Understanding how rural Indian women interpret the Edinburgh postnatal depression scale: a cognitive interview study

The Edinburgh Postnatal Depression Scale (EPDS) is a widely used screening tool for perinatal depression, effective in detecting symptoms during pregnancy and postpartum. Though not diagnostic, it identifies individuals needing further evaluation. The EPDS has been translated into over 60 languages, but cultural adaptation is crucial for accuracy. This study evaluates the cultural comprehensibility and content validity of the translated Marathi EPDS among rural women in western Maharashtra, India, through cognitive interviews, ensuring accurate interpretation within the sociocultural context. This qualitative study, part of a larger research project, examined postpartum depression (PPD) among rural women in western Maharashtra, India. Conducted under the university’s community outreach initiative and using cognitive interviews, researchers assessed the cultural comprehensibility of the translated Marathi EPDS. A purposive sample of 30 postpartum women from 30 villages participated in the study. Interviews were systematically analysed, revealing key insights into comprehension barriers. The study, supported by community health workers and a multidisciplinary team, received ethical approval and contributes to improving culturally adapted mental health assessments in underserved populations. Most women aged 18–38 years have secondary education, while others have only primary education or are illiterate. Women work as housewives, farmers, tailors, and salon workers, while their husbands’ occupations range from labour to entrepreneurship. Household incomes vary widely, from ₹5,000 to ₹100,000 ($60–$1200) per month. The majority of participants faced significant challenges in comprehending the scale items in their local language, necessitating additional probing and explanatory support. Several EPDS items were interpreted through participants’ lived experiences rather than as intended psychological constructs. Women associated happiness with their newborn’s activities or family visits, self-blame with giving birth to a second daughter, anxiety with breastfeeding and maternal responsibilities, and distress with family conflict, lack of support, sleep deprivation, and financial or social concerns. Four types of comprehension issues were identified: semantic barriers, conceptual non-equivalence, contextual reframing, and ambiguous emotional terminology, indicating that participants often understood items through sociocultural experiences rather than as discrete emotional states. Cognitive interviewing revealed comprehension challenges that were not identified through translation and psychometric validation alone among rural women in western Maharashtra, India. Evaluating cultural comprehensibility is essential to ensure the appropriate use of mental health screening instruments in diverse populations.