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BMC Psychology logoLink to BMC Psychology
. 2024 Oct 24;12:588. doi: 10.1186/s40359-024-02112-x

Turkish adaptation of the antenatal risk questionnaire-revised: study of validity and reliability

Ali Cetin 1, Filiz Yarsilikal Guleroglu 1,, Melike Punduk 1, Tuba Ucar 2, Osman Tayyar Celik 3, Zehra Golbasi 4, Emine Fusun Akyuz Cim 5, Sinem Tekin 1, Nicole Reilly 6,7
PMCID: PMC11506243  PMID: 39448983

Abstract

Objective

This study sought to translate the Antenatal Risk Questionnaire-Revised (ANRQ-R) into Turkish and evaluate its psychometric properties for assessing psychosocial vulnerabilities among Turkish-speaking pregnant women.

Methods

The ANRQ-R was translated into Turkish following standard linguistic adaptation procedures. Psychometric properties were then examined using a cross-sectional study design, involving 156 pregnant women recruited from antenatal clinics in Turkey. Participants completed the Turkish ANRQ-R and the Edinburgh Postnatal Depression Scale (EPDS). Statistical analyses, including intraclass correlation coefficients (ICC) for test-retest reliability, Pearson correlation analysis for item-total test correlations, and Receiver Operating Characteristic (ROC) analysis for diagnostic accuracy, were conducted.

Results

The ANRQ-R Turkish version showed high test-retest reliability with an ICC of 0.888 for the total score. Moderate to good ICCs were obtained for individual Likert-type items (0.572–0.849). Criterion-related validity was established via moderate correlations with the EPDS and its anxiety subscale EPDS-3 A (r = 0.537 and r = 0.431, respectively). ROC analysis demonstrated good discriminatory power (Area Under the Curve = 0.75) with an optimal cut-off score of 17, yielding 78% sensitivity and 65% specificity for identifying potential depression cases.

Conclusions

This study provides preliminary evidence of the overall reliability of the Turkish version of the ANRQ-R as a measure of psychosocial risk among Turkish-speaking women during pregnancy. Despite some limitations in item-level internal consistency indicators, integration of the ANRQ-R into routine antenatal care could enhance early identification and intervention strategies, potentially improving maternal health outcomes. Future research should aim to further validate the scale across diverse populations and settings, using a diagnostic tool as the reference standard.

Keywords: ANRQ-R, Perinatal mental health, Psychometric evaluation, Turkish adaptation, Reliability, Validity

Introduction

The perinatal period represents a transitional stage of a woman’s life, marked by significant physiological, psychological, and social adjustments. Although the perinatal period is frequently viewed as a special time, for many women it can also pose substantial challenges influencing mental health and well-being. The burden of mental health disorders throughout pregnancy and within a year after childbirth has been increasingly recognized [13]. Perinatal depression and perinatal anxiety, for example, are common, with studies reporting prevalence rates of up to 40% [47]. If left untreated, the effects of perinatal depression can be far-reaching, including complications during pregnancy, impaired mother-infant bonding, and a host of adverse outcomes for both mother and infant, deteriorating physical health, diminished quality of life, increased relationship distress and increased risk of suicidal ideation [8].

Understanding the intricate interplay between psychosocial factors and mental health in the perinatal period is vital for targeted interventions and support services. Early identification of at-risk individuals can facilitate timely interventions, including counseling, therapy, or support group involvement, thereby mitigating the potential negative impact on maternal mental health and the well-being of the newborn [1]. In response, there has been a growing emphasis on developing effective psychosocial assessment tools to support the early identification of pregnant women and new mothers who may be at greater risk of poorer mental health or parenting outcomes [2, 3, 9]. Timely identification during pregnancy can significantly mitigate the potential adverse effects of perinatal depression on maternal health, parenting, and child development. Implementing comprehensive screening measures can provide essential support and interventions to at-risk mothers, fostering improved maternal and child well-being throughout the postpartum period [46].

The Antenatal Risk Questionnaire-Revised (ANRQ-R) is one such tool that has been developed to support the early identification of psychosocial strengths and vulnerabilities and has been validated for use with pregnant women [10, 11]. However, to date, no studies have reported on the development and use of a translated version of the ANRQ-R. A Turkish adaptation of the ANRQ-R would provide healthcare practitioners and researchers with a culturally sensitive and reliable instrument for identifying and addressing potential psychosocial risk factors that may predispose Turkish-speaking expectant and new mothers to mental health challenges during the perinatal period. This is particularly important because there are currently no known instruments to assess for risk of perinatal mental health conditions available in Turkey. In response, the aim of this study was to develop an adaptation of the ANRQ-R to Turkish language and culture and to test the psychometric properties of this adapted version.

Methods and participants

A two-stage methodological and observational adaptation study was conducted: the focus of Stage 1 was translation and cross-cultural adaptation of the ANRQ-R and the focus of Stage 2 was the psychometric testing of the translated version. Participants were recruited among adult pregnant women attending an outpatient obstetric service at a tertiary care hospital. They were invited consecutively to participate in this study during the third trimester of their pregnancy. Participants who screened positive for high risk of perinatal depression or other mental health concerns were referred for psychological consultation within the hospital’s mental health services. The study’s exclusion criteria included cognitive impairments affecting questionnaire comprehension, undergoing treatment for physical ailments, anemic conditions, history of psychiatric diagnoses, chronic medication usage, and pre-existing sleep disorders prior to pregnancy.

The study was conducted in accordance with the principles of the Declaration of Helsinki [12]. The study was approved by the Human Ethics Committee of the University of Health Sciences (Registered as 116–2023 and dated as June 22, 2023). The permission for the translation, cultural adaptation, and psychometric validation of the ANRQ-R instrument in Turkish was requested and granted via e-mail from the authors.

Stage 1. Translation and cross-cultural adaptation process

In the initial phase, established standards and steps [13, 14] were followed to translate and cross-culturally adapt the ANRQ-R based on a sample of 30 pregnant women in their third trimester, as follows:

Step 1. Forward translation

Two native Turkish-speaking translators with proficiency in English translated the original scale into Turkish. One translator possessed familiarity with scientific terminology in obstetric and psychological research. The translators were instructed to create an acceptable and natural language version of the scale, ensuring simplicity, clarity, and relevance for the general Turkish-speaking population. They were directed to focus on providing conceptual equivalents rather than literal translations.

Step 2. Synthesis and resolution of inconsistencies

Following a meeting involving two translators and two researchers, the two translations were merged to create the first Turkish version of the ANRQ-R. In forming the initial Turkish version, the most suitable translation for each item of the scale was chosen.

Step 3. Backward translation

At this stage, the first Turkish version of the ANRQ-R was backward translated into English by additional two translators, both native English speakers not involved in the previous translation phase. Both translators were unfamiliar with the questionnaire’s concepts, and neither had a medical background. They were instructed to avoid technical terms and jargon.

Step 4. Synthesis and resolution of inconsistencies

After a meeting with two translators and the research group leader, the two translations were combined to form the English version of the ANRQ-R. When creating the English version, the most appropriate translation for each item of the scale was selected.

Step 5. Review and revision

In case of discrepancies between the backward translation and the original scale, a reiteration commenced from re-reviewing the forward translation, ensuring corrections to the translation. If identified differences did not warrant another cycle of translation and review, the process proceeded to the next stage.

Step 6. Expert panel review and preparation of the pre-final Turkish version of the ANRQ-R

An online multidisciplinary expert panel comprising researchers and professional translators compared the original and backward-translated English versions in a collaborative session. The cultural appropriateness of each item in the translated scale was discussed concerning semantic, idiomatic, experiential, and conceptual compatibility with the original version. Panel members evaluated the cultural appropriateness of each item using a 4-point Likert scale (1 = completely irrelevant, 2 = moderately irrelevant, 3 = moderately relevant, 4 = clearly relevant). The classification of all items as clearly relevant by the panel experts was considered a success. The process was considered successful when all items were rated as ‘clearly relevant’ by the panel experts, confirming the cultural suitability of the adapted items.

Step 7. Pilot study

For the pilot study, a sample of 30 exclusively Turkish-speaking pregnant women were invited to complete the pre-final Turkish version of the ANRQ-R online via the Google Forms platform. Volunteers were recruited from antenatal care units affiliated with a university hospital in Istanbul. Eligible women were asked if they were willing to participate in a research study related to perinatal mental health issues; those who agreed were provided with information about the scope of the research, and electronic informed consent was obtained from those willing to participate. A member of the research team engaged with participants to identify items that were challenging to understand or answer. This stage also assisted in understanding how patients comprehended and interpreted scale items.

Step 8. Acceptance of the final Turkish version of the ANRQ-R

Finally, summaries obtained from discussions during the pilot study were reviewed by the researchers in a consultation meeting. If the scale items were found to be adequately feasible, the final pre-final Turkish version of the ANRQ-R, ready for implementation, was achieved.

Stage 2. Psychometric evaluation of the Turkish version of ANRQ-R

The second stage involved the assessment of the psychometric properties, including validity and reliability, of the Turkish version of ANRQ-R completed by 156 women during the third trimester. A sample size equivalent to ten times the number of items in the ANRQ-R was planned (N = 110); however, to account for potential participant dropouts or losses over the course of the study, 156 participants were initially recruited [15]. A total of 30 pregnant women also completed the Turkish version of the ANRQ-R questionnaire a second time, two weeks apart, for test-retest reliability.

Study instruments

Personal data form

The following data were collected from the participants enrolled in the study for the psychometric evaluation of the Turkish version of ANRQ-R: age, educational status (pre-high school/high school or higher education), occupational status (stay at home parent /unemployed/employed), income status (inadequate/sufficient), smoking (no/yes), exercise (moderate/adequate), family type (nuclear/extended), relationships with spouse, family and environment (positive/moderate/challenging), current pregnancy type (natural/assisted), gravidity, parity, mode of previous deliveries (no/vaginal birth/cesarean birth), gestational age at enrollment, preconception body mass index (normal/overweight/obese), gestational weight gain, amniotic fluid status (oligohydramnios/normal/polyhydramnios), pregnancy co-morbidities (preeclampsia/diabetes mellitus/other), and satisfaction with the course of current pregnancy (inadequate/satisfied).

The ANRQ-R

The ANRQ-R is a validated measure used to assess psychosocial risks during pregnancy [10]. It comprises 11 scored items within a range of 5 to 55, where higher scores indicate increased psychosocial risk. Additionally, non-scored items provide valuable clinical and contextual information concerning previous treatment or professional support for mental health issues, adverse childhood experiences such as childhood sexual abuse, and the nature of recent stressful life events. It can be filled out using pen and paper, verbally, or embedded within computer-based or existing data platforms. The ANRQ-R total score demonstrates good test-retest reliability in a community sample (intraclass correlation coefficient = 0.79) [10, 11].

Among its items, two ANRQ-R questions specifically focus on aspects related to anxiety. These questions ask about trait anxiety (translated Turkish version: ‘Would you describe yourself as someone who often worries?‘) and the impact of disorder in life causing distress (translated Turkish version: ‘Do you feel upset when things are not organized in your life?‘). Respondents rate these items on a Likert-type scale ranging from one to five. The total anxiety score, derived from these two items, ranges from 2 to 10, with higher scores indicating a higher level of anxiety symptoms. These anxiety-related items were derived from the comprehensive ANRQ-R questionnaire administered to all participating women [16].

Edinburgh postnatal depression scale (EPDS)

The EPDS is a self-report questionnaire consisting of 10 items originally designed to assess for symptoms of depression during the postnatal period using a 4-point Likert scale. Developed by Cox et al. in 1987 [17], the EPDS was adapted into Turkish and validated by Engindeniz et al. in 1996 [18]. Items 3, 5, 6, 7, 8, 9, and 10 are scored in decreasing order (3, 2, 1, 0), while items 1, 2, and 4 are scored as (0, 1, 2, 3). The total score is the sum of the scores obtained from individual responses, ranging from a minimum of 0 to a maximum of 30. Higher scores indicate a higher level of depression.

Within the EPDS framework, items 3, 4, and 5 have been identified as constituting a distinct subset known as the EPDS-3 A, specifically targeting symptoms of anxiety [1921]. Respondents rate their experiences regarding these EPDS-3 A items on a Likert-type scale, resulting in a cumulative score ranging from 0 to 9. These anxiety-related items have been isolated from the comprehensive EPDS administered universally to women [16].

Conduct of data collection

All participants of the study provided informed consent for participation. The adapted and other study forms were then converted into an online survey questionnaire using the Google® Forms (google.com/forms/about/). Relevant information about the study was given on the first page of the online survey and also in the email or social media message containing the link to the survey. The information given was the same as the paper-based information sheet, containing the identity of the researchers, contact details, the reason for conducting the survey and how the data would be used. Participants were informed that they have the right to pull out from the study at any time. The respondents were required to click the ‘Consent’ button as an indication that they have given an informed consent before the next page of the questionnaire could be accessed. The questionnaire was divided into three sections. Section 1 contained questions on the inclusion and exclusion criteria. Participants could only proceed to Sects. 2, 3, and 4, if they fulfil the eligibility criteria. Sections 2 and 3 contained questions covering the Turkish versions of the ANRQ-R and EPDS, respectively. Section 4 included questions on personal information. Participants could choose to skip any of the items as no items required an obligatory response (other than those relating to the consent) before they could proceed until the end of the questionnaire. The investigator’s telephone number and e-mail were made available to the participants, to clarify any doubts during the investigation process. All data were anonymized, and no identifying data were stored.

Statistical analysis

The psychometric properties of the Turkish version of the ANRQ-R were assessed, using the Statistical Package for Social Sciences (SPSS) Version 26. For the sociodemographic characterization of the sample, descriptive statistics was performed and a significance level of p < 0.05 was considered.

The ANRQ-R’s complex structure, comprising dichotomous and Likert-type items (including two non-standard Likert items), as well as scored and unscored questions, precludes traditional unidimensional psychometric analyses. We adopted a multifaceted approach tailored to the scale’s diverse item types and scoring methods, focusing on external reliability measures and item-total correlations. This strategy allows for a comprehensive evaluation of the ANRQ-R’s psychometric properties while respecting its multidimensional nature and unique item characteristics.

Reliability analyses

In the process of adapting a scale, it is important to conduct reliability tests to ensure the consistency and accuracy of the instrument over time. The ANRQ-R asks about a range of psychosocial risk domains and includes both dichotomous and Likert-type questions. Given the multidimensional nature of the measure, test-retest reliability and item-total test correlations were considered the most appropriate reliability tests.

Test-retest reliability evaluates the stability of the responses over time by administering the ANRQ-R to the same group of participants at two different points in time. In the test-retest reliability of the ANRQ-R, intraclass correlation coefficients (ICC; two-way mixed effects model) were used for total score and Likert-type items, and Kappa coefficients were used for dichotomous items. Item-total test correlations of the ANRQ-R were analyzed by Pearson correlation analysis (for Likert-type questions) and point–biserial coefficient (dichotomous questions).

The following definitions were used to aid clinical interpretation of results: ICC values: < 0.50 = poor; 0.50-0.75 = moderate; 0.75-0.90 = good; > 0.90 = excellent [22]; Kappa coefficients: 0.01-0.2, slight, 0.21-0.4; fair, 0.41-0.60; moderate, 0.61-0.80; substantial, and 0.81-1, almost perfect [23]; and correlation coefficient (r): ≥ 0.70 = high, 0.70-0.30 = moderate, < 0.30 = low level relationship [24].

Validity analyses

Criterion-related validity was used to validate the ANRQ-R. Criterion-related validity is determined by comparing the scores obtained from one or more measurement tools that are assumed to measure a behavior or trait related to the measurement tool that is assumed to measure the desired trait as standard [25]. In the absence of a diagnostic reference standard, the EPDS was applied to examine the criterion-related validity of the ANRQ-R. In the correlation analysis between ANRQ-R and EPDS, Pearson correlation analysis was used for Likert-type questions of ANRQ-R and point-biserial coefficient was used for dichotomous questions of ANRQ-R. Additionally, a Receiver Operating Characteristic (ROC) analysis was conducted to evaluate the performance of the ANRQ-R in predicting depression as identified by the EPDS. The ROC curve was plotted using EPDS scores as the reference standard (with a cut-off score of ≥ 13 indicating probable depression) and ANRQ-R scores as the predictor. The Area Under the Curve (AUC) was calculated to assess overall diagnostic accuracy. The optimal cut-off point for ANRQ-R was determined by maximizing the Youden Index. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated at this optimal cut-off point. The ROC analysis was performed using Python with the scikit-learn library.

Results

Baseline characteristics

In the context of our study employing the ANRQ-R, a detailed table was prepared to outline the sociodemographic and obstetric characteristics of our participants (Table 1). This table provides a comprehensive demographic and clinical background against which the antenatal risk factors identified through the ANRQ-R can be interpreted. The diverse sociodemographic and obstetric profiles of our study participants, as outlined in our detailed characteristics table, offer a robust foundation for exploring the antenatal risk factors targeted by the ANRQ-R. With a range that spans various ages, sociodemographic statuses, and personal and pregnancy features, our cohort mirrors the broader pregnant population of women who give birth in Turkey, enabling us to effectively capture and analyze a broad spectrum of risk factors related to perinatal emotional disturbances. This inclusivity enhances the ANRQ-R’s utility in identifying key risks for future psychological disturbances, promising comprehensive insights into the complexities of maternal and fetal health during the antenatal period.

Table 1.

Baseline characteristics of the study population (n = 156)

Characteristics Values
Age, year 28 (18–43)
Educational status

 Pre-high school

 High school

 Higher education

45 (28.8%)

47 (30.1%)

64 (41.0%)

Occupational status

 Stay at home parent

 Unemployed

 Employed

80 (51.3%)

39 (25.0%)

37 (23.7%)

Income status

 İnadequate

 Sufficient

55 (35.3%)

101 (64.7%)

Smoking

 No

 Yes

142 (91.1%)

14 (8.9%)

Exercise

 Moderate

 Adequate

74 (47.5%)

82 (52.5%)

Family type

 Nuclear

 Extended

135 (86.5%)

21 (13.5%)

Relationships with spouse, family and environment

 Positive

 Moderate

 Challenging

20 (12.8%)

93 (59.6%)

43 (27.6%)

Current pregnancy type

 Natural

 Assisted

151 (96.8%)

5 (3.2%)

Gravidity

 1

 2

 3

 ≥4

78 (50.0%)

37 (23.7%)

26 (16.7%)

15 (9.6%)

Parity

 0

 1

 2

 ≥3

80 (51.3%)

42 (26.9%)

25 (16.0%)

9 (5.8%)

Mode of previous deliveries

 No

 Vaginal birth

 Cesarean birth

85 (54.5%)

30 (19.2%)

41 (26.3%)

Gestational age at enrollment, week 35 (16–40)
Preconception BMI, kg/m2

 Normal

 Overweight

 Obese

87 (55.8%)

50 (32.1%)

19 (12.2%)

Gestational weight gain, kg 10 (0–25)
Amniotic fluid

 Oligohydramnios

 Normal

 Polyhydramnios

2 (1.2%)

148 (94.9%)

6 (3.8%)

Pregnancy co-morbidities

 Preeclampsia

 Diabetes mellitus

 Other*

12 (7.7%)

18 (11.5%)

12 (7.7%)

Satisfaction with the course of current pregnancy

 Inadequate

 Satisfied

12 (7.7%)

144 (92.3%)

*Others includes hyperemesis gravidarum,

asthma, anemia, and recurrent urinary infection

Distribution of ANRQ-R data

When presenting the results of the ANRQ-R, it is important to consider the unique structure and scoring system of the scale. The ANRQ-R comprises both scored and unscored questions, including a mix of dichotomous and Likert-type items. This diversity in question types requires a comprehensive approach to data presentation to fully capture the scale’s nuances and the range of responses provided by participants. Table 2 provides an item-level summary of responses to the ANRQ-R among study participants. To address this complexity, we have created a detailed table that encapsulates all responses, segregating them into scored and unscored categories, and further distinguishing between dichotomous and Likert-type responses. This approach ensures that the multifaceted nature of the questionnaire is accurately reflected, providing a holistic view of the antenatal risk factors as reported by the study cohort. The detailed tabulation aids in the meticulous analysis of the data, adhering to the scoring guidelines of the ANRQ-R and enhancing the interpretability of the findings within the context of antenatal risk assessment.

Table 2.

Distribution of ANRQ-R replies in the study population (n = 156)

Questions Type of Question Score Responses Risk type
ANRQ-R-1 MCQ Scored (1/2/3/4/5) M (SD) 2.81 (1.03) Social support
ANRQ-R-2 MCQ+ Scored (1/2/3/4/5/5) M (SD) 2.12 (0.82) Emotional support
ANRQ-R-3 DQ Scored (0/5)

No

Yes

n (%)

154 (98.1%)

2 (1.3%)

Domestic violence
ANRQ-R-4 DQ Not scored

No

Yes

n (%)

124 (79.4%)

32 (20.6%)

Experienced traumatic event
ANRQ-R-4 A MCQ Scored (1/2/3/4/5) M (SD) 1.63 (1.34)

Problems related to

experienced traumatic event

ANRQ-R-5 MCQ+ Scored (1/2/3/4/5/5) M (SD) 2.47 (1.20) Emotional support during childhood
ANRQ-R-6 DQ Scored (0/5)

No

Yes

Physically

Emotionally

Sexually

n (%)

141 (90.4%)

15 (9.6%)

5 (33%)

10 (67%)

0 (0%)

Experienced childhood trauma
ANRQ-R-6 A DQ Not scored

No

Yes

n (%)

141 (90.4%)

15 (9.6%)

Problems related to experienced

emotional and traumatic conditions

ANRQ-R-7 DQ Scored (0/5)

No

Yes

n (%)

127 (81.4%)

29 (18.6%)

Experienced emotional problems
ANRQ-R-7 A MCQ Scored (1/2/3/4/5) M (SD) 1.17 (0.99)

Problems related to experienced

emotional problems

ANRQ-R-7B DQ Not scored

No

Yes

n (%)

23 (79.3%)

6 (20.7%)

Problems related to experienced

emotional problems

ANRQ-R-7 C DQ Not scored

No

Yes

n (%)

26 (89.7%)

3 (10.3%)

Problems related to experienced

emotional problems

ANRQ-R-7D DQ Not scored

No

Yes

n (%)

26 (89.7%)

3 (10.3%)

Problems related to experienced

emotional problems

ANRQ-R-7E DQ Not scored

No

Yes

n (%)

26 (89.7%)

3 (10.3%)

Problems related to experienced

emotional problems

ANRQ-R-7 F DQ Not scored

No

Yes

n (%)

10 (34.5%)

19 (65.5%)

Problems related to experienced

emotional problems

ANRQ-R-8 DQ Scored (0/5)

No

Yes

n (%)

155 (99.4%)

1 (0.6%)

Drug or alcohol abuse
ANRQ-R-9 MCQ Scored (1/2/3/4/5) M (SD) 2.78 (0.99) Current emotional problems
ANRQ-R-10 MCQ Scored (1/2/3/4/5) M (SD) 3.18 (1.14) Emotional personality
ANRQ-R-R Total Score M (SD) 16.06 (6.14)

ANRQ-R, antenatal risk questionnaire revised. MCQ, multiple-choice question.

MCQ+, multiple-choice question with double 5 score. DQ, dichotomous question

Reliability

As shown in Table 3, the ICC of the ANRQ-R total score is 0.888, indicating good reliability. ICCs for individual Likert-type items were also moderate to good; It ranged between 0.572 (current emotional problems, ANRQ-R-9) and 0.849 (emotional support during childhood, ANRQ-R-5). Kappa coefficients for dichotomous items varied between 0.359 (experienced emotional problems, ANRQ-R-7) and 1 (experienced traumatic event, ANRQ-R-4).

Table 3.

Test-retest reliability and item-total correlation analysis of the ANRQ-R

Item No. ANRQ-R test (n = 30) ANRQ-R retest (n = 30) ICC (95%CI) Item-total correlations (n = 156)
M (SD) M (SD)
ANRQ-R Total Score 16.10 (6.60) 16.20 (6.96) 0.888** (0.764-0.946)
Likert-type items
ANRQ-R-1 Social support 3.13 (1.07) 3.00 (1.07) 0.749** (0.473-0.881) 0.408**
ANRQ-R-2 Emotional support 2.57 (0.95) 2.33 (0.95) 0.678* (0.323-0.847) 0.399**
ANRQ-R-5 Emotional support during childhood 2.73 (1.17) 2.73 (1.23) 0.849** (0.682-0.928) 0.447**
ANRQ-R-9 Current emotional problems 2.83 (0.98) 2.37 (0.85) 0.572** (0.100-0.796) 0.463**
ANRQ-R-10 Emotional personality 2.87 (1.27) 3.10 (1.26) 0.815** (0.612-0.912) 0.450**
Dichotomous items n (%) n (%) Kappa (95% CI)
ANRQ-R-3 Domestic violence 2 (6.7) 3 (10.0) 0.783** (0.731-0.834) 0.306**
ANRQ-R-4 Experienced traumatic event 9 (30.0) 9 (30.0) 1.00** 0.491**
ANRQ-R-6 Experienced childhood trauma 4 (13.3) 2 (6.7) 0.634** (0.619-0.649) 0.509**
ANRQ-R-7 Experienced emotional problems 3 (10.0) 6 (20.0) 0.359* (0.309-0.409) 0.737**
ANRQ-R-8 Drug or alcohol abuse 5 (16.6) 6 (20.0) 0.889** (0.862-0.916) 0.308**

*p value is significant at the 0.05 level.

**p value is significant at the 0.01 level

In item-total correlation analysis, the relationship between individual and dichotomous items of ANRQ-R and its total score was examined. Correlations ranged from 0.306 to 0.737; this indicates that they have a moderate to high relationship with the overall scale (Table 3).

EPDS and EPDS-3 A were used as criteria to determine the criterion-related validity of ANRQ-R. The scales were applied simultaneously to 156 people. As seen in Table 4, the relationship between the total score of ANRQ-R and EPDS and EPDS-3 A was moderate (r = 0.537, r = 0.431, respectively). The correlation between ANRQ-R anxiety score and EPDS and EPDS3-A was high and moderate (r = 0.858, r = 0.464, respectively). Correlations between individual Likert-type items and the EPDS were low to moderate, ranging from 0.290 (emotional support during childhood) and 0.420 (current emotional problems). Correlations between individual Likert-type items and the EPDS-3 A were also low to moderate; It ranged from 0.209 (emotional support) to 0.405 (current emotional problems). The correlation coefficients between dichotomous items and EPDS and EPDS-3 A vary between 0.180 (experienced traumatic event) and 0.330 (experienced emotional problems).

Table 4.

The correlation between the mean scores of EPDS and EPDS-3 A with ANRQ-R (n = 156)

Item No. EPDS EPDS-3 A
ANRQ-R Total score 0.537** 0.431**
ANRQ-R Anxiety 0.858** 0.464**
Likert-type items
ANRQ-R-1 Social support 0.328** 0.319**
ANRQ-R-2 Emotional support 0.331** 0.209**
ANRQ-R-5 Emotional support during childhood 0.290** 0.284**
ANRQ-R-9 Current emotional problems 0.420** 0.405**
ANRQ-R-10 Emotional personality 0.355** 0.356**
Dichotomous items
ANRQ-R-3 Domestic violence 0.270** 0.150
ANRQ-R-4 Experienced traumatic event 0.206** 0.180*
ANRQ-R-6 Experienced childhood trauma 0.189* 0.119
ANRQ-R-7 Experienced emotional problems 0.330** 0.232**
ANRQ-R-8 Drug or alcohol abuse 0.157 0.049

*Correlation is significant at the 0.05 level.

** Correlation is significant at the 0.01 level

ROC analysis

A ROC analysis was conducted to evaluate the performance of the ANRQ-R in predicting depression as identified by the EPDS. Using EPDS scores ≥ 13 as the criterion for probable depression, the AUC for the ANRQ-R was 0.75, indicating moderate to good discriminatory power. The optimal cut-off point for the ANRQ-R was determined to be 17, balancing sensitivity and specificity. At this threshold, the ANRQ-R demonstrated a sensitivity of 0.78 (78%) and a specificity of 0.65 (65%). The PPV at this cut-off was 0.40 (40%), indicating that 40% of individuals identified as positive by the ANRQ-R were true depression cases according to the EPDS. The NPV was 0.91 (91%), suggesting that 91% of individuals identified as negative by the ANRQ-R were true non-depression cases. These results suggest that the ANRQ-R has good potential as a screening tool for antenatal depression, particularly in ruling out depression cases. However, positive results should be followed up with more comprehensive assessments to confirm the presence of depression.

Discussion

This study developed and examined the reliability and validity of the Turkish adaptation of the ANRQ-R to support the identification of psychosocial risks among pregnant women in Turkey. The process of adaption was comprehensive, overall test-retest reliability was good, and moderate correlations between EPDS and ANRQ-R scores were observed. Additionally, the ROC analysis demonstrated good discriminatory power of the ANRQ-R in identifying potential depression cases, further supporting its validity. The study sample encompassed a wide age range and various educational, occupational, and health statuses, and were broadly representative of the broader pregnant population in Turkey.

Overall, women in this study reported having moderate levels of social and emotional support and around one in five reported a previous history of mental health, with almost two-thirds of women reporting that this had occurred in the previous two years. Few women endorsed current or recent experiences of domestic violence, however 9.6% reported traumatic events during childhood, highlighting the importance of a comprehensive approach to psychosocial assessment in this population.

The study demonstrated that ANRQ-R has good reliability with moderate to good ICCs for individual Likert-type items, such as emotional support during childhood and current emotional problems, confirm the scale’s reliability in assessing specific psychosocial factors. The Kappa coefficients for dichotomous items, such as experienced emotional problems and domestic violence, vary, indicating varying levels of agreement over time for these questions. This study and Reilly’s research [11] share similarities in evaluating the psychometric properties of the ANRQ-R, using EPDS for validity assessment, and employing ROC analysis. However, they differ in cultural context (Turkish adaptation vs. original English), sample size (156 vs. 1166), and focus (pregnancy only vs. perinatal period). Unlike Reilly’s study, this research includes a cultural adaptation process and test-retest reliability analysis. The optimal cut-off points also differ (17 vs. 18). These differences highlight the importance of cultural validation and provide insights into the ANRQ-R’s performance across diverse populations.

The study used the EPDS to estimate the criterion-related validity of the ANRQ-R using the correlation between the ANRQ-R and the EPDS total score and its anxiety subset as the outcome of interest. The moderate correlation between the total score of ANRQ-R and both EPDS and its anxiety subset implies that the ANRQ-R is effective in identifying risks related to perinatal depression and anxiety. Furthermore, the ROC analysis yielded an AUC of 0.75, indicating moderate to good discriminatory power of the ANRQ-R in identifying potential depression cases. The optimal cut-off score of 17 on the ANRQ-R provided a good balance between sensitivity (78%) and specificity (65%). These findings suggest that the ANRQ-R has good potential as a screening tool for antenatal depression, particularly in ruling out depression cases.

The development and validation of psychosocial risk assessment tools in perinatal care have been a focus of numerous studies over the past decade. The Antenatal Risk Questionnaire (ANRQ) and its revised version (ANRQ-R) have emerged as prominent instruments in this field. Our study, which adapted the ANRQ-R for use in Turkey, contributes to this growing body of research by extending its applicability to a new cultural context.

The evolution from ANRQ to ANRQ-R, as demonstrated by Reilly et al. [10, 11], represents a significant advancement in comprehensive psychosocial risk assessment. The ANRQ-R’s inclusion of items addressing substance misuse and domestic violence enhances its utility in identifying a broader spectrum of risk factors. Our findings align with those of Reilly et al., showing good test-retest reliability and effectiveness in identifying potential depression and anxiety risks. This consistency across different cultural settings underscores the robustness of the ANRQ-R as a screening tool.

Several studies, including those by Austin et al. [26], Reilly et al. [27], and Kalra et al. [28], have highlighted the high acceptability and effectiveness of the ANRQ in various maternity care settings, both public and private. Our study extends these findings to the Turkish context, demonstrating the tool’s adaptability across different healthcare systems and cultures. The consistent theme across these studies, including ours, is the potential for routine psychosocial assessments to significantly improve maternal mental health outcomes.

However, the research collectively highlights a critical gap in perinatal mental health care. As noted by Schmied et al. [29], there is often a discrepancy between the identification of psychosocial risks and women’s engagement with specialized mental health services. This challenge, also evident in our findings, suggests that while tools like the ANRQ-R are effective in identifying risks, there is a pressing need for more accessible and culturally appropriate mental health support systems.

The integration of psychosocial risk assessment into routine antenatal care, as proposed by models like PRAM [30] and supported by our study, represents a promising approach. However, as Johnson et al. [31] and our research indicate, there is an ongoing need for further validation and refinement of these tools, particularly in diverse cultural contexts. Our study’s ROC analysis, showing good discriminatory power of the ANRQ-R in identifying potential depression cases, contributes valuable data to this endeavor.

Synthesizing our findings with the existing literature, our adaptation and validation of the ANRQ-R in Turkey, alongside the broader body of research, underscores the tool’s versatility and importance in perinatal mental health screening. It also highlights the universal challenges in translating risk identification into effective intervention. Future research and clinical practice should focus not only on refining these assessment tools but also on developing culturally sensitive, accessible mental health support systems that can effectively address the identified risks across diverse populations.

Taken together, considering the strengths of this study, the successful adaptation of the ANRQ-R into Turkish addresses a significant gap in assessing perinatal mental health risks within the Turkish speaking population. This adaptation enhances the tool’s applicability and relevance, ensuring that the nuances of cultural and linguistic contexts are adequately considered in the assessment process. The study provides a comprehensive framework for evaluating a wide range of antenatal psychosocial risk factors. By doing so, it facilitates a deeper understanding of the psychosocial landscape affecting pregnant women in Turkey, highlighting the tool’s importance in capturing diverse risks. The thorough assessment of the ANRQ-R’s reliability and validity within a Turkish context is a strength. Despite some challenges, the tool demonstrated consistency over time and showed moderate to strong correlations with established measures like the EPDS, underscoring its potential utility in clinical and research settings. The ROC analysis further supports the ANRQ-R’s utility as a screening tool, with good sensitivity and specificity at the optimal cut-off point. The findings have significant policy implications, emphasizing the need for healthcare systems to integrate comprehensive psychosocial assessments into routine antenatal care. This approach could enable early identification and intervention, potentially improving maternal health outcomes.

While the study provides initial evidence for the ANRQ-R’s reliability and validity in a Turkish context, ongoing research is needed to further test the tool. For example, although the study sample was broadly representative of the population of pregnant women in Turkey, participants were recruited from a single site may limit the generalizability of the results. Future research should aim to validate the Turkish version of the ANRQ-R across a wider demographic and geographic distribution to enhance its applicability. Further studies could also focus on validating the cut-off point identified in the ROC analysis and exploring its predictive validity for various perinatal mental health outcomes. Exploring the predictive validity of this adapted version for postnatal mental health and parenting outcomes, and its acceptability in different healthcare settings, would also be of value. The implications of integrating the ANRQ-R into routine antenatal care, including the need for training healthcare providers, ensuring the tool’s use does not overburden the clinical workflow., and the need for appropriate and accessible care pathways for those identified as is need of additional support, need to understood. Additionally, future studies could investigate how the ANRQ-R’s performance compares to other screening tools in the Turkish context, particularly in terms of its ability to identify women at risk of depression. Addressing these challenges is crucial for the effective utilization of the ANRQ-R in practice. This research marks a significant step toward enhancing the assessment of perinatal mental health risks among Turkish-speaking populations. By considering both the strengths and limitations, future work can build on this foundation to refine the ANRQ-R, expand its utility, and ultimately contribute to improved maternal and fetal health outcomes.

Conclusions

The Turkish adaptation of the ANRQ-R provides a reliable and valid measurement tool that can be used to support the identification of psychosocial risk profile of pregnant women in Turkey. The ROC analysis further supports its utility as a screening tool for antenatal depression, with a well-balanced sensitivity and specificity at the optimal cut-off point. This study is an important step in meeting the need for the development and evaluation of culturally appropriate instruments for Turkish-speaking pregnant women, which are critical for early detection and intervention of mental health risks in the antenatal period. Future studies should be aimed at expanding the scope and applicability of the Turkish version of the ANRQ-R in larger sample groups and with pregnant women from different socioeconomic levels. Additionally, research on the implementation of the ANRQ-R in routine antenatal care, including its integration with existing screening protocols and its impact on clinical decision-making and patient outcomes, would be valuable in optimizing its use in Turkish healthcare settings. In this way, it will be possible to identify and manage psychosocial risk factors in the antenatal period more effectively and to improve pregnancy-related mental health outcomes.

Acknowledgements

The authors would like to thank all the participants in this study for their participation.

Abbreviations

ANRQ-R

Antenatal Risk Questionnaire-Revised

EPDS,

Edinburgh Postnatal Depression Scale

ICC,

Intraclass correlation coefficients

ROC,

Receiver Operating Characteristic

AUC,

Area Under the Curve

Author contributions

Conceived and designed the study protocol: AC, FYG, and EFAC. Collected the data: AC, MP and ST. Analyzed the data: AC, TU, OTC, and ZG. Wrote the paper: AC, FYG, MP, and EFAC. Supervised the paper: AC, FYG, MP, TU, OTC, ZG, EFAC, ST and NR. All authors contributed to the article and approved the submitted version.

Funding

This study received no financial support.

Data availability

The raw data supporting the conclusions of this article will be made available by the authors with reasonable request.

Declarations

Ethics approval and consent to participate

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethical Committee of the Health Sciences University. In addition, before conducting the surveys, the informed consent was obtained from all study participants by the researchers.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Permission to reproduce material from other sources

Not applicable.

Study registration

Not applicable.

Footnotes

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors with reasonable request.


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