Conceptualisation and Culturally Appropriate Assessment of Executive Function in Children in Ghana and Nigeria

Background: Assessment for executive function (EF) is an integral part of child and adolescent mental health services (CAMHS). However, presently there are no known culturally appropriate tools for assessing EF in Ghana and Nigeria. This study aimed to explore the local conceptualization of EF and adapt an appropriately selected EF tool for the cross-cultural context of Ghana and Nigeria. Methods: This study was carried out in two phases: phase 1 was geared towards exploring the burden of executive dysfunction, the current state of assessment of executive functions in Ghana and Nigeria and selecting an appropriate existing western-derived tool for possible adaptation for Ghana and Nigeria, while phase 2 explored the local conceptualisation of EF and evaluated the content validity of the selected candidate tool (from phase 1). These were done by conducting in Phase 1 a scoping and systematic review of the literature for EF tools validated in low-and-middle-income countries (LMICs) following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) checklist (see chapter 2), and an in-person and online self-administered survey of 133 health workers in rural and urban areas from all tiers of the healthcare system (see chapter 3). In phase 2, I conducted 26 focus group discussions with parents (n=61) and healthy typically developing adolescents aged 10 to 18 years (n=73) using an embedded design of mixed methods study with a qualitative emphasis (see chapters 5 – 8). To ensure rigorous analysis, a team of three independent coders, employing both inductive and deductive coding approaches, facilitated the two forms of thematic analysis I used. Quantitative content analysis of the transcripts complemented the qualitative analysis. Results: The systematic review in Phase 1 showed that there have been little home-grown efforts at indigenous tool development, while the modest efforts at adaptation of western-based tools have overwhelmingly focused on parameters like internal consistency and structural validity while neglecting crucial first steps such as good quality content validation and cross-cultural validation which are vital to cross-cultural adaptation. Nonetheless, the Behavior [sic] Rating Inventory of Executive Functions (BRIEF) was the EF assessment tool that showed the best relative evidence of being the most rigorously validated in LMICs. The survey of health workers showed adolescents were the most seen age-category among primary and secondary care health workers, while there was a reported high burden of conditions and complaints that could potentially have significant executive dysfunction such as Epilepsy, brain injury, ADHD and other neurodevelopmental problems, and anxiety problems. In phase 2, the exploration of local conceptualisation of EF showed that there were some generational differences in conceptualisation of EFs by parents and adolescents with parent tending to consider BRIEF items as “normal” (non-pathological), often as merely character flaws. Further, there were also various unintended barriers to conceptual understanding as intended, such as a tendency to concrete thinking, while parents and adolescents in the general population tended to struggle conceptually mostly with items related to Autism-related and ADHD-related EF domains. Finally, among adolescents understanding of the English phrasing of the BRIEF was generally quite poor, likely due to disparities in English literacy and proficiency, particularly between rural and urban participants. Items were generally relevant and culturally acceptable to participants, but with a few exceptions where cultural objections were raised about some items and format. Conclusion: These findings have implications for tool development of accurate, culturally sensitive tools, the potential for integrating lower cadres of health workers into cognitive assessment in a task-shifting approach, health promotion and communication strategies regarding certain executive dysfunction-related disorders like ASD and ADHD, changing health-seeking behaviour and influencing CAMH policy in West Africa. It has also drawn attention to the need for caution in the use of so-called “standard English language” version of such tools even among educated cross-cultural contexts and potentially even among disadvantaged sub-populations in HICs.

Name dc:type.qualificationname

Doctor of Philosophy (PhD)

Level dc:type.qualificationlevel

Doctoral

Grantor dc:publisher.institution

University of Cambridge

Year dc:date.issued

2023

Author dc:creator

• Kusi-Mensah, Kwabena

Advisors dc:contributor.advisor

• Bateman, Andrew
• Burn, Ann Marie

• executive function
• child and adolescent mental health
• BRIEF
• validation
• Africa
• cross-cultural
• psychometric
• Ghana
• Nigeria
• cognitive function

Licence

• https://apollo8-f-pro.lib.cam.ac.uk/bitstreams/291a272e-565b-4001-95ae-c3a4d526700d/download
• https://www.rioxx.net/licenses/all-rights-reserved/

Language dc:language

eng

Author Identifier

0000-0003-0165-8405

OAI identifier oai:identifier

oai:www.repository.cam.ac.uk:1810/376024