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Multiculturally Sensitive Mental Health Scale (MSMHS): Development, Factor Analysis, Reliability, and Validity
Ruth Chu-Lien Chao and Kathy E. Green University of Denver
Effectively and efficiently diagnosing African Americans’ mental health has been a chronically unre- solved challenge. To meet this challenge we developed a tool to better understand African Americans’ mental health: the Multiculturally Sensitive Mental Health Scale (MSMHS). Three studies reporting the development and initial validation of the MSMHS were conducted with African American student samples. First, an exploratory factor analysis of an initial item pool yielded 5 factors assessing subscales of perceived racism, depression, well-being, anxiety, and suicidal thoughts. Second, a confirmatory factor analysis supported the MSMHS’s 5-dimensional factor structure. Third, test–retest reliability, internal consistency, and validity coefficients supported the viability, use, and potential for continued develop- ment of this new instrument. Implications for theory and research on multicultural mental health scales are discussed.
Keywords: racism, African Americans, psychological distress, anxiety, well-being
The Multiculturally Sensitive Mental Health Scale (MSMHS) was developed to respond to the need for assessing African Amer- icans’ mental health, including perceptions of racism. The absence of an adequate assessment of perceived racism has contributed to a misdiagnosis of African American clients (Clark, Anderson, Clark, & Williams, 1999; Landrine & Klonoff, 1996). Thus, we had three reasons for developing this scale. One, the MSMHS responds to a decades-old belief that if people want to understand African Americans’ psychology, they must understand African Americans’ experience of racism. Specifically, racism is a unique stressor for African Americans (Clark et al., 1999; Harrell, 2000); according to Landrine and Klonoff (1996), 98% of African Amer- icans report experiencing racism in their life. Given that almost every African American experiences racism, it seems prudent to include perceptions of racism in an instrument measuring African Americans’ mental health.
Two, some theorists have urged development of a conceptual model that organizes, explains, and leads to understanding the psychological behavior of African Americans on the basis of an African American worldview (Caldwell, Jackson, Tucker, & Bow-
man, 1999. For example, Caldwell et al. (1999) explained that constructs and instruments developed primarily for Whites have often been inappropriate for African Americans because African American heritage and experiences of slavery and racial oppres- sion have resulted in a framework different from that of other groups. Thus, most current mental health measures that are extrap- olated from Caucasian Whites’ perceptions of mental distress may fail to include assessment of mental health stressors related to perceived racism (Constantine & Sue, 2006; Ridley, 2005; Sue & Sue, 2008). African Americans and White Americans may func- tion psychologically under distinct cosmologies (Broman, Mavad- dat, & Hsu, 2000). These cosmological systems show different ontological systems that reflect their distinct approaches to con- ceptualizing psychological distress. Three, some scholars have found that perceived racism explained additional variance in Af- rican Americans’ psychological distress beyond general stress (Smedley, Myers, & Harrell, 1993). This empirical evidence sug- gests that perceived racism plays a distinct role for African Amer- icans.
Psychological Dimensions of Perceived Racism
Despite the ubiquity of the word racism in everyday language, no consensus on its definition has emerged from the scientific literature. For example, Ponterotto, Utsey, and Pedersen (2006) said that racism is the abstract component of physical racial slavery. Although the physical bondage of slavery has ended in the United States, racism maintains African Americans in a state of psychological oppression. Some scholars have described racism as a relationship between members of oppressed and nonoppressed groups (Constantine & Sue, 2006); others, such as Clark et al. (1999), have indicated racism as a stressor for African Americans, defining it as “beliefs, attitudes, institutional arrangements, and acts that tend to denigrate individuals or groups because of phe- notypic characteristics or ethnic group affiliation” (p. 805). Indeed,
This article was published Online First April 25, 2011. Ruth Chu-Lien Chao, Counseling Psychology Program and Quantitative
Research Methods Program, Morgridge College of Education, University of Denver; Kathy E. Green, Quantitative Research Methods Program, Morgridge College of Education, University of Denver.
This study was supported by two research grants, the Promoting Psy- chological Research and Training on Health Disparities Issues at Ethnic Minority Serving Institutions (ProDIGS) of the American Psychological Association/Science Directorate and the Division 17 Counseling Psychol- ogy Fund of the American Psychological Foundation, awarded to Ruth Chu-Lien Chao.
Correspondence concerning this article should be addressed to Ruth Chu-Lien Chao, Counseling Psychology Program, University of Denver, 1999 East Evans Avenue, Denver, CO 80208. E-mail: [email protected]
Psychological Assessment © 2011 American Psychological Association 2011, Vol. 23, No. 4, 876 – 887 1040-3590/11/$12.00 DOI: 10.1037/a0023710
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it would be almost impossible for a people to endure more than 300 years of enslavement and not be psychologically affected and for the relation between racism and psychology to not be culturally transmitted to succeeding generations after the overt slave era ended. Because African Americans experienced slavery over a long period of time, mental and psychological behaviors of African Americans may still be consciously or unconsciously related to slavery, because their emancipation was proclaimed only about 150 years ago. Legalized segregation, the core of racist ideology or racism, ceased in American only around 55 years ago. With the continuance of individual and institutional racism, African Amer- icans still experience various aspects of oppression.
Anderson (2003) pointed out that, according to Black psychol- ogy, even if African American behavioral effects from slavery are minimized or discounted, the thesis that African Americans are still afflicted with psychological oppression associated with racism is generally supported by African American psychologists (Wil- liams, Neighbors, & Jackson, 2003). Moreover, the perceived racism or racial oppression is related not only to social dysfunction but also to the mental health of African Americans (Williams & Williams-Morris, 2000).
Perceived racism occurs widely and has been measured in different spheres, from one-item measures to full scales (Essed, 1990; Williams & Williams-Morris, 2000), and a high proportion of racially discriminatory experiences have been reported by Af- rican Americans (Landrine & Klonoff, 1996). A majority, 38 of 47 empirical research studies of African Americans, reported signif- icant relationships between perceived racism and psychological problems (Williams et al., 2003). Because racism could be expe- rienced by African Americans on almost a daily basis, Landrine and Klonoff (1996) suggested that an assessment of the degree of racism or an appraisal of African Americans’ experience of racism may be more important than measuring the types of racism. Spe- cifically, two African Americans may encounter the same racist situation, and yet whereas one may find it very stressful or be severely hurt, the other may just dismiss it.
The omnipresence of perceived racism over generations and on campus has been found to be significantly negatively related to the quality of life for African American college students. Scholars have also proposed that perceived racism taxes individual and collective resources and threatens well-being. Depression, anxiety, tension, and anger about racism (Fernando, 1984), as well as lower life satisfaction and suicidal thoughts (Broman, 1997; Jackson et al., 1996), are common problems in psychotherapy (Klonoff, Lan- drine, & Ullman, 1999). Despite abundant studies on the relation- ship between perceived racism and mental health (see e.g., Kes- sler, Mickelson, & Williams, 1999) and the unique role of racism in African Americans’ lives, it is surprising that no scale today includes an appraisal of the experience of racism as a correlate of mental distress among African Americans. Thus, our MSMHS is necessary on three counts.
First, a culturally sensitive scale is lacking. Psychological liter- ature increasingly attends to the role of racism in mental health (Clark et al., 1999; Williams & Williams-Morris, 2000), and yet scales that assess racism and quantify its relationship to aspects of mental health are lacking. For example, some intake checklists (e.g., the Presenting Problems Checklist; Draper, Jennings, & Baron, 2003) recognize the importance of racism to African Amer- icans and other ethnic minority populations and include perceived
racism as one item in their intake checklist. However, these intake checklists with a single racism item are limited in assessing a relationship between perceived racism and other psychological factors. An absence of adequate scales contributes to a misdiag- nosis of African Americans (Constantine & Sue, 2006; Ridley, 2005). For example, without including racism/discrimination items, intake checklists may have limitations in understanding the nature of African Americans’ mental health problems and then have difficulties in conceptualizing their psychological distress (Draper et al., 2003; Klonoff et al., 1999). By examining the association between perceived racism and psychological distress, the MSMHS can be useful for preventive mental health interven- tion.
Second, current mental health scales were developed with pri- marily White samples and may as such be inappropriate for Afri- can Americans. Many instruments in minority mental health re- search are criticized as taking White middle-class values as the norm (Ponterotto, 1988). For example, the Brief Symptom Inven- tory (Derogatis, 1993) was developed on a Eurocentric conceptual base and then used with non-Whites (e.g., African Americans) and non-middle-class participants (Lonner & Ibrahim, 1989) without revision. Most current scales also lack an appraisal of racism- related stress because they were developed from a majority per- spective. Some culturally specific measures (e.g., the Vietnamese American Depression Scale; Kinzie et al., 1982) are highly spe- cific to a cultural group or difficult to access (Sodowsky, Kuo- Jackson, & Loya, 1997). Current race-related stress scales—for example, the Minority-Status Stress (Smedley et al., 1993) or the Cultural Mistrust Inventory (Terrell & Terrell, 1981)— do not assess mental health issues or psychological distress (e.g., depres- sion, anxiety, and school/work adjustment). Ignoring racism- related stress amounts to applying the standards of the majority culture to conceptualize African Americans’ mental health issues (Smith, 1985; Sue & Sue, 2008).
Third, current mental health instruments have items reflecting only generic stressful events (e.g., “I feel stressed at work/school”) and lack race-specific stress. Racist events differ from the generic life events (e.g., getting fired) and hassles (e.g., losing one’s keys) typically assessed by measures of stressful events. Furthermore, a racism-inclusive scale fulfills the mandates of guidelines in psy- chotherapy. Racism-related stress is recognized as a crucial issue in the “Guidelines for Providers of Psychological Services to Ethnic, Linguistic, and Culturally Diverse Students” (American Psychological Association, 1993) and again in the “Guidelines of Multicultural Education, Training, Research, Practice, and Orga- nizational Change for Psychologists” (American Psychological Association, 2003). In short, development of the MSMHS not only responds to the urgent demands of current research but also fulfills the American Psychological Association’s ethical considerations by including the issue of perceived racism in assessing mental health issues among African Americans.
Theoretical Model for the MSMHS
Perceived Racism as a Stressor
Current social stress models assume that exposure to stress leads to psychological distress; stress is a term used to describe an event generated from antecedent, mediating, and response components
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(Lazarus & Folkman, 1984). Antecedent factors are called stres- sors, events that elicit response to stress. The present study con- ceptualizes perceived racism as analogous to but different from generic life events and daily hassles, for racist events are culture- specific stressors for African Americans. As generic stressors are related to psychological distress such as depression and anxiety, so are racist events (Williams et al., 2003). Although life stress occurs for Whites and non-Whites alike, for African Americans life stress includes unique interactions with perceived racism. The literature suggests that perceived racism is associated with lower self-esteem (Broman, 1997; Jackson et al., 1996), lower well-being (Williams, Yu, Jackson, & Anderson, 1997), increased distress and anxiety (Kessler et al., 1999), and higher levels of depression and suicidal thoughts (Karlsen & Nazroo, 2002) for African Americans than for their White counterparts. Klonoff et al. (1999) examined how racism relates to psychiatric symptoms. Hierarchical regression showed that perceived racism contributed significantly to overall psychiatric problems beyond variance explained by somatization, obsession– compulsion, interpersonal difficulty, depression, anxi- ety, and suicidal thoughts. Suicidal thoughts among Blacks can also be due to their deleterious sociocultural context, one salient factor of which is racism, and racism increases their feelings of alienation (Chance, Kaslow, Summerville, & Wood, 1998).
Differentiating African Americans who perceived racism from those who did not, Broman et al. (2000) found perceived racism was significantly related to psychological distress and that per- ceived racism came from varied sources: job applications, work settings, shopping, and involvement in the legal system. Further, according to Clark et al. (1999) and Williams et al. (2003), research on stress also converges with a sociological understand- ing of racism, underscoring the need to measure stress from the cultural frame of African Americans, not from a general human perspective.
Overview
The present study reports the development of a scale that in- cludes a perceived racism subscale. The study also reports the
results of three studies detailing the MSMHS’s psychometric prop- erties. The purpose of Study 1 was to generate an item pool to assess perceived racism, depression, well-being, anxiety, and sui- cidal thoughts. Items originated from the literature review and from focus group discussion of racism and its association with mental health. We asked African American students to complete the items and then conducted an exploratory factor analysis (EFA) of responses, computed subscale correlations, and assessed initial internal consistency. The purpose of Study 2 was to investigate the structural stability of the Study 1 factor solution and to provide additional validity evidence. Study 3 assessed test–retest and in- ternal consistency reliability of the instrument and provided evi- dence of convergent validity. Table 1 displays the steps taken in developing the MSMHS.
Study 1
Development of Item Pool
The MSMHS items were generated on the basis of research on African American experiences (see Clark et al., 1999; Williams & Williams-Morris, 2000), from the psychological literature on per- ceived racism and African Americans’ mental health (Essed, 1990; Harrell, 2000), and from focus group discussions. Items were oriented to constructs of anxiety, depression, well-being, perceived racism, and suicidal thoughts.
The development of the initial items included on the MSMHS was based on informal interviews with 30 African American college students about their personal life experiences, psycholog- ical problems, and well-being and also on a review of the litera- ture. Efforts were made to ensure that the items could be easily understood (i.e., an eighth-grade reading level). The researchers reviewed all potential items for redundancy, and those found to be repetitious were eliminated from the scale. Then six African Amer- ican licensed psychologists (three men and three women) who had at least 4 years of counseling with African Americans reviewed the items. These psychologists either eliminated certain items or sug-
Table 1 Measure Development and Validation Steps
Development phase Scale development steps
Planning Determine the purpose of the measure Identify the subjects as African Americans Conduct a review of the literature Conduct focus groups Select the rating scale as an item format
Construction Generate an item pool that has redundant and overinclusive items Conduct expert reviews of all items for content validation Reduce the item pool as dictated by an expert panel
Quantitative evaluation Administer the items to the development sample Derive subscales by means of exploratory factor analysis Assess the concordance of the subscales with the original purpose of the measure Evaluate the subscale items by means of item analysis and adapt them if necessary Assess the internal consistency reliability of the subscales Administer the reduced item pool to a new sample to confirm the structure Repeat the item analysis and assess the internal consistency reliability of the subscales Assess the stability reliability
Validation Assess the convergent validity via use of multiple external measures
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gested changes to items to further describe African Americans’ experiences of racism and their impact on mental health. On the basis of these procedures, a total of 54 items were generated.
To aid in assessing the content validity of the MSMHS, the primary researcher facilitated a focus group comprising eight Af- rican American college students (four women, four men; ages 19 –23 years) for approximately 2 hr. The MSMHS was not only evaluated for content validity but examined for its efficiency of administration and any potential harmful effects that might result from its completion. The group members completed the test and then discussed its structure, item clarity, item domain appropriate- ness, and comprehensiveness. As a result of the focus group’s efforts, concerns were raised that led to several changes being made. First, the anchors of the original 5-point response scale (1 � no reaction; 2 � a little bit of reaction; 3 � some reaction; 4 � strong reaction; and 5 � extreme reaction) were changed because group members found it difficult to differentiate between some of the response choices (e.g., strong reaction and extreme reaction). The new anchor labels ranged from 1 (almost never happened to me) to 5 (almost always happened to me). Second, some of the descriptions or items were ambiguous and needed clarification. Third, the group pointed out that several significant events fitting the criteria for inclusion were missed (e.g., “My teachers gave me poor grades because of my race” and “I think I have got most of what I want”). Fourth, these participants also expressed the neces- sity of adding well-being or resilience items to represent African American psychology. Indeed, according to Veit and Ware (1983), measures of mental health need to include items assessing a range of psychological distress including well-being. Items were written to reflect depression, anxiety, suicidal thoughts, and well-being as well as perceptions of racism to provide a complete mental health scale.
In addition to the focus group, five scholars with extensive research background in race/ethnicity, African Americans’ mental health, and cultural issues examined the MSMHS items for clarity and domain appropriateness. Items rated as not being appropriate were either rewritten or eliminated.
After redundant items were eliminated, 40 items remained from the initial pool of 54 items plus the four generated by the focus group. In a final content review, three female and three male counseling psychology doctoral students (all African Americans) reviewed the items. They judged items on the basis of whether they reflected perceived racism, suicidal thoughts, depression, anxiety, and well-being and offered suggestions for improvement. This process resulted in minor modifications to items.
Method
Participants. Participants were 397 African American stu- dents (264 men, 133 women) recruited at a large southern univer- sity. They ranged in age from 18 to 48 (M � 20.30, SD � 4.02) and included 94 freshmen (23.68%), 84 sophomores (21.16%), 88 juniors (22.17%), 79 seniors (19.90%), and 52 graduate students (13.10%).
Measures. The measures in Study 1 included a demographic questionnaire, the MSMHS–Initial, the Index of Race-Related Stress (IRRS; Utsey & Ponterotto, 1996), the Outcome Question- naire (OQ; Lambert, Lunnen, Umphress, Hansen, & Burlingame, 1994), and the Satisfaction With Life Scale (SWLS; Diener, Em-
mons, Larsen, & Griffin, 1985). The IRRS, OQ, and SWLS were used to assess the concurrent validity of the MSMHS–Initial.
Demographic questionnaire. Participants were asked to pro- vide demographic information on age, gender, year in school, and ethnicity.
MSMHS–Initial. The 44 items in the MSMHS–Initial were randomly ordered. Participants were asked to indicate their re- sponses by using the following 5-point response scale: 1 (almost never happened to me) to 5 (almost always happened to me). Sample items are “People treat me differently because of my racial background,” “I feel happy,” and “I feel tired or fatigued” (the first author may be contacted for the complete list of 44 items).
IRRS (Utsey & Ponterotto, 1996). The IRRS is a 46-item, four-component measure utilizing a 5-point response scale ranging from 0 (unaffected by the event) to 4 (extremely upset by the event). A Global Racism score can also be obtained by summing scores from all items. A sample item is “White people have expected you to denounce or reject the views or remarks of controversial Black leaders.” The IRRS measures racism-related events that respon- dents or their family members have experienced over their lifetime and the perceived stress caused by these events. Utsey and Pon- terotto (1996) established structural validity from an aggregate- item confirmatory factor analysis (CFA) to determine the best fit to a four-component oblique model. Significant, positive correlations were found to exist among all subscales of the IRRS with valida- tion measures (The Racism and Life Experiences Scales; Harrell, 1997). Utsey and Ponterotto (1996) reported the following ade- quate internal consistency reliabilities for the IRRS subscales: Cultural Racism � � .87, Institutional Racism � � .85, Individual Racism � � .84, and Collective Racism � � .79. Our study found these results: Cultural Racism � � .89, Institutional Racism � � .83, Individual Racism � � .85, and Collective Racism � � .80.
OQ (Lambert et al., 1994). The OQ is a self-report instrument used for repeated measurement of people’s changes through the course of mental health treatment. OQ instructions direct respon- dents to answer according to how they felt over the past week. The instrument consists of 45 items, with responses on a 5-point scale ranging from 0 (never) to 4 (almost always). The OQ was con- structed to have increasing scores correspond with increasing levels of distress on 36 items and increasing scores correspond with decreasing levels of distress on nine items. In the process of scoring, the scores obtained on these nine items are reversed to allow OQ item, subscale, and total scores to be uniformly inter- preted, where higher scores correspond with increasing levels of distress. The OQ is a psychometrically sound instrument with adequate 3-week test–retest reliability (.84) and high internal con- sistency reliability coefficients (.93; Lambert et al., 1994). The OQ also has strong concurrent validity coefficients with a variety of self-report scales (e.g., the Beck Depression Inventory, the State– Trait Anxiety Inventory; Umphress et al., 1997). The data from the present study yielded a total scale coefficient alpha of .85.
SWLS (Diener et al., 1985). The SWLS is a five-item self- report measure of subjective well-being rated on a scale ranging from 1 (strongly disagree) to 7 (strongly agree), with a higher score reflecting greater life satisfaction. Sample items are “In most days my life is close to my ideal” and “I am satisfied with my life.” The SWLS has good internal consistency reliability estimates (� � .87; test–retest over an 8-week interval, r � .82), has demonstrated convergent validity with other well-being measures, and correlates
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predictably with personality measures (Diener et al., 1985). The present study yielded a coefficient alpha of .86.
Procedure. Approval was obtained from the university’s human participants review committee. Students were informed that their participation was voluntary and their responses would be anonymous. The first author oversaw completion of the question- naires by students in African studies courses and psychology courses, with students earning course credit for their participation. Before taking the test, participants were given an introduction that described the purpose of the study, their rights as research partic- ipants, and how to complete the questionnaires (all three studies reported here generally followed this procedure).
In Study 1, 410 students completed the demographic question- naire, the MSMHS–Initial, the IRRS, the OQ, and the SWLS. As a check on inattentiveness, distractions, or lack of interest, several survey items (e.g., “Please do not respond to this item,” “Please circle 1 to this item”) were used to evaluate random responding. Using a conservative approach to data screening (e.g., elimination of any case that contained a single indicator of potentially mali- cious or random responding), we eliminated 13 cases from the data set. Thus, 397 cases were used for Study 1.
Results
Prior to conducting principal axis factor analysis, we checked to see whether necessary assumptions were met. The Kaiser-Meyer- Olkin measure of sampling adequacy for the initial EFA was .92, indicating that a factor analysis is useful (Bartlett, 1950). Bartlett’s test of sphericity, converted to a chi-square statistic and tested for significance, was significant at the .001 level, indicating that (a) the correlation matrix did not come from a population where the correlation matrix is an identity matrix and (b) the sample size was large enough to allow evaluation of the factor structure (Tabach- nick & Fidell, 2001). The correlation matrix was considered ap- propriate for factor analysis.
Six factors had eigenvalues higher than 1.00, but a parallel analysis found five factors to have eigenvalues exceeding chance values. Parallel analysis is considered a more effective method for determining the number of factors to retain (Patil, McPherson, & Friesner, 2010; Thompson & Daniel, 1996). The first five factors had eigenvalues ranging from 1.57 to 10.92. Additionally, a scree test indicated that a five-factor solution might be interpretable. The researchers forced a one-, four-, five-, and six-factor solution using both orthogonal and oblique rotation. The most interpretable of the analyses was the five-factor oblique-rotation solution. The five components together accounted for 56.24% of the variance. The criteria for retaining items were (a) items with loadings of .40 or higher were selected and (b) items meeting the .40 criteria on more than one factor were eliminated due to cross-loading. Ten items were eliminated on the basis of these two selection criteria. Table 2 lists the 34 retained MSMHS–Initial items, factor loadings from the principal axis factor analysis, means, standard deviations, eigenvalues, and percentage variance accounted for by factors. We labeled the resultant factors Perceived Racism (Factor 1, 10 items measuring racism experiences), Depression (Factor 2, nine items measuring depressive mood), Well-Being (Factor 3, seven items measuring subjective satisfaction with life quality), Anxiety (Factor 4, five items measuring anxiety symptoms), and Suicidal Thoughts (Factor 5, three items measuring symptoms that
could be related to African Americans’ experiences of racism; Chance et al., 1998). Subscale means and standard deviations are provided in Table 3. All the subscale scores were normally dis- tributed (see Table 3 for skewness and kurtosis).
Internal consistency and subscale intercorrelations. The coefficient alphas for the MSMHS subscales were .92 for Per- ceived Racism, .88 for Depression, .84 for Well-Being, .82 for Anxiety, and .82 for Suicidal Thoughts (see Table 2). Subscale intercorrelations for the instrument were moderate to high and statistically significant at p � .05 (see Table 4). Perceived Racism correlated .54 with Depression, –.63 with Well-Being, .51 with Anxiety, and .58 with Suicidal Thoughts. The significant correla- tions of the Perceived Racism subscale with other subscales indi- cate that more experiences of racism are associated with a lower level of psychological well-being and higher levels of depression, anxiety, and suicidal thoughts. Gender had no significant correla- tion with the MSMHS subscales.
Relationships between MSMHS factors and other measured subscales. Positive correlations were found between the MSMHS–Perceived Racism subscale score and the IRRS total score (r � .70), IRRS–Cultural Racism (r � .67), IRRS– Institutional Racism (r � .71), IRRS–Individual Racism (r � .62), and IRRS–Collective Racism (r � .58). The OQ was statistically significantly correlated with MSMHS–Depression, MSMHS– Well-Being, MSMHS–Anxiety, and MSMHS–Suicidal Thoughts, with low to moderate correlations (�r� � .39 to .64). The five factors of the MSMHS also correlated statistically significantly with the SWLS (�r� � .45 to .61; see Table 4).
Study 2
Study 2 further examined the MSMHS’s reliability and validity, as well as the stability of its factor structure using CFA. Competing models of the MSMHS factor structure were tested to investigate its structural validity. Study 2 hypothesized that the data obtained would fit the factor model established in Study 1 and that the pattern of reliability coefficients and subscale correlations for the MSMHS would be similar to those found in Study 1. Additional measures were administered to extend validity information.
Method
Participants and procedure. The participants were a differ- ent group of 434 African American students (228 men, 206 women) at a large southern public university. They ranged in age from 17 to 43 (M � 19.94 years, SD � 4.39) and included 151 freshmen (34.79%), 73 sophomores (16.82%), 136 juniors (31.34%), 65 seniors (14.98%), and 9 graduate students (2.07%). All participants were enrolled in psychology courses and received course credit for their participation.
Measures. The questionnaire in Study 2 consisted of the same demographic questionnaire used in Study 1 plus the 34-item MSMHS, the Brief Symptom Inventory (BSI; Derogatis, 1993), the Schedule of Racist Events (SRE; Landrine & Klonoff, 1996), and the Happiness Measure (HM; Fordyce, 1977).
BSI (Derogatis, 1993). The BSI is a 58-item self-report mea- sure of the frequency of experiencing a list of physical and psycho- logical symptoms in the past 7 days. The measure consists of sub- scales to assess symptoms in five dimensions: Somatization, Anxiety,
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Obsessive–Compulsiveness, Interpersonal Sensitivity, and Depres- sion. Participants respond on a 4-point scale ranging from 1 (not at all) to 4 (extremely). Derogatis (1993) reported reliability coefficients ranging from .84 to .87 for each of the subscales, 1-week test–retest reliability coefficients ranging from .75 to .84, and support for criterion-related validity and construct validity. Data from the present study yielded a coefficient alpha of .92 for the total scale and alphas of .89, .84, .86, .88, and .79, respectively, for the Somatization, Anxiety, Obsessive–Compulsiveness, Interpersonal Sensitivity, and Depression subscales.
SRE (Landrine & Klonoff, 1996). This is an 18-item instru- ment developed to assess African Americans’ frequencies of experi- ences of racist events in the past year (SRE–Recent Racist Events),
over their lifetime (SRE–Lifetime Racist Events), and the overall degree of racism-related stress (SRE–Appraised Racist Events). Each item is presented three times. For the two frequency scales, a 6-point scale ranging from 1 (if this has never happened to you) to 6 (if this has happened almost all of the time [more than 70% of the time]) is used, and for the stress scale, a 6-point scale ranging from 1 (not at all) to 6 (extremely) is used. A sample item is “How different would your life be now if you had not been treated in a racist and unfair way?” Landrine and Klonoff (1996) reported reliability coefficients ranging from .94 to .95 for the three subscales and split-half reliability coefficients ranging from .91 to .93. Evidence of the SRE’s validity was observed in the correlations between the three SRE subscales and all BSI subscales. The present sample yielded coefficient alphas of .90
Table 2 Items, Factor Loadings, Means, Standard Deviations, Communalities, Cronbach’s Alpha, and Eigenvalues for the Multiculturally Sensitive Mental Health Scale
Item
Factor loadings
1 2 3 4 5 M SD h2
1. People treat me differently because of my racial background .64 .21 2.67 0.93 .37 2. I feel discriminated against because I am Black .62 2.51 0.99 .49 3. I feel that our society doesn’t treat everyone equally in
regard to their racial backgrounds .60 .01 �.12 .11 2.74 0.92 .39 4. My teachers gave me poor grades because of my race .54 .13 �.02 .06 2.73 1.05 .32 6. Being Black, I have to tolerate racist policies or systems in
institutions .59 .10 �.13 .11 2.83 0.95 .39 7. I would have fewer difficulties in school or work if I were a
Caucasian White .61 .18 �.08 .12 2.65 1.01 .43 8. Being Black, I was followed by salespersons while shopping .57 .21 �.12 .16 2.79 0.99 .41 9. I feel that people look at me through their stereotypes .64 .11 �.14 .09 2.70 1.04 .35
10. Being Black, despite my capabilities, I am not appreciated by my boss or co-workers .69 .19 �.17 .13 2.52 1.02 .31
11. People have biased racial impressions about Blacks, e.g., Blacks are lazy .62 .18 .20 .15 2.53 0.97 .38
12. I feel depressed .65 3.16 0.97 .45 13. I feel tired or fatigued .62 3.15 1.06 .46 14. I worry about things .59 �.24 2.98 0.90 .64 15. I think I am less interested in things now than before .60 �.20 2.87 0.93 .62 16. I feel blue or downhearted .66 2.89 0.88 .38 17. I feel stressed or pressured .55 3.04 1.08 .29 18. Quite often nothing turns out as I wanted .52 �.22 2.50 0.91 .35 19. I feel like crying .60 �.22 2.60 1.02 .46 20. I tend to feel lonely .61 2.65 0.85 .36 32. I feel happy �.57 2.35 0.92 .40 34. I am satisfied with my life .20 �.22 �.68 2.39 0.93 .52 35. I feel calm, peaceful, or relaxed �.66 2.70 1.01 .50 36. I do not have much to be proud of .69 2.54 0.98 .53 39. I feel refreshed when I wake up �.61 2.38 1.02 .42 41. I tend to feel not supported by family or friends �.21 .57 2.79 1.03 .41 42. I feel I am loved or wanted by family or friends �.52 2.70 0.97 .33 21. I tend to be nervous �.21 .67 2.61 0.91 .50 22. I feel anxious for no reasons �.21 .53 2.51 1.19 .35 23. It’s not easy to calm down .22 .51 2.34 1.03 .35 25. I feel jittery or jumpy .61 2.53 1.10 .43 26. I feel impatient �.24 .26 .57 2.44 1.02 .46 27. Sometimes I have thoughts of ending my life �.21 .80 2.40 0.98 .63 29. Things would be better off if I die �.24 .86 2.36 0.89 .62 30. I sometimes think of taking my own life .86 2.12 0.82 .64
Eigenvalue 10.92 4.74 2.80 2.23 1.59 Percentage of variance 27.31 11.59 6.74 6.08 5.00 Cronbach’s alpha for subscale .92 .88 .84 .82 .82
Note. Factor loadings ��.40� are in bold. Loadings ��.20� are omitted. Factor 1 � Perceived Racism/Discrimination; Factor 2 � Depression; Factor 3 � Well-Being; Factor 4 � Anxiety; Factor 5 � Suicidal Thoughts; h2 � item communalities at extraction.
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for the SRE–Recent Racist Events subscale, .88 for the SRE–Lifetime Racist Events subscale, and .87 for the SRE–Appraised Racist Events subscale.
HM (Fordyce, 1977). The HM measures happiness by com- bining frequency and intensity of positive affect. It has been used extensively and is one of the validated measures of happiness, showing good test–retest reliability for the overall score (.86 over a 2-week interval and .67 over a 4-month interval; ps � .001). A sample item is “In general, how happy or unhappy do you usually feel?” The HM has significant validity coefficients with measures of personality characteristics of happiness (Compton, Smith, Cor- nish, & Qualls, 1996). The HM also has significant validity coef- ficients with measures of positive mood or affect.
Results
CFA. To examine the stability of the five-factor solution derived from EFA, we conducted a CFA on the 34 items of the MSMHS using LISREL 8.72 (Jöreskog & Sörbom, 2005). Com- parisons were made between an identified five-component oblique model (hypothesized model) found in the EFA in Study 1, two simpler models—a global component model (Competing Model A) and a four-component model (Competing Model B)—and a six-factor model (Competing Model C).
Several indices assessing the degree to which the model fit the data were computed for all four competing models. First, a chi- square statistic was computed for each model. As suggested by Byrne (2001), we computed several alternative indices of fit, including the �2/df ratio, goodness-of-fit index (GFI), adjusted
goodness-of-fit index (AGFI), root-mean-square residual (RMSR), comparative fit index (CFI), parsimony comparative fit index, and root-mean-square error of approximation (RMSEA). Goodness-of- fit indicators for the competing hypothetical models for the 34- item MSMHS are shown in Table 5.
The hypothesized model (five-component oblique model) con- sisted of five latent variables, representing the five subscales, with 10 (Perceived Racism), 9 (Depression), 7 (Well-Being), 5 (Anxiety), and 3 (Suicidal Thoughts) items. Table 5 indicates that this model repre- sented an acceptable fit to the data, with all the fit indices being “good” (CFI � .97; normed fit index [NFI] � .94; nonnormed fit index [NNFI] � .96; incremental fix index [IFI] � .97; RMSEA � .041; 90% CI [0.034, 0.048]; Byrne, 2001; Quintana & Maxwell, 1999; Schumacker & Lomax, 1996). Of the models tested, the hy- pothesized model had the lowest �2 value (925.23), the highest GFI (.92) and AGFI (.90), the lowest �2/df value (1.75), the lowest RMSR (.06), and the highest relative noncentrality index (.94).
We compared the hypothesized model with three competing models to determine whether another structure had acceptable, if not the best, fit. Specifically, competing Model A showed poor fit (i.e., .82–.83 for CFI, NNFI, and IFI). The indices of GFI and RMSEA for competing Models B and C were lower than indices of our hypothesized model (see Table 5). Thus, the hypothesized five-component oblique model was selected as the best of the models tested.
Internal consistency and correlations of MSMHS subscales. The internal consistency reliability estimates of the MSMHS sub- scales were determined to be adequate. For the Perceived Racism
Table 3 Means, Standard Deviations, Internal Consistency Estimates, Skewness, and Kurtosis for MSMHS Subscale Scores for Studies 1–3
Study and variable Perceived Racism Depression Well-Being Anxiety
Suicide Thoughts
Study 1 (N � 394) M 2.67 2.87 2.55 2.49 2.43 SD 0.99 0.97 0.98 1.05 0.96 � .89 .89 .85 .80 .81 Skewness 1.21 1.32 1.56 1.64 1.53 Kurtosis 1.48 1.54 2.13 1.88 1.76
Study 2 (N � 434) M 2.60 2.85 2.48 2.51 2.45 SD 0.92 0.94 0.92 0.90 0.93 � .88 .86 .85 .88 .82 Skewness 1.04 1.14 1.11 1.50 1.55 Kurtosis 1.53 1.62 1.78 1.34 1.41
Study 3a (N � 40) M 2.61 2.82 2.57 2.43 2.49 SD 0.89 0.93 0.94 0.99 0.95 � .87 .84 .82 .87 .84 Skewness 1.17 1.71 1.81 1.82 1.71 Kurtosis 1.32 2.16 2.08 1.54 1.76
Study 3b (N � 38) M 2.59 2.89 2.47 2.55 2.41 SD 0.93 0.92 0.96 0.98 0.92 � .88 .85 .84 .83 .83 Skewness 1.52 1.11 1.41 1.45 1.63 Kurtosis 1.76 1.42 1.94 1.08 1.45
Note. Study 1: N � 394; Study 2: N � 434; Study 3 (a): N � 40. Study 3b: N � 38. In Study 3b, participants were retested 2 weeks after initial testing in Study 3a. MSMHS � Multiculturally Sensitive Mental Health Scale.
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subscale, Cronbach’s alpha was .88; for Depression, alpha was .88; for Well-Being, alpha was .85; for Anxiety, alpha was .84; and for Suicidal Thoughts, alpha was .82. The MSMHS subscale correla- tions approximated those found in Study 1 (see Table 5). These correlation coefficients indicate that the MSMHS subscales mea- sure related yet distinct aspects of racism and mental health prob- lems.
Convergent validity. Pearson product–moment correlation coefficients were computed between MSMHS subscales and the BSI, SRE, and HM (see Table 5). All correlations between MSMHS subscales and these measures were statistically signifi- cant (�r� � .34 –.72). The means for the MSMHS subscales indicate that the participants generally have some level of experience with
racism that in turn is significantly related to their psychological distress (depression, anxiety, and well-being).
Study 3
Study 3 provided additional reliability data, specifically test– retest reliability estimates, for the MSMHS.
Method
Thirty-nine African American undergraduates (21 men, 18 women) ages 18 – 44 (M � 20.95, SD � 6.27) completed the 34-item MSMHS for Study 3.
Table 4 Correlations Between MSMHS Subscales, Demographic Variables, and Selected Predictor Variables
Variable
Study 1 (N � 394) Study 2 (N � 434)
1 2 3 4 5 1 2 3 4 5
MSMHS subscale 1. Perceived Racism — — 2. Depression .54�� — .46�� — 3. Well-Being �.63�� �.49�� — �.62�� �.44�� — 4. Anxiety .51�� .44�� �.50�� — .50�� .46�� �.43�� — 5. Suicidal Thoughts .58�� .52�� �.60�� .45�� — .61�� .48�� �.55�� .49�� —
Gender .07 .02 .03 .04 .03 .08 �.01 �.01 �.00 .02 OQ
Subjective Distress .61�� .64�� �.52�� .57�� .63��
Interpersonal Relations .55�� .42�� �.49�� .45�� .58��
Social Role .57�� .39�� �.42�� .46�� .55��
IRRS Cultural Racism .67�� .46�� �.56�� .52�� .70��
Institutional Racism .71�� .41�� �.54�� .42�� .68��
Individual Racism .62�� .37�� �.42�� .32�� .60��
Collective Racism .58�� .36�� �.44�� .39�� .55��
SWLS �.50�� �.61�� .45�� �.54�� �.48��
BSI Depression .65�� .69�� �.63�� .60�� .52��
Anxiety .61�� .68�� �.60�� .72�� .68��
Global Distress .63�� .71�� �.62�� .68�� .56��
SRE Past year .67�� .37�� �.45�� .39�� .43��
Entire life .61�� .34�� �.44�� .41�� .48��
Appraisal .66�� .42�� �.41�� .50�� .42��
HM �.43�� �.51�� .54�� �.48�� �.50��
Note. MSMHS � Multiculturally Sensitive Mental Health Scale; OQ � Outcome Questionnaire; IRRS � Index of Race-Related Stress; SWLS � Satisfaction With Life Survey; BSI � Brief Symptom Inventory; SRE � Schedule of Racist Events; HM � Happiness Measure. �� p � .01.
Table 5 Goodness-of-Fit Indicators for the Competing and Hypothesized Models for the 34-Item MSMHS for Study 2
Model �2 df �2/df GFI AGFI RMSR CFI PCFI RMSEA 90% CI
Null 3,269.12 570 6.61 .54 .47 .18 .80 .47 .18 [0.16, 0.20] A: One-factor 2,662.97 533 5.00 .57 .49 .15 .83 .49 .17 [0.16, 0.18] B: Four-factor 2,040.88 529 3.86 .74 .69 .08 .88 .63 .11 [0.11, 0.12] C: Six-factor 1,446.52 527 2.74 .72 .69 .09 .89 .85 .09 [0.08, 0.10] Five-factor oblique 925.23 528 1.75 .92 .90 .06 .97 .92 .04 [0.03, 0.05]
Note. N � 434. All chi-square differences are statistically significant at the p � .01 level. MSMHS � Multiculturally Sensitive Mental Health Scale; GFI � goodness-of-fit index; AGFI � adjusted goodness-of-fit index; RMSR � root-mean-square residual; CFI � comparative fit index; PCFI � parsimony comparative fit index; RMSEA � root-mean-square error of approximation.
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Participants were recruited from four undergraduate-level engi- neering, chemistry, psychology, and agriculture courses in a south- ern public university. The retest was administered 2 weeks after the first administration. Participants signed a consent form at the first administration and completed the MSMHS and a demo- graphic questionnaire during each of two class periods. Partici- pants were given a debriefing form describing the hypotheses of the study after the second administration.
Results
Reliability estimates. The 2-week test–retest reliability esti- mates for the MSMHS subscales were .87 for Perceived Racism, .88 for Depression, .86 for Well-Being, .85 for Anxiety, and .84 for Suicidal Thoughts. Table 3 also reports internal consistency esti- mates with subscale means and standard deviations from all stud- ies. Internal consistency estimates from Study 3 were comparable to those from Studies 1 and 2.
Discussion
The present study reported (a) development of a measure of mental health among African Americans inclusive of experiences of racism and (b) evidence of initial reliability and validity for this new instrument. Inclusion of perceived racism in a mental health measure stems from previous research that found perceived racism to play a substantial role in mental health for African Americans. The present study found evidence of validity for the MSMHS in the following results: (a) significant positive correlations be- tween the Perceived Racism subscale of the MSMHS and the IRRS and SRE, indicating that the MSMHS appropriately de- scribed racist stress among African Americans; (b) the Depression, Anxiety, and Suicidal Thoughts subscales of the MSMHS corre- lated with two existing measures of mental health; and (c) corre- lations between four subscales of the MSMHS (e.g., level of perceived racism significantly and negatively correlated with level of well-being) were in the hypothesized direction.
The results of EFA and CFA of the MSMHS revealed that the relationships between the original MSMHS items were explained by the five hypothesized subscales. The MSMHS included (a) African Americans’ daily life stressor racism and (b) items of mental health representing depression, anxiety, well-being, and suicidal thoughts. The strength and significance of the subscale correlations for Studies 1 and 2 were highly consistent, as were subscale reliability coefficients.
The relationship between perceived racism and mental health (e.g., well-being, depression) among African Americans is of interest to many researchers and counselors. For researchers, these relationships support previous literature on the influence of per- ceived racism on well-being and psychological distress. For coun- selors, items addressing perceived racism can be used to describe an individual African American client’s experience of racism and give counselors an initial understanding of how racism relates to an individual African American’s mental health (Utsey & Pon- terotto, 1996).
For African Americans, perceived racism has been found to be a more powerful predictor of psychological symptoms than have generic stressors and social status (Klonoff et al., 1999). Because most research on stress and symptoms has been conducted with
White Americans, current mental health scales lack items on perceived racism.
Racism as a scale. Previous researchers measured racism in a wide variety of ways, ranging from a single statement such as “ever experienced any unfavorable or unfair event in the past” (Sanders Thompson, 1996), through self-designed questionnaires on frequency of racist events, to a full five-factor instrument (Utsey & Ponterotto, 1996). The present MSMHS has a multi-item subscale measuring African Americans’ perceived racism that ranges from personal experience of a racist event to institutional racism. This inclusion of a multi-item subscale is in contrast to the previous use of separate measures to assess perceived racism and psychological distress, despite wide agreement on significant re- lationships between racism and mental health concerns.
The present study measured African Americans’ mental health with an instrument focused on their daily experiences. Perceived racism is a daily stressor. Such stress is shared among African men and women but not by Caucasian Whites, who may report no significant racism stress.
The other four subscales of the MSMHS (Depression, Well- Being, Anxiety, and Suicidal Thoughts) were appropriately related for this sample of African Americans. The Well-Being subscale of the MSMHS was significantly related to the SWLS and the HM in the hypothesized direction. The Well-Being subscale of the MSMHS was negatively related to the OQ and the BSI, indicating that a higher level of well-being is related to less psychological distress.
Frequently used mental health instruments such as the OQ claim to be useful in assessing cross-cultural populations because scores from varied racial groups (e.g., Whites, African Americans, Lati- nos/Latinas) were not found be significantly different (Lambert et al., 1994). Partially on the basis of this conclusion, researchers have used the OQ to investigate the mental health of participants from different racial groups. Unfortunately, previous mental health instruments did not measure perceived racism and so could not assess its role in mental health. Thus, the previous instruments failed to assess how racism relates to mental health.
When we examined African Americans’ scores on the Depres- sion, Well-Being, Anxiety, and Suicidal Thoughts subscales of the MSMHS, together with the Perceived Racism subscale, we noted that for African Americans racist experiences are related to well- being, depression, and anxiety. Scholars and counselors alike may need to understand the components of mental health by taking into account people’s cultural experiences. For example, it is a double- edged dilemma for counselors to consider the role of racism for African Americans. On the one hand, many African Americans may wish to discuss perceived racism, because racist experience has been part of their daily life. On the other hand, some (though few) African Americans report no serious racist events, possibly due to their specific environment (Smedley et al., 1993). For example, some students in historically black universities reported little racist experience, possibly because they have fewer daily interactions with non-African American communities. As a result, the role racism plays for individual African Americans is individ- ual. To take this into account, the MSMHS assesses racial stressors on an individual basis.
Limitations and future studies. The MSMHS conceptual- izes overall experiences of perceived racism as a stressor for African Americans but does not specify types of racism or ascer-
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tain number of factors on racism. According to Williams et al. (2003), acutely perceived racism creates immediate acute stress, whereas lifetime racism contributes to chronic, long-term stress. The variation in duration and severity of stress may in turn exert different impacts on African Americans’ mental health. The MSMHS is limited to distinguishing perceived racism from other mental health concerns and does not differentiate acute from lifetime, chronic stress. Another relevant limitation is that overall experience of racism does not equate to a multidimensional solu- tion for racism (Williams & Williams-Morris, 2000). Future re- search may further examine the number of factors on racism- related experience and their relations to psychological distress.
The MSMHS was developed specifically for use with African American populations, so the item content, measure structure, and validity are unique to the samples employed. Although findings were positive with respect to the stability and validity of the instrument, additional research is necessary to further examine the stability and validity of the MSMHS structure with additional African American participants and to expand its use with other racial groups such as Latino/Latina and Asian American groups. Thus, extending the concept of racially related stress as a compo- nent of mental health to other groups requires replication of this process with individuals from other racial backgrounds. Our par- ticipants were mainly African American college students, and the homogeneous sample could be a limitation. Our results may be limited in assessing samples from clinical settings, communities, or populations other than college students. Thus, future research is needed to examine whether our results are applicable to other African American populations. Finally, we did not focus on the relation between gender and the MSMHS subscales, though gender may moderate the relations between racism and well-being or psychological distress (Clark, 2006). Future studies can further evaluate whether gender moderates racism and other MSMHS subscales such as Well-Being and Suicidal Thoughts.
We found in various studies of test–retest reliability, when developing new scales, that sample sizes for test–retest reliability are below 50 in many scales (e.g., 38 participants in Waelde et al., 2010; 26 participants in Hill, Terrell, Hladkyj, & Nagoshi, 2009; 38 participants in Murphy, MacKillop, Skidmore, & Pederson, 2009; 31 participants in Utsey & Ponterotto, 1996; 37 participants in Worthington, Dillon, & Becker-Schutte, 2005). Still, we believe that our sample size (n � 38) for Study 3 on test–retest reliability was a limitation.
The MSMHS assesses constructs relevant to mental health. However, the causal relationships between these constructs are not necessarily evidenced by their correlation. The question remains whether perceptions of racism cause differences in mental health or whether differences in mental health cause differences in per- ceptions of racism. In either case, inclusion of perceptions of racism proves clinically useful. Understanding clients’ perceptions of racism enhances clinicians’ conceptualization of clients’ pre- senting problems. Future research can also investigate causal re- lationships between racism and mental health. In other words, do mental health problems make people vulnerable to racism, or does the constant experience of racism engender mental health prob- lems?
In sum, the findings of the present study support the reliability and validity of the MSMHS as a measure of the multidimensional aspects of mental health among African Americans and can prove
useful for assessing the impact of racism on well-being and dis- tress for these clients and for determining specific issues related to experience with racism.
Because it is a subscale sensitive to African Americans, the MSMHS may also prove valuable in future research. The research utility of the MSMHS demands examination of effects of moder- ating variables such as education and socioeconomic status on perceived racism and relationships with psychological distress. Other research directions include understanding the effects of therapy targeted at racial stressors among African American cli- ents, the impact of racism on racial identity development (Ridley, 2005), within-group variation in perceptions of racism and its relationship to life satisfaction, and the impact of racism on per- sonal interactions and academic outcomes.
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Received October 20, 2009 Revision received December 7, 2010
Accepted March 15, 2011 �
New Editors Appointed, 2013–2018
The Publications and Communications Board of the American Psychological Association an- nounces the appointment of 5 new editors for 6-year terms beginning in 2012. As of January 1, 2012, manuscripts should be directed as follows:
● Journal of Experimental Psychology: Learning, Memory, and Cognition (http://www.apa.org/ pubs/journals/xlm/), Robert L. Greene, PhD, Department of Psychology, Case Western Reserve University
● Professional Psychology: Research and Practice (http://www.apa.org/pubs/journals/pro/), Ronald T. Brown, PhD, ABPP, Wayne State University
● Psychology and Aging (http://www.apa.org/pubs/journals/pag), Ulrich Mayr, PhD, Depart- ment of Psychology, University of Oregon
● Psychology, Public Policy, and Law (http://www.apa.org/pubs/journals/law/), Michael E. Lamb, PhD, University of Cambridge, United Kingdom
● School Psychology Quarterly (http://www.apa.org/pubs/journals/spq/), Shane R. Jimerson, PhD, University of California, Santa Barbara
Electronic manuscript submission: As of January 1, 2012, manuscripts should be submitted electronically to the new editors via the journal’s Manuscript Submission Portal (see the website listed above with each journal title).
Current editors Randi C. Martin, PhD, Michael C. Roberts, PhD, Paul Duberstein, PhD, Ronald Roesch, PhD, and Randy W. Kamphaus, PhD, will receive and consider new manuscripts through December 31, 2011.
887MULTICULTURALLY SENSITIVE MENTAL HEALTH SCALE
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