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Health and Quality of Life Outcomes
Open Access
Research
The 12-item General Health Questionnaire (GHQ-12): translation
and validation study of the Iranian version
Ali Montazeri*, Amir Mahmood Harirchi, Mohammad Shariati,
Gholamreza Garmaroudi, Mehdi Ebadi and Abolfazl Fateh
Address: Iranian Institute for Health Sciences Research, Tehran, Iran
Email: Ali Montazeri* - [email protected]; Amir Mahmood Harirchi - [email protected]; Mohammad Shariati - [email protected];
Gholamreza Garmaroudi - [email protected]; Mehdi Ebadi - [email protected]; Abolfazl Fateh - [email protected]
* Corresponding author
Abstract
Background: The objective of this study was to translate and to test the reliability and validity of
the 12-item General Health Questionnaire (GHQ-12) in Iran.
Methods: Using a standard 'forward-backward' translation procedure, the English language version
of the questionnaire was translated into Persian (Iranian language). Then a sample of young people
aged 18 to 25 years old completed the questionnaire. In addition, a short questionnaire containing
demographic questions and a single measure of global quality of life was administered. To test
reliability the internal consistency was assessed by Cronbach's alpha coefficient. Validity was
performed using convergent validity. Finally, the factor structure of the questionnaire was
extracted by performing principal component analysis using oblique factor solution.
Results: In all 748 young people entered into the study. The mean age of respondents was 21.1
(SD = 2.1) years. Employing the recommended method of scoring (ranging from 0 to 12), the mean
GHQ score was 3.7 (SD = 3.5). Reliability analysis showed satisfactory result (Cronbach's alpha
coefficient = 0.87). Convergent validity indicated a significant negative correlation between the
GHQ-12 and global quality of life scores as expected (r = -0.56, P < 0.0001). The principal
component analysis with oblique rotation solution showed that the GHQ-12 was a measure of
psychological morbidity with two-factor structure that jointly accounted for 51% of the variance.
Conclusion: The study findings showed that the Iranian version of the GHQ-12 has a good
structural characteristic and is a reliable and valid instrument that can be used for measuring
psychological well being in Iran.
Background
The General Health Questionnaire (GHQ) is a measure of
current mental health and since its development by Gold-
berg in the 1970s it has been extensively used in different
settings and different cultures [15]. The questionnaire
was originally developed as a 60-item instrument but at
present a range of shortened versions of the questionnaire
including the GHQ-30, the GHQ-28, the GHQ-20, and
the GHQ-12 is available. The scale asks whether the
respondent has experienced a particular symptom or
behavior recently. Each item is rated on a four-point scale
(less than usual, no more than usual, rather more than
usual, or much more than usual); and for example when
using the GHQ-12 it gives a total score of 36 or 12 based
Published: 13 November 2003
Health and Quality of Life Outcomes 2003, 1:66
Received: 13 October 2003
Accepted: 13 November 2003
This article is available from: http://www.hqlo.com/content/1/1/66
2003 Montazeri et al; licensee BioMed Central Ltd. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all
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on the selected scoring methods. The most common scor-
ing methods are bi-modal (0-0-1-1) and Likert scoring
styles (0-1-2-3). Since the GHQ-12 is a brief, simple, easy
to complete, and its application in research settings as a
screening tool is well documented; it was decided to trans-
late the GHQ-12 into Persian (the Iranian language) and
to examine the psychometric properties of the question-
naire in a sample of young Iranian adolescents. This was
to develop the Iranian version of the GHQ-12 to meet the
increasing demand for the questionnaire. There is evi-
dence that the GHQ-12 is a consistent and reliable instru-
ment when used in general population samples [6].
Methods
The standard "forward-backward" procedure was applied
to translate the questionnaire from English into Persian.
Two independent health professionals translated the
items and two others translated the response categories
and a provisional version was provided. Subsequently it
was back translated into English and following a careful
cultural adaptation the final version was provided. Finally
after pilot testing, the translated questionnaire was
administered to a sample of healthy young people aged
18 to 25 years old. The sample was recruited through a
national family journal and from two higher education
institutes. The participants who were recruited through
the journal returned the completed questionnaire by post
and those who were recruited from two higher education
institutes were tested in several groups while the assessors
were present. In addition each respondent was asked to
complete a short questionnaire containing demographic
questions and to rate a measure of global quality of life; a
subscale derived from the validated Iranian version of the
European Organization for Research and Treatment of
Cancer Quality of Life Questionnaire (EORTC QLQ-
C30)[7]. Global quality of life subscale contains 2 items
and each item is rated on a seven-point scale. A linear
transformation was performed to standardize the row
scores. Scores range from 0 to 100 and the higher value
indicates a higher level of global quality of life [8].
To test the reliability, the internal consistency of the ques-
tionnaire was assessed by Cronbach's alpha coefficient
and alpha equal to or greater than 0.70 was considered
satisfactory [9]. Validity was performed using convergent
validity to demonstrate the extent to which the GHQ-12
correlates with global quality of life. It was expected that
the GHQ-12 would correlate negatively with global qual-
ity of life. This was assessed by the Pearson product
moment statistic (Pearson's correlation coefficient = r)
and r equal to 0.40 or above was considered satisfactory.
Furthermore the factor structure of the questionnaire was
extracted by performing principal component analysis
using oblique factor solution. The study used Goldberg's
original scoring method. In this method response catego-
ries score 0, 0, 1, and 1 respectively. This gives scores rang-
ing from 0 to 12 [10].
Results
Descriptive findings
In all 748 young people aged 18 to 25 years entered into
the study. The descriptive findings are presented in Table
1. The mean age of respondents was 21.1 (SD = 2.1) years
and most were female (76%), single (84%) and college/
university students (50%). Employing the bi-modal
method of scoring (ranging from 0 to 12) the mean GHQ
score was found to be 3.7 (SD = 3.5). Forty-four percent
scored above the mean GHQ score for the whole popula-
tion of the respondents. The mean global quality of life
score was 65.1 (SD = 21.5).
Reliability
To test the reliability the internal consistency of the ques-
tionnaire was measured using Cronbach's alpha coeffi-
cient. The alpha for the whole sample was found to be
0.87 and was the same for both males and females indi-
cating satisfactory results.
Table 1: The characteristics of respondents and descriptive
findings (n = 748)
No. %
Age (group)
1819 209 28
2022 335 45
2325 204 27
Mean (SD) 21.1 (2.1)
Gender
Female 567 76
Male 181 24
Educational level (n = 730)
Primary/
Secondary
310 41
College/
University
420 56
Marital status
Single 632 84
Married 105 14
Widowed 11 2
Employment status (n = 556)
Employed 114 22
Student 280 50
Housewife 69 12
Unemployed 93 16
GHQ score
Mean (SD) 3.7 (3.5)
Range 012
Global quality of life (n = 743)
Mean (SD) 65.1 (21.5)
Range 0100
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Validity
Validity of the instrument was performed using conver-
gent validity. When the correlation between the GHQ-12
and global quality of life scores was investigated, as
expected a significant negative correlation emerged (r = -
0.56, P < 0.0001) indicating that those who were more
distressed showed lower levels of global quality of life.
Factor structure
The principal component analysis with oblique rotation
solution was performed and a two-factor structure was
loaded that jointly accounted for 51% of the variance. The
results are shown in Table 2. Apart from item seven (enjoy
normal activities), other items loaded in two distinct fac-
tors producing the factors of 'psychological distress' and
'social dysfunction'.
Discussion
The GHQ is a well-known instrument for measuring
minor psychological distress and has been translated into
a variety of languages [1116]. However, it is not a tool for
indicating a specific diagnosis. This study reports data
from a validation study of the 12-item GHQ in Iran. In
general, the findings showed promising results and were
comparable with most research findings throughout the
world. Our two-factor solution was similar to those
reported in the WHO study of psychological disorders in
general health care [17]. Reliability was assessed by inter-
nal consistency of the questionnaire reporting Cronbach's
alpha coefficient and validity was examined by conver-
gent validity performing correlation between the GHQ-12
and global quality of life scores and both showed satisfac-
tory results.
It is argued that although the GHQ-12 was originally
developed as a unitary screening measure for psychologi-
cal problems, there have also been efforts to identify
whether it has a multidimensional structure [18]. The
World Health Organization study of psychological disor-
ders in general health care in 15 different centers indicated
that for the GHQ-12 substantial factor variation between
centers exist. However, the study reported that after rota-
tion two factors expressing depression and social dysfunc-
tion could be identified [17]. The findings from present
study showed that the Iranian GHQ-12 is a valid measure
of psychological distress and the factor structure of the
questionnaire was very similar to that of the original lan-
guage. Interestingly a recent findings from a Japanese
study reported that the GHQ-12 could be used as an inter-
nally reliable and homogenous scale that produces
mainly the factors of psychological distress and social dys-
function [16].
We used the bi-modal fashion of scoring and the results
indicated that this method in Iran appears to be useful.
Evidence suggests that there is no tendency for the GHQ
to work less efficiently in developing countries [19]. The
mean GHQ-12 score in this study was 3.7 (SD = 3.5). It is
recommended that the mean GHQ score for the whole
population of respondents provides a rough guide to the
best cut-off threshold [20]. Thus considering people who
scored above the mean, the findings from the present
study indicated that 44% of the respondents showed an
indication of mental health problems [21]. This clearly
suggests that if investigators wish to use a screening instru-
ment as a case detector, the shorter GHQ is remarkably
robust and works as well as the longer instrument [19].
Similar studies among young adolescents reported that
the GHQ-12 is a particularly useful measure with adoles-
cents where there are likely to be a number of different
threats to their psychological health, such as poor self-
esteem, that may not necessarily constitute a formal psy-
chiatric condition [22]. In contrast, studies have shown
that the GHQ-12 is not a suitable instrument for some
special populations such as elderly patients [23].
Iran has a very young population. In general, the findings
from this study indicated that mental health in young
people in Iran is poor and it is strongly associated with
their quality of life. Since mental health in young adoles-
cents could be regarded as a risk factor for psychological
disorders such as antisocial behavior, criminal activity,
suicidal behavior, substance abuse, depression, and eating
disorders [24], improving quality of life in this age group
becomes very important task. However, in interpreting the
study findings it should be noted that the young people in
the sample were a selected sample and thus it cannot be
generalized to the whole population of young adolescents
in Iran.
Table 2: Factor structure of the GHQ-12 using principal
component analysis with oblique rotation solution
Factor 1 Factor 2
GHQ-12 Items
1. Able to concentrate 0.57 -
2. Lost much sleep - 0.69
3. Playing useful part 0.81 -
4. Capable of making decisions 0.56 -
5. Under stress - 0.68
6. Could not overcome difficulties - 0.62
7. Enjoy normal activities 0.57 0.46
8. Face up to problems 0.64 -
9. Feeling unhappy and depressed - 0.64
10. Losing confidence 0.62 -
11. Thinking of self as worthless 0.79 -
12. Feeling reasonably happy - 0.56
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Conclusion
The findings suggest that the Iranian version of the 12-
item GHQ is a reliable and valid instrument to measure
minor psychological distress in young people and has a
good factor structure.
List of abbreviations
GHQ: General Health Questionnaire; SD = standard devi-
ation; WHO: World Health Organization.
Competing interest
None declared.
Authors' contribution
AM was the main investigator, analyzed the data, and
wrote the paper. AMH, MSh GhG, ME, and AF all contrib-
uted to the study design, the translation procedure, data
collection and first draft of the paper in Persian.
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