C.N. Igwesi-Chidobe1, R.C. Muomah2, I.O. Sorinola3, E.L. Godfrey4,3
1University of Nigeria, Department of Medical Rehabilitation, Enugu, Nigeria, 2University of Nigeria, Department of Psychological Medicine, Enugu, Nigeria, 3King's College London, Department of Physiotherapy, London, United Kingdom, 4King's College London, Department of Psychology, London, United Kingdom

Background: Recent qualitative studies of people living with chronic low back pain (CLBP) in rural Nigeria and the practitioners they consulted revealed emotional distress in ‘a life of living death’, explaining participants’ prolonged hopelessness due to CLBP. Participants described ‘tiredness’ in relation to depression; ‘escaping from the self’ associated with extreme distress; and feelings of ‘something moving about the body’. The Hospital Anxiety and Depression Scale (HADS), is one of the best measures for assessing emotional state because it differentiates anxiety and depressive symptoms from somatic symptoms of physical illness.

Purpose: To cross-culturally adapt and psychometrically evaluate the Igbo-HADS.

Methods: Translation, cultural adaptation, test-retest measurements and cross-sectional study of psychometric properties. The HADS was forward/back translated by clinical/non-clinical translators and evaluated by an expert review committee. The questionnaire was pre-tested/piloted amongst twelve people with CLBP in a rural Nigerian community utilising the ‘think-aloud’ cognitive interviewing. Internal consistency, test–retest reliability, and responsiveness were assessed with Cronbach’s alpha, intraclass correlation coefficient and Bland–Altman plots, and minimal detectable change respectively, amongst 50 adults with CLBP in rural and urban Nigeria communities. Construct validity was investigated using Pearson’s correlation analyses with the Igbo versions of Roland Morris Disability Questionnaire (Igbo-RMDQ), World Health Organisation Disability Assessment Schedule (Igbo-WHODAS), Fear Avoidance Beliefs Questionnaire (Igbo-FABQ) and the eleven-point box scale of pain intensity (BS-11); and exploratory factor analysis with 200 adults with CLBP in rural Nigerian communities.

Results: Idioms and colloquialisms were difficult to translate. Of the seven items for each subscale, only two items for each subscale reflected the original items after forward/back translation. An Igbo clinical psychologist in the expert review committee advised on the use of equivalent Igbo idioms and colloquialisms. Examples included replacing ‘wound up’ with its Igbo equivalent ‘not relaxed’, and ‘butterflies in the stomach’ with its Igbo equivalent ‘my breathing flying out of my stomach’. Participants understood the initial translation of ‘restless’ as ‘useless in life’. Hence, ‘I don’t have rest’, understood as ‘restless’, was used instead in combination with ‘I am not able to stay still…,’ to reflect the original item.
Internal consistency was good (α = 0.78) and acceptable (α = 0.67) for the anxiety and depression subscales respectively. Intraclass correlation coefficients were very good (ICC ≃ 0.8) for both subscales. Minimal detectable change was 6.23 and 5.06 for the anxiety and depression subscales respectively. The Igbo-HADS and the anxiety subscale had strong correlations (≃ 0.7) with generic self-reported disability (Igbo-WHODAS); high moderate correlations (≃ 0.5-0.6) with pain intensity (BS-11), self-reported back pain-specific disability (Igbo-RMDQ), and fear avoidance beliefs (Igbo-FABQ). The depression subscale had the lowest correlations (≃ 0.3-0.4) with these measures. A two-factor solution of the Igbo-HADS was produced with cross-loading of items.

Conclusion(s): The Igbo-HADS is a measure of emotional distress in Nigeria.

Implications: Anxiety and depression may be articulated differently in rural Nigeria possibly due to the expression of emotional distress through somatisation. This has important implications for the use of the HADS in rural Nigeria.

Funding, acknowledgements: Tertiary Education Trust Fund, Nigeria; Schlumberger Faculty for the Future Fellowship grant, The Netherlands.

Keywords: Anxiety, Depression, Chronic low back pain

Topic: Pain & pain management

Did this work require ethics approval? Yes
Institution: Kings College London and University of Nigeria Teaching Hospital
Committee: Kings College London; University of Nigeria Teaching Hospital
Ethics number: (Ref: BDM/13/14-99); Ref: UNTH/CSA/329/Vol.5

All authors, affiliations and abstracts have been published as submitted.

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