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Inquiry Article

Assessing mental wellness in a context of extreme poverty: Validation of the rosenberg cocky-esteem scale in rural Republic of haiti

• Emily Taylor

Assessing mental wellness in a context of extreme poverty: Validation of the rosenberg self-esteem calibration in rural Republic of haiti

• Keetie Roelen,
• Emily Taylor

x

• Published: Dec 14, 2020
• https://doi.org/x.1371/journal.pone.0243457

Figures

Abstract

A widening evidence base beyond low- and middle-income countries (LMICs) points towards mutually reinforcing linkages between poverty and mental health problems. The use of validated and culturally relevant measures of mental wellness outcomes is crucial to the expansion of bear witness. At present, in that location is a paucity of measures that have been tested and validated in contexts of extreme poverty. Using data from adult women living in farthermost poverty in rural Haiti this report assesses the cross-cultural validity of the widely used Rosenberg Self-Esteem Scale (RSES) and its applicability in assessing linkages betwixt poverty and mental health outcomes. Nosotros find no evidence for a one-dimensional 10-factor structure of the RSES within our data and agree with other authors that the standard self-esteem model does not fit well in this cultural context. Comparisons with another widely used measure of mental health–the K6 measure out–indicate that the RSES cannot exist used as a proxy for mental health outcomes. We conclude that the utilize of the RSES in dissimilar cultural contexts and with samples with different socioeconomic characteristics should be undertaken with caution; and that greater consideration of the validity of psychosocial constructs and their measurement is vital for gaining robust and replicable insights into breaking the wheel between poverty and mental health problems.

Citation: Roelen K, Taylor Due east (2020) Assessing mental health in a context of extreme poverty: Validation of the rosenberg self-esteem scale in rural Haiti. PLoS ONE xv(12): e0243457. https://doi.org/10.1371/journal.pone.0243457

Editor: Pablo Brañas-Garza, Universidad Loyola Andalucia Cordoba, SPAIN

Received: April 14, 2020; Accepted: November 22, 2020; Published: Dec xiv, 2020

Copyright: © 2022 Roelen, Taylor. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in whatsoever medium, provided the original author and source are credited.

Information Availability: All relevant information are inside the manuscript and its Supporting Information files.

Funding: This survey was made possible with funding from Due west.K. Kellogg Foundation (URL: https://www.wkkf.org/). Funding was provided to K. Roelen at the Institute of Development Studies through an institutional contract with implementing partner Fonkoze in Haiti. The funders had no part in report blueprint, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Despite widespread poverty and loftier levels of mental health disorders, research on the relationship between poverty and mental wellness in depression and center-income countries (LMICs) has but started emerging in the concluding two decades [ane,2]. Evidence from beyond LMICs finds an association between indicators of poverty such as low socioeconomic condition and food insecurity, and mutual mental health disorders [ii]. While some studies suggest that poor mental health is not strongly associated with poverty [3,4], others have dispelled this past attributing lack of association to narrow or inadequate apply of poverty measures [five,six]. More recent research in countries including Republic of india and Indonesia points towards a causal relationship betwixt depression income and poor mental wellness [seven,8]. Withal, inquiry on linkages between poverty and mental health, and particularly the role of poverty alleviation interventions in improving mental health, in low-resource settings is deficient [1].

The utilize of validated, comparable and culturally relevant measures of mental health outcomes is central to the expansion of inquiry. Efficiency and generalisability are central requirements of such measures, particularly when mental health is not the primary focus of research but one of a broad set of socio-economic outcomes, as is common in relation to anti-poverty interventions [9,10]. Despite a widening of the evidence base of operations, at that place is a paucity of measures that have been validated inside the context of LMICs and that ensures their relevance in different resource and cultural contexts [xi,12]. Against the properties of this paucity, we assess the validity of a widely used measure of cocky-esteem in a context of low resources and high levels of farthermost poverty in rural Haiti.

Cocky-esteem describes an individual'south positive or negative evaluation of their self-worth, self-confidence and cocky-respect [thirteen]. Cocky-esteem is positively associated with goal-directed behaviour [14], negatively associated with depression [xv] and a wide range of other psychiatric disorders [sixteen]. Evidence leans towards self-esteem being an etiological cistron in the evolution of depression (the vulnerability model) rather than a side-outcome (the scar model) of depression [17]. Therefore, cocky-esteem is not just an indicator of psychological wellbeing [eighteen] but may also serve equally an early on indicator of vulnerability to depression or other psychological distress. The Rosenberg Self Esteem Calibration (RSES) [xix] is regarded as the gold-standard measure out of self-esteem, with established reliability and validity, and is used across different contexts, languages and cultures [xx].

In this paper, nosotros use data from developed women living in extreme poverty in rural Republic of haiti to assess the cantankerous-cultural validity of the RSES, and its applicability in studies on linkages between poverty and on mental health outcomes. For this purpose, we investigate ii specific questions in reference to our data and context: (i) Does a Creole-language version of the RSES accept a coherent factor construction when applied in Haiti? and (ii) Can the RSES serve as a proxy for mental wellness? We practise so by investigating the gene construction of the RSES and past comparison results for the RSES with another measure of mental health in order to plant construct validity, namely the K6 [21].

RSES in LMICs

Nosotros provide a short review of applications of the RSES in LMICs.

The RSES was originally designed equally a single-dimension construct [22] measuring cocky-esteem via ten items and a iv-point calibration. Items cover what are understood to be universal indicators of cocky-esteem such as self-worth, self-respect and self-like using both positively and negatively worded items (more detail is provided in the section Measures below). A comparative study of the RSES in 53 nations, including 10 LMICs, found broad statistical back up with a one-gene model [20]. Other country-focused studies, such equally in Brazil, also observe high internal consistency [23]. However, the amount of variance accounted for by the single factor was low in some countries, especially in Botswana, the Democratic Republic of Congo (DRC) and Ethiopia, where it vicious below 30 pct. This was reflected in poor internal consistency as measured by Cronbach's alpha in the DRC, Ethiopia, and Tanzania [20].

Confirmatory cistron analyses (CFA) provide a more thorough validation of a scale's internal structure. Nosotros institute five studies using CFA with samples from LMICs, describing six samples (run across Table 1). Only Fromont et al [24] institute support for a one-gene model, in Burundi, with weak internal consistency (α = .63). All other studies establish that a two-cistron model achieved the all-time fit beyond multiple indices. 2 studies excluded particular 8 to achieve the best fit, resulting in a ix-detail scale [22,25]. Both these samples were Chinese, but some other study with a Chinese sample preferred a ten-item model [26].

Two features recurred across these studies. Firstly, method effects were mutual across samples with items splitting into two factors depending on whether they were negatively or positively worded. Secondly, item 8 "I wish I could have more respect for myself" seems to have been variously interpreted by dissimilar cultures, with the consequence of it not reliably loading onto the one-factor model or onto the negatively worded cistron in the two-factor version. This does not appear to be a language translation issue, as the phenomenon has been noted in English-speaking LMICs such equally Botswana and Zimbabwe [twenty]. These features advise a cultural effect. The differential understanding of item 8 has contributed to an argument that the effect is in some way caused by collectivist culture, although this argument has been applied to countries that would non fit the typically understood collectivist epitome. Wu, Zuo [26] argued that particular 8 should be treated every bit a positively worded item. Nevertheless, in other studies detail 8 does not appear to be a useful part of the scale construct, and may be measuring something unlike altogether.

Arguments nearly the cultural specificity of cocky-esteem more generally tend to exist polarised. Hewitt [27] argued that self-esteem is essentially socially constructed and therefore culturally situated. Du, Rex [28] point out that individualistic cultures may place more emphasis on personal self-esteem while relational aspects of self-esteem may be more salient in collectivist cultures. At the other end is the position of cocky-esteem as a trait characteristic of humans and therefore universal [29]. The possible cultural specificity of self-esteem, and therefore the RSES, aligns with a wider literature cautioning against comparing mental health outcomes beyond interventions and contexts without ensuring that construct and measurement of it are applicative to that culture [xxx]. The picture is farther complicated by the assertion that cocky-esteem is gendered, with large-scale cross-cultural evidence showing that men consistently have higher self-esteem than women [31]. Researchers should therefore approach self-esteem measurement in specific populations with caution, with routine validation within samples preliminary to other analyses. However, evaluations of anti-poverty interventions in unlike LMICs, having employed the RSES as a mensurate of psychological wellbeing, tend not to written report steps to found sample-level validation such as confirmatory cistron assay [10,32,33].

This written report therefore prepare out to validate the RSES in a sample of Haitian women, testing construct validity using confirmatory gene analysis and discriminant validity through comparison with a measure of mental health, namely K6. Secondly, we aim to test whether self-esteem, as measured by the RSES, can be used as a proxy measure out for mental health, hypothesising that self-esteem volition predict mental health.

Methods

Design, sample and procedure

The data is drawn from the baseline study of a quasi-experimental impact evaluation of the Chemen Lavi Miyò (CLM)—"the pathway to a better life"–programme in rural Haiti, which is implemented by local NGO Fonkoze. The CLM programme targets adult women who are extremely poor [34] and supports them with a package of cash and asset transfers, skills development, coaching and service provision over a period of 18 months in a bid to motion them out of poverty [35].

The data includes 1,381 women from across treatment and command groups in the Primal Plateau region in Republic of haiti. The sample for the treatment group (n = 631) was pre-determined by programming considerations, with all women in the program sites who were eligible having been selected into the programme. Inclusion criteria include living in extreme poverty (based on a wide set of indicators such as having little income, beingness unable to send their child(ren) to school and having limited assets), having dependants and being able to work. Women from similar communities in the same region were selected into the command group (north = 750) using participatory wealth rankings (PWRs) within selected communities. PWRs are widely used participatory and community-based exercises that inquire a pocket-size group of community members to rank those living in the community according to their wealth, serving equally a proxy for poverty status and helping to found programme eligibility.

The ii sub-samples are described in Table two for illustrative purposes. Women had an average age of 33.49 years with median household size of 5 members, including median of three children nether 18 years and 1 child nether five years. More than three out of four women were traditionally or legally married. Participants' literacy was ranked on a four-signal calibration from completely illiterate to able to read and write; 67 percent were unable to read or write. Although differences betwixt groups in household size, numbers of children and marital status reached significance, effect sizes were negligible (Cohen's d<0.ii, r<0.2).

Information was nerveless over an extended catamenia from June to Dec 2017. The length of this period was in office due to the remoteness of fieldwork sites and the fourth dimension-consuming process of selecting women for the command group through participatory wealth ranking exercises. Information collection was undertaken by the Social Bear on squad, which is a semi-democratic monitoring and evaluation co-operative within Fonkoze.

Enquiry adhered to ethical protocol, including informed consent, anonymity in data analysis and broadcasting and respectful conduct in the field. All inquiry respondents provided informed consent before participating in the report. They received verbal information (in Haitian Creole) about the inquiry objectives and the requested input. Respondents were allowed to offer consent in the near culturally appropriate fashion, which in all cases proved to be verbal consent (due to high levels of illiteracy among inquiry participants). Ethical clearance for this study was provided by the Research Ethics Committee of the Institute of Evolution Studies in March 2017.

Measures

Rosenberg Cocky-Esteem Scale.

The RSES is a ten-item measure of self-esteem [19], with a scoring range of 0–30, that includes half positively and half negatively worded statements such as "On the whole, I am satisfied with myself" and "I certainly feel useless at times". It is the almost widely used measure of cocky-esteem employed with adults and youth globally. Information technology has been extensively validated with evidence for cultural variations in its constructs (the focus of this report). In this sample, internal consistency for the total ten-item calibration was α = 0.52. This low alpha is consequent with several studies using the RSES as a single-cistron structure in LMICs including Fromont, Haddad [24] in Burundi; Oladipo and Kalule-Sabiti [36] in Nigeria; and Schmitt and Allik [20] in the Autonomous Commonwealth of Congo, Federal democratic republic of ethiopia and Tanzania. Information technology contrasts with improve internal consistency found in a Republic of costa rica sample Li, Delvecchio [25] (see Table 1).

K6.

The K6 is a vi-item cocky-report measure out with a v-point response scale designed to screen for serious mental illness [21], and has been validated for use in multiple cultural contexts with very practiced specificity and sensitivity for psychological distress [37]. Items cover typical symptoms of psychological distress including feelings of hopelessness, nervousness, depression, and worthlessness. It has been adopted by the World Wellness Organisation for use in World Mental Health surveys and is therefore i of the most widely used screening tools for mental illness [38]. The measure out has been translated into Haitian Creole and used in a Haitian population but not been formally validated in this context [39–41]. In this sample, the internal consistency was α = 0.83.

Table 3 provides a detailed overview of items included in the RSES and K6 measures.

Statistical analysis plan

Following initial data cleaning and testing for normality, confirmatory factor analyses (CFA) were used to replicate previously published factor structures, and exploratory gene analysis (EFA), as needed, using Maximum Likelihood extraction method and Varimax rotation, to exam for novel models. Items were forced into 1 or 2 factors, with and without particular viii, as per previously published models.

CFA using MPlus seven.two were then conducted to plant model fit with models suggested by EFA. Items with <twoscore% (r² < .4) of their variance deemed for by the overall construct were removed from the assay. CFA typically involves the random splitting of a sample into two to allow testing and confirmation of a measurement model. As membership of the control and treatment groups had non been randomly allocated in the first instance and statistical differences had been plant between the two groups on demographic and test variables, these groups were accounted unsuitable for use. Therefore, they were collapsed together and so randomly carve up. No differences were found between the two new groups on ways for age, K6 or RSE full score, nor between medians for marital status, literacy, or number of children, making them suitable groups for CFA model testing and confirmation. Multiple fit indices were used to address limitations within private fit indices: a comparative fit index (CFI) of >.90 is acceptable and >.95 is adept; a Root Mean Foursquare Error of Approximation (RMSEA) of < .06 is good, and < .05 (or a 95% confidence interval that was < .05) is very good; and a Standardized Root Mean Square Residual (SRMR) of < .08 is good (Hu & Bentler, 1999). The chi-foursquare was besides documented. Meaning improvements in model fit were compared using the Satorra–Bentler scaled chi square statistic (S-B χ²) [42].

Correlational analyses and ANOVA were used to test the association betwixt self-esteem (RSES) and serious mental illness (K6).

For CFA, estimating sample size is not straightforward. Whilst Everitt [43] suggest a ratio of 10xNitems, with small scales this can lead to under-estimation of required sample size. Comrey and Lee [44] suggest that 500 participants is a very good sample and that i,000 or more is excellent. Based on Everitt'southward guidance, and as the sample was divide for the CFA, we doubled the Nx10 number, and in apprehension of conducting the assay between the RSES and K6 as a path analysis, calculated Nitems = xvi. The minimum required sample size was therefore 320. Our terminal sample size of i,381, comfortably exceeded Comrey and Lee'due south benchmark for excellence.

Results

Information preparation

At that place was no missing data. The sample had a hateful RSES score of 15.6 (SD = 2.8). A slight positive skew was evident with significant results for the Kolmogorov-Smirnov test (.090, p < .001). The K6 had a mean score of 19.0 (SD = 4.ane) and showed a similar trend with a significant Kolmogorov-Smirnov test (.060, p < .001). Tests of normality tend towards being over-conservative for large samples, and consequences for assay tend to disappear in samples over Due north = 200 [45]. A slight positive skew was evident on visual inspection of the histogram (see S1 Fig), merely both measures provided an otherwise normal distribution. There was no correlation between age and either of the measures.

As no published validation for the K6 in a Haitian sample could exist found, we conducted a brief CFA on the calibration. The six items loaded onto a single factor achieving a practiced or acceptable fit on three indices (CFI = 0.931, RMSEA = 0.074 (95%CI = 0.000–0.168), SRMR = 0.080), and a non-significant χ² of 12.19 (df = 9, p = .203).

Testing the RSES gene structure

The factor analysis was conducted in two stages. Initially, we attempted to replicate pre-existing CFA of the RSES. The information did not fit any of these models (run across Table four). In the second stage, data was subjected to exploratory factor analysis to establish grounds for a novel model which could be tested through CFA. Items 1 and 8 failed to load on whatever factors, and were removed before repeating EFA. This time ii factors emerged with 4 items loading onto each gene (see Tabular array 5), both with eigen values >1 accounting cumulatively for 48.half-dozen% of the variance. There was clear delineation betwixt positively and negatively worded items. This was and then tested with CFA using a dissever-half sample. This model achieved expert overall fit (CFI = 0.940, RMSEA = 0.061 (CI = 0.044–0.078), SRMR = 0.040) with co-variances immune between ii items within each factor and between the two factors (run across Fig i). The model remained within acceptable parameters for all fit indices when re-tested in the other half of the sample, confirming this was the best plumbing equipment model.

Internal consistency for this new 8-item scale with two sub-scales was tested with Cronbach'due south alpha. These were: RSE-8 Positive = .61, RSE-8 Negative = .65 (both questionable) and RSE-8 Total = .58 (poor). The sub-scales are therefore recommended for use in preference to the total calibration.

Discriminant validity

The new sub-scales scores were compared with the K6 total score to assess the extent to which the RSE-8 represented a distinct construct from psychological wellbeing. The RSE-viii Positive was significantly correlated with the K6, merely the size of the correlation was negligible (r = .08, p = .005), with statistical significance reflecting the very large sample size rather than a meaningful relationship between the two variables. By contrast the RSE-8 Negative was significantly correlated with a medium effect size (r = .32, p < .001). This suggests that there is an clan between negative cocky-esteem and serious mental illness but the size of the event suggests that they are distinct constructs. The two sub-scales were not significantly associated with each other (r = -.06, ns), suggesting they measure out unique constructs.

Self-esteem as a predictor of mental health

Quartile groups were created for each RSE-viii sub-scale, and K6 scores plotted against these groups (run across Figs ii and iii).

One-fashion ANOVA found a significant divergence betwixt groups for the K6 and the RSE-viii Positive sub-calibration (F = 3.31, df = 1380, p = 0.019, ηⁱⁱ = .007) just the effect size was marginal, explaining less than 1% of the variance between the groups. This is reflected in the box plots which shows an most flat pattern with a slight curve suggesting that those in the mid-range for positive self-esteem had the highest levels of mental wellness problems compared to those with low or high self-esteem.

The RSE-eight Negative subscale showed a clearer pattern in relation to the K6 with negative cocky-esteem increasing in line with mental health difficulty. A significant departure was found between groups (F = 35.68, df = 1380, p < .0001, η^two = .072) with cocky-esteem predicting 7% of the divergence in K6 scores. This represents a pocket-sized but noticeable consequence.

These findings propose that whilst the negative sub-scale is clearly associated with mental health, this is a small clan. The positive self-esteem sub-calibration shows no such upshot. Overall, the hypothesis that cocky-esteem, every bit measured by the RSES, can be used equally a proxy measure for mental health is non supported.

Discussion

In this study we set out to test the validity of the RSES and its applicability every bit a proxy mensurate for mental health within a sample of women living in rural Haiti. We did so against the backdrop of expanding interest in studying the negative cycle between poverty and mental health issues and potential solutions, and the concurrent need for robust and validated measures of mental health for doing so.

We discover no show for a one-dimensional 10-item gene construction of RSES for adult women in rural Haiti. Instead, we find a ii-dimensional eight-item factor structure with sub-scales for positively and negatively worded items that meets multiple fit indices in CFA, although the internal consistency of the overall structure and sub-scales is weak. Comparisons with the K6 mensurate of psychological distress display no significant correlation with the RSE-8 Positive sub-scale. They do show significant clan with the RSE-8 Negative sub-scale, thereby endorsing the calibration as a measure of depression self-esteem. However, effect size suggests that the RSE-8 negative sub-scale and K6 are distinct constructs. Similarly, lack of clan betwixt RSE-8 positive and negative sub-scales ways that they do not reflect the aforementioned constructs. In curt, the applicability of the RSES as a measure out of self-esteem for developed women in Haiti may be limited, and it should non exist used as a proxy for mental wellness. It has psychometric backdrop that allow use in complex statistical analysis where its internal structure can be mapped as part of the analysis, e.one thousand. path analyses.

Follow-upward conversations with Fonkoze programme staff and enumerators allowed for farther reflection on cross-cultural applicability of individual items. In line with research in other LMICs [20,24,26,36], particular 8: "I wish I could have more respect for myself" did not work well in the Haitian context. Although a new round of two-manner translation from English to Haitian Creole and back to English revealed that the question had been accurately translated, its interpretation was likely to be dissimilar from its intended pregnant. Programme staff and enumerators indicated that the statement could accept been interpreted in a rhetorical manner, with respondents indicating: "Well of class I would like to respect myself more". Indeed, the large majority of respondents (94.7%) indicated to concur or strongly agree with this argument. Item 1: "On the whole, I am satisfied with myself" also did not load on whatever factors in our sample. The reason for this is less clear. Two-way translation confirms that the meaning and estimation of this argument is largely the aforementioned in Haitian Creole. Descriptive analysis and farther conversations with program staff suggest that the particular may exist too ambiguously worded.

The apparent cultural differences in applicability of the RSES may reflect that self-esteem is a civilisation-specific construct. Other inquiry in the Haitian context has as well questioned the universal applicability of the self-esteem construct and the RSES as a measure out for capturing this construct. A study with urban Haitian women at risk of HIV-infection establish that feelings of self-worth and a sense of self were strongly related to other's perceptions of them and the power to care for their family unit [46]. In contrast to our findings, discussions with clinic staff and attendees during determinative stages of the research suggested that negative and self-deprecating items in the RSES such as "I feel I do not take much to be proud of" may non exist culturally advisable (ibid). Equally a consequence, the RSES was non administered in this study. Others have highlighted that concepts of personhood in Haiti are multifaceted and that Haitians' conceptualisation and advice of mental health is highly localised and civilization-specific [47]. At present, few assessments in Republic of haiti use culturally advisable language, hampering efforts to expand agreement of mental health outcomes and guide models for mental health care [48].

Conclusions

Our findings lend weight to the hypothesis that self-esteem is a culture-specific construct that cannot be assumed to be universal. It adds to a pocket-size but substantial torso of literature from Haiti that highlights the need for more localised and contextualised understandings of self-esteem and mental health and illness more broadly. Further research is needed to localise self-esteem in the lives of women living in extreme poverty in rural Haiti, and to develop and validate a culturally relevant mensurate of self-esteem.

More than broadly, our results betoken that caution is warranted when using RSES in different cultural contexts and with samples with different socioeconomic characteristics. Given the limits to cross-cultural applicability of the RSES and its use as a proxy measure, scrutiny is needed when using psychometric scales that were designed and validated in (generally) high-income countries with very dissimilar populations.

This is especially pertinent within the burgeoning field of studies assessing linkages between poverty and mental health and widening involvement in impacts of anti-poverty interventions on mental health and psychological wellbeing. With studies including many measures and indicators, they tend to rely on psychometric validation undertaken in unrelated contexts and populations. Equally a result, studies risk nether- or over-reporting results, drawing inaccurate conclusions or de-contextualising findings. Greater consideration of the validity of psychosocial constructs and their measurement is crucial for studies to offering robust and replicable insights into how the wheel betwixt poverty and mental wellness issues may be broken.

Supporting information

Acknowledgments

This study was made possible with funding from W.K. Kellogg Foundation.

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