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ORIGINAL ARTICLE
Year : 2016  |  Volume : 29  |  Issue : 1  |  Page : 126-130

Validity of the General Health Questionnaire as a screening tool for mental health disorders among secondary school students (Menoufia Governorate)


Department of Public Health and Community Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission11-Feb-2015
Date of Acceptance04-Apr-2015
Date of Web Publication18-Mar-2016

Correspondence Address:
Nasser EM Gebril
MBBCh, Alcawady Village, Ashmoun, Menoufia Governorate, 32511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.179002

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  Abstract 

Objective
The aim of this study was to assess the validity of the Arabic version of the 30-item General Health Questionnaire (GHQ-30) and the prevalence of psychiatric morbidity among the studied students in Menoufia governorate, Egypt.
Background
The GHQ was developed by Goldberg in the 1970s. It has been translated into many languages, and it is extensively used in different settings and different cultures. A Medline and an Egyptian literature search showed no study that validated the Arabic version of the GHQ-30 in primary healthcare in Egypt.
Participants and methods
A cross-sectional comparative study was carried out in 454 secondary school students in Ashmoun city, Menoufia governorate, Egypt. Socioeconomic standard application, Arabic version of the GHQ-30, and Structured Clinical Interview according to DSM-IV were administered to 454 students.
Results
Using the Structured Clinical Interview of DSM-IV for studied groups, the prevalence of psychiatric disorders was 16.7%. Anxiety disorders were the most common in the sample with an incidence of 10.3%, including phobia (3.7%), generalized anxiety disorder (3.3%), and obsessive compulsive disorder (3.3%). The incidence of depressive disorder was 4.8%, conduct disorder was 1.1%, and that of adjustment disorder was 0.4%.
This study has shown that the Arabic version of GHQ-30 is a valid and useful screening instrument of psychiatric morbidity in a primary care setting in Egyptian patients. The best cutoff point was found to be 38 between sensitivity (77%) and specificity (78%). The principal component analysis with the varimax rotation of the Arabic version of GHQ-30 was found to contain four underlying factors. These factors were identified as psychological distress, self-esteem, daily life activities, and social relationships.
Conclusion
The Arabic version of GHQ-30 was found to have satisfactory internal consistency and construct validity, and it was a useful instrument for assessing the psychological well-being of secondary school students.

Keywords: General Health Questionnaire, mental health disorders, validity


How to cite this article:
Abdel-Rasoul GM, Mahrous OA, El Shazly HM, Kasemy ZA, Elbahy MS, Gebril NE. Validity of the General Health Questionnaire as a screening tool for mental health disorders among secondary school students (Menoufia Governorate). Menoufia Med J 2016;29:126-30

How to cite this URL:
Abdel-Rasoul GM, Mahrous OA, El Shazly HM, Kasemy ZA, Elbahy MS, Gebril NE. Validity of the General Health Questionnaire as a screening tool for mental health disorders among secondary school students (Menoufia Governorate). Menoufia Med J [serial online] 2016 [cited 2019 Sep 21];29:126-30. Available from: http://www.mmj.eg.net/text.asp?2016/29/1/126/179002


  Introduction Top


The General Health Questionnaire (GHQ) was developed by Goldberg in the 1970s [1]. It has been translated into many languages and it is extensively used in different settings and different cultures [2]. A Medline and an Egyptian literature search showed no study that validated the Arabic version of the 30-item GHQ (GHQ-30) in primary healthcare in Egypt.

Many mental disorders have their onset during childhood or adolescence. The prevalence of any psychiatric disorder in the adolescent general population is estimated to be about 20-25%. During adolescence and young adulthood, mood disorders comprise one of the most prevalent diagnostic categories [3].

Depressive disorders are common among children and adolescents [4]. They impair psychosocial functioning and are often accompanied by comorbid psychopathology [5]. Despite its detrimental effects, pediatric depression is often undertreated.

The risk for depression increases during childhood [6]. The 1-year prevalence and lifetime prevalence rates of depression are even higher. A survey of adolescents aged 12-17 years in the USA (n > 45 000) during 2010 and 2011 found that the 1-year prevalence rate for major depression was 8% [4]. Another study found that the lifetime prevalence rate in adolescents was 11% [7].

Depression was prevalent in a sample of Egyptian female secondary school students. Hence, there is a need for better screening, psychoeducational programs, and services for better identification, early intervention, and targeting for those at risk [8].

The GHQ is by far the most popular screening instrument for mental illnesses [9]. It is a self-reporting questionnaire developed by Goldberg (1970) to detect functional psychiatric disorders in the community and primary care settings. It has been extensively tested in various cultures and linguistic groups showing good validity results [10]. The GHQ should be standardized on the basis of the population where it is to be applied, because validity coefficients obtained in one setting do not necessarily hold in another. Therefore, validation of a screening instrument such as the GHQ in the patients' language takes a little time and is important in epidemiological research to improve detection and recognition of psychiatric morbidity [3].


  Participants and methods Top


The study design was cross-sectional and was carried out in Ashmoun city, Menoufia governorate secondary schools. Multistage random sampling technique was used. After taking oral consent from each student included in the study, they were subjected to socioeconomic standard application, Arabic version of the GHQ-30, and the Diagnostic and statistical manual of mental disorders, 4th ed. (DSM-IV).

In our study, we used the psychiatric evaluation through Structured Clinical Interview of DSM-IV to diagnose psychiatric disorders as a gold standard to test the sensitivity and specificity of the Arabic version of the GHQ-30.

Data management

Receiver operating characteristic (ROC) curve is a graphic representation of the relationship between sensitivity and specificity for a diagnostic instrument [Figure 1] [11].
Figure 1: Receiver operating characteristic (ROC) curve for 30-item General Health Questionnaire and clinical diagnosis.

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The internal consistency of the GHQ-30 in the present study was tested using Cronbach's α. Kaiser-Meyer-Olkin measure of sampling adequacy determines the suitability of using factor analysis on data, whereas Bartlett's test of sphericity is used to determine the appropriateness of the sample size for conducting the analysis.

Subsequently, the factor structure of the GHQ was obtained by performing a principal component analysis with varimax rotation. The number of factors was determined by eigenvalue greater than 1 [Figure 2].
Figure 2: Screen plot for factor analysis.

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  Results Top


On comparing the clinical positive group and the clinical negative group as regards the distribution of sociodemographic characteristics, there were no significant differences between students [Table 1].
Table 1: Distribution of the clinical diagnosis results based on their characteristics

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However, on comparing the positive GHQ group and the negative GHQ group as regards the distribution of sociodemographic characteristics, there were no significant differences between students. As regards sex, the proportion of female participants was significantly higher among students with positive GHQ (85.9%) compared with students with negative GHQ (67%) (P < 0.001) [Table 2].
Table 2: Distribution of the 30-item General Health Questionnaire results based on their characteristics

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The ROC curve of GHQ-30 itself is a good indicator of clinical psychiatric diagnosis.

The best cutoff that maximizes sensitivity and specificity is 38. At that score, the sensitivity was 0.77 and specificity was 0.78 (1−specificity = 0.22) [Figure 1].

The ROC curve of GHQ-30 itself is a good indicator of clinical psychiatric diagnosis among male participants.

The best cutoff that maximizes sensitivity and specificity is 33.5. At that score, the sensitivity was 0.93 and specificity was 0.75 (1−specificity = 0.25) [Figure 1] and [Table 3].
Table 3: Distribution of the studied groups based on the cutoff point 38 of 30-item General Health Questionnaire

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  Discussion Top


This study has shown that the GHQ-30 is a valid and useful screening instrument of psychiatric morbidity in a primary care setting in Egyptian patients. The best cutoff point was found to be 38, which is comparable to that recommended by Goldberg for general practice settings [10], whereas corresponding cutoff scores of the GHQ-30 for male and female participants were 33.5 and 39.5, respectively.

This cutoff point represented the best trade-off between sensitivity (77%) and specificity (78%). Although the validity of the GHQ-30 in our study was not high, it was still in the range reported in many other studies [1,12-14]. Even though Goldberg [13] reported higher sensitivity and specificity values, other studies conducted in British and USA communities reported lower values for sensitivity and specificity comparable to that reported in our results.

Construct validity was also supported by a logical four-factor solution that explained 40.8% of the variance. According to Goldberg and Williams [15], most factor analyses of the GHQ-30 tend to yield between four and six factors, which account for approximately half of the variance. In addition, the four factors extracted from the factor analysis in the present study seemed to cover dimensions supported by former testing studies of the instrument in different countries and settings [16]. In the present study, items covering these dimensions were distributed on four factors, although most of the items were included in one factor explaining 25.43% of the variance. The principal component analysis with the varimax rotation was performed on the GHQ-30. The results are shown in [Table 5]. The GHQ-30 was found to contain four underlying factors. These factors were identified as psychological distress, self-esteem, daily life activities, and social relationships, which altogether accounted for 40.8% of the variance.

The Arabic version of the GHQ-30 was found to have satisfactory reliability in terms of internal consistency and construct validity [Table 4].
Table 4: Factor analysis for General Health Questionnaire

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Table 5: Principal component analysis with varimax rotation of Arabic version of 30-item General Health Questionnaire for
the study group (rotated component matrix)


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Using the structured clinical interview of DSM-IV for studied groups, the prevalence of psychiatric disorders was 16.7%. Anxiety disorders were the most common in the sample with an incidence of 10.3%, including phobia (3.7%), generalized anxiety disorder (3.3%), and obsessive compulsive disorder (3.3%). The incidence of depressive disorder was 4.8%, conduct disorder was 1.1%, and that of adjustment disorder was 0.4%.

This study has shown that the Arabic version GHQ-30 is a valid and useful screening instrument of psychiatric morbidity in a primary care setting in Egyptian patients. The best cutoff point was found to be 38 between sensitivity (77%) and specificity (78%). The principal component analysis with the varimax rotation of the Arabic version GHQ-30 was found to contain four underlying factors. These factors were identified as psychological distress, self-esteem, daily life activities, and social relationships.

The Arabic version of the GHQ-30 was found to have satisfactory reliability in terms of internal consistency and construct validity. In the present study, the chosen cutoff scores using Likert format scoring of the GHQ-30 was 38.


  Acknowledgements Top


The authors thank all students and participants who generously agreed to participate, and the administrator of the secondary schools who facilitated the access to the study group, especially the social worker.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Goldberg DP. The detection of psychiatric illness by questionnaire (Maudsley monograph, no. 21). London: Oxford University Press; 1972.  Back to cited text no. 1
    
2.
Chan DW. The Chinese version of the General Health Questionnaire: does language make a difference?. Psychol Med 1985; 15 :147-155.  Back to cited text no. 2
    
3.
Wittchen HU, Nelson CB, Lachner G. Prevalence of mental disorders and psychosocial impairment in adolescents and young adults. Psychol Med 1998; 28 :109-126.  Back to cited text no. 3
    
4.
Perou R, Bitsko RH, Blumberg SJ, Pastor P, Ghandour RM, Gfroerer JC, et al. Centers for Disease Control and Prevention (CDC). Mental health surveillance among children - United States, 2005-2011. Morb Mortal Wkly Rep Surveill Summ 2013; 62 :1-35.  Back to cited text no. 4
    
5.
Zuckerbrot RA, Cheung AH, Jensen PS, Stein RE, Laraque D, GLAD-PC Steering Group. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management. Pediatrics 2007; 120 :e1299-e1312.  Back to cited text no. 5
    
6.
Wesselhoeft R, Sørensen MJ, Heiervang ER, Bilenberg N. Subthreshold depression in children and adolescents - a systematic review. J Affect Disord 2013; 151 :7-22.  Back to cited text no. 6
    
7.
Avenevoli S, Swendsen J, He JP, Burstein M, Merikangas KR. Major depression in the national comorbidity survey - adolescent supplement: prevalence, correlates, and treatment. J Am Acad Child Adolesc Psychiatry 2015; 54 :37-44.  Back to cited text no. 7
    
8.
Rabei AA, Abdel-Rasoul GM, Omaima AM, Nabil RM, Reda AI. Prevalence of depression, anxiety, and obsessive-compulsive disorders among secondary school students in Menoufiya governorate. Menoufia Med J 2013; 26 :44-48.  Back to cited text no. 8
    
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Mayou R, Hawton K. Psychiatric disorders in the general hospital. Br J Psychiatry 1986; 149 :172-190.  Back to cited text no. 9
    
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Goldberg D. Use of the general health questionnaire in clinical work. Br Med J (Clin Res Ed) 1986; 293 :1188-1189.  Back to cited text no. 10
    
11.
Zweig MH, Campbell G. Receiver-operating characteristic (ROC) plots: a fundamental evaluation tool in clinical medicine. Clin Chem 1993; 39 :561-577.  Back to cited text no. 11
    
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Goldberg DP, Blackwell B. Psychiatric illness in general practice. A detailed study using a new method of case identification. Br Med J 1970; 1 :439-443.  Back to cited text no. 12
    
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Goldberg D. Identifying psychiatric illness among general medical patients. Br Med J (Clin Res Ed) 1985; 291 :161-162.  Back to cited text no. 13
    
14.
Tarnopolsky A, Hand DJ, McLean EK, Roberts H, Wiggins RD. Validity and uses of a screening questionnaire (GHQ) in the community. Br J Psychiatry 1979; 134 : 508-515.  Back to cited text no. 14
    
15.
Goldberg D, Williams P. A user′s guide to the General Health Questionnaire. Windsor: NFER-NELSON Publishing Company Ltd; 1988.  Back to cited text no. 15
    
16.
McDowell I. Measuring health. A guide to rating scales and questionnaire. 3rd ed. New York: Oxford University Press; 2006.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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