The initial step of study one involved the adaptation of the CESD-R items. This step followed the first three stages of the test development guidelines proposed by Foxcroft (2018) and the International Test Commission Guidelines for Translating and Adapting Tests (ITC, 2017). The adaptation of the CESD-R items during studies one and two is highlighted (Table 1). For study one, CESD-R items were either rephrased or removed from the tool. Three items were removed from the CESD-R, which included the two items which assessed suicide ideation. Guided by the South African literature regarding depression (Anderson et al., 2015; Hertog et al., 2016; Kaiser et al., 2015; Mosotho et al., 2008), three items were added to the tool (see Table 2). The online adapted CESD-R for study one consisted of 20 items, which were free of psychological jargon. The response format (Not at all, 1 to 2 days, 3 to 4 days, 5 to 7 days and nearly every day for 14 days) and time period (2 weeks) that symptoms are experienced were not changed from the CESD-R.

Individuals were invited to participate in the study based on their expertise, the field of depression screening and depression. A non-probability, purposive sample of 50 mental healthcare personnel participated in the study (Patton, 1990). The participant demographics for study one are highlighted (Table 2). The majority of the sample was psychiatrists (n = 15), followed by psychologists (research, clinical and counselling psychologists) (n = 14) and Psychology Honours¹ students enrolled for a psychological assessment module (n = 13). Seven of the participants described their occupations as ‘other with nurses, religious leaders, a paediatrician and a campus coordinator being specified. The majority of the participants stated that they had been practising in their respective fields for more than 10 years (n = 19), followed by 14 participants practising for less than 10 years. Women made up the majority of the participants (n = 43). Half of the participants identified as white people (n = 25). Most participants identified as being Christian (n = 24), followed by Muslim and no religious affiliation (n = 13 and n = 8, respectively). Thirty-six participants identified English as being their home language, while Afrikaans was spoken by eight individuals and an African language (isiZulu, Ndebele, Sepedi, Setswana & Swati) was spoken by six of the participants as a home language (see Table 3).

Just over half of the sample (n = 26) diagnosed depression² in their capacity as a psychologist or psychiatrist, with the majority diagnosing depression at least weekly (n = 17). Interesting to note was that, out of the 26 individuals who stated that they diagnose depression, only 16 of these individuals had utilised a depression screening tool (see Table 2). The most cited screening tool utilised was the BDI-II, followed by the PHQ and the Hamilton-D (HAM-D).

Participants were required to complete a brief demographic questionnaire requesting information on occupation, number of years practising, gender, population group, religious affiliation, home language, frequency in diagnosing depression as well as previous experience using a depression screening tool. Once the demographic questions were completed, participants were presented with a page detailing the content validation instructions. Participants were required to only read the instructions, items, scoring as well as feedback of the adapted CESD-R, and not to complete the tool. This was followed by 10 (yes or no response format) questions which were informed by the COSMIN evaluation of content validity of a PROM. Participants were given the choice to provide additional comments in relation to the 10 questions. Given the unique nature of the tool where instant feedback would be provided to the individual, two specific questions assessing the appropriateness of the scoring and feedback of the tool were included.

Once items were finalised, an email was circulated to various South African healthcare professionals listed above (see Table 2) inviting them to participate in the study. Experts were identified based on their clinical and psychometric experience in the field of mental health and depression. The email described the nature of participation and contained a web link to the actual tool and content validation questions. Once participants clicked on the link (generated from SurveyMonkey), a participant information sheet appeared detailing the nature of the study. The survey was anonymous and, on average, took between 10 and 15 min to complete. Data collection took place electronically between July and October 2019 through an online survey tool.

Data were downloaded from the online tool and coded for analysis. Demographic variables and yes or no response options were analysed using frequencies on Statistical Package for the Social Sciences (SPSS) Version 25 (IBM Corp, 2017), and qualitative data were analysed using thematic analysis as specified by Braun and Clarke (2006).

Results are discussed in terms of the three broad themes recommended in the COSMIN guidelines that are relevance and comprehensiveness, comprehensibility and scoring and feedback.

Because of the open-ended nature of the questions, various themes regarding the relevance of the tool emerged, namely, depression according to the DSM criteria, appropriateness of the items, time period, response format as well as the cultural applicability of the items.

The majority of the participants indicated that the tool does appear to measure depression (n = 46) (see Table 3), which is echoed through the following comment made by participant 40: ‘It definitely does measure depression according to the DSM 5 framework’. Two participants noted that the items provided on the tool measured depression according to the DSM-5 criteria for depression, while three participants stated that not all the DSM symptoms of depression were measured by the tool. One participant specifically commented that the DSM criteria do not include local idioms of distress or depression, while two participants indicated that suicide ideation had not been included in the tool. It was noted by one of the participant that the tool measured depression similar to the K10 (Kessler Psychological Distress Scale) and CESD (original version of the online adapted CESD-R). One participant specifically cautioned against using the tool as a diagnostic measure.

As evident in Table 3, the majority (n = 31) of the participants felt that the items were appropriate for the South African context. In order to accommodate the African view of the self, participants were asked if items need to be rephrased to ‘My family and friends’. Results indicate that the majority (n = 24) of the participants suggested that items do not need to be rephrased (see Table 3). Item appropriateness can be divided into three sub-themes, namely, items to be added, items to be removed and items to be rephrased or re-considered (see Table 3).

Items to be added: Five participants noted that weight gain and increased appetite are symptoms of depression that are commonly overlooked. Therefore, participants recommended that these two items should be added to the tool. Participant 9 expressed this as follows:

Four participants felt that an item targeting indecisiveness should be added as it is a common cognitive symptom of depressed patients. In addition, suicide ideation items were recommended to be included by five participants as they are symptom criteria for depression, according to the DSM.

Items to be removed: Two participants suggested removing the items: ‘I feel like I am moving too slow’ and ‘I have the need to play with my fingers or move around for no reason’ (psychomotor agitation) (see Table 1), as this is less common in depressed adults. One participant felt item 18 was unclear and another stated that item 17 was unclear, but they did not suggest removing these items. Two participants suggested that there were too many sleep items and some should be removed or replaced with another item. Item 20 (‘I feel bewitched almost all of the time’) was viewed as being the most inappropriate item (n = 11), implying that the item should be removed.

Items that need to be reconsidered or rephrased: Participants felt that items needed to be rephrased so that the tenses would be consistent throughout the tool. A suggestion was made that the items need to be edited for grammatical accuracy.

This theme is closely related to the theme of item appropriateness as the item, ‘I feel bewitched almost all of the time’, was the most commonly cited item that was inappropriate. This was because the term ‘bewitched’ is not culturally appropriate and the term was not clearly understood. Participants suggested that the item questions the cultural aetiology of depression in a tool which needs to relate to the experience of depression. In addition, participants suggested that the term ‘bewitched’ can have both negative and positive connotations. Participants suggested that if a culturally fair item is to be added, it should have follow-up questions.

With regards to the time frame of ‘two weeks’, three participants noted that the time frame needed to be reconsidered as the symptoms experienced could be a result of life changes or a traumatic event, as indicated by Participant 1:

In addition to the change in the time frame of the symptoms experienced, the attribution of symptoms to life changes was also found in the narratives of four other participants. These participants highlighted that symptoms could be attributed to various medical conditions (chronic conditions or stomach bugs) as well as the lifestyle the individual leads (symptoms of sleep attributed to exhaustion). Therefore, these suggestions showed the need for a statement ruling out medical conditions, lifestyle, as well as life changes causing the symptoms experienced.

Although no specific questions targeted the response format, six participants made comments which related to it. One participant specifically suggested that it might not be understood by the general public, while four participants suggested that the response format did not match well with the items, recommending that either the items be rephrased or the response format be changed for specific items. One participant felt that placing a time frame in the response format was inappropriate.

Lastly, two participants suggested that the responses can yield many false positives or negatives or be easily faked. The use of reverse scoring as well as a control question was suggested in order to prevent faking.

Comprehensibility of the tool is discussed in terms of appropriateness of the instructions, effectiveness of the language used, length of the tool and item order.

As evidenced in Table 3, a majority of the participants (n = 47) felt that the instructions provided were appropriate. Five participants recommended specific changes to the instructions, while one participant suggested that the last statement in the instructions (‘Ask a friend or family member to assist you’) could deter individuals from taking the test and would need further consideration. Two of the participants suggested grammatical changes be made to the instructions provided. One participant suggested that a sentence encouraging individuals to complete all items be added.

A majority of the participants (n = 49) felt that the tool will be easily understood by diverse groups in South Africa (see Table 3), as echoed by the following participant phrases ‘simple English’, ‘does not contain any difficult words’, ‘very simplistic words’ and ‘simply put and easy to understand’. Three participants made reference to the general public of South Africa not being English first language speakers and said it was imperative to ensure that all South Africans understand the items. These three participants suggested that the tool be translated into African languages, with one participant highlighting caution when doing translations.

All participants who commented on the length of the tool felt that it was appropriate for an individual who is depressed. This sentiment is represented by the following comment by participant 9: ‘The short length of the questionnaire is a strength of the tool as someone with moderate to severe depression will struggle to complete tasks’.

Only two participants mentioned that the order of the items needs to be reconsidered. Participants suggested that items measuring similar symptoms do not appear together and to prioritise symptoms specific to the South African context in the ordering of items.

Although scoring and feedback does not form part of the COSMIN criteria for content validity, it is a vital point to discuss as the end-users of the tool will ultimately receive immediate feedback in a non-typical, face-to-face interaction. Table 3 shows that it is evident that the majority of participants felt that the scoring and feedback provided are appropriate (n = 41 and n = 35, respectively).

Only five participants commented on the scoring of the tool, with three participants suggesting that the scoring was not transparent as they did not know the score that was attributed to each response and the cut-offs were not mentioned upfront. Comments made regarding the feedback given to participants all emphasised the need to highlight the urgency of seeking help when individuals receive a high score on the tool. In addition, participants stated that the feedback was calmly stated so that it should not further perpetuate depression symptoms. Participants indicated that individuals who do not meet the criteria for depression should also be offered contact details if they feel the need to seek help. Lastly, participants felt that ‘consulting with your family practitioner’ should be the first point of contact that needs to be included.

A non-probability, purposive sample of 21 mental healthcare personnel participated in the study (Patton, 1990), with a majority of the sample represented by psychologists (n = 16). A greater part of the participants stated that they had been practising in their respective fields between 10 and 20 years (n = 10), with only one participant practising for under 10 years. A majority of the sample were females (n = 17). Just over half of participants identified as belonging to the White population group (n = 11) and being Christian (n = 11). English was noted as the dominant home language used by participants (n = 16) (see Table 2).

Only eight participants had not previously diagnosed depression, with the majority of participants (n = 6) diagnosing depression weekly. Lastly, a larger part of the participants (n = 15) had previously utilised a depression screening tool. The most commonly cited screening tool used was the BDI-II followed by the HAM-D.

The first step of this study involved item refinement based on the results of study one. Weight, eating patterns and sleep items were represented by one item each which accounted for either side of the scale (weight gain or loss, increased or decreased appetite and less or more sleep) (see Table 1). The item regarding bewitchment was removed from the scale based on the results of study one. Items representing self-blame, loneliness and guilt were added. Therefore, a total of 20 items were included in study two. Given the occurrence of violence and traumatic events in South Africa as well as comments made in study one regarding the time period, this was changed to a 2-month period of symptoms experienced as this will rule out symptoms experienced because of these events which could result in an overdiagnosis of depression. Lastly, based on the feedback received regarding the response format in study one, the response format was changed to: ‘Not at all’, ‘Some of the time’, ‘Most of the time’ and ‘All of the time’.