of mental disorder among Hmong refugees in the U.S.: Lessons from the period 1976-1986. Social Science and Medicine, 25,941-947. Westermeyer, J. (1988). DSM-111 psychiatric disorders among Hmong refugees in the United States: A point re valence study. American Journal of Psychiatry, 145, 197-202. Westermeyer, J., Neider, J., & Vang, T. F. (1984). Acculturation and mental health: A study of Hmong refugees at 1.5 and 3.5 years postmigration. Social Science Medicine, 18(1),87-93. Westermeyer, J., Vang, T. F., & Neider, J. (1983). Migration and mental health among Hmong refugees: Association of pre- and post-migration factors with self-rating scales. The lournal of Nervous and Mental Disease, 171, 91-96. Zung, W. W. F. (1965). A self rating depression scale. Archives of General Psychracry, 12, 63-70.
Lillian G. Brown California School of Professional Psychology 1350 M Street Fresno, CA 93721 Received October 8, 1990
ISSN: 0022-3891 (Print) 1532-7752 (Online) Journal homepage: http://www.tandfonline.com/loi/hjpa20
A Hmong Adaptation of the Beck Depression Inventory Vang Leng Mouanoutoua , Lillian G. Brown , Gordon G. Cappelletty & Robert V. Levine To cite this article: Vang Leng Mouanoutoua , Lillian G. Brown , Gordon G. Cappelletty & Robert V. Levine (1991) A Hmong Adaptation of the Beck Depression Inventory, Journal of Personality Assessment, 57:2, 309-322, DOI: 10.1207/s15327752jpa5702_9 To link to this article: http://dx.doi.org/10.1207/s15327752jpa5702_9
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JOURNAL OF PERSONALITY ASSESSMENT, 1991, 57(2), 309-322 Copyright o 1991, Lawrence Erlbaum Associates, Inc.
Hmong Adaptation of the Beck Depression Inventory Vang Leng Mouanoutoua and Lillian G. Brown California School of Professional Psychology-Fresno Downloaded by [Deakin University Library] at 00:47 07 November 2015
Gordon G. Cappelletty and Robert V. Levine California State University- Fresno
We developed the Hmong Adaptation of the Beck Depression Inventory (HABDI) and evaluated the instrument's psychometric characteristics. Also examined was the relationship between depression and demographic variables such as age, sex, length of stay in America, English-speakingability, and social support in Hmong refugees. One hundred twenty-three Hmong living in Fresno County, between the ages of 18 and 66, participated in the study. The new measure demonstrated a high coefficient alpha (.93), and test-retest reliability (.92), and a significant mean score difference between the nondepressed and the depressed groups. Individual items were distributed evenly and correlated highly with the total depression score. The HABDI correctly identified 94% of depressed and 78% of nondepiressed in the Hmong sample. The results suggest that quality of social support and years of education play important roles in buffering Hmong refugees against depression, whereas length of stay in America and number of social supports do not.
Depression is the most prevalent emotional problem among recent refugees, according t o a statewide survey conducted in California t o assess the mental health needs of Southeast Asian refugees (GongGuy, 1987). Hmong refugees manifest more depressive symptoms than Vietnamese, Kampuchean, Laotian, or Chinese-Vietnamese refugees. Recent studies consistently report widespread and profound multiple losses, traumatic escape journeys, and consequent acculturation problems among Hmong refugees (e.g., Cerhan, 1990; Westermeyer, 1987, 1988). T h e Hmong have experienced less favorable adjustment to U.S. culture (Nicassio, 1983); they have manifested more disorientation and fear than other Southeast Asian refugee groups (Aylesworth, 1983). Language barriers as well as cultural and traditional value differences between the host country and the Hmong have contributed t o their difficulties adjusting and
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acculturating (Camp, 1981). Overwhelming homesickness and sorrow related to losses of family members and familiar cultural traditions as well as family problems engendered by role reversals and other acculturation related issues have also taken a particular toll on the Hmong (Boehnlein, 1987; Kinzie, Tran, Breckenridge, & Bloom, 1980; Muecke, 1983). In a study examining continuing ethnic solidarity of the Hmong in San Diego, Scott (1982) concluded that their unmet basic needs were so great that Hmong were responding to the stress by interacting more with each other and less with outsiders, resulting in a vicious cycle of increased isolation from the dominant culture and consequently greater problems adjusting.
BACKGROUND The Hmong people, mountain dwellers from rural northern Laos, experienced minimal contact with Western culture prior to 1961 (Viviano, 1986). This lack of exposure to Western values and culture compounded by their experience of multiple traumata and losses exacerbate their difficulty adjusting effectively to the advanced technological society of the U.S. Research to date has identified English language proficiency, age, and length of stay in the U.S. to be related to adjustment in refugees. English language proficiency is inversely related to feelings of social isolation, hopelessness, despair, anxiety, and stress among Southeast Asian refugees (Nicassio, 1983). Psychiatric symptoms diminish over time as a function of English proficiency and employment (Westermeyer, Neider, & Vang, 1984). There is a striking need to develop psychometrically adequate and culturally sensitive assessment methods, enabling mental health professionals to identify and treat the depressive symptomatologyof Hmong refugees. To date, only the Zung (1965)Self Rating Depression Scale and the Depression scale of the 90-item Symptom Checklist (SCL-D; Derogatis, Lipman, & Covi, 1973) have been translated into Hmong (Westermeyer, 1986). Although the scales were significantly correlated with each other and predicted patients' clinical status, inspection of the data revealed several unexpected findings. Contrary to predictions, Zung scores did not correlate with treatment intensity, and the SCL-D scores were inversely related to treatment duration. These call the instruments' validity into question. Perhaps more unsettling were findings that nondepressed controls reported significantly higher symptom levels on two Zung and one SCL item. Finally, on 6 of 30 Zung and 3 of 13 SCL-D items there was no significant difference between depressed and nondepressed Hmong refugees. In an effort to create a more useful measure to assess depression, we adapted the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) into Hmong to investigate its utility for this population. The BDI was selected because of its well-established validity with American and
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cross-cultural samples (e.g., Comas-Diaz, 1981; Steer, Beck, & Garrison, 1986; Tarighati, 1980). It is important to note that we did not intend merely to translate BDI items from English to Hmong, however. Our intent was t~oadapt the BDI (both in content and format) to make it maximally useful as a predictor of depression in Hmong refugees-many of whom are illiterate. The adapted measure was standardized on two Hmong samples to determine its potential for differentiating depressed from nondepressed individuals. We also sought to investigate the relationships between depression/emotional distress and age, gender, length of stay in the U.S., English-speaking ability, and social support. Older persons, men, recent arrivals, non-English-speakingpersons, and those with limited sources of social support were hypothesized to displzy more depression than younger, female, early arrivals who spoke English and had more social support.
METHOD Subjects One hundred twenty-three Hmong refugees between 18 and 66 years old who left Laos after 1975 and who, through secondary or tertiary migration, were residing in Fresno County, California, participated in this study. Fifty individuals were classified as depressed, and 73 were classified as nondepressed (with a procedure described later). The nondepressed group was drawn from various community-based agencies (e.g., the Lao Family Community, Inc., the Department of Social Services, Adult Education) and from the community at large. Within the depressed group, 46 of 50 participants were active outpatient clients being treated for their depression. Another 4 individuals who were not mental health clients were found to meet the selection criteria for depression during the introduction phase (described later), so they were classified depressed. Among the 46 outpatient clients, only 13 carried major depression as the primary diagnosis. For the remaining 33 diagnosed participants, primary diagnosis involved somatic complaints with depressive features in 11 cases and other disorders (i.e., 7 posttraumatic stress disorder, 7 medical problems, 3 psychosis, 1 paranoid, 1 adjustment, 1 anxiety, 1 conversion, and 1 uncomplicated bereavement) for the remaining 22 clients. Despite the underrepresentation of depressive diagnoses, these clients were selected because review of clinical records revealed that in the course of treatment these refugees had reported events, symptoms, and facts related to their daily functioning that clearly qualified as criteria for depressive diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev. [DSM-Ill-R]; American Psychiatric Association, 1987). The failure of the diagnosing clinician to identify
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depression and PTSD in refugees is commonplace (Kinzie et al., 1990)for several reasons. Refugee victims of trauma underreport traumatic events spontaneously; shame or guilt contribute to their hesitance to discuss "personal" feelings with strangers; and disabling symptoms are frequently viewed not as "problemsn but as additional inconveniences in an already troubled life. Furthermore, client reports tend to emphasize somatic complaints (headaches, stomach aches, chronic back pain, poor sleep), which lead many clinicians to overlook the depressive symptoms that typically coexist with these physical problems.
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Instruments The BDI (Beck et al., 1961)of 21 depressive symptoms, each of which is rated on a scale ranging from not intense (0) to very intense (9,was translated into the Hmong language (Latinized script) by the first author. A number of changes were made in the Hmong version in order to achieve a culturally sensitive, more readily understood, simplified form. First, the scale indicating the severity of each symptom was changed to a 3-point frequency of occurrence scale. The shift from a severity to a frequency format occurred as a result of pretesting experiences which revealed that many Hmong became frustrated and did not respond to the subtle severity distinctions among the rating categories. This was especially true for the participants who required oral presentation of the HABDI. The oral presentation strains the memory and demands greater efforts (than written) to recall both the stem and the rating category. Especially for the depressed participants, this requirement put the task beyond reach. In contrast, the revised frequency format elicited no similar frustration and yielded clear responses from even the most severely depressed Hmong. Second, item Number 2 in the original version of the BDI, "I feel like the future is hopeless and cannot improve," was transformed into two separate items in the Hmong version because of difficulty translating the original item's connotation into Hmong. These items became: "I feel like the future is hopeless," and "I feel like things cannot improve." Scores on the adapted measure range from 22 to 66 instead of 0 to 63, as they do in the original BDI. The new instrument, the HABDI was back translated into English by four Hmong who spoke and read both English and Hmong. These translators were blind to the intent of the instrument and were instructed to make as accurate a translation as possible. Discrepancies in the choices of Hmong words were resolved by discussions among the translators. Particular difficulties arose with the BDI item Numbers 6 and 12, which refer to feeling "ashamed" and "irritated," respectively, as there are no corresponding terms for those concepts in the Hmong language. In these items, the Hmong words that have the closest meaning to those American concepts were substituted ("shy to oneself" and "trouble-hearted") in the HABDI.
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A demographic questionnaire constructed for this study elicited information about age, gender, and length of residence in the U.S. English-speaking ability, perceived social support, and satisfaction with life overall were also assessed using Likert scales. Observable depressive symptoms were rated by the first author in the initial interview (described next) to categorize subjects into depressed andl nondepressed groups. The ratings were derived from six depressive symptoms specified in the DSM-111-R: depressed mood, diminished interest in activities, weight loss or gain, psychomotor agitation or retardation, fatigability, and diminished ability to think or concentrate. Subjects observed to display more than three of these symptoms were classified as depressed. These ratings were obtained in addition to the demographic information just described. Procedure All participants were approached at their homes or offices by the first author and were asked to participate in the study. If they agreed, subjects then listened to an introductory description of the task and signed an informed consent form before they began to complete the questionnaires. It was during this initial contact with the subjects that the first author observed them and rated their level of depressive symptoms for classification as depressed or nondepressed. Participants then completed the demographic questionnaire and the HABDI. Nondepressed subjects were identified based on two criteria. First, during the interview, all nondepressed subjects displayed fewer than three of the six observable depressive symptoms. Second, they reported having at least "a little" satisfaction with their life overall on the demographic questionnaire. For all depressed subjects (n = 50) and for nondepressed subjects who couild not read Hmong (23 of 73), the instructions and the questionnaire items were read aloud and the principal investigator recorded their oral responses. The remaining subjects (50 nondepressed) were asked to read the instructions and complete the questionnaires themselves. Within 2 weeks of the initial interview, participants completed the questionnaires again to provide data for a test-retest analysis. The retest interview was conducted in the same manner as the initial interview. Immediately following the second interview, each subject was informed of the goal of the study. The participants were also encouraged to express their views regarding Hmong depression in order to provide qualitative information to the investigator for future research. Subjects were advised that anyone interested could call the principal investigator to find out the results of the study at a later date.
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RESULTS
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Characteristics of Subjects Subjects in this study were 76 men and 47 women who ranged in age from 18 to 66 years (M = 39; SD = 11.94). Their mean length of time in the U.S. was close to 7 years (SD = 5.10). The average number of people with whom they reported they could share their problems (their social support network) was approximately 7 (SD = 17.41). Four out of seven people identified to be social supports were relatives (SD = 7.23). Among the subjects, 94 (76.4%) were married, 3 (2.4%)were separated, 4 (3.3%)were divorced, 13 (10.6%)were widowed, and 9 (7.3%)were single. Most of the participants (67.5%)rated their English-speaking ability as "not good" (i.e., no English), 31 subjects (25.2%) believed they spoke English' "fairly well" (understand and speak some English), and only 9 subjects (7.3%)claimed to communicate in English "very well" (speak English fluently). A comparable pattern of the need to have an interpreter emerged when speaking to Americans. There were 83 subjects (67.5%)indicating "yes," 13 (10.6%)saying "sometimes," and 27 (22.0%) stating "no" to the need for an interpreter. A sizable number of the subjects (43.8%)stated that they were at least a little satisfied with their life overall, and the majority of them (56.1%) reported otherwise. Table 1 summarizes the frequencies and percentages for demographic variables.
Comparison of Depressed and Nondepressed Subjects Analysis of the mean differences on the HABDI between depressed and nondepressed individuals on each demographic variable revealed that age, education, English-speaking ability, and need for an interpreter significantly differentiated the two groups (see Table 2). Findings indicate that nondepressed subjects tended to be younger, to have more years of education, to speak better English, and to show less need for an interpreter than the depressed individuals. As indicated in Table 2, length of stay in the U.S. and social support did not differentiate the depressed and nondepressed groups significantly. Although in the initial categorization of subjects depression did not differentiate men and women (see Table 3), a significant gender difference emerged on the HABDI. Table 4 displays the mean depression scores, with women reporting significantly more depression than men.
Item Analysis The response frequency for each of the items of the HABDI was distributed relatively evenly throughout the three categories of response, with most of the responses clustering in the sometimes category. The only two items on which fewer than 20 people endorsed any one particular category of response were
HMONG ADAPTATION OF BDI
TABLE 1 Frequencies and Percentages for Demographic Variables
-
Variable
Category
Frequency
Pnzentage
Gender
Male Female Married Separated Divorced Widowed Never married Very well Fairly well Not well No Sometimes Yes Very satisfied Fairly satisfied A little satisfied A little dissatisfied Fairly dissatisfied Very dissatisfied Male Female Either sex Very satisfied Fairly satisfied A little satisfied A little dissatisfied Fairly dissatisfied Very dissatisfied
76 47 94 3 4 13 9 9 31 83 27 13 83 24 29 28 17 7 18 80 41 2 11 26 17 18 14 37
61.8 38.2 76.4 2.4 3.3 10.6 7.3 7.3 25.2 67.5 22.0 10.6 67.5 19.5 23.6 22.8 13.8 5.7 14.6 65.0 33.0 1.6 8.9 21.1 13.8 14.6 11.4 30.1
Marital status
English-speaking ability
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Need of interpreter
Satisfaction with social support
Gender of social support
Life satisfaction overall
-
sadness (Number 1) and pessimism (Number 2). On these two items, few people reported never experiencing sadness or pessimism about their future. Correlations were computed for each item to measure the relationship between the item and the total score with the item removed. Table 5 illustrates that most of the corrected item-total correlations range from moderate to high (r = .49 to .75). Expectation of punishment (r = .30), self-accusation (r =: .36), and weight loss (r = .38) yielded the lowest item-total correlations. Thus, no items were eliminated from the test.
Reliability Reliability was calculated by comparing the initial test scores with the 2-week retest scores. Test-retest reliability for all 123 subjects was .92. Internal consistency, evaluated by computing the alpha coefficient (Cronbach, 1951), was .93, suggesting good internal consistency for the HABDI.
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TABLE 2 Comparisons of Depressed a n d Nondepressed Subjects o n Demographic Variables
M Variable
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Age Length of stay in U.S. (years) Education ears) English-speaking ability (3-point scale) Need for interpreter (3-point scale) Social support (number of persons)
Depressed
Nondepressed
SD
t
43.90 7.26 2.30 2.45 1.24 3.30
34.89 6.53 6.47 2.82 1.75 9.12
11.93 3.89 5.10 .55 .83 17.41
4.41* 0.96 4.48* 3.34* 3.15 1.84
Note. N = 123. *p < .01.
TABLE 3 Initial Classification of Depressed Versus Nondepressed by Gender Depressed
Nondepressed
Gender
n
%
n
%
n
Male Female Total
37 31 68
49% 66%
39 16 55
51% 34%
76 47 123
Note. XZ(l,N = 123) = 3.51, ns.
TABLE 4 Mean Responses o n the HABDI for Male and Female Participants Depression Score Gender
M
SD
n
Male Female Note. t(l21) = -2.31, p < .05.
Validity The mean score of the nondepressed group (39.1 1; SD = 7.76), was significantly lower than the mean score of the depressed group (55.46; SD = 5.50; p < .001). The effect size (Howell, 1987) was 9.12, which has a power > .99. These results demonstrate that the HABDI is useful in discriminating between depressed and nondepressed Hmong individuals. To assess the hit rate of this measure, all subjects were assigned either to the depressed or the nondepressed group on the basis of their scores on the test. A cutoff score of 46 was selected, as this was
HMONG ADAPTATION OF BDI TABLE 5 Item-Total Correlations for the HABDI
-r
Item
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1 Sadness 2 Pessimism 3 Helplessness 4 Sense of failure 5 Dissatisfaction 6 Guilt 7 Expecration of punishment 8 Self-dislike 9 Self-accusation 10 Suicidal ideation I1 Crying 12 Irritability 13 Social withdrawal 14 Indecisiveness 15 Body image change 16 Work difficulty 17 Insomnia 18 Fatigue 19 Loss of appetite 20 Weight loss 21 Somaric preoccupation 22 Loss of libido
.70 .71 .70 .71 .49 .49 .30 .64 .36 .62 .59 .75 .59 .59 .72 .69 .53 .55 .57 .38 .63 .75
approximately 1 standard deviation above the mean for the nondepressed individuals. All subjects who obtained a score of 45 or below were classified as not depressed. All other subjects (i.e., with scores of 46 or above) were claljsified as depressed. Table 6 displays a sensitivity of 94% and a specificity of 78%, with 22% false positives and 6% false negatives. This results in an overall accuracy or hit rate of 85%, with 75% positive predictive power and 97% negative predictive power. TABLE 6 Classification of Depressed and Nondepressed Hmong With the HABDI p p
-
-
Actual Diagnosis Depressed
Nondepressed
Test Classificution
n
%
n
%
Total
Depressed Not depressed Total
47 3 73
94 6
16 57 50
22 78
63 60 123
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Demographic Factors and Depression Pearson product-moment correlations were computed to determine the associations of various demographic variables with HABDI scores. As predicted, age correlated significantly with depression score (r = .43, p < .001), indicating that younger Hmong tended to have fewer depressive symptoms than older Hmong. Education was also significantly (negatively) correlated with depression (r = - .51, p < .001), suggesting that as education in the U.S. increases, depressive symptoms in Hmong individuals tend to decrease. English-speaking ability (and need for an interpreter) were also significantly associated with depression ( r = - .47, and r = .50, respectively, both p < .001), as Hmong who did not speak English well and who needed interpreters tended to report more depression than those who had a better grasp of the English language. Hmong who felt satisfied with their social support systems tended to report less depression than those who were relatively dissatisfied with their social supports (r = .37, p < .001). On the other hand, length of stay in the U.S., the actual number of persons constituting social support, and the number of relatives considered social support were not found to be related to depression. The correlations between the HABDI scores and the demographic variables are displayed in Table 7. A simultaneous multiple regression of demographic characteristics (the effects of education, English-speaking ability, need for interpreter, gender, age, and time in the U.S.) on depression was computed. The beta weights af these variables were examined to determine the relative importance of each. This analysis revealed that (lack of) education contributed more to the prediction of depression than did either proficiency in English or the need for an interpreter. Higher levels of education appear to be associated with lower depression scores. The analysis further indicates that gender, age, and education ~redict37% of the total variance in depression scores, with the other variables contributing very little above this amount (see Table 8). TABLE 7
Correlations Between HABDI Scores and Demographic Variables Variables
As. Length of stay in US. Education (years) English-speakingability Need of interpreter Number of social support Gender of social support Relatives as social support Satisfaction with social support
r
HMONG ADAPTATION OF BDI TABLE 8 Multiple Regression of Demographic Variables on Depression Variables
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Gender Age Educatton Length of stay in the U.S. English-speaking ability Need for interpreter Constant
B
Standard Error of B
4.245 .202 - .699 .472 - 1.749 -1.148 29.406
1.627 .075 .255 .245 2.256 1.895 8.948
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-
Beta
T
.I95 .227 - .336 .I73 -.PO2 - .090
2.609* 2.667** -2.740** 1.922 .775 -0.606
-
Note. R = .633. F(6, 116) = 12.966, p < .001. R' = .370. *p < .05. **p < .01.
A second regression analysis of social support variables was conducted by entering level of social support, satisfaction with support, and gender of support in the regression analysis at the same time. Inspection of the beta weights for these variables indicated that the level of social support and the gender of social support were not significant predictor variables. On the other hand, satisfaction with social support rkrnained the best predictor for depression. As the beta weights remove the influence of the other variables in this analysis, this indicates that, among the social support variables, satisfaction is the most important predictor of level of depression even when the amount of social support is controlled. Satisfaction with social support accounted for 16% of the total variance in depression, whereas the other variables explained very little (see Table 9).
DISCUSSION Psychometric Properties The findings obtained in this study indicate that the HABDI is a highly reliable and useful instrument in assessing depression in Hmong individuals. The entire TABLE 9
Multiple Regression of Social Support on Depression Variables
B
Standard E m of B
Social support Satisfaction with support Gender of social support Constant
- .068 2.142 1.913 35.100
.052 .560 1.777 3.019
Note. R = .403. F(3, 199) = 7 . 6 7 9 , ~< .001. R2 = .162. *p < .001.
--
Beta
T
.I12 .332 .093
1.306 3.825* 1.076
-
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scale showed high test-retest reliability with a comparably high level of internal consistency. It also yielded an accuracy rate of 94% in identifying depressed Hmong individuals and of 78% in identifying nondepressed Hmong. The superiority of this instrument's sensitivity and specificity to depression relative to previously translated instruments in Hmong (Westermeyer, 1986) is attributable to the attention to format as well as content issues, which ensured it was readily understood by depressed and nondepressed Hmong. The expression of depressive symptoms differs across cultures (Marsella, 1978) and these differences (including relative priority of emotional, somatic, interpersonal, and energy related experiences) require careful attention to detail in wording and format to create effective assessment instruments. Analysis of the items suggested that subjects used the three response categories equally for most items. The exceptions were to items describing sadness, pessimism, and helplessness, which over 75% of the respondents indicated they experience "some" or "often." This is consistent with the history of losses, trauma, and difficulties acculturating that most Hmong exhibit (Cerhan, 1990). Despite the tendency toward severity in the distributions of the three symptoms just mentioned, the item-total correlations indicate that all of the items in the HABDI were measuring the same construct that the total score assessed.
Demographic Variables and Depression Age related significantly to the total depression score, consistent with earlier findings that older adult refugees have more depressive symptoms than their younger counterparts (Nicassio, 1983; Westermeyer, Vang, & Neider, 1983). As predicted, English-speaking ability and the need for an interpreter as well as education were all strongly related to depression. Our findings confirmed those of Krupinski and Burrows (1986) and Nicassio (1983), which indicated that Southeast Asian refugees who can speak English are less alienated and depressed than those who only communicate in their native languages. When Englishspeaking ability, need for an interpreter, and education were analyzed together, lack of education best accounted for the variance in depression. The factors required to pursue advanced educational goals are perhaps incompatible with depression-relatedsymptoms such as apathy, lethargy, low energy, and feelings of hopelessness and helplessness. Unexpectedly, length of stay in the U.S. was not a significant factor in predicting depression, suggesting that Hmong who came to the U.S. earlier tend to be as depressed as those who arrived recently. This finding may be related to Scott's (1982) study which described the formation of Hmong enclaved communities for maintaining their own customs and beliefs. This may inhibit their learning the mainstream's values and language, which may in turn create more isolation. These Hmong may be expected to continue to feel inadequate,
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underproductive, and uncertain about their future regardless of their length of time in the U.S. Total amount of social support and number of relatives used as social support also were not related significantly with depression, whereas satisfaction with social support was the best predictor of depression. This finding corroborates the results of other investigators (Golding & Burnam, 1990) who also found that perceived social support outweighs actual support in its buffering effect against the negative consequence of stress. The findings from this study suggest that service providers who work with Hmong refugees should take quality of social support into consideration as a significant buffer against depression. In conclusion, the HABDI is a useful screening tool for depression. Individuals who can read Hmong can complete the HABDI themselves; for those who cannot, an interpreter can administer the measure orally. Furthermore, apart from its clinical utility, the HABDI provides an excellent opportunity to explore the factor structure of Hmong versus Western (e.g., Euro-American) expression of depressive symptomatology. The way it was adapted to Hmong culture and language rather than being merely translated contributes to its usefulness. This study underscores the importance of attending to format as well as cont(ent issues when transforming existing instruments for use with other cultures.
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Lillian G. Brown California School of Professional Psychology 1350 M Street Fresno, CA 93721 Received October 8, 1990
