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Journal of Mental Health,

August 2008; 17(4): 424434

Measuring psychological distress symptoms in individuals

living with HIV in western Kenya



Department of Psychiatry, School of Medicine, Washington University, St. Louis, Missouri, USA,
Department of Applied Health Science, Indiana University, Bloomington, Indiana, USA, 3Department
of Biostatistics, School of Medicine, Indiana University, Indianapolis, Indiana, USA, 4Department of
Sociology, Indiana University, Bloomington, Indiana, USA, 5School of Medicine, Moi University,
Eldoret, Kenya, and 6AMPATH Support Network, Moi University, Eldoret, Kenya

Background: As the HIV-related infrastructure continues to develop in sub-Saharan African
countries, it will be important to consider appropriate mechanisms that will support attention to
psychological distress among those seeking care and treatment.
Aim: The purpose of this study was to assess the reliability and validity of the Brief Symptom
Inventory (BSI) in order to consider its potential for use in measuring psychological distress symptoms
among individuals living with HIV in Kenya.
Method: Data were collected from a convenience sample of 397 individuals living with HIV who were
participating in psychosocial support groups as part of their care in a large HIV-related treatment and
prevention program in western Kenya. Internal consistency, factorial validity, and convergent validity
analyses were conducted to measure the reliability and validity of the BSI. Test-retest reliability
measures were conducted with a sample size of 187. Content validity was assessed during four singlegendered focus groups, in which a total of 24 individuals participated.
Results: Multiple analyses revealed test-retest reliability levels ranging from .51 to .95 on the BSI
subscales and overall global severity index.
Conclusions: The findings suggest that the BSI may serve as a reliable instrument for assessing
psychological distress in Kenya. However, further research is needed to continue understanding issues
associated with the measurement of psychological distress in this particular country and across its
cultural groups.
Declaration of interest: None.

Keywords: Kenya, HIV, AIDS, mental health, psychological distress, BSI, reliability, validity

Significant advances have been made toward improving the efficacy and availability of medical
treatments for Human Immunodeficiency Virus (HIV) infection yet the epidemic continues to
present numerous challenges to the quality of life and wellbeing of those living with this disease
(Nilsson-Schonnesson, 2002). Research has demonstrated that individuals living with HIV have
Correspondence: Enbal Shacham, PhD, Department of Psychiatry, 40 N. Kingshighway, Suite 4, Washington University School of
Medicine, St. Louis, MO 63108, USA. Tel: 1 314 286 2499. Fax: 314 285 2265. E-mail:
ISSN 0963-8237 print/ISSN 1360-0567 online Shadowfax Publishing and Informa UK Ltd.
DOI: 10.1080/09638230701530192

HIV and psychological distress in Kenya


significantly higher levels of psychological distress than the general population and are impacted
by fluctuating levels of distress as HIV progresses (Atkinson & Grant, 1994; Blechner, 1997;
Burnam et al., 2001; Kalichman, 1998; McShane et al., 1994; Perkins et al., 1994; Perry et al.,
1990; Perry et al., 1993; Reece, 2003; Treisman et al., 2001). It is well known that during periods
of such psychological distress individuals with a chronic illness have more difficulty in engaging in
behaviors that are health promoting (Arnsten et al., 2002; Paterson et al., 2000; Singh et al., 1996;
Tucker et al., 2003). Therefore, continuing to understand and respond to psychological distress is
important as systems of care continue to increase their capacity to meet the needs of individuals
living with HIV throughout the world (Reece et al., 2005).
Given that psychological distress has been recognized as an important factor to be
addressed in HIV prevention and care programs in areas of the world with well-developed
HIV-related infrastructures, and the extent to which the lessons learned in these countries
are informing the development of programs in countries like Kenya, understanding the
nature of psychological distress among individuals in African countries will be important as
we attempt to be responsive to the psychological correlates of health promoting behaviors
that are the focus of these developing HIV-related programs.
Limited research has explored mental health in sub-Saharan Africa (Carson et al., 1998,
Ice & Yogo, 2005; Kiima et al., 2004) but this research has not been specific to HIV. This
region currently accounts for 60% of the worlds HIV prevalence (UNAIDS, 2005). In
Kenya, it is estimated that 6.7% of the adult population is living with HIV, ranking Kenya
fourth in HIV prevalence among sub-Saharan nations (UNAIDS, 2005).
To assess these mental health issues necessitates measures that are reliable and valid (Kellett
et al., 2003). Currently, no instruments have been assessed for their psychometric properties
among individuals living with HIV in Kenya and there is a need to identify tools that can be
used as mental health services are developed there. There are measures that have demonstrated
high levels of reliability and validity for use among individuals living with HIV in the U.S.
The Brief Symptom Inventory (BSI) is one such measure that has been used to assess
psychological distress among individuals living with HIV (Derogatis, 1977; Derogatis &
Melisaratos, 1983; Derogatis & Spencer, 1982; Perkins et al., 1994; Perry et al., 1990; Perry
et al., 1993; Reece, 2003; Reece et al., 2004). The BSI is a shortened version of the original
Symptom Checklist-90 (SCL-90) and was developed to be self-administered to individuals
comfortable reading sixth-grade American English. The BSI consists of 53 items that ask
participants to recall the presence of symptoms within the seven days prior to completing the
measure. Of the 53 items, 49 collectively measure nine different dimensions of psychological
distress, including: anxiety, somatization, obsessive-compulsive, interpersonal sensitivity,
depression, hostility, phobic anxiety, paranoid ideation, and psychoticism. The responses
for each item are arranged on a Likert-type scale that ranges (0 4) from not at all to
extremely (Derogatis & Melisaratos, 1983; Derogatis & Spencer, 1982). In addition to
the nine psychological distress dimensions, the BSI provides three global indices, the global
severity index (GSI), positive symptom total (PST), and the positive symptom distress index
(PSDI) that offer a composite assessment of an individuals overall psychological well-being
(Derogatis, 1993).
Initial reliability assessments of the BSI demonstrated internal consistency (Cronbachs
alpha coefficients) that ranged from a low of .71 on the psychoticism dimension to a high of
.85 on the depression dimension. Also, test-retest assessments of reliability resulted in
correlation values that ranged from a low .68 on the somatization dimension to a high of .91
on the phobic anxiety dimension. In convergent validity assessment, the BSI correlated
highly with the associated dimensions on the SCL-90, which strengthened the argument to
shorten the SCL-90 to the BSI (Derogatis & Melisaratos, 1983; Derogatis & Spencer, 1982).


E. Shacham et al.

Initial factorial validity of the BSI was assessed with an exploratory principal component
analysis, which anticipated the identification of nine theoretically-defined dimensions. Nine
interpretable factors were derived and accounted for 44% of the variance (Derogatis &
Melisaratos, 1983; Derogatis & Spencer, 1982).
Convergent validity analyses have been conducted with other symptom measures
including those of the Social Comparison Scale (Gibbons & Buunk, 1999), the Beck Depression Inventory (Beck et al., 1961), Life Satisfaction Scale (Diener et al., 1985), the Minnesota
Multiphasic Personality Inventory (MMPI) (Butcher et al., 1989), and Eysenck Personality
Questionnaire (Eysenck & Eysenck, 1975) which resulted in significant correlations with the
BSI (Boulet & Boss, 1991; Ruiperez et al., 2001; Sahin et al., 1998; Sahin et al., 2002. In
several studies, the factor structure of the BSI was examined and limited support was found
for the theorized factors. These studies revealed that the majority of the variance was
accounted by a number of factors other than the proposed nine (Boulet & Boss, 1991; Hayes,
1997; Kellett et al., 2003; Perna et al., 1998; Perry et al., 1990; Perry et al., 1993; Piersma
et al., 1994; Ruiperez et al., 2001; Sahin & Durak, 1994; Sahin et al., 2002).
In cross-cultural and international examinations of the reliability and validity of the BSI, this
scale has shown to hold similar levels of reliability as those detected in the original reliability
and validity assessments of the BSI (Boulet & Boss, 1991; Hayes, 1997; Kellett et al., 2003;
Piersma et al., 1994; Ruiperez et al., 2001; Sahin et al., 1998; Sahin et al., 2002). However
these international assessments of BSI properties have occurred more in Western countries
and there is no data on the BSI in sub-Saharan Africa. Given that the BSI has been a useful
tool in other countries, and particularly useful for HIV in the U.S., it may be an appropriate
tool for assessing psychological distress in African countries, like Kenya, which have been
developing HIV-related programs in partnership with the U.S. and other Western countries.
Purpose of this study
The purpose of this study was to assess the reliability and validity of the BSI for assessing
psychological distress symptoms among individuals living with HIV and seeking HIVrelated psychosocial support in Western Kenya. This study was conducted in order to assess
the potential for using the BSI as a mental health screening tool in a large HIV-related
prevention and treatment program in this region.
Study protocols were approved by both the Institutional Review Board at Indiana
University-Bloomington and the Institutional Research Ethics Committee of Moi University
in Kenya. This study was conducted in a participatory manner by HIV and mental health
researchers and practitioners from the United States and western Kenya in the context of a
long-term collaborative research and practice partnership, the Academic Model for the
Prevention and Treatment of HIV/AIDS (AMPATH), that has existed between Indiana
University and Moi University since 1989 (Einterz, 1989; Einterz et al., 1995; Hannan et al.,
2004; Mamlin et al., 2004; Wools-Kaloustian, et al., 2006).
Participant recruitment
Participants were recruited from nine weekly psychosocial support groups held at Moi
University Teaching and Referral Hospital (MTRH) in Eldoret, Kenya. Kenyan support

HIV and psychological distress in Kenya


group facilitators invited individuals to participate in this study during regularly scheduled
support groups meeting the week prior to data collection. Individuals received a cash
incentive for participation in this study. Those participating received 150 Kenya Shillings
(equivalent to approximately $2.00 US).
Data collection
Data were collected over a two-week period in November 2005. Baseline measures were
completed by all participants and every other individual was invited to return the following
week to complete retest measures. The baseline and retest surveys were administered in
English, although research assistants had access to a version of the BSI that had been
translated into Swahili so that terms could be clarified if questions arose during the study.
The translated version was back-translated to English prior to the study to ensure
consistency with the original instrument.
Four focus groups (n 24) were conducted to assess the content validity of the BSI. The
focus groups were conducted in English given that the English version of the BSI was used
for the study. A Kenyan research assistant co-facilitated the focus groups in order to offer
assistance with the translation of certain terms or phrases. The participants for focus groups
were selected on the basis of their interest in the groups and their comfort with expressing
themselves in English specifically due to the assessment of the English version. Each group
was separated by gender to increase comfort and richness throughout the group discussions
(Debus, 1988). The facilitators were both women and therefore did not match by gender for
the male groups.
Demographic characteristics. Demographic measures included: age, gender (male/
female), tribal affiliation, religion (Catholic, Protestant, Muslim, atheist, other), relationship
status (married, divorced, widowed, significant other/partner, single), number of
children, highest level of education attained (none, standard 1 3, standard 4 8, form
1 2, form 3 4, university), and employment status (unemployed, part-time work, full-time
HIV-related characteristics. HIV-related measures included: HIV and AIDS diagnoses (yes/
no) and length of time since HIV and AIDS diagnoses (months, years). Medical chart
abstractions were conducted to obtain the most recent CD4 cell count for each participant
that had been documented within six months prior to this study.
Brief Symptom Inventory (BSI). All participants completed the BSI in English.
Statistical analyses
Reliability. Evaluation of the reliability of the BSI included analyses of internal consistency
and test-retest reliability. The internal consistency was analyzed for each of the subscales
of the BSI and estimated with Cronbachs alpha coefficients. The intraclass correlation
coefficient (ICC) was computed to analyze the test-retest reliability of the BSI. This ICC
employed a two-way random effects model and single measure approach because the two
measures and participants were conceptualized as random. Therefore, in practice,


E. Shacham et al.

assessments would be conducted randomly and scores would not be an average over
multiple occasions (Shrout & Fleiss, 1979). The ICC was an index of absolute agreement.
That is, index (2, 1) in Shrout and Fleiss (1979) was used. However, because chaotic
events may have occurred between occasions resulting in a mild true score shift for all
participants; two indices of consistency were also inspected: ICC (2, 1) in Shrout and
Fleiss (1979) and the Pearson correlation coefficient.
Validity. Factorial validity analyses were conducted for the BSI as a measure of
psychological distress with nine dimensions, specifically in this cultural context.
Exploratory factor analysis was conducted given that there was no existing data to
support that the original version of the BSI would hold the same properties that had been
demonstrated in Western cultures. A principal component method of factor extraction and
squared multiple correlations were specified as the initial communalities. Items were said
to load on factors if the loadings were greater than or equal to .40 in absolute value.
Convergent validity analyses were conducted to measure the relationship between each of
the BSI dimensions and the Patient Health Questionnaire-9 (PHQ-9) (Kroenke et al.,
2001; Spitzer et al., 1994; Spitzer et al., 1999). Content validity analyses were conducted
using the narrative data that were collected during focus groups that were specifically
conducted to increase knowledge of how participants understood the psychological
distress instruments. The narrative data were analyzed for themes that consistently arose
during the groups.

Participant characteristics
Demographics. The sample included a total of 397 participants, with 71.5% (n 284) being
female and 27% (n 107) being male. The mean age of the sample was 36.4 (SD 7.84)
years with a range of 18 to 61 years. Almost 40% (n 150) of the sample reported being
married, 26% (n 103) were widowed, 24.4% (n 97) were single, and 10.6% (n 42)
were divorced. The average number of children for participants who had them (92.4%,
n 367) was 3.3 (SD 1.9) and the median was 3.0. The average age of having their first
child was 21.6 (SD 5.8). The tribal affiliation reported were primarily Kikuyu (22.9%,
n 91), Luhya (22.4%, n 89), Luo (18.4%, n 73), Kalenjin (12.8%, n 51), and Nandi
(6.5%, n 26). There were 18 other tribes represented, each comprising 2.8% or less of the
present sample. The majority of the sample reported being affiliated with a type of
Christianity (95.4%, n 376).
The highest level of education that was reported as having been completed varied. Just
over 40% (n 161) of the sample completed the equivalent to the American elementary
school system (i.e., Standard 4 8); and 32% (n 127) of the sample completed the
equivalent to American high school (i.e., Form 3 4). The majority of the sample was not
employed (69.7%, n 277), while 10% (n 40) were employed full time.
HIV-related characteristics. The entire sample was living with HIV (100%, n 397). The
mean length of time in which participants reported knowing they were living with HIV was
2.25 years (SD 2.5 years). Forty-three percent of the sample reported having been
diagnosed with AIDS (n 172). The mean time with an AIDS diagnosis was 1.75 years
(SD 2.0). The mean CD4 cell count of the participants (n 342) was 346.90 cells/mm3
(SD 219.83) and the median was 310.00.

HIV and psychological distress in Kenya


BSI reliability
Internal consistency. The internal consistency of the GSI was documented by a Cronbachs
alpha coefficient of .95 (n 201); for the subscales this ranged from a low of .63 on the
psychoticism subscale to a high of .78 on both the depression and anxiety subscales. Table I
provides the internal consistency measures for each of the subscales of the BSI.
Test-retest reliability. A test-retest methodology was used to further assess the reliability of the
BSI. The BSI provides a raw score and a t-score that norms the data based on the original
findings and gender norms associated with psychological distress symptoms (Derogatis,
1993). The t-scores were not used in this study because they were established based on
gender-related considerations in Western cultures and may therefore not have been
appropriate for Kenyan culture. The ICC measure of agreement ranged from a low of .49 on
the psychoticism subscale to a high of .61 on both the anxiety and the hostility subscales,
indicating a moderate degree of agreement between the two time points (Table II). The
agreement version of the ICC for the GSI was .70 indicating higher agreement for the
general index than the subscales. The consistency measures (the ICC index of consistency
and the Pearson correlation) were only slightly larger than the agreement ICC. Consistency
measures are expected to be at least slightly larger. These measures did not differ drastically
from the agreement ICC indicates (along with scatter plots) indicated that there was not a
large constant shift in all participants scores from one time to the other Table II provides the
ICCs of the BSI subscales and GSI.
BSI validity
Convergent validity. The correlations between the depression dimension of the BSI and the
overall PHQ-9 score were calculated to analyze the relationship between the two scales.
Results indicated a moderate-to-large Pearson correlation coefficient of .64. Other
convergent validity analyses of the other subscales of the BSI and the PHQ-9 resulted
with Pearson correlation coefficients of a low of .51 on the hostility scale to a high of .68 on
the anxiety subscale. The PHQ-9 correlated highly with the GSI of the BSI (r .82).
Factorial validity. The sample size for these analyses was dependent on the use of a pairwise
deletion procedure which resulted with a range of 372 to 384. The first factor accounted for
30.43% of the total variance and included five items that scored 0.40 or higher. The oblique

Table I. BSI internal consistency (n 397).

BSI dimensions
Interpersonal sensitivity
Paranoid ideation
Phobic anxiety
Global severity index

Cronbachs alpha coefficient

No. of items on subscale





E. Shacham et al.

Table II. BSI test-retest reliability (n 187).

n (Raw scores)


Absolute agreement

Pearsons correlation
coefficient (r)
Raw score





Intraclass correlation coefficient

BSI dimensions
Interpersonal sensitivity
Paranoid ideation
Phobic anxiety
Global severity index

varimax rotation did not clearly delineate additional factors beyond the one primary factor; it
accounted for 30.44% of the total variance and had seven items with 0.40 or higher. The
secondary factor accounted for 3.05% of the total variance and six items. The scree plot
indicated a single dominant factor.
Content validity. Focus groups were conducted to assess the content validity of the BSI.
These assessments revealed some confusion with regard to participants ability to comprehend the terms in some items. For example, a depression-related item on the BSI that
asks participants about feeling blue, was not understood by most of the participants.
These assessments also revealed some culture-specific challenges with the items on the BSI.
For example, men reported that blocked referred to a physical barrier, like something I
want to do . . . wash my clothes and I have no water, blocked or as one man stated, my feet
hurt, I cannot walk. Additionally, some participants appeared to regard the items on the
BSI as being specific to their HIV infection. One of the men described feeling fear when I
meet someone because of my status in response to never feeling close to another person,
which is another item on the interpersonal sensitivity subscale on the BSI.
The five-point Likert-type scale (0 4) was also challenging for participants. Many
discussed how they could not discern between a little bit and quite a bit. One woman
thought . . . a little and quite a bit mean the same, so I just chose a little bit. During one of
the male groups, there was thorough discussion of the percentage of the time that they
associated with these responses. They deciphered the Likert-type scale to make the
responses relate to the amount of time spent in the last week that they may have felt these
This study was conducted to examine the properties of a widely used psychological distress
assessment (the BSI) in order to assess its potential for use among individuals seeking HIVrelated prevention and care services in western Kenya.
The internal consistency reliability assessments revealed strong correlations (a) across the
dimensions, ranging from a low of .63 on the psychoticism scale to a high of 0.78 both the
anxiety and depression scales and a very high correlation across the GSI (.95). These
findings are comparable to the original internal consistency coefficients established for the

HIV and psychological distress in Kenya


BSI that suggested an expected range of .71 on the psychoticism subscale to a .85 on the
depression subscale (Derogatis & Melisaratos, 1983). Additionally, these findings are
comparable to those of other studies that measured the internal consistency of the subscales
and the GSI, specifically rendering the lowest internal consistency coefficient on the
psychoticism scale (Boulet & Boss, 1991; Hayes, 1997; Kellett et al., 2003; Ruiperez et al.,
2001; Sahin et al., 2002).
The test-retest reliability results suggested moderate reliability for the BSI. The
developers of the scale had stability coefficients results that ranged from a .68 on the
somatization subscale to .91 on the phobic anxiety subscale (Derogatis & Melisaratos,
1983). Other reported estimates of the stability correlations ranged from .65 to .80 across
the dimensions and a GSI correlation of .80 (Piersma et al., 1994; Ruiperez et al., 2001). In
this sample, the test-retest Pearsons correlation coefficients ranged from a low of .46 on
psychoticism to a high of .66 on the GSI, and therefore seems to suggest lower levels of
reliability compared to other studies using this method of analysis. Upon further
investigation, both the consistency and agreement correlations of the ICCs between test
and retest measures were similar for the BSI. This suggests that inconsistent change
occurred among participants from the baseline to retest. Many support group members
chose to participate in data collection sessions rather than attend a support group between
the time the baseline and retest surveys were completed. Therefore, some of the inconsistent
change may be due to elevated levels of distress for those participants who did not participate
in support groups as usual. Thus, the test-retest reliability coefficients are likely capturing
measurement error not systemic error, which is the intention of a reliability coefficient.
Test-retest reliability for psychological distress symptoms may fail to be as consistent as
other stability measures given that the measures are state-determined, and therefore may
vary highly (Derogatis & Melisaratos, 1983). It is conceivable that symptoms of distress
vary regularly among individuals living with HIV in this setting and therefore, the testretest measures may not be an accurate reflection of the true reliability of the BSI in this
sample. In future research, it will be important to further examine reliability of the BSI by
assessing its sensitivity to change among individuals living with HIV over time (Lowe
et al., 2004).
The original validity study utilized a varimax rotation of the principal components; these
methods were replicated even though the items were expected to be intercorrelated
(Derogatis & Melisaratos, 1983). It resulted with nine interpretable dimensions, even
though not all the dimensions loaded all of the appropriate items. The results of this
particular study, regardless of the rotation and number of proposed factors in a principal
components analysis, suggested that only one factor was measured by the BSI in this Kenyan
sample. These results are similar to those of several other studies who were unable to
replicate the subscale structure of the BSI through principal component analyses (Boulet &
Boss, 1991; Hayes, 1997; Kellett et al., 2003; Perna et al., 1998; Piersma et al., 1994;
Ruiperez et al., 2001).
Consequently, factorial validity may not be an accurate method of assessing whether the
BSI is valid for measuring multiple dimensions of psychological distress. The items for each
dimension were purposefully developed to theoretically measure different dimensions of
psychological distress. Content validity may therefore be more appropriate as an assessment
of the validity of the BSI.
The findings of the qualitative data suggest that the validity of the BSI would improve if
some confusing terminology was clarified and items were reassessed for their cultural
appropriateness. Additionally, the Likert-type response scales may not be appropriate for
this population. Response options based on gradation may be more appropriate in a context


E. Shacham et al.

where such gradations are consistent with cultural and linguistic norms. Additionally, this
confusion may also be a result of the labels associated with the five-point Likert-type scale.
A little bit as opposed to quite a bit seemed arbitrary to the Kenyan participants,
although other cultures have routinely accepted these gradations. Using dichotomous
responses rather than Likert-type may be an acceptable way to address these challenges as
has been done by others who have conducted research in Kenya (Ice & Yogo, 2005).
The BSI is a well-established instrument and suggesting a wide range of changes to the
English version seems illogical based on one sample of western Kenyans. It is recommended
however that the instrument be translated and administered entirely in Swahili and its
psychometric properties assessed.
While the cultural context of western Kenya seemed to not necessarily restrict the
feasibility of using the BSI as mental health systems are being developed, further research
should be conducted with more diverse segments of the Kenyan population prior to
implementing the BSI as a standard psychological distress measure for use in this country.

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