Evaluating the cross-cultural measurement invariance of the PHQ-9 between American Indian/Alaska Native adults and diverse racial and ethnic groups

Background: The Patient Health Questionnaire-9 (PHQ-9), a self-reported depression screening instrument for measurement-based care (MBC), may have cross-cultural measurement invariance (MI) with a regional group of American Indian/Alaska Native (AI/AN) and non-Hispanic White adults. However, to ensure health equity, research was needed on the cross-cultural MI of the PHQ-9 between other groups of AI/AN peoples and diverse populations. Methods: We assessed the MI of the one-factor PHQ-9 model and five previously identified two-factor models between non-Hispanic AI/AN adults (ages 18–64) from healthcare systems A (n = 1759) and B (n = 2701) using secondary data and robust maximum likelihood estimation. We then tested models for full or partial MI between either combined or separate AI/AN groups, respectively, and Hispanic (n = 7974), White (n = 7,974), Asian (n = 6988), Black (n = 6213), and Native Hawaiian/Pacific Islander (n = 1370) adults from healthcare system B. All had mental health or substance use disorder diagnoses and were seen in behavioral health or primary care settings from 1/1/2009 to 9/30/2017. Results: The one-factor PHQ-9 model was partially invariant, with two-factor models partially, or in one case fully, invariant between AI/AN groups. The one-factor model and three two-factor models were partially invariant between all seven groups, while a two-factor model was fully invariant and another partially invariant between a combined AI/AN group and other racial and ethnic groups. Conclusions: Achieving health equity in MBC requires ensuring the cross-cultural validity of measurement tools. Before comparing mean scores, PHQ-9 models should be assessed for individual racial and ethnic group fit for adults with mental health or substance use disorders.

Abstract licence: CC BY-NC-ND

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