key: cord-0747240-fqmh8piu
authors: Khaled, Salma M.; Petcu, Catalina; Bader, Lina; Amro, Iman; Al‐Assi, Marwa; Le Trung, Kien; Mneimneh, Zeina N.; Sampson, Nancy A.; Kessler, Ronald C.; Woodruff, Peter W.
title: Conducting a state‐of‐the‐art mental health survey in a traditional setting: Challenges and lessons from piloting the World Mental Health Survey in Qatar
date: 2021-07-05
journal: Int J Methods Psychiatr Res
DOI: 10.1002/mpr.1885
sha: 5abcbcc01feb3d8a1b3baa913645381f20032e36
doc_id: 747240
cord_uid: fqmh8piu

OBJECTIVES: A small country in the Arabian Peninsula, Qatar experienced rapid economic growth in the last 3 decades accompanied by major socio‐demographic shifts towards a younger and more highly educated population. To date, no national epidemiological study has examined the prevalence, associated factors, or sequelae of mental disorders in Qatar's general population. METHODS: The World Mental Health Qatar (WMHQ) is a national mental health needs assessment survey and is the first carried out in collaboration with the World Mental Health Survey initiative to assess the prevalence and burden of psychiatric illnesses among the full Arabic speaking population (nationals and non‐nationals) within the same country. RESULTS: Standard translation and harmonization procedures were used to develop the WMHQ instrument. A survey quality control system with standard performance indicators was developed to ensure interviewer adherence to standard practices. A pilot study was then carried out just prior to the COVID‐19 pandemic. Endorsement from public health authorities and sequential revision of the interview schedule led to full survey completion (as opposed to partial completion) and good overall response rate. CONCLUSIONS: The WMHQ survey will provide timely and actionable information based on quality enhancement procedures put in place during the development and piloting of the study.

Mental disorders are a leading health concern globally (Rehm & Shield, 2019; Scott et al., 2018; Vigo et al., 2016; Whiteford et al., 2016) and of increasing interest within the Arab world (El Rassi et al., 2018; Karam & Itani, 2015; Maalouf et al., 2019; Zeinoun et al., 2020) . Disability-adjusted life years attributable to mental disorders in Arab countries have been reported to be higher than the global average (Charara et al., 2017; Maalouf et al., 2019; Mokdad et al., 2016) . The Global Burden of Disease study estimates that mental and substance misuse disorders account for a higher proportion of global years lived with disability in Qatar (36.7%) than any other country (21% median, 15.4-36.7% range) (Vos et al., 2015) .

However, this estimate is a projection based on a simulation across many countries and have been criticized for yielding inaccurate estimates for individual countries (Vigo et al., 2016) . Actual needs assessment survey data collected in the country are necessary to determine the true burden of mental disorders. To date, no national epidemiological study of this sort has been carried out in Qatar.

Qatar is a small country in the Arabian Peninsula that has witnessed a rapid pace of urbanization, modernization, and economic growth in the last three decades accompanied by major shifts in its socio-demographic profile towards a younger and more highly Diagnostic Interview (CIDI), a highly structured diagnostic interview, typically administered by trained lay interviewers (Kessler & Ustün, 2004; World Health Organization, 1990 ). The CIDI has been shown to have good reliability and validity for estimating prevalence of common mental disorders across cultures (Andrews & Peters, 1998; Haro et al., 2006; Kessler et al., 2020; Peters & Andrews, 1995; Robins, 1988; Wittchen, 1994) . To date, WMH surveys have been implemented in over 30 countries worldwide, building the necessary infrastructure to collect comprehensive comparative data in countries around the world, several of which are in the Arab world, including Lebanon, Iraq, and Saudi Arabia (Al-Habeeb et al., 2020; Altwaijri et al., 2020; Aradati et al., 2019; Harris et al., 2020; Hcp.med.harvard. edu, n.d.; Karam et al., 2019; Shahab et al., 2017) . The WMHQ study will be based on a representative sample of n = 5000 Arabs, including both Qataris and non-Qataris, living in Qatar. The inclusion of non-Qataris is important because other Arab WMH surveys were either carried out in war-afflicted countries (Iraq and Lebanon) or focused solely on nationals (Saudi Arabia). Inclusion of non-nationals, which make up a large proportion of the population in many Arabic countries (e.g., about one-third of the populations of Lebanon and Saudi Arabia and 90% of the Qatari population) is essential to ensure complete coverage of the mental health care delivery needs within the country. Furthermore, the WMHQ fills in an important need for reliable, valid, and culturally appropriate assessment tools for DSM-5 disorders (Mokdad et al., 2016) . Lastly, the study aims to support research training opportunities for investigators from the Arab region, which remain substantially underrepresented in the mental health research arena to date (Zeinoun et al., 2020) .

This study describes the original methodology of the WMHQ face-to-face pilot study conducted just prior to the COVID-19 pandemic. We also describe the survey processes used in adapting, translating, testing, administering, and monitoring data quality in the context of the rapidly developing urban yet traditional setting of Qatar.

The state of Qatar is divided into eight administrative municipalities.

The municipalities are further subdivided into 98 zones, which are in turn subdivided into districts and blocks. A sampling frame of all housing units in Qatar was used to draw a representative sample of Qatari nationals (Qataris) and Arab expatriates (non-Qataris), who were 18 years or older and lived in residential housing units in Qatar during the survey reference period. The sampling frame was developed by SESRI with the assistance from Qatar General Electricity and Water Corporation (Diop et al., 2017) . In this frame, all housing units in Qatar were listed with information about the housing address and information to identify if residents in the housing units are Qataris (non-migrants) or non-Qataris (migrants).

To assure representation of all municipalities, stratified sampling was used whereby each municipality was treated as one stratum.

Inside each municipality, housing units in the zones, subdivisions of municipalities, were ordered by geographic location to permit well distributed sampling of housing units from different areas or blocks.

A systematic probability sample with probabilities of selection proportionate to size was constructed for Arab households (Qataris and non-Qataris). Inside each selected household, one eligible adult was randomly selected using a computerized within-household selection method appropriate to Middle East culture (Le-Trung et al., 2013) .

The collected data were weighted to account for variation in within-household probabilities of selection based on household size, non-response, and post-stratification calibration to known population targets to help reduce residual effects of non-response and undercoverage of the sampling frame. Our weighting variable ranged from 441 to 13,279 with a variance of 1360 and mean of 1744.

Non-response propensity score weighting at the household level was applied to adjust the within-household inverse probability of selection to account for non-response by municipality and prespecified gender sampling information (Trung Le et al., 2014) , using the following formula:

where ∝, the adjustment factor for non-response, was based on the propensity that a sampled unit was likely to respond to the survey (Ridgeway et al., 2015) .

Post-stratification was then carried out with these weighted data using a raking method to align survey distributions with known population characteristics for age, gender, nationality (Qatari/non-Qatari), and marital status obtained from Census bureau (Ministry of Development Planning and Statistics, 2015).

The final status of sampled households and two corresponding response rates (RR1 and RR2) were calculated using standards set by the American Association for Public Opinion Research (AAPOR, 2015).

First, RR1 which is the ratio of the number of completed interviews to the total sample size after excluding those who were ineligible: 

Arabic is a polyglossic language with dialects that differ across regions of the Arab world. As our target population consisted of Qatari and non-Qatari Arabs, the language of the instrument had to be understood by all Arabic speaking respondents alike. The conceptual equivalence of the Arabic CIDI has already been established in prior WMH surveys conducted in Arabic-speaking countries like Lebanon (Karam et al., 2006) , Iraq (Alhasnawi et al. 2009 ), and the latest in Saudi Arabia . But to further ensure conceptual equivalence in our Arabic version of the CIDI 5.0, which was translated from English to a standard modern conversational form of Arabic, we used the process of translation and adaptation of instruments as outlined by the WHO guidelines (WHO, n.d.) and the Translation, Review, Adjudication, Pretesting and Documentation method (Kessler et al., 2008) .

The first team in charge of the forward-translation from English to Arabic consisted of five bilingual team members who are from different We relied on extensive back-translation process to assess conceptual equivalence to the original English version of the CIDI 5.0.

The back-translation stage from Arabic to English lasted approximately 2 months and was conducted in parallel (as newly translated Arabic modules became available) by a second team of two other bilingual researchers who had not seen the original English version of the CIDI 5.0. The back-translation team lead by a senior researcher resolved any inconsistency in the back-translated English versions and produced a single unified back-translated English version.

In the last consolidation stage, the two leads from the two teams met and reviewed the entire Arabic and English versions of the instrument. For the most part, minor discrepancies in translation arose and were resolved by consensus among the leads of the bilingual teams. There were only two instances where the leads resorted to the larger translation team for advice in reaching agreement on unresolved issues.

We also used findings from the cognitive interviews conducted by the Saudi National Mental Health survey to make cultural adaptations to sensitive questions in the survey . Qatar and Saudi Arabia-both Arab states that are part of the Gulf Cooperation Council-share the same traditional conservative Islamic culture and their people would have similar sensitivity concerns and misunderstandings of certain concepts. Furthermore, the pre-testing stage entailed this relatively large pilot study during which detailed feedback about our version of the instrument was received from the interviewers who administered the instrument in face-to-face interviews leading to subsequent modification to certain problematic (comprehension) or potentially insensitive or offensive wordings. KHALED ET AL.

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A team of programmers from SESRI and the Harvard-Michigan WMH coordinating centers programmed the questionnaire in Blaise 5.2 (Blaise, 2017) . Trained interviewers used Computer-assisted personal interviewing (CAPI) to administer the instrument during faceto-face interviews conducted in households of Arabic speaking residents and nationals of Qatar. These respondents were recruited from January 2020 through February 2020.

In order to customize our version of the questionnaire to Qatar's context, we adapted culturally sensitive questions, entire optional sections, and added non-CIDI sections using a CAPI modularization program. The final survey instrument consisted of 25 sections including 20 sections from the CIDI 5.0. For more details about the content of the WMHQ survey, please refer to Table 1 .

In addition to the CAPI mode, SESRI IT team used the audio computer-assisted self-interviewing (ACASI) Blaise feature to program an ACASI version for two modules of CIDI 5.0 that were particularly sensitive in the cultural context of Qatar: the Self Harm and Tobacco, Alcohol and Drugs modules.

ACASI enabled respondents to listen to the questions through headphones and to enter responses using a touch-screen. The questions of the sensitive CIDI modules were presented as recorded audio voice-overs. As mispronunciation and unfamiliar accents could influence the participants' responses, two recorders (one female and one male) fluent in the Arabic language clearly enunciated the questions without any heavy accent to ensure the audios were understandable to the study population.

The study team, including the principal investigator of the study, three research assistants, field operation team, and two experienced interviewers, attended 2 days of webinar-based training on the administration of the CIDI 5.0 instrument conducted by the CIDI training center at University of Michigan Institute for Social

Research. Participants were provided with password-protected access to online training modules for the CIDI and were required to participate in live interaction webinars. Upon completion of the CIDI training, participants received their certificates, which enabled them to train the local field interviewers.

Initially, 31 field interviewers were nominated for training based on their extensive experience and performance in previous surveys conducted by SESRI. Upon further screening, 29 interviewers (20 females and 9 males) were invited to attend the WMH survey-training workshop.

Culturally, it is more acceptable for female interviewers to visit households and interview male respondents. As such, more females were trained than males.

Prior to the workshop, potential interviewers received the study material, which included a hard copy of the questionnaire, the training slides, and the respondent package, as presented in details in 

As the sampled households were spread geographically all over Qatar and across zones; the supervisors were responsible for allocating to each male interviewer or HoG a detailed list of sampled households, their location, and a timeline for completing these potential -5 of 13 interviews within each zone. Each HoG then allocated a specific number of sampled households within the same zone to each group of interviewers based on sample location, which was often close to the interviewers' home locations, starting with sampled households that are closest to each other.

As In turn, supervisors monitored fielding progress in terms of achieving target completed interviews by teams and ensured smooth survey fielding experience for participants and survey fielding team alike. In particular, supervisors monitored and evaluated interviewers as they collected data to ensure data integrity by conducting face-toface verification of visited households and by conducting random checks to verify adherence to fielding protocol and practices including wearing appropriate uniform and carrying valid ID, study permit, and consent forms.

Interviewers worked from 4 to 8 p.m. Sunday to Friday, but also worked to accommodate scheduled appointments with potential respondents. Interviewers were paid per working day rather than per competed interview, which has been shown previously to yield better data quality (Kessler & Üstün, 2004 ).

Field procedures and strategies utilized by interviewers in handling most scenarios commonly encountered in the field are shown in 

As part of the study's safety procedures, interviewers provided all participants with contact sheets that included information about: (1) the Mental Health Service hotline;

(2) the emergency department contact number; and (3) contact details for local primary healthcare centers.

We aimed to ensure that the interviewers' performance adhered to preset quality criteria. To this end, SESRI IT team, in collaboration with University of Michigan, developed and implemented a Quality Control (QC) system to monitor interviewer activity in the field.

The 

In addition to the QC indicators with flags, performance indicators were also calculated and monitored regularly. Furthermore, a random sample of interviews were selected for face-to-face or phone verification.

Phone verification was conducted by interviewers from the computer-assisted telephone interviewing lab at SESRI. Two demographic questions and three general health variables (height, weight, and presence of one or more life-threatening or seriously impairing chronic physical health problem) were re-asked during the phone verification, as the mental health variables were considered too sensitive to verify over the phone.

We also developed and monitored indicator for discrepancy between the frame (expected) location and the actual location of interviews or geolocation. Two methods allowed the interviewers to capture their geolocations: mobile application developed for the purpose of capturing interviewers' visit points and the CAPI system installed on their laptops. Field Operations Manager reviewed discrepancies daily and discrepancy representing a distance of greater than 30 m was flagged for verification.

Supervisors also conducted in-person random visits of interviewers in the field and evaluated the status of each visit as good, warning, or suspended from field based on preset scored criteria (such as adherence to consenting protocol, carrying an identifying badge, and physical appearance).

The total pilot sample consisted of n = 1076 households selected proportional to size of municipalities in Qatar. Response rates ranged from 41.2% to 54.9% across municipalities based on 395 completed survey interviews (see Table 2 ).

The overall response rates and final status of sampled households in the survey are shown in Table 3 

Weighted descriptive statistics of the overall sample of respondents who completed the interview are presented in 

Out of the total 1076 households that were visited, 129 visited households were randomly selected for one of the following types of location within the expected household frame of 30 m) and an additional 8.6% had no information on the actual geolocation points. All 173 random visits were reported as "good" during the fielding of this pilot, verifying good adherence to field practice by all interviewers.

This study highlighted the methodology used in adapting, translating, testing, training, administering, and monitoring data quality of the CIDI 5.0 for the WMHQ pilot, which was based on a large and representative sample of Qatar's population prior to the COVID-19 pandemic.

The overall response rates based on our pilot study ranged between 46.1% and 56.9%, which is comparable to 60.0% obtained in Saudi National Mental Health Survey , but on the lower end, for other WMH surveys where a response rate as low as 45.9% was reported in France and as high as 97.2% reported in Colombia-Medellín (Hcp.med.harvard.edu., n.d.) . However, most of these surveys were conducted in the early 2000s and response rates for all surveys have been on the decline worldwide (Leeper, 2019) . Our pilot response rates are still considered relatively high compared to typical response rates (20%-30%) for face-to-face surveys in developed countries like Germany and the United States (Massey & Tourangeau, 2013; Schröder, 2016; Wittwer & Hubrich, 2015) .

We summarize below some of the main methodological challenges and lessons learned during the course of the pilot.

To facilitate agreement on terminology and the type of Arabic language used in the initial stages of the forward-translation process, all team members translated the same first four modules and met in person several times over 3-to-4 weeks to discuss and agree on consistent terminology to use throughout the survey. This initial step in the forward-translation stage in addition to regular weekly meetings to review as a group all translated modules by the different team members was important to ensure that the final Arabic translated instrument was consistent and less susceptible to idiosyncratic and dialectical influences by different members of the forwardtranslation team. The whole process was extremely time consuming and required a lot of resources. In our study, two independent teams undertook forward-and back-translations of the instrument. The entire process including the final consolidation stage took approximately 6 months to complete.

The average length of completed interviews was approximately 97 min. The shortest interview was 43 min, while the longest interview was 277 min. Although the length of the CIDI interview was expected to be the main challenge of the study, we were surprised that it was not the main issue for recruitment purposes as "hard" refusals accounted for only 3.5% of the total sample. Interviewers were often able to circumvent concerns about length by explaining well the importance of the study to potential participants.

In this regard, we learned that having an informative study brochure and an endorsement letter by a figurehead from public health authorities as part of the distributed study package were crucially important in gaining cooperation from the head of the visited households. As we had a relatively low proportion of partially completed interviews (3.7%), we learned that it was very important for interviewers to show flexibility. Here, it was important to allow respondents to take multiple breaks, including time for prayer and to attend to their family's needs.

Some of the CIDI questions were sensitive in a way that may make respondents inclined to refuse to answer them or respond to them in socially desirable manner in line with conservative Qatari/Arab culture. For example, suicide attempts, drinking alcohol, using drugs, and sexual harassment/rape are taboo topics in this region of the world.

We found that the process of adaption of the questionnaire was very important in our context. Particularly, it was very important to phrase questions in a culturally acceptable way, such as using terms like "putting an end to your life" as opposed to "kill yourself" for suicidality and "prohibited substances" instead of "drugs.". As ACASI is better method for collecting information about culturally sensitive behaviors and thoughts than face-to-face interviews (Brown et al., 2013) , we used ACASI for sensitive survey modules including suicidality and Tobacco, Alcohol & Drugs (99% of completed interviews used ACASI for these sections), which ensured that we did not have unusually high item-refusal or missing rates for sensitive questions or offend respondents and risk losing interviews that would otherwise be complete.

Similar challenges related to the adaptation of the questionnaire to the cultural context and instrument validation were found in a population-based mental health survey among Lebanese adolescents (Ghandour et al., 2018) . Furthermore, the translation process, sensitive questions and interview length were presented as challenging in another WMH survey conducted in Saudi Arabia (Shahab et al. 2017 ).

The length of the instrument also presented the team with challenges related to programming and testing. Adequate resources in terms of staff and time were necessary for implementation and verification of changes to the instrument. The programmed Arabic version of the questionnaire was subjected to countless changes. In this regard, we KHALED ET AL. 

An important challenge that was pronounced in the CIDI 5. were developed for measuring performance and for quality monitoring purposes in the field. In general, we learned that hiring interviewers with good IT literacy from the start would mean less time needed for IT-related training and less problems in the field not only for administering the CIDI, but also for the fulfillment of the entire study protocol including quality requirements of the data.

Debriefing sessions with interviewers revealed that it was specially challenging to persuade members of working families to complete these lengthy interviews during regular fielding working hours-from 4 to 8 p.m., Sunday to Thursday. Often, interviewers approached households whose members have just returned home from work, who may be taking a nap or taking care of their children or preparing meals for tomorrow, or getting ready for the next workday. Often, working families preferred weekend appointments. Therefore, flexibility in scheduling appointments outside of fielding operations' working hours and on weekends was important to accommodate this segment of the population. One additional challenge faced by interviewers was late arrival for appointments-often due to unpredictably long interview beforehand, which could lead to losing potential interviews. Because of these issues, productivity was largely impacted; most interviewers were only able to complete one interview per day.

Compared to other studies, we did not encounter difficulties in terms of household access, political instability, funding constraints (Ghandour et al., 2018) , respondent attitudes and household location (Shahab et al., 2017) .

As several CIDI-specific flags were not showing accurate data during the pilot study, further examination and reconstruction of computations were carried out during and after the pilot. This was expected since the pilot was used to test the QC system. As such, we also monitored raw data from the interviewers' laptops, to allow for 

Twelve-month treatment of mental disorders in the Saudi National Mental Health Survey

The prevalence and correlates of DSM-IV disorders in the

The Saudi National Mental Health Survey: Survey instrument and field procedures

Diagnostic and statistical manual of mental disorders: DSM-5

The psychometric properties of the Composite International Diagnostic Interview

Using knowledge management tools in the Saudi National Mental Health Survey helpdesk: Pre and post study

release-CBS' Blaise

Application of audio computer-assisted self-interviews to collect self-reported health data: An overview

The burden of mental disorders in the Eastern Mediterranean Region

Demography, migration, and labour market in Qatar

Social capital and citizens' attitudes towards migrant workers

Medical research productivity in the Arab countries: 2007-2016 Bibliometric analysis

Qatar National Mental Health Strategy, Changing Minds, Changing Lives

Contextual challenges and solutions to undertaking a household adolescent mental health survey in a developing country

Concordance of the Composite International Diagnostic Interview Version 3.0 (CIDI 3.0) with standardized clinical assessments in the WHO World Mental Health Surveys

Findings from world mental health surveys of the perceived helpfulness of treatment for patients with major depressive disorder

The World Mental Health Survey Initiative

Mental health research in the Arab world: An update

Determinants of treatment of mental disorders in Lebanon: Barriers to treatment and changing patterns of service use

Prevalence and treatment of mental disorders in Lebanon: A national epidemiological survey

Clinical reappraisal of the Composite International Diagnostic Interview Version 3.0 in the Saudi National Mental Health Survey

The World Mental Health (WMH) Survey Initiative version of the World Health Organization (WHO)

Composite International Diagnostic Interview (CIDI)

The WHO World Mental Health Surveys: Global perspectives on the epidemiology of mental disorders

Where have the respondents gone? Perhaps we ate them all

Seismic performance evaluation of RC beam-column connections in special and intermediate moment frames

Mental health research in the Arab region: Challenges and call for action. The Lancet Psychiatry

Where do we go from here? Nonresponse and social measurement

The general simplified census of population. Housing & Establishment

The Saudi National Mental Health Survey: Sample design and weight development

Global burden of diseases, injuries, and risk factors for young people's health during 1990-2013: A systematic analysis for the Global Burden of Disease Study

Procedural validity of the computerized version of the Composite International Diagnostic Interview (CIDI-Auto) in the anxiety disorders

/Woman_Man_2018_EN.pdf Planning and Statistics Authority. Qatar Census. (n.d.). Planning and Statistics Authority. Retrieved

What is Power BI?

Global burden of disease and the impact of mental and addictive disorders

Propensity score analysis with survey weighted data

The Composite International Diagnostic Interview: An epidemiologic instrument suitable for use in conjunction with different diagnostic systems and in different cultures

Face-to-face surveys

Institute for Social Sciences (GESIS Survey Guidelines

Mental disorders around the world: Facts and figures from the world mental health surveys

The Saudi National Mental Health Survey: Methodological and logistical challenges from the pilot study

Implementing the TRAPD model for the Saudi adaptation of the World Mental Health Composite International Diagnostic Interview 3.0

Population of Qatar by nationality

Standard definitions. Final dispositions of case codes and outcome rates for surveys

Gender prespecified sampling for cost control

Estimating the true global burden of mental illness

Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: A systematic analysis for the Global Burden of Disease Study

Challenges to estimating the true global burden of mental disorders

How many Qatari nationals are there? Middle East Quarterly

Reliability and validity studies of the WHO-Composite International Diagnostic Interview (CIDI): A critical review

Nonresponse in household surveys: A survey of nonrespondents from the repeated cross-sectional study "mobility in cities -SrV" in Germany

Composite International Diagnostic Interview. World Health Organization

WHO | Process of translation and adaptation of instruments

The Arab region's contribution to global mental health research (2009-2018): A bibliometric analysis

Conducting a state-of-the-art mental health survey in a traditional setting: Challenges and lessons from piloting the World Mental Health Survey in Qatar