Cultural Adaptation of the PTSD Checklist- Military version (PCL-M) among Army Personnel in Ghana


 Background: The type of deployment duties performed by military personnel differs across the world, as some perform combat related deployment, others are sent on peacekeeping duties. Due to the difference in events experienced when performing any of the deployment duties as combat veterans are more likely to encounter traumatic events than peacekeeping duties personnel, the occurrence of PTSD symptoms might differ. The study aims to construct a PTSD Checklist – Military version that is relevant to peacekeeping duty army personnel in Ghana (PCL-M-G), on the basis of the original scale by Weathers and colleagues.Methods: A cross-sectional study was undertaken with a purposive and convenient sample of 189 army personnel of the Ghana Armed Forces who have returned from peacekeeping duties within the last year as at the time of data collection. The original scale containing 17 items was administered for data collection. Principal Component Analysis (PCA) with Varimax rotation was used in the extraction of factor structures. Cronbach’s Alpha was used to determine the internal consistency of the scale. Bivariate correlation was used to examine the external validity of the scale. Results: 12 items with three factors, namely, Hyperarousal (Cronbach alpha= .92), Re-experience (Cronbach alpha= .92) and Avoidance (Cronbach alpha= .79) was identified. The three factors altogether explained 77.21% of the total variance. The scale had a significant positive correlation with post deployment transition experience over at most a year (r = .33), as this shows evidence of construct and discriminatory validity. Even though the factors identified in this study are similar to the original scale, there are some differences, indicating the significations of cultural diversity.Conclusion: The current study of PCL=M among Ghanaian army personnel identified difference with regards to item factor loadings and dimension. It is suggested that the scale would be validated locally before it is used. The PCL-M-G is reliable and valid, therefore, researchers, clinicians as well as other health workers can cautiously use this scale when assessing PTSD symptoms among Ghanaian military personnel.

The experience of military personnel upon their return home is as signi cant as exposure to combat or deployment stressors as some studies have shown signi cant similarities with regards to the in uence of post deployment transition and combat experience on the psychological well-being of soldiers (Afful, 2017;Bonanno et al., 2012) with one study ndings suggesting that mental health of military personnel were affected the most by post deployment stressors than deployment or combat related events (Michel et al., 2003). It is therefore relevant to assess PTSD symptoms in the context of post-deployment military duties.
The Post-Traumatic Stress Disorder Checklist-Military version(PCL-M) has become the most universally used instrument to measure PTSD symptoms with regards to military deployment. The PCL-M is a selfreport instrument that was developed by Weathers et al. (1993) to measure the extent to which military personnel have experience any PTSD symptoms, namely, reexperiencing, avoidance and hyperarousal.
The PCL-M is made up of 17 items and has been shown to have adequate levels or reliability and validity (Weather et al., 1993). It has been widely used in the Western world, particularly in the United States America and has shown an acceptable level of reliability across various studies (Forbes, Creamer & Biddle, 2001, Keen et al., 2008, Weathers et al., 1993. For most of these studies, PTSD symptoms has been linked with combat duty operations with less focus on post-peacekeeping operation experiences.
However, deployment duties performed by most if not all Ghanaian soldiers are in the form of peacekeeping operations. Stressors related to combat operations are relatively different from postpeacekeeping operation related stressors. Therefore, using a scale that was originally designed using war veterans for service men returning from peacekeeping operations cannot be deemed entirely valid and reliable. Therefore, it is necessary to examine how PTSD symptoms correlates with post deployment experiences with regards to peacekeeping operations. No such measure has been developed speci cally for Africa and Ghana to be precise. There is therefore the need to develop a new scale or adapt and validate an already existing one. It is more practical as well as economical to adapt and already existing scale as this also allows one to compare data from similar studies around the world.
Even though the scale has been widely used in studies across the world, it has not been validated in Ghana or Africa at large. Cross cultural adaptation and validation of the PCL-M for Ghana would indicate a signi cant progress in the assessment of PTSD symptoms in relation to post deployment transition among army personnel in Ghana as well as aid in enhancing collaborative studies with regards to comparing Ghanaian studies with others. In view of this, the aim of the current study was to validate the psychometric properties of the PCL-M in Ghana; assess the factor structure of the instrument as well as examine the construct validity or predictive power of the PCL-M among army personnel in Ghana by relating it to post deployment transition among army personnel who have returned from peacekeeping duties.

Sample and Participants
A total of one hundred and eighty-nine (N = 189) army personnel who have returned from peacekeeping operations were invited to partake in the study. Participants involved in the study were from ve military barracks in the Greater Accra Region, namely, Flagstaff House barracks, Burma Camp barracks, El-Wak barracks, 37 Military Hospital barracks and Tema Michel Camp barracks. Participants were presented with questionnaires on PTSD symptoms as well as Post Deployment Transition and were all advised to respond to items on each scale. In the initial MPhil research project, 92 out 134 army personnel involved in the study have returned from peacekeeping operations. For the purpose of validating the cultural adaptation of the PDSS, an additional 97 army personnel were included in the study out 100 invited personnel. All personnel involved in the study were purposively and conveniently sampled. Demographic data obtained from the participants include age, gender, military status, educational level, years of service, number of children, religion, deployment status and post deployment duration.
The purpose of the study was explained to all participants and personnel were asked to a sign a consent form before data collection. Guidelines were given to participants with regards to responding to items on the questionnaire and were encouraged to draw the attention of the researcher or the research assistants when needed. For some, there was the need to explain some of the items in twi (local language) in order for them to be able to respond to them. Assurance was given to participants with respect to con dentiality and anonymity of responses while emphasizing the purely academic purpose of the study. Some of the questionnaires were given to participants and retrieved later on another day while others ll the questionnaire on the spot. Human Issues Scale -Homecoming Attitudes (HIS-HA) Homecoming Attitudes, which is a subscale of the Human Issues Scale was used to address issues that are of relevance to homecoming experiences of military personnel such as readjustment problems, positive attitudes/engagement and negative attitudes/disengagement (Murphy & Farley, 2000). It is a ve-point Likert scale ranging from 1 to 5 (Never = 1, Rarely = 2, Sometimes = 3, Frequently = 4 and Very frequently = 5) with a higher score indicating greater transition di culty. It is a 23 item scale, however, item 18 is a double barrel item and therefore was divided into two separate item in this study, given the scale a total of 24 items. The scale has a minimum and maximum score ranging from 24 to 120 respectively. In a study conducted by Thompson and Blais (2000) the subscales in the scale recorded a Cronbach alpha ranging from .63 to .78.

Analytic Strategy
The Statistical Package for Social Sciences (SPSS) version 21 software program was employed in the analysis of data. Initially, descriptive analysis which includes Means, Standard Deviations, Frequencies and Percentages were examined as a form of data cleaning technique. Afterwards, in order to identify patterns, a Principal Component Analysis (PCA) and varimux rotation were also conducted. All items on the PDSSS were entered on an equal footing. In the initial PCA analysis, three (3) components were extracted with eigenvalues greater than 1 that would explain 70.45% of total variance. The prescribed PCA criteria used required that Kaiser-Meyer-Olkin Measure of Sampling Adequacy (MSA) must be greater than 0.5 for each item and also the group of items for them to be included in further analysis. For the group of items included in the initial analysis, total MSA recorded was .93 with a signi cant Bartlett test of Sphericity probability of p < .001. None of the individual items had MSA of less than .50 however one item had a communality value of less than .50 and four items had loadings higher than .40 on more than one component. These variables were therefore not included in subsequently conducted analysis. From this step by step designated criteria, 12 items were used in the nal PCA analysis. The scales internal consistencies were analyzed by calculating the Cronbach's alpha and item-total correlation coe cients.

Descriptive Data
Out of a total number of 189 army personnel who participated in the study, 132 were males (69.8%) and 57 were females (39.2%). 3 participants were between the ages of 20-29, 128 participants were between the ages of 30-39 and 57 participants were aged 40 years and above representing 1.6%, 68.3% and 30.2% of the total number of participants. With regards to army ranks, personnel with the rank of staff sergeant constituted the highest number of participants (n = 39) and individuals with the rank of Warrant O cer Class One had the least number of participants (n = 18). Most of the participants (n = 81) reported Secondary Education as their highest form of education with a total of 14 participants having a Tertiary degree. Also, 141 participants involved in the study had spent 20 years or less in the service, representing 74.6% of the total participants involved in the study. In addition, all the army personnel in this study had at least one child as well as associated themselves with a formal religion with 141 personnel associating themselves with the Christian religion and 48 being Muslims. In addition, all participants had returned from deployment and have been at home for not more than a year as at the time of data collection with majority of them having spent between 6-9 months at home post deployment.

Construction of Ghana Version of the PTSD Checklist-Military Version (PCL-M-G)
From the PCA analysis, a 12-item scale was identi ed with an internal consistency .92 that consisted of 3 main factors, namely, hyperarousal (5 items), reexperiencing (5 items) and avoidance (2 items) with each accounting for 54.65%, 13.39% and 9.17% of variance respectively. Factor 1 (Hyperarousal/D symptoms) recorded an internal consistency of .92, Factor 2 (reexperiencing/B symptoms) recorded an internal consistency of .92 and Factor 3 (avoidance/C symptoms) recorded an internal consistency of .79. In the nal analysis, the total scale accounted for 77.21% of the total variance (Table 1) as well as an MSA of .91 with a signi cant Bartlett test of Sphericity probability of < .001. The arrangement of the factors identi ed in this study differ from the original scale, thus, in the original scale, B symptom (reexperiencing), C symptom (Avoidance/numbing) and D symptom (hyperarousal) indicates factor 1, 2 and 3 respectively. In addition, a moderate inter-item correlation was observed between the factors ( Table 2). The scale's external validity was examined by assessing the relationship between the scale and post deployment transition ( Table 3). Each of the sub scales as well as the total scale indicate scores that had signi cant positive relationship with post deployment transition challenges.   Findings from the study is consistent with that of the original study as well as other related studies as three factors, namely, B symptoms/reexperiencing, C symptoms/avoidance/numbing and D symptoms/hyperarousal were identi ed as being associated with Ghanaian army personnel who have returned from peacekeeping duties and have been home for not more than one year. However, there is a difference in the arrangements of the factors as identi ed by the present study as D symptoms loaded on Factor 1, B symptoms loaded on Factor 2 and D symptoms loaded on Factor 3. In addition, even though similar to the original PCL-M scale, this study recorded ve items on the B symptoms and C symptoms each, only two items were retained on the C symptoms and both items measured avoidance only. This missing items on the scale implies cultural difference with respect to the experience of PTSD symptoms indicating that such items on the original scale are not relevant in the context of Ghanaian military personnel.
Factor 1 which was assigned the name "Hyperarousal" is consistent the ones Keen et al. (2008) in their study that examined the psychometric properties of the scale labelled as "Cluster D (Hyperarousal)". This factor was labelled as "hyperarousal" because items loaded re ect hyperarousal symptoms that are related to PTSD occurrences among military personnel. and "B symptoms" respectively. Also, all the items under Factor 2 in this study was labelled as "Re-experience" as this is linked with similar items under the sub-scale "Cluster B(Reexperiencing)". This factor was assigned the name re-experience as items loaded re ects reexperiencing events that are related to PTSD occurrences among military personnel. These similarly identi ed factors shows that, the experience of PTSD symptoms with regards to hyperarousal and reexperiencing in Ghanaian army personnel are similar to their counterparts in the United States of America. The Ghanaian culture coupled with the military culture, are cultures that do not encourage military personnel show any sign of weakness and be act "macho" all the time. Showing any signs of psychological problems with regards to relieving past events as well being super alert all the time, especially in Ghana is seen as a sign of weakness, Therefore the identi cation of these PTSD symptoms among Ghanaian military personnel is an eye opener and very interesting as well.
The term "Avoidance" was given to the third factor as this factor share some similarities with that of the sub scale labelled "Cluster C(Avoidance/Numbing)" in the scale's psychometric study by keen et al. (2008). However, in this study, out of seven items identi ed by Keen et al. (2008) two items (Avoid thinking about or talking about a stressful military experience or avoid having feelings related to it? and Avoid activities or talking about stressful military experience or avoid feelings related to it?) loaded on the factor. This factor was labelled as "Avoidance" since items re ected military personnel's intentions to avoid re ecting on their past experiences. It was also observed that none of the items that measured numbness loaded on this factor. This is indicative on the cultural difference with respect to PTSD symptoms relating to numbing one's feelings. In other words, the numbing of ones' feelings that was identi ed among United States of America war veterans does not apply to Ghanaian military personnel. This nding from the study could be as a result of Ghanaian army personnel being involved in peacekeeping operations. In other words, as oppose to combat related operations where soldiers are likely to encounter more traumatic events and therefore likely to numb their feelings in order not to relapse, soldiers on peacekeeping duties are less likely to experience any form of combat related trauma. In view of this, not experiencing any form of combat related trauma by Ghanaians army personnel unlike their combat veterans involved in Keen et al. (2008) study, they are less likely to show any PTSD symptoms relating to numbness trauma-related amnesia, diminished interest, detachment, restricted affect and foreshortened future. In addition, participants involved in this study were active duty personnel as opposed to veteran participants in Keen et al. (2008), therefore, the Ghanaian soldiers are less likely to suffer a numbness symptom like foreshortened future since they still remain in service after returning from deployment operations unlike the veterans. These factors explain why the Ghanaian army personnel involved in this study avoidance symptoms only but not numbness and this indicated relevance of cultural difference with respect to PTSD symptoms among military personnel.
The external validity of the scale was assessed by examining its relationship with post deployment transition challenges or experiences. By conducting a bivariate correlation, it was observed that factors that were identi ed in this study represents PTSD symptoms among military personnel as well as had a signi cant positive relationship with post deployment transition experiences. This indicates that PTSD symptoms among Ghanaian army personnel is an essential predictor of the how successful personnel will be with regards to their transition from deployment duties to being at home. In order, the higher the levels of PTSD symptoms among personnel, the more likely that they would experiences challenges transiting to daily lives at home and vice versa. In addition, the less challenges experienced by personnel when transiting back home after deployment, the lees likely that they would develop PTSD symptoms and vice versa.

Conclusion
The present study's most signi cant nding has to do with the identi cation of important cultural difference with respect to the experience of PTSD symptoms among military personnel. It is therefore indicative that using a non-validate PCL-M in studies that involve army personnel in Ghana or Africa at large can result in ndings that are not representative of the culture or population in question. Therefore, this paper encourages researchers and other stakeholders of the military organization to make use of the 12-item PCLM-G in Ghana since is culturally appropriate for use among army personnel of the Ghana Armed Forces. An adequate proportion of variance (77.21%), a high internal consistency (.92) as well as a satisfactory external validity was recorded by the scale. Nonetheless, care should be taken when interpreting this study's ndings since participants were selected purposively and conveniently from army personnel in Greater Accra Region of Ghana only and therefore generalizing it to all military personnel of the Ghana Armed Forces, especially, Air Force and Navy personnel who are also involved in peacekeeping duties in Ghana, would not be appropriate.

Declarations Ethics approval and consent to participate
This study is an extension of the author's MPhil research project which was approved by the Ethics Committee on Humanities (ECH) of the University of Ghana and written informed consent was acquired from every individual who participated in the study.

Consent for publication
Not applicable Availability of data and materials All datasets used in this study are available from the corresponding author on reasonable request.

Competing interests
The author declares that he has no competing interest.

Funding
The current research had no form of funding from any agency.

Authors' Contributions
Not applicable