ORIGINAL PAPER

The factor structure of the CES-D in a sample of Rwandangenocide survivors

Justin J. Lacasse • Marie J. C. Forgeard •

Nuwan Jayawickreme • Eranda Jayawickreme

Received: 16 September 2012 / Accepted: 17 September 2013 / Published online: 31 October 2013

� Springer-Verlag Berlin Heidelberg 2013

Abstract

Background Past research suggests that culture shapes

the way psychopathology is experienced and expressed.

Standard psychiatric assessment instruments may therefore

not capture the same underlying constructs in different

contexts. The present study investigated the factor structure

of a standard depression scale in a sample of Rwandan

genocide survivors.

Methods One hundred ninety six Rwandan adults pro-

vided socio-demographic information and completed the

Center for Epidemiological Studies-Depression scale

(CES-D), one of the most widely used self-report instru-

ments assessing depressive symptoms, as part of a larger

study on well-being and mental health in Rwanda.

Results A two-factor solution provided the best fit for

these CES-D data. The first factor corresponded to general

depressive symptoms (including depressed affect, somatic

symptoms, and interpersonal concerns) and explained

37.20 % of the variance. The second factor included items

assessing positive affect and explained 8.68 % of the

variance.

Conclusions The two-factor solution found in the present

study deviates from the commonly reported four-factor

structure, but is consistent with studies showing that

depressed affect and somatic symptoms may not be expe-

rienced as distinct in certain non-Western and minority

cultural groups.

Keywords Depression � Psychopathology � Culture �Idioms of distress � Factor analysis

The factor structure of the CES-D in a sample

of Rwandan adults

Past research suggests that culture, defined as a ‘‘system of

meaning’’ shared by a particular group [1], affects the way

psychiatric disorders are experienced and expressed [2–4].

Culture plays an important role in determining how indi-

viduals interpret internal and external events, leading

Kleinman [5] to propose that ‘‘illness’’ should be under-

stood as ‘‘the personal, interpersonal, and cultural reactions

to disease’’. In keeping with this, many in the field have

stressed the importance of looking at the specific mecha-

nisms explaining how culture impacts the experience and

expression of psychopathology [2, 6–9].

In spite of this growing body of evidence, there appears

to be a widespread belief among public health and medical

researchers that assessment measures developed for use in

J. J. Lacasse and M. J. C. Forgeard contributed equally to this paper.

J. J. Lacasse

School of Osteopathic Medicine, University of Medicine

and Dentistry of New Jersey, Stratford, USA

Present Address:

J. J. Lacasse

Department of Psychiatry of Tufts Medical Center,

Tufts University School of Medicine, Boston, USA

M. J. C. Forgeard

Department of Psychology, University of Pennsylvania,

Philadelphia, USA

N. Jayawickreme

Department of Psychology, Manhattan College,

New York City, USA

E. Jayawickreme (&)

Department of Psychology, Wake Forest University,

P.O. Box 7778, Winston-Salem, NC 27109, USA

e-mail: jayawide@wfu.edu

123

Soc Psychiatry Psychiatr Epidemiol (2014) 49:459–465

DOI 10.1007/s00127-013-0766-z

Western samples are capable of meaningfully capturing

psychopathology as it is expressed and experienced in a

diverse range of populations around the world [10]. In a

comprehensive review of research on the health status of

refugee populations exposed to trauma, Hollifield et al.

[11] noted that a majority of studies utilized assessment

measures whose validity or reliability had not been inves-

tigated in the populations at hand.

One way to begin to address these issues is to investigate

the factor structure of standard measures of psychopa-

thology in various cultures. Factor structure can tell us not

only if an instrument reliably measures what it is supposed

to measure, but also if it measures the same underlying

constructs in distinct populations. Thus, by examining how

particular items group in different contexts, researchers can

develop a culturally informed understanding of the distinct

symptom patterns that emerge in particular groups. The

present study reports such an investigation, examining the

factor structure of the Center for Epidemiological Studies-

Depression Scale (CES-D) [12] in a sample of Rwandan

genocide survivors and comparing this factor structure with

the ones found in previous studies conducted with other

populations.

The Center for Epidemiological Studies-Depression

scale (CES-D)

The CES-D is one of the most widely used self-report

instruments assessing depressive symptoms. This 20-item

scale was first validated in three primarily White Ameri-

can samples [12]. In the original validation study, a

principal components analysis (PCA) revealed four factors

together explaining 48 % of the variance in the data.

These included (1) depressed affect (e.g., sadness, crying);

(2) positive affect (e.g., hope, enjoyment); (3) somatic and

retarded activity (e.g., appetite problems, problems ‘‘get-

ting going’’); and (4) interpersonal concerns (e.g., per-

ceiving others as unfriendly). This initial analysis

presented a number of methodological problems. First, the

use of PCA (instead of factor analysis) is not recom-

mended for a scale with as few as 20 items as it can lead

to inflated factor loadings [13]. Second, this analysis was

conducted using orthogonal varimax rotation, which

assumes uncorrelated factors. This assumption is prob-

lematic given that depressive symptoms likely covary, at

least to some degree (for example, individuals who pres-

ent depressed affect often also report little positive affect).

Finally, the interpersonal problem factors only included

two items, and a minimum of three items is generally

recommended to ensure reliability across samples [14]. In

light of these limitations, it is unclear whether the four-

factor solution provided the best fitting solution for these

original data.

A meta-analysis of 28 studies using exploratory factor

analysis (EFA) or PCA provided support for the four-factor

solution [15] although it remains unclear whether the ori-

ginal studies suffered from the same limitations noted

above. This solution was compared to a two-factor (general

depression and positive affect) and a three-factor (general

depression, positive affect, and somatic symptoms) solu-

tion. Despite support for the four-factor structure,

researchers have noted that the CES-D is in practice treated

as a unidimensional scale, as it yields only one score [16].

A study using confirmatory factor analysis again provided

support for the four-factor solution, and found that an

acceptable one-factor solution could only be produced by

eliminating the four items assessing positive affect from

the scale [16]. Thus, some authors have recommended the

use of a shortened scale to produce a meaningful and valid

total score [16, 17].

Factor structure of the CES-D in ethnically diverse

samples

Several studies conducted with ethnically diverse samples

have replicated the scale’s original four-factor solution.

These studies were conducted among Hispanic individuals

in the United States [18–21], African Americans [21],

Korean immigrants in Canada [22], and Colombian adults

[23]. However, other studies have found different versions

of the four-factor structure. For example, in a sample of

older African Americans, the four factors corresponded to

depressive/somatic symptoms (combined), positive affect,

interpersonal problems, and an ambiguous fourth factor

termed ‘‘social well-being’’ [24]. The same first three

factors emerged in a sample of Asian-Americans (includ-

ing Chinese, Korean, Japanese, and Filipino Americans), in

addition to a fourth factor termed pessimism [25]. Finally,

in a sample of Brazilian college students, the fourth factor

corresponded to a hybrid and somewhat ambiguous

depressive/somatic symptoms factor, while the other fac-

tors corresponded to positive affect, depressive, and

somatic symptoms [26].

Other similar studies have evidenced a three-factor

structure. Studies conducted with samples of Mexican-

Americans, Cuban Americans and Puerto Ricans [27, 28],

Chinese immigrants [29, 30], depressed Spanish-speaking

internet users from around the world [31], female Arab

medical students from the United Arab Emirates [32], and

Greek psychiatric inpatients [33] have produced a three-

factor solution by combining depressive and somatic

symptoms into one single factor. In samples of American-

Indian [34, 35] and Chinese [36] participants, the emerging

three factors resulted from the omission of the interper-

sonal factor (resulting in a depressed affect factor, a

somatic/retardation factor, and positive affect factor).

460 Soc Psychiatry Psychiatr Epidemiol (2014) 49:459–465

123

Finally, some studies have found evidence for a two-

factor solution. In studies conducted with Filipino Ameri-

can adolescents [37] and ethnic Armenians living in Leba-

non [38], the two factors included a general depression

factor and a positive affect factor. In a sample of Hong

Kong adolescents, the two factors corresponded to depres-

sive/somatic symptoms and interpersonal problems [39].

The present study

The present study investigated the factor structure of the

CES-D in a sample of Rwandan adults having experienced

the 1994 genocide. The Rwandan genocide is widely

considered to constitute one of the worst atrocities of the

20th century, with more than 800,000 mostly Tutsi civil-

ians brutally slaughtered [40]. Examining the meaning of

depression in this sample is important given the high levels

of depressive symptomatology and associated functional

impairment in this population [41]. Given results of prior

studies, we expected that a two-, three-, or four-factor

structure would emerge.

Method

Participants

Participants were 200 adults (97 males, 103 females) from

five districts in three provinces—the districts of Bugesera

in the East Province (n = 51), Kamonyi in the South

Province (n = 48), and Gasabo (n = 56), Kicukiro

(n = 19), and Nyarugenge (n = 26) in the Kigali Province

of Rwanda. Participants were 29.40 years old on average

(SD = 10.17 ranging from 18 to 75). Although recom-

mendations regarding sample size for factor analytic

studies vary [14, 42], we recruited 200 participants based

on past research indicating that 10 participants per item is

an acceptable ratio [43–46].

Procedures and materials

Participants were invited to take part in a study about well-

being and mental health by a team of 12 Rwandan research

assistants who visited a total of five genocide survivor vil-

lages (one from each district). Participation was voluntary,

and all participants provided consent before taking part in

the study. The total time to complete the battery of measures

for this study was around 75 min. While individuals were

not compensated individually for their participation (fol-

lowing the advice of the Rwandan Ethics Commission) a

token of appreciation was provided to each village at the

completion of data collection. Participants first received

general instructions in how to respond to the questionnaire

items, and were provided with examples of how to select

appropriate responses. All administered measures were in

Kinyarwanda. These measures had been translated and

back-translated by two bilingual Rwanda translators with

prior experience in translating mental health measures.

The CES-D [12], the 20-item self-report measure

described above, was administered as part of this assess-

ment. Only socio-demographic data (as reported above)

and CES-D results are included in the present study. CES-

D instructions ask respondents to indicate the degree to

which they have experienced various symptoms of

depression during the past week on a 4-point scale (ranging

from 0 to 3). The response scale includes the following

fixed category choices: ‘‘0 = rarely or none of the time

(\1 day),’’ ‘‘1 = Some or a little of the time (1–2 days),’’

‘‘2 = Occasionally or a moderate amount of time

(3–4 days),’’ and ‘‘3 = Most or all of the time (5–7 days)’’.

Following standard practice, four positively worded items

measuring positive affect (‘‘I felt that I was just as good as

other people,’’ ‘‘I felt hopeful about the future,’’ ‘‘I was

happy,’’ and ‘‘I enjoyed life’’) were reverse scored.

Responses on the CES-D range between 0 and 60 points.

Results

Data were analyzed using SAS 9.3. Four participants who

had more than 50 % of datapoints missing were excluded

from the analysis (i.e., 4 participants who did not provide

any answers, and 1 participant who only answered 8 out of

20 CES-D items). The final sample included 196 partici-

pants (89 % of participants had no missing data, 6 % had

one data point missing, 4 % had two data points missing,

0.50 % had three data points missing, and 0.50 % had four

data points missing). Missing data points (0.89 % of all

data) were imputed using the Markov-Chain Montecarlo

method to create five datasets with no missing data. As all

of the missing data imputed was non-monotone, no other

imputation method was needed. The resulting five datasets

were merged by calculating the mean of the five imputed

values for all missing data points.

Participants’ mean score on the CES-D was 22.02 points

(SD = 10.65, min = 0, max = 47). 69.90 % of partici-

pants in this sample had a total score exceeding 16, a cutoff

used in past research to identify individuals experiencing

marked levels of psychological distress [47]. Given the

current paucity of research on the use of the CES-D as a

screening tool in non-Western populations, it is not clear

whether this cutoff is meaningful in the present sample,

and further research should therefore seek to establish

culture-specific cutoffs. These descriptive statistics never-

theless suggest that the present sample displayed high

levels of depressive symptoms on average.

Soc Psychiatry Psychiatr Epidemiol (2014) 49:459–465 461

123

Initial tests on these data indicated that they were suit-

able for EFA. The Kaiser–Meyer–Olkin measure of sam-

pling adequacy was 0.88, above the recommended value of

0.6 [48, 49], and Bartlett’s test of sphericity was signifi-

cant, v2(190) = 1426.40, p \ 0.001.

Given the polytomous nature of the data, a smoothed

polychoric correlation matrix was created in MicroFact 2.0

[50] for use in EFA (using Principal Factor Analysis). The

number of factors to include in the model was estimated

using Velicer’s minimum average partialling (MAP) Test,

which recommended a two-factor solution. Given mixed

results in past research, we tested a one-, two-, three- and

four-factor solutions using oblique promax rotation, as

factors extracted from the CES-D should theoretically be

correlated. For all factor solutions, promax rotation was

conducted using k = 2, 3, and 4 [51]. For each factor

solution, the k value which maximized the hyperplane

count was retained.

The quality of each factor solution was judged by

examining: (1) the amount of variance explained by each

factor, (2) the proportion of items loading on a factor, (3)

hyperplane counts (in percentages), (4) the reliability of

extracted factors, and finally (5) the meaningfulness of

extracted factors. According to these criteria, we retained

the two-factor solution.

In this solution, the first factor explained 37.20 % of the

variance and the second factor explained 8.68 % of the

variance. For the promax rotation, k was set at 2 (hyper-

plane count = 25 %). MicroFact 2.0 also reported two

goodness-of-fit tests (the Goodness of Fit Index and the

Root Mean Squared Residual). Both of these statistics

indicated that the two-factor solution was a good fit for the

data (GFI = 0.98, RMSR = 0.06).

The correlation between the two factors was r = 0.34.

Fifteen items loaded on the first factor (Cronbach’s

a = 0.90). This factor appeared to assess a wide array of

depressive symptoms (including cognitive, somatic, and

interpersonal symptoms). The remaining five items loaded

on the second factor (Cronbach’s a = 0.57), which mainly

included items assessing positive affect (reverse-coded

prior to data analyses). One item loading on this factor was,

however, negatively correlated with others and decreased

its reliability (‘‘I felt everything I did was an effort’’). The

second factor reached an adequate level of reliability by

excluding this item (Cronbach’s a = 0.76).1

The one-, three-, and four-factor solutions were not

retained for the following reasons. The one-factor solution

explained less of the variance (the unique factor explained

36.95 % of the variance) and only included 18 items out of

20 (instead of 19 for the two-factor solution). This was

nevertheless the most plausible solution following the two-

factor solution. The three- and four-factor solutions yielded

a factor with only two items (Items 5 and 7) and insuffi-

cient reliability (Cronbach’s a = 0.34).

Discussion

The present study found that a two-factor solution best

fitted data obtained from a sample of 196 Rwandan geno-

cide survivors on the CES-D. The amount of variance

explained by these two factors (46 %) was similar to the

amount of variance explained by the four factors found in

Radloff’s initial validation study of the CES-D (48 %)

[12]. The two factors in this study corresponded to a gen-

eral depression factor (including depressed affect, somatic/

retardation symptoms, and interpersonal problems) as well

as a positive affect factor (Table 1). The findings of our

study are limited by the somewhat modest sample size used

in this study. These results nevertheless replicate the

findings of previous studies conducted in samples of Fili-

pino American adolescents [37] and ethnic Armenians

living in Lebanon [38]. They confirm that affective and

somatic symptoms are not distinct in this population, as

seen in other cultural contexts [52].

From our results, it remains unclear whether the positive

affect factor truly corresponds to a different construct or

merely constitutes a method factor given that these items

were positively worded, a concern echoed by other

researchers [15]. These items have precluded researchers

from finding a reliable one-factor solution in the CES-D,

which is problematic in light of the fact that this instrument

produces a single score and is therefore in practice treated

as a unidimensional scale [16]. If these four items indeed

form a method factor, then a one-factor solution might best

represent the structure of depression in the Rwandan

context.

Results found regarding one specific item, ‘‘I felt that

everything was an effort,’’ also provide an interesting

example of the need to carefully investigate the specific

meanings of items in different cultural contexts. In this

study, it appeared that this item might have been inter-

preted as positive by participants since it loaded on the

positive affect factor (although not highly enough to be

included in our final solution). This is an important prob-

lem to be considered when using instruments with new

populations.

1 We also reverse-coded this item to examine the resulting factor

reliability, which was improved (Cronbach’s a = 0.71). However,

this item still displayed a lower corrected item-total correlation

(r = 0.19) than all four other items (all rs = 0.51-0.63). Further-

more, it remained unclear whether the content of this item was

meaningfully related to the content of the four positive affect items.

Given these limitations, we decided to exclude this item from the final

solution.

462 Soc Psychiatry Psychiatr Epidemiol (2014) 49:459–465

123

This finding points to the crucial need to investigate

local expressions of distress, as instruments developed in

one context may not capture all of the symptoms consid-

ered important in another context [53, 54]. Future research

must use ethnographic methods to investigate the rela-

tionship between social/cultural factors and psychological

processes, find out what specific words and phrases people

use to describe these experiences, and finally develop

questionnaires that use these idioms and are validated using

standard methods [2, 11, 55, 56].

In the context of Rwanda, Bolton [57] has for example

delineated specific local syndromes and symptoms that do

not completely overlap with the DSM-IV-TR [58] diag-

nostic criteria for depression. These local syndromes

resembling depression include guhahamuka (best

translated as ‘‘mental trauma’’), which includes common

idioms of depression, as well as culturally specific idioms

such as ‘‘feeling like you have a cloud inside’’. Agahinda

(best translated as ‘‘deep sadness or grief’’) provides

another example of a local syndrome again including

common idioms of depression as well as culture-specific

idioms such as ‘‘burying one’s cheek in one’s palm’’. Thus,

combining standard instruments with culturally informed

ones may be important when conducting psychiatric epi-

demiological and intervention work in ethnically diverse

populations [59].

Conclusion

Given that culture provides a system of meaning that

influences the experience and expression of psychological

distress, researchers run the risk of measuring constructs

that are ‘‘experientially meaningless’’ [60] if they do not

investigate the reliability and validity of the instruments

they use in the particular populations they are studying.

Furthermore, future research should supplement the use of

validated standard instruments with locally meaningful

instruments incorporating local idioms of distress, as this

would help improve the assessment of psychiatric disorders

in populations at risk (such as Rwandan genocide survi-

vors), and in turn the evaluation of the effectiveness of

intervention efforts in such populations [10].

Acknowledgments We are grateful to the Positive Psychology

Center and the Department of Psychology at the University of

Pennsylvania for providing the funding for this project. Additional

funding was generously provided by Eva Kedar, Ph. D. We thank

Virgile Uzabumugabo and his research team (Beza Gisele, Igena

Clarisse, Kankindi Antoinette, Mugisha Norbert, Mushimiyimana

Delphine, Mwiseneza Sophie, Nsengiyumva Joselyne, Runyurangabo

Philbert, Twajamahoro Contstantin, Ufitemariya Janviere, Usabimana

Hawa, and Uwanyiligira Honorine) for collecting the data for this

project. We also thank Paul Di Stefano and Richard Bisa for assisting

with the translation process and Eli Tsukayama for advice on data

analysis.

Conflict of interest The authors declare that they have no conflict

of interest.

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Table 1 Factor loadings for the two-factor solution using promax

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Items Construct Depressive

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Positive

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SR 0.68 –

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SR 0.59 –

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PA – 0.63

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SR – (-0.40)

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DA 0.69 –

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