Discussion
PSQ-S., depression, CHC, depressive symptoms
SENSITIVITY
The present study is the first analysis of the Swedish version of the SEEK-PSQ and its psychometric properties. As a whole, the PSQ-S showed good sensitivity and NPV values and low to moderate specificity and PPV values compared to the standardized instruments. The psychometric properties varied considerably between domains, with sensitivity ≥ 80% for economic worries and depressive symptoms, 78% for parental stress, 47% for IPV and 70% for alcohol misuse. Sensitivity and NPV were significantly higher for women compared to men with regard to depressive symptoms and IPV. Internal consistency was low to moderate for the separate domains and moderate for the PSQ-S composite. Factor analysis corroborated the domains of IPV and alcohol misuse as separate components, while items from the remaining domains were intermixed in three components, suggesting that the targeted domains of economic worries, depressive symptoms and parental stress are not represented as separate and unique factors in the PSQ-S.In the areas that can be compared, the performance of the PSQ-S was similar to or better than the original U.S. version of the PSQ. Analyses of the U.S. version showed that, for food insecurity, sensitivity was 59%, specificity was 87%, PPV was 70% and NPV was 81% [Over two thirds of parents had a positive screen for at least one risk factor in the PSQ-S. Although this proportion seems strikingly high, other studies focusing on specific psychosocial issues among parents have shown comparable results. Prevalence studies in Sweden have reported that 23% of children 0–4 years of age live in families with low economic standard, 23% of infants have at least one parent with depressive symptoms, 20% of children live with a parent who drinks too much and 14% have witnessed IPV between their parents [High composite sensitivity of the PSQ-S indicates that few parents who have problems are missed and high NPV suggests that most parents with a negative screen on the PSQ-S do not have the problem. Both of these aspects are important when assessing the psychosocial environment in families with young children. Specificity and PPVs however were low to moderate for the PSQ-S as a whole, indicating a relatively large number of false positives. This may be acceptable in the context of the SEEK model, as a positive screen should quickly be followed by a brief assessment clarifying the parent’s situation and should not entail a burden to healthcare workers, unwarranted referrals or parental concern.Although sensitivity and NPV were high in total for economic worries, differences were seen between genders particularly regarding sensitivity. The lower sensitivity for fathers should be interpreted with caution due to the small number who participated. To our knowledge, research regarding screening instruments for financial problems is very limited [Previous research has indicated that screening instruments for depression often are more effective at identifying this problem in women than men [Regarding parental stress, the cutoff level (90th percentile) for the reference instrument (SPSQ) yielded moderate sensitivity and specificity for the PSQ-S. Approximately one fifth of parents in the top 10% of SPSQ scores were missed, and, one fifth of those under this cutoff had a positive screen in the PSQ-S. As mentioned above, false positive screens are not necessarily problematic in the context of CHC visits, as the most common outcome is a discussion with the nurse during the visit. We could find no previous studies regarding screening instruments for parental stress that provided the psychometric properties presented here, therefore comparisons can not be made. The high NPV for parental stress indicates that most parents with a negative screen on the PSQ-S do not have a high score on the SPSQ.IPV stands out as the domain with the lowest sensitivity for both mothers and fathers. In general, sensitivity has been found to be low for survey instruments about IPV with considerable variation between methods [In the present study, the specificity for IPV was over 90%, indicating that only a few who had not experienced IPV were falsely identified as having been exposed. The NPV for IPV was also the lowest among the risk factors, indicating that as many as a fourth of fathers and a fifth of mothers with a negative screen were likely exposed and missed being identified. This may be seen as a shortcoming of the PSQ-S.An important component of the SEEK model is that parents answer the PSQ-S several times during the child’s first five years of life, which offers many opportunities to reflect upon and respond to the questions. Seeds may be planted that the nurse cares about them and also about this problem. Thus parents may later disclose IPV as well as other problems, when they may be ready to address their situation. For this reason, missing the earlier identification may not be so consequential. Another consideration is that without systematic screening, many instances of IPV are likely missed. Given the importance of this problem, the modest sensitivity may be acceptable albeit suboptimal. Further research is needed to identify questions with greater sensitivity.Sensitivity regarding alcohol misuse was lower than expected, given that the AUDIT-C, which is included in the PSQ-S, has previously been shown to be valid in primary care screening compared to the full version of AUDIT [