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Post-traumatic stress disorder (PTSD) is a psychiatric condition resulted from witnessing or undergoing traumatic or life-intimidating incidents (Iribarren et al., 2005), it is characterized by symptoms and signs grouped into five main clusters, including “exposure to severe stress (Cluster A), intrusion symptoms (Cluster B), persistent avoidance (Cluster C), negative alterations in cognitions and mood associated with the traumatic events (Cluster D), and hyper arousal (Cluster E) (Cornelius, 2013; Setti & Argentero, 2015; APA, 2000).

Even though there exist numerous tools developed to assess PTSD, Post-traumatic Stress Disorder Checklist (PCL), developed by National Center for PTSD is one of the most extensively used tools of PTSD with high diagnostic and research utility. Incorporation of symptoms of PTSD as described in Diagnostic and Statistical Manual of Mental Disorders is the distinctive quality that makes this tool highly entrusted in nature. There exists three versions of PCL, which are; PCL-M (military), which asks about symptoms, in response to “stressful military experiences.” PCL-C (civilian) asks about symptoms in relation to generic “stressful experiences” and PCL-S (specific) asks about symptoms in relation to an identified “stressful experience.” Being a tool developed and validated in the west, the employability of this tool in India is debatable. Thus, for benefiting the researches and clinical use in India, the tool was translated into one of the prominent local languages, Malayalam.

Majority of the studies related to PTSD falls under the stream of disaster mental health, but a lion share of them are focusing on the victims of disasters, which often result in the downfall of studies among rescue workers. According to National Center for PTSD, America, Posttraumatic stress disorder (PTSD) among rescue and response workers has a prevalence rate ranging from 0%-34%. Considering these statistical evidence and lack of studies devoted to the sample in Indian context, a cross-sectional study using PCL-C (civilian version) was commenced among 100 rescue workers in the background of Kerala flood-2018. As the rate of Posttraumatic stress among survivors of natural disaster ranges between 30% and 40% (Neria et al., 2008), the chosen background of Kerala flood-2018 may provide an appropriate scenario to develop the study.

Major aim of the current study is to translate PTSD checklist to Malayalam and thereby provide an Indian cultural adaptation to the tool. Allied with that standardisation of the translated version among rescue workers will flourish the areas of disaster mental health especially, studies related to PTSD. Being a tool with good diagnostic utility, translation of this will widen the application of PTSD checklist in Indian clinical settings. Rather than merely providing a standardised translated tool, current study also attempt to explore factors underlying the development of PTSD among rescue workers. It may aid the study for being a base to further upcoming studies in the area.

This is the very first attempt to translate and validate The Post-traumatic Stress Disorder Checklist (PCL) developed by National Center for PTSD, USA, (1993) in India among the population of rescue workers. For serving the purpose, both qualitative (i.e., cognitive interviews to measure content validity and face validity) and quantitative methods (i.e., used survey results to assess split-half reliability) were used to measure the validity and reliability of this tool.

Participants

The study encompassed 105 rescue workers aged from 25- 60. Eligibility criteria for selection comprised the ability to read Malayalam, and the experience of serving in Kerala flood-2018. Rescue workers who have retired from the service and who does not have experience of serving in Kerala flood-2018 were accepted from the study. Participants were conscripted through purposive sampling methods and they were advanced through various fire stations in Alappuzha, Kerala. For finding internal consistency of the tool, responses of the rescue workers in the quantitative data collection collected using PTSD Checklist (Malayalam version) was used. Later 10 of them participated in the cognitive interview to establish content validity.

Translation Of The Ptsd Checklist

There exists no officially validated Malayalam version of the PTSD Checklist even though it is extensively used in English–Malayalam bilingual settings. Thus both qualitative and quantitative measures used in the study were deciphered into Malayalam, a prominent local language in South India with reference to WHO guidelines for translation and revalidation of tools (Figure 1). Initially, after obtaining permission from authors, a researcher with bilingual expertise translated PTSD Checklist into Malayalam by referring to the norms of cross-cultural translation technique (Banville et al., 2000). After doing the forward translation, two bilingual experts from Kerala with extensive knowledge in psychological research attempted to identify and resolve the inappropriate expressions/concepts in the translation, and the discrepancies between original and translated versions.

Figure 1: Shows the process of translation

Incorporating their suggestions the questionnaire was furthered for back-translation to a bilingual expert who does not have access to the original version. Then, each of the items in the original and back-translated items was reviewed in terms of conceptual understanding, language clarity and simplicity. Finally, pre-test and cognitive interviews were done among 10 rescue workers, and suggestions were incorporated in the final draft of the questionnaire.

Ptsd Checklist

The Post-traumatic Stress Disorder Checklist (PCL) is a 17-item self-report checklist of PTSD symptoms developed based on DSM-IV criteria. It was developed by National Center for PTSD, Boston, USA, in 1993. Three versions of PCL are available they are; PCL-M (military) which asks about symptoms in response to “stressful military experiences.”, PCL-C (civilian) asks about symptoms in relation to generic “stressful experiences” and PCL-S (specific) asks about symptoms in relation to an identified “stressful experience.” PCL has revealed a good diagnostic utility; it also has strong psychometric properties. Estimates of internal consistency (Cronbach’s alpha) range between .94 (Blanchard et al., 1996) to .97 (Blake et al., 1995). Test- retest reliability has been reported as .96 at 2-3 days and .88 at 1 week (Blanchard et al., 1996; Ruggiero et al., 2003). A total symptom severity score (range = 17-85) can be obtained by summing the scores from each of the 17 items that have response options ranging from 1 “Not at all” to 5 “Extremely”. The total scores may range from 17 to 85 (Blanchard et al., 1996).

Socio-Demographic Datasheet

The demographic variables included in the demographic data sheet includes age, gender, marital status, education, number of dependents, annual income, designation, nature of work, employment status, years of experience, working time (in hours), approximate number of missions encountered per year, number of missions served till date, housing, usage of drugs, history of injuries happened during duty, sleeping hours, post-disaster health issues and history of psychiatric issues. It also consists of forced-choice questions to understand their work-life balance and attitude towards work as well as a checklist of critical events that they tend to goes through. It was also incorporated with rating scales for assessing their perceived organizational support and job satisfaction.

Analysis

To test reliability, Cronbach’s alpha (internal consistency) was used, confirmatory factor analysis was performed to find convergent, discriminant and construct validity. Finally, for finding the determinants of PTSD among rescue workers Mann-Whitney U test and Kruskal-Wallis H test were incorporated.

Face Validity

The participants in the study reported an understanding of the questionnaire and its instructions during cognitive interviews and pre-test. Thus the data collection using PTSD Checklist was proceeding without any further alteration to the translation.

Content Validity

The content validity of the PTSD Checklist Malayalam version was verified by the researchers with subject knowledge by performing the parallel back-translation. It included 2 steps;

1. Each item of the back-translated version was compared with the original version. When all the items of the reverse English translation seemed identical with original, the Malayalam items satisfied the first criteria.

2. Technical words and expressions used in the Malayalam translations were dissected to verify the accuracy of their content.

After that, cognitive interviews in which participants were instructed to define each item of the questionnaire were held. As a consequence of this systematic process done to establish content validity, no further steps were taken for the matter.

Table 1 indicates that there exist no discriminant validity concerns for the tool as the square root of AVE of the variable is greater than the value of the correlation with other factors

Table 1: Shows the discriminant validity values obtained from confirmatory factor analysis

Table 2 shows that the current tool has convergent validity as all the values of AVE are above .5 and CR is above .7.

Table 2: Shows the convergent validity values obtained from confirmatory factor analysis

Table 3 that Cronbach’s alpha value of the translated tool is .89, this higher Cronbach’s alpha value indicate that the tool is internally consistent and reliable.

Table 3: Internal consistency of PTSD Checklist (Malayalam version) among rescue workers

Determinants of Post-Traumatic Stress Disorder among rescue workers:

Table 4 shows that there is a significant difference in the level of Post-Traumatic Stress Disorder with respect to categories of education.

Table 4: Kruskal Wallis test of Post-Traumatic Stress Disorderon the basis of education

Table 5 shows that there is a significant difference in the level of Post-Traumatic Stress Disorder with respect to number of casualties witnessed.

Table 5: Kruskal Wallis test of Post-Traumatic Stress Disorderon the basis of number of casualties witnessed.

Being a tool with high diagnostic utility, PTSD Checklist has been used in numerous studies and clinics across the world. Yet, only limited attempts for translation of this tool are recorded. The current study attempts to acclimatise the tool to Indian culture by attempting its translation to an eminent local language, Malayalam. Rather than merely revamping the tool, this study attempts to standardize it among rescue workers and identify the underlying risk factors of PTSD among this population. Subsequently, a translation of PTSD Checklist to Malayalam was done by adhering to the criteria of cross cultural translation and evaluation of its reliability and validity were detained.

Attempts to standardise the tool were initiated by consulting multiple experts in the subject field and by conducting cognitive interview on 10 samples. Through both of these steps face and content validity issues were addressed. Confirmatory factor analysis was performed for running further validation procedures, and for performing this items in tool were sub-divided in to 3 subscales, including avoidance, re-experiencing and hyper arousal–numbing. These were divided with respect to the study of following this discriminant and convergent validity were performed.

“Discriminant validity can be recognised if the levels of square root of the AVE for each construct are greater than the correlation involving the constructs”. (Fornell-Larcker, 1981; Alarcón et al., 2015). As from Table 1, it is evident that the square root of AVE of the variable is greater than the value of the correlation with other factors, this tool tend to possess discriminant validity.

Convergent validity of the tool can be weighed by considering values of Average Variance Extracted and Composite Reliability. For any test with high convergent validity AVE should be greater than 0.5 and Composite Reliability should be greater than 0.7 (Alarcón et al., 2015; Fornell-Larcker, 1981). As Table 2 clearly depict that all the values of AVE is above .5 and CR is above .7, the current tool tend to have high convergent validity.

The construct validity can be attained by establishing convergent validity and discriminant validity (Alarcón et al., 2015). Thus Construct validity was obtained by consulting the values of Table 1 and Table 2 which indicates convergent and discriminant validity.

It was evident from Table 3 that Cronbach’s alpha value of the translated tool is .89, this higher Cronbach’s alpha value indicate that the tool is internally consistent and reliable. Considering these findings as the base, it can be proclaimed that PTSD Checklist Malayalam version is a milieu pertinent standardised tool which can be used among the population of rescue workers.

The study also endeavoured to reconnoitre the underlying influence of certain socio-demographic variables on PTSD. The variables considered for the purpose included age, education, marital status, years of experience, annual income, number of dependents, history of injuries, number of casualties witnessed and sleeping hours. Results of the current study corroborate that chances of developing PTSD may vary according to education and number of casualties witnessed. It was found that rescue workers with higher education had lower levels of PTSD. This finding can be substantiated in the light of a study by Xue et al. (2015), were they suggested that “different educational levels indirectly influences multiple, including economic resources, social status, social networks, and health behaviour. Therefore, higher education levels may help to use better coping methods as they have better access to more resources, thereby reducing the incidence of depression”. Current finding is in contrary with findings of Zhou et al. (2013), who proclaimed that, there is no significant difference in the levels of PTSD on the basis of education. Whereas most of other studies strongly highlight a preventive role of education on the risk to develop PTSD (Carmassi et al, 2018; Maia & Ribeiro, 2010; Engel et al., 2015).

The results also indicate that, number of casualties witnessed also influences the chances of developing PTSD. There exist no sufficient studies exploring the influence of number of casualties witnessed and PTSD. A possible explanation of the current finding can be developed by examining the definition of Posttraumatic stress disorder (PTSD) by APA in DSM-V. According to DSM-V, “PTSD is a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, rape or other violent personal assault” (Friedman et al., 2011). It is evident from this definition that witnessing traumatic events can contribute to the development of PTSD, thus as the number of traumatic events witnessed increases, chances to develop PTSD also increases. Apart from these two variables, none other was found to have influence up on PTSD.

PTSD Checklist Malayalam version is a valid and reliable measure of Post-Traumatic Stress Disorder among rescue workers, the study also found that an increase in education level of rescue workers and number of casualties witnessed can increase the chances of developing PTSD.

The PTSD Checklist Malayalam version is suggested as a reliable and valid measure for usage in future researches. In spite of its use in bilingual clinical settings, it can be also employed among Malayalam speaking communities. The study can be used as a framework for upcoming studies in the area.