Examining the Cross-Cultural Applicability of the Spanish PMQ-9: A Comparative Validation Study

Abstract: Background
Patient-reported measures like the Patient Health Questionnaire-9 (PHQ-9) and Patient Mania Questionnaire-9 (PMQ-9) play a crucial role in bipolar disorder treatment in collaborative care models. However, the PMQ-9 lacks cultural validity in the Spanish language, hampering its utilization and contributing to treatment disparities. This study aims to culturally validate the Spanish-language PMQ-9.

Methods
This IRB-approved study is focused on the validation and cultural adaptation of a diagnostic test, which has two components: evaluating the perspectives of a) Spanish-speaking psychiatrists and b) individuals diagnosed with bipolar disorder. Specifically, it aims to assess perceptions of the professionally translated Spanish version of the PMQ-9. Part one incorporates a mixed-methods approach: designing a survey to measure perceptions of Spanish-speaking psychiatrists (recruited via professional networks) from both Latin America and the United States, alongside a qualitative evaluation of cultural validity utilizing open-ended questions. The survey for professionals included reviewing the instrument and rating its helpfulness, acceptability, and cultural relevance on a Likert scale from 0 to 5. Part two involves qualitative methods initiated in March 2024. Ten patients recruited by clinicians who completed the survey in part one will participate in qualitative interviews to provide feedback on the PMQ-9's cultural validity (e.g. interpretability, understandability, and relatability). Recorded interviews will be transcribed and analyzed using the constant comparative method to refine the Spanish PMQ-9. This phase of the study will conclude by September 2024 due to the conclusion of the project budget.

Results
A total of 71 clinicians participated in the survey (63% response). Quantitative findings included high mean ratings for helpfulness/acceptability (mean 4.21, SD 1.5) and cultural sensitivity (mean 4.1, SD 1.4). Nearly 9 out of 10 respondents (87.1%) expressed intent to utilize the PMQ-9 in their clinical practice, with 95% indicating they would recommend it to their peers. Clinician qualitative findings highlighted language nuances and proposed modifications for enhancing cultural relevance. For example, direct translations of "argumentative" (e.g. “discutidor”) may not culturally adapt to evaluating clinical symptoms of mania and need modification.

Discussion
Initial findings suggest promising cultural validity of the Spanish PMQ-9 for manic symptom monitoring among Latin American and US Spanish-speaking clinicians. The next phase of our study involves patient interviews to further assess cultural validity. At the time of submission, one participant had been recruited for qualitative interviews. High ratings from clinicians indicate the PMQ-9's potential utility in Hispanic populations, with many expressing intent to use it in Spanish-language settings. Addressing language nuances and proposed modifications is crucial for enhancing the PMQ-9's cultural validity.

Conclusion
Cultural validation is essential for patient-report measures to ensure equitable treatment. Addressing language nuances and enhancing cultural relevance can improve the PMQ-9's clinical utility. Ongoing validation efforts are necessary to further refine the Spanish PMQ-9 and enhance its effectiveness in clinical practice.