The Sierra Leone Perinatal Psychological Distress Scale (SLPPDS)

1. Abstract

The Sierra Leone Perinatal Psychological Distress Scale (SLPPDS) is a culturally adapted, clinically grounded screening instrument developed by Abdulai Jawo Bah and colleagues (2025) to identify psychological distress among pregnant women and newly delivered mothers in low-resource, post-conflict settings. Developed using an integrated emic-etic conceptual approach, the scale addresses the well-documented limitations of applying Western-centric psychiatric assessment tools across diverse ethnocultural populations. The development process originated with a pool of 31 candidate items reflecting local idioms of distress, somatic complaints, and affective disturbances common during the perinatal period in Sierra Leone. Following cognitive interviewing, translation and back-translation between English and Krio, and community-based face validity evaluations, a 25-item prototype was administered to perinatal women across the Western Area and Bombali districts. Psychometric refinement via principal component analysis and exploratory factor analysis with varimax rotation yielded a concise, unidimensional 10-item instrument explaining 54.9% of the total variance.

The SLPPDS employs an innovative 4-point Likert response architecture utilizing visual representations of local water containers (jerry cans) to overcome literacy barriers and ensure intuitive measurement of symptom severity. Confirmatory factor analysis verified the robust fit of the unidimensional construct (χ²-based fit indices: Comparative Fit Index [CFI] = 0.952, Incremental Fit Index [IFI] = 0.955, and Root Mean Square Error of Approximation [RMSEA] = 0.054). The scale exhibits excellent internal consistency (Cronbach’s alpha = 0.883), robust convergent validity with functional impairment, and marked discriminant validity, demonstrating significant score divergence between clinical cases (mean = 13.6, SE = 0.9) and non-cases (mean < 3.3, SE = 0.9; p < .0001). Receiver operating characteristic analysis established an area under the curve (AUC) of 0.90, displaying 80.0% sensitivity and 85.7% specificity. The SLPPDS represents an essential psychometric contribution to global maternal mental health, facilitating rapid, non-stigmatizing community and primary-care screening.

2. Keywords

Sierra Leone Perinatal Psychological Distress Scale, SLPPDS, perinatal mental health, maternal psychological distress, cross-cultural screening, global mental health, psychometrics, Krio, diagnostic validity, emic-etic approach, postpartum depression

3. Authors

• Abdulai Jawo Bah, PhD — Institute for Global Health and Development, Queen Margaret University, Edinburgh, United Kingdom; College of Medicine and Allied Health Sciences, University of Sierra Leone. (ORCID: 0000-0002-3334-7882; Email: [email protected]).
• Haja Ramatulai Wurie, PhD — College of Medicine and Allied Health Sciences (COMAHS), University of Sierra Leone, Freetown, Sierra Leone.
• Mohamed Samai, PhD — College of Medicine and Allied Health Sciences (COMAHS), University of Sierra Leone, Freetown, Sierra Leone.
• Rebecca Horn, PhD — Institute for Global Health and Development, Queen Margaret University, Edinburgh, United Kingdom. (ORCID: 0000-0002-9869-544X).
• Alastair Ager, PhD — Institute for Global Health and Development, Queen Margaret University, Edinburgh, United Kingdom. (ORCID: 0000-0002-9474-3563).

4. Purpose

The primary purpose of the Sierra Leone Perinatal Psychological Distress Scale (SLPPDS) is to provide a brief, culturally sensitive, and psychometrically validated screening tool capable of identifying clinically significant psychological distress among women during pregnancy and the first postpartum year. Maternal mental health represents a neglected global health priority, particularly in sub-Saharan African contexts recovering from chronic complex emergencies, civil conflict, and epidemic shocks such as the 2014–2016 West African Ebola outbreak and the COVID-19 pandemic. Perinatal psychological distress is known to produce adverse obstetric, neonatal, and developmental outcomes, including preterm delivery, low birth weight, infant undernutrition, and impaired mother-infant bonding. Despite this immense burden, detection rates in primary healthcare centers remain critically low due to the lack of context-appropriate screening instruments.

Historically, global maternal health initiatives have relied on imported Western instruments such as the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire-9 (PHQ-9). While these instruments have yielded valuable comparative epidemiological data, they frequently suffer from conceptual, linguistic, and cultural misalignment when implemented in low-literacy, resource-constrained settings. Symptoms of affective suffering in Sierra Leone are frequently expressed through culturally patterned idioms of distress, such as somatic manifestations, somaticized anxiety, “thinking too much” (tin-tin tumas in Krio), and profound social-relational isolation, which are poorly captured by standardized psychiatric rating scales. The SLPPDS was engineered precisely to bridge this diagnostic gap by translating local subjective phenomenologies of distress into an empirical rating scale designed for task-sharing and delivery by community health workers, midwives, and public health practitioners.

In clinical settings, the SLPPDS serves as a first-line triaging tool within routine antenatal care (ANC) and postnatal care (PNC) services. Its rapid 10-item structure enables healthcare staff to swiftly differentiate between normative perinatal emotional fluctuations and severe psychological distress that warrants psychosocial support or psychiatric intervention. For research applications, the scale offers an epistemologically grounded metric for quantifying perinatal distress in intervention trials, longitudinal cohort studies, and population-level health surveys, systematically eliminating measurement biases inherent in unadapted cross-cultural testing.

5. Psychological Construct

The psychological construct evaluated by the SLPPDS is perinatal psychological distress, conceptualized as a broad, transdiagnostic syndrome encompassing depressive mood, generalized and somatic anxiety, cognitive perseveration, exhaustion, and interpersonal withdrawal occurring during the antenatal and postnatal periods. Rather than forcing women’s experiences into narrow categorical diagnostic classifications (such as major depressive disorder or generalized anxiety disorder under DSM-5 or ICD-11), the SLPPDS models distress as a cohesive dimensional spectrum reflecting both universal emotional reactions and locally embedded suffering.

Through psychometric investigation, the scale emerged as a unidimensional construct consisting of ten tightly intercorrelated manifestations of distress:

• Cognitive Perseveration and Rumination: Locally articulated as intense mental preoccupation or internal cognitive overwhelm (often corresponding to idioms such as tin-tin tumas or excessive worry). This dimension reflects recurrent, uncontrollable thoughts concerning domestic survival, infant health, economic precariousness, and personal vulnerability.
• Affective Dysphoria and Anhedonia: Core feelings of profound sadness, emotional heaviness, crying spells, and the pervasive inability to experience pleasure or maternal joy. In the perinatal context, this dysphoria is exacerbated by guilt regarding maternal competency and fear of social judgment.
• Somaticized Distress and Vegetative Changes: Physical expressions of psychological strain, including unexplained bodily aches, tension headaches, severe fatigue uncharacteristic of normal pregnancy, and sleep disturbances uncoupled from the physical demands of infant care. Cross-cultural psychopathology demonstrates that in non-Western cultures, somatic symptoms are not secondary epiphenomena but primary linguistic vehicles for emotional distress.
• Relational and Functional Withdrawal: The subjective feeling of isolation, disconnection from community support systems, diminished capacity to engage in domestic and agricultural livelihoods, and withdrawal from critical social networks. Because West African maternal identity is embedded within communal networks, social disconnection serves as a primary bellwether of mental crisis.

The dimensional cohesion of these manifestations is supported by psychometric analysis: exploratory and confirmatory factor analyses converged on a single latent factor representing global perinatal psychological distress, demonstrating that in this population, somatic, affective, cognitive, and relational symptoms form an integrated, mutually reinforcing distress syndrome.

6. Theoretical Framework

The construction and validation of the SLPPDS are grounded in the theoretical integration of the emic-etic model of cross-cultural psychiatry (Kleinman, 1980; Berry, 1989) and the biopsychosocial-cultural model of perinatal mental health. The emic-etic paradigm asserts that psychological phenomena feature both universal, biological components (etic) and deeply localized, culturally bounded idioms, meanings, and symptomatic manifestations (emic). Classical psychometric screening tools deployed in global health frequently operate under a categorical “etic fallacy” (or category mistake), assuming that psychiatric categories developed in high-income Western societies map seamlessly onto non-Western subjective realities.

To avoid this epistemological trap, Bah et al. (2025) applied an iterative, bottom-up exploratory methodology that prioritized the lived experiences and explanatory models of Sierra Leonean women. Qualitative cognitive interviewing and target-population adjudication ensured that the scale’s items genuinely reflected authentic community narratives of maternal hardship. At the same time, the framework integrates modern measurement theory, linking local idioms to standardized psychometric constructs of psychological distress and functional impairment. This synthesizes Kleinman’s explanatory models with established psychometric standards outlined by the American Psychological Association (APA).

Furthermore, the scale’s visual measurement design draws from Betancourt and colleagues’ (2015) non-verbal psychometric adaptation theories. In populations characterized by high rates of structural educational deprivation and multi-language environments, conventional verbal-numeric rating scales (e.g., assessing distress via abstract numbers from 0 to 3) introduce substantial cognitive load and response bias. By employing visual cultural analogies—specifically standardized water containers (jerry cans) filled to varying graduated levels—the tool aligns psychological measurement with concrete, ubiquitous domestic objects, minimizing construct-irrelevant variance caused by numeric or linguistic confusion.

7. Validity

The psychometric validation of the SLPPDS adhered to rigorous standards, demonstrating strong validity across multiple empirical domains:

• Content and Face Validity: Initial content generation produced 31 candidate items derived from ethnographic inquiries and perinatal clinical encounters. Cognitive testing evaluated item clarity, semantic equivalence, and emotional acceptability. Community members and perinatal women acting as target-population judges systematically reviewed candidate statements, leading to the deletion of ambiguous items and resulting in a refined 25-item prototype exhibiting high face validity.
• Construct Validity: Factor-analytic procedures demonstrated that all ten retained items loaded strongly onto a single latent distress dimension. The absence of orthogonal secondary factors confirms that the instrument measures a coherent, unidimensional psychological construct.
• Convergent Validity: Convergent validity was assessed by evaluating the linear association between SLPPDS total distress scores and standardized measures of functional disability and psychiatric morbidity. The authors observed a monotonic, statistically significant escalation in psychological distress scores across ascending tiers of functional impairment. Furthermore, SLPPDS scores correlated robustly with established depression metrics, specifically the PHQ-9, confirming that the scale effectively detects clinical manifestations of depressive and anxious morbidity.
• Discriminant Validity: The scale demonstrated exceptional capacity to differentiate between symptomatic psychiatric cases and healthy non-cases identified via structured clinical evaluations. The mean total symptom score among validated cases was 13.6 points (SE = 0.9), whereas the mean score for non-cases was below 3.3 points (SE = 0.9), demonstrating a marked, statistically significant divergence (p < .0001). This pattern was consistent with parallel comparisons conducted using the PHQ-9.
• Diagnostic Validity and ROC Analysis: Receiver Operating Characteristic (ROC) curve analysis demonstrated an Area Under the Curve (AUC) of 0.90, confirming outstanding overall diagnostic accuracy. Utilizing the empirically derived cut-off threshold, the SLPPDS achieved a sensitivity of 80.0% and a specificity of 85.7%, providing an optimal balance between minimizing false negatives in clinical triage and avoiding excessive false-positive referrals that would overwhelm constrained maternal healthcare infrastructures.

8. Reliability

The reliability of the SLPPDS was evaluated using classical test theory metrics, focusing on internal consistency and measurement precision. In the validation cohort comprising pregnant and postpartum women across the Western Area and Bombali districts of Sierra Leone, the 10-item instrument demonstrated high internal consistency, yielding a global Cronbach’s alpha of 0.883.

This alpha coefficient confirms that the ten items reflect a unified latent construct without displaying excessive item redundancy (alpha values exceeding 0.95 often indicate redundant item formulation). Corrected item-total correlations across the retained items remained consistently strong, confirming that each item contributes uniquely and substantially to the total score. The standard error of measurement (SEM) associated with the instrument was low, supporting the scale’s precision across both low-scoring community samples and high-scoring clinical cohorts.

9. Factor Analysis

The dimensional structure of the SLPPDS was evaluated through a sequential, multi-phase factor-analytic strategy combining Principal Component Analysis (PCA), Exploratory Factor Analysis (EFA), and Confirmatory Factor Analysis (CFA):

Principal Component and Exploratory Factor Analysis

The initial 25-item prototype was administered to the validation sample. Principal Component Analysis revealed an unambiguous single dominant component exhibiting an eigenvalue substantially greater than 1.0 (Watkins, 2018 criterion). Subsequent Exploratory Factor Analysis with varimax rotation was executed on a 1-factor extraction model. During this iterative reduction, items with weak factor loadings (< 0.40), excessive cross-loadings, or high residual variance were systematically removed. A total of 15 items were eliminated, leaving a parsimonious 10-item structural core that accounted for 54.9% of the total variance, meeting the standard thresholds for construct parsimony and explanatory power in psychiatric scale development.

Confirmatory Factor Analysis (CFA)

The unidimensional 10-item structural model was cross-validated using Confirmatory Factor Analysis to assess goodness-of-fit against empirical observation matrix standards (Tabachnick & Fidell, 2007). The goodness-of-fit metrics established an excellent fit to the observed data:

• Root Mean Square Error of Approximation (RMSEA): 0.054 (indicating close approximate fit, with standard cut-offs accepting ≤ 0.06 as excellent).
• Comparative Fit Index (CFI): 0.952 (surpassing the conventional ≥ 0.95 benchmark for superior model fit).
• Incremental Fit Index (IFI): 0.955 (demonstrating outstanding fit relative to the null baseline model).
• Normed Fit Index (NFI): 0.845 (reflecting adequate fit given sample constraints and model parsimony).

All standardized factor loadings for the ten retained items were positive, statistically significant (p < .001), and substantively robust, establishing that a single latent variable appropriately accounts for the inter-item covariance structure.

10. Instrument / Measurement Tool

• Instrument Name: Sierra Leone Perinatal Psychological Distress Scale (SLPPDS)
• Alternative Title: The SLPPDS Rating Scale
• Instrument Type: Visual Analogue / Culturally Adapted Likert Rating Scale
• Target Population: Perinatal women (pregnant women and new mothers within the first 12 months postpartum)
• Target Age Group: Adulthood (18 years and older; adaptable for adolescent mothers with appropriate local ethical clearance)
• Administration Format: Interviewer-administered (ideal for low-literacy clinical or community outreach settings) or self-report
• Total Item Count: 10 items (retained from the preliminary 31-item pool following EFA/CFA refinement)
• Language Editions: English and Krio (Creole / Sierra Leonean Patois)
• Visual Response Scale: 4-point visually supported ordinal scale utilizing standardized culturally recognizable illustrations of water containers (jerry cans) filled to graduating capacities:
  • Empty Jerry Can (Level 0): Never / None of the time (0 points)
  • Quarter-Full Jerry Can (Level 1): A little / Some of the time (1 point)
  • Half-Full Jerry Can (Level 2): Moderate / A lot of the time (2 points)
  • Completely Full Jerry Can (Level 3): Extreme / All of the time (3 points)
• Scoring Procedures: Item ratings are summed across all 10 items to generate a composite total distress score ranging from 0 to 30. Higher composite scores correspond to elevated levels of perinatal psychological distress.
• Screening Cut-Offs: ROC analysis identified an empirical diagnostic cut-off point corresponding to an ROC coordinate optimization showing AUC = 0.90, Sensitivity = 80.0%, and Specificity = 85.7%. Mean clinical cases score 13.6 (SE = 0.9) versus non-cases < 3.3 (SE = 0.9).

11. Permissions & Fee and Test Year

Test Year: 2025

Copyright and Governance: The Sierra Leone Perinatal Psychological Distress Scale (SLPPDS) is copyrighted by the original authors (Abdulai Jawo Bah, Haja Ramatulai Wurie, Mohamed Samai, Rebecca Horn, and Alastair Ager) and their associated research institutions (Institute for Global Health and Development, Queen Margaret University; and College of Medicine and Allied Health Sciences, University of Sierra Leone).

Fee: The scale is distributed free of charge for non-commercial academic research, humanitarian public health monitoring, and routine clinical screening within non-profit healthcare institutions in low- and middle-income countries.

Permissions & Contact: Prior written approval and formal acquisition of the complete, validated English and Krio interview schedules (including high-resolution visual jerry-can response flashcards) should be requested directly from the corresponding author:

• Corresponding Author: Abdulai Jawo Bah, PhD
• Institutional Affiliation: Institute for Global Health and Development, Queen Margaret University, Edinburgh, United Kingdom
• Contact Email: [email protected]

12. References

• Bah, A. J., Wurie, H. R., Samai, M., Horn, R., & Ager, A. (2025). Developing and validating the Sierra Leone perinatal psychological distress scale through an emic-etic approach. Journal of Affective Disorders Reports, 19, Article 100852. https://doi.org/10.1016/j.jadr.2024.100852
• Berry, J. W. (1989). Imposed etics-emics-derived etics: The operationalization of a compelling idea. International Journal of Psychology, 24(6), 721–735. https://doi.org/10.1080/00207598908247841
• Betancourt, T. S., Scorza, P., Kanyanganekwe, C., Fawzi, M. C. S., Sezibera, V., Cyamatare, F., Beardslee, W., & Gilman, S. E. (2015). Validating an adapted depression scale for use in Rwandan children and adolescents: A psychometric study. BMC Psychiatry, 15(1), Article 31. https://doi.org/10.1186/s12888-015-0402-6
• Kleinman, A. (1980). Patients and healers in the context of culture: An exploration of the borderland between anthropology, medicine, and psychiatry. University of California Press. https://doi.org/10.1525/9780520340848
• Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x
• Tabachnick, B. G., & Fidell, L. S. (2007). Using multivariate statistics (5th ed.). Allyn & Bacon / Pearson Education.
• Watkins, M. W. (2018). Exploratory factor analysis: A guide to best practice. Journal of Black Psychology, 44(3), 219–246. https://doi.org/10.1177/0095798418771807

13. Items of the Scale