To our knowledge, this is the first validated trauma-related mental health assessment tool in Zambia. Standard validity testing of psychological assessments is done with a criterion comparison of a structured clinical interview by mental health professionals, and is generally based on strict criteria to a diagnostic category within the DSM or ICD. There are multiple issues with using this procedure across cultures in low and middle income countries [18
]. First, there are rarely enough mental health professionals available who are knowledgeable about the local culture and local idioms of mental health symptoms. Second, this procedure is based on a Western diagnostic model that may or may not be applicable across cultures. Third, children and adolescents who have experienced trauma are often difficult to fit into existing diagnostic categories, often presenting with a wide range of symptoms [45
]. Therefore, this study did not seek to confirm a diagnosis, but rather to find and validate an instrument that would be useful in identifying local trauma-related symptoms that are seen as problematic within this culture using an alternative and previously used methodology [17
]. Using this methodology, Zambian-specific expressions of trauma obtained from an earlier qualitative study were incorporated into the instrument prior to testing.
The validation method used varied slightly from some past efforts [17
] in that rather than using a key community member or members to identify those with a disorder, we used the self-report by children and caregivers as to whether the child had problems. This method has been used before by Bolton and colleagues [19
], however, research from the West suggests a range of concordance rates between parent and child reports of mental health symptoms in response to a traumatic event [51
]. Although our study identified a number of discordant caregiver/child dyads, this was expected, and not the focus of the analysis. Our focus was on the most probable "cases" and "non-cases", which we identified by finding the caregiver/child dyads who did agree on the case status. Our assumption is that when there is agreement, then it is closer to the true situation. When there is no agreement, we cannot be sure which respondent to 'believe' and thus their case definition is unclear.
This study showed that this adapted PTSD-RI demonstrated good reliability. Similar to previous studies [21
], the Cronbach's alphas demonstrated good internal reliability. The correlations of the local symptoms are comparable to the original 20 items based directly from the DSM criteria suggesting that these are part of the local expression of trauma-related symptoms in children. Although these additional items create a longer measure, our local collaborators expressed interest in retaining them as locally expressed symptoms.
Analysis of the traumatic events data showed many youth reporting more than a single traumatic event. This is similar to other reports of children seeking treatment for sexual abuse [53
]. Since the target population was children who were coming into a One-Stop Centre for sexual abuse, a large majority reported sexual abuse (63%). Although it is known objectively, because of their presence in the Centre, that 100% of the population did in fact experience some form of sexual abuse, it is common for children to deny or avoid reporting this type of event(s) or only report one act of abuse out of shame, embarrassment, fear, or to protect someone if more than one event had occurred. By some estimates between 60-80% of CSA victims withhold disclosure suggesting that many children and adolescents endure prolonged victimization and do not receive any therapeutic intervention [54
]. Studies that examine latency to disclosure report a mean delay from 3-18 years [56
]. Disclosure is essential to recovery as literature suggests that simple acts of disclosing past traumatic experiences to others can exert a positive effect on health and well-being [57
]. Furthermore, disclosure of CSA in particular is often a prerequisite for access to mental health care services [58
Some adolescents who came to the One-Stop Centre may have denied sexual abuse because they saw the sexual encounter(s) as consensual. There is a phenomenon in Zambia called "sugar daddy" whereby young girls may take up with much older men to receive housing, monies and/or other tangible goods. This 'Sugar Daddy Syndrome' is heavily blamed for not only increased cases of child sexual abuse but also for the spread of HIV [60
]. After some time, many adolescents are eventually left or taken back to their families. The parents of such adolescents viewed this situation as sexual abuse because the perpetrators were far older than the adolescents and almost all were over 18 years. These two factors, the shame and/or fear of disclosure and the sense that the experience was not abuse may explain why there were some children (n = 28) reported no traumatic experiences at all, even though we know that they had at least experienced sexual abuse by their presence in the clinic. Denial of trauma is a common problem across all trauma measures [61
In addition to the sexual abuse, there were additional frequently reported traumas including experience of and/or witnessing community violence (38.1%, 26.5% respectively), and seeing a dead body in the community. Although Zambia is a relatively stable country, there is still a degree of violence seen regularly - largely thought to be due to poverty and/or lack of governance (Haworth, unpublished data 2007). A significant number of youth also reported violence in the home, which corroborates with a previous qualitative study where local Zambians reported this to be a significant problem [20
]. Overall, our results support the use of a tool asking about different traumatic experiences, even with populations known to have one specific trauma. This also suggests need for assessing traumatic experiences and symptoms among youth in Zambia to obtain appropriate services since the majority experienced multiple traumas (which remains likely to be an under-estimate) [61
This study showed good discriminant validity of the adapted PTSD-RI. Regardless of the case definition used, the average scores on the two subscales (the original 20 items of the PTSD-RI and the added 18 locally-defined items) were statistically significantly higher among the cases compared to non-cases with a large difference. We can look to the standard cut-offs used with the symptom section of the PTSD-RI in Western-based research as an interesting comparison. Research on the PTSD-RI psychometrics suggests a cut-off of 38 having a sensitivity of 0.93 and specificity of 0.87 in detecting PTSD (21). This is slightly higher than our average case scores (using the case definition of number of validity questions endorsed) on the scale using the original 20-items, but likely due to the strict adherence to the DSM criteria and a formal PTSD diagnosis. The non-case mean scores in this study were indicative of those who would not classify as having symptoms based on previous studies using the PTSD-RI [30
The significant association of symptom scores across increasing numbers of reported traumas confirmed the expectation that higher exposure would be associated with more severe distress, our assessment of concurrent validity [63
The ROC curve analysis provides evidence that the scales can adequately identify cases and non-cases significantly greater than chance. The area under the curve analyses presents adequate results. In utilizing ROC curves to define cut-off scores, it is necessary to consider a variety of factors such as the types of services provided. For example, for use with community settings where the goal may be to serve all that have any need, a lower cut-off may be chosen to maximize sensitivity. In a clinic-based program which seeks to serve more severe cases, or in a case where limited services are available and the goal is to treat the most severely affected, a higher cut-off score may be selected. Our current analyses do not provide information on what appropriate cut-off scores are for different programs.
Child sexual abuse is increasingly being suggested as a major contributor to the HIV/AIDS epidemic through direct transmission, or indirectly through mental health problems and other high-risk behaviors [3
]. HIV/AIDS is one of the most serious public health issues worldwide and sub-Saharan Africa one of the worst affected regions, with significant impact on use of health care services, family and community fabrics, economies, overall quality of life, mortality, and morbidity [66
]. It is critical that greater efforts are put towards understanding the nature of sexual violence and its consequences, using validated measures, and promoting treatment for related issues. The staff at the One-Stop Centre found the psychosocial forms helpful in assessing the child's need for services, particularly as their training is mostly medical (personal communication, 2008), and the Centre has continued using these forms. This suggests that incorporating structured mental health assessments into existing medical structures in low-resource countries can be acceptable and feasible.