Vol. 1, núm. 2 - Julio 2002 Revista Internacional On-line / An International On-line Journal
The factor structure of the GHQ-60 in a community sample: a scaled
version for the Spanish population. (pág. 1)
La estructura factorial del GHQ-60 en una muestra de población general: una versión escalar para
población española.
J. D. Molina y C. Andrade.
Correspondencia:
Dr. Juan de Dios Molina
Coordinador del Hospital de Larga Estancia
Complejo Asistencial Benito Menni
C/ Jardines nº 1
Ciempozuelos 28350 Madrid. España.
Resumen
Antecedentes: El General Health Questionnaire (GHQ) de 28 ítems está construido a partir del análisis
de componentes principales del GHQ-60 (escoge 28 ítems que se agrupan en cuatro subescalas).
Lógicamente, la utilización en población española de la traducción del GHQ-28 desarrollado en población
inglesa, debe presentar peores valores predictivos.
Método: Analizamos la estructura factorial de la versión de 60 ítems del GHQ, a partir de los resultados
obtenidos en una muestra de población general de un núcleo urbano próximo a Madrid. Posteriormente
realizamos todo el proceso de construcción del GHQ-28 para población general española utilizando la
misma metodología empleada en la versión original inglesa.
Resultados: En este trabajo se proponen dos versiones más cortas del GHQ: una con 6 escalas y 30
ítems y ,una segunda, con cuatro escalas y 28 ítems. Ambas son comparadas con las versiones inglesas
y, la última, con la versión mejicana del GHQ de 28 ítems.
Conclusiones: con este trabajo presentamos una adaptación real del GHQ-28 en población general
española.
Palabras clave: Cuestionario de Salud General, GHQ, GHQ-28, versión española del GHQ-28, estructura
factorial del GHQ-60, versión escalar, estudio comunitario, población general española, análisis factorial,
estadística, tests psicológicos, cuestionarios.
Abstract
Background: The 28-item General Health Questionnaire (GHQ) is constructed on the basis of a principal
components analysis of the GHQ-60 (28 items selected and grouped under four subscales). When used
on a Spanish population, a translation of the GHQ-28 developed for an English population logically yields
worse predictive values.
Methods: Data from a community study conducted in a town near Madrid was used to explore the factor
structure of the 60-item version of the GHQ. Using the methodology employed in the original English
version, a 28-item version of the GHQ was constructed based on the general Spanish population.
Results: Two shorter versions were proposed: one with 6 scales and 30 items, and the other with four
scales and 28 items. These and the 28-item Mexican versions were then compared to the English version.
Conclusions: The resulting GHQ-28 was a successful adaptation for use on the Spanish population.
Key words: General Health Questionnaire, GHQ-28, spanish version of GHQ-28, factor structure of GHQ60, scaled version, community study, general spanish population, factor analysis, statistical,
psychological tests, questionnaires.
The late 70s saw the emergence of an approach which relied on standardised methods of diagnosis and
which Dohrenwend and Dohrenwend (1982) termed "third-generation studies". At this same point in
time, coinciding with the introduction of two-phase sampling methodology for psychiatric epidemiological
research, the first structured interview, the Clinical Interview Schedule (CIS) (Goldberg et al. 1970), and
the first non-symptomatic "psychiatric case" detection scale purpose-designed as a screening instrument,
the General Health Questionnaire (GHQ) (Goldberg, 1972), were both published.
The conjunction of these two types of instruments, one designed to detect symptoms or signs in the
population capable of rendering a case potentially suspect, and the other derived from clinical psychiatric
examination and designed to arrive at an accurate and reliable diagnosis, has enabled two-phase
sampling to be used to study large-sized populations in a reliable manner. In the first phase, the study
population is classified (usually by means of a survey) in terms of the probability of the presence or
absence of psychiatric morbidity. In the second, a variable proportion of probable cases and non-cases
must be simultaneously examined by a psychiatrist in order to assess the definitive diagnosis.
At present, the GHQ is the most widely used instrument for detecting non-psychotic psychiatric "cases",
whether in the general population or among patients attending a given general practitioner's practice.
This questionnaire exists both as a 60-item version and in the form of shorter versions (comprising 30,
28 and 12 items). In terms of validity, reliability and prediction coefficient, the 60-item version has
outperformed its shorter counterparts (Goldberg, 1972), yet thanks to their brevity, the 12- and, above
all, the 30-item versions have seen wide use in general population studies.
The 28-item version (GHQ-28) developed by Goldberg and Hillier (1979) is constructed on a basis unlike
that of the other versions. Whereas the 30- and 12-item versions contain a selection of items that retain
a similar discriminative power, the GHQ-28 is based on an analysis of the principal components of the
GHQ-60, with 28 items then being chosen and grouped under four subscales.
Over the last ten years, use of the GHQ-28 has come to assume growing importance in epidemiological
studies, a trend reflected in the increasing interest in adapting this instrument to different populations
and languages. It is succinct, simple to use and yields comparable results in general population and
primary-care settings. Furthermore, as mentioned above, it derives from an approach totally different to
that of the remaining General Health Questionnaire versions, and apart from providing an overall
assessment, also contains four scales that furnish additional information with a breakdown by symptom
area.
Seva et al. (1992) reported the predictive validation data for the GHQ-28, using the Spanish translation
of the English GHQ-28 in a general Spanish urban population such as ours, with a sample of 117 patients
and the same instrument as in the original validation, the CIS. In Spain there was a clear fall-off in
specificity and a rise in the percentage of misclassified subjects vis-à-vis the original English version,
namely, 21.3% versus 14.2% for the same cut-off point of 5/6. This same loss of specificity and increase
in the number of misclassified subjects (17% for a cut-off point of 5/6) had previously been observed by
us in a sample of 100 general medicine patients, in which the CIS was again used as the external
validation criterion (Lobo et al.1986). Although raising the cut-off point (6/7) places the percentages on a
par with the English version, it nevertheless results in a marked decline in sensitivity. Indeed, what is
reflected here is the different predictive performance of a questionnaire constructed on the basis of an
English population versus the selfsame questionnaire transferred to a Spanish population, in both
community studies and primary-care settings.
The important study by Medina-Mora et al.(1983) is noteworthy for having developed a scaled 28-item,
as well as a 30-item, version based on a factor analytic study of the results obtained with the GHQ-60 in
a Mexican population. The scaled 28-item version, constructed on the basis of this Spanish-speaking
population with the same methodology as the original, shows only 67% of the items selected by the
British authors.
Lastly, Vázquez-Barquero (1988) analysed the factor structure of the GHQ-60 in a Spanish rural
population sample. This study reported differences between the structure identified in his factor analysis
and that described by Goldberg and Hillier and by Medina-Mora et al. An overall comparison of the data
obtained in these three studies is not possible, since Vázquez-Barquero et al. did not draw up a scaled
28-item version and used a different technique to retain items with greatest loading on each factor
(Catell scree test). Nevertheless, in their principal components analysis with varimax rotation they
identified six factors with a different item composition, in which no equivalent was found for the "Somatic
symptoms" factor described by Goldberg and Hillier.
The present study therefore sought to replicate the entire process of construction of the GHQ-28 in a
general Spanish population, using the same methodology as the original. Available data indicated that
the same items as those comprising the English version would not be obtained. For study purposes, we
used the Spanish version of the GHQ-60, drawn up on the basis of the 140-item English version (Muñoz
et al., 1978,1979).
METHOD
Data-collection
This study relied on data generated during the first phase of field work undertaken for a project entitled,
"Estudio de validación predictiva de diferentes versiones del GHQ en población general
urbana" (Predictive validation study of different versions of the GHQ in a general urban population), and
sponsored by the Spanish Health Research Fund (Fondo de Investigación Sanitaria -FIS). We used all the
GHQ-60 questionnaires completed in the first phase of the above study as the basis for comparison and
development of our 28-item version of the GHQ.
The designated study population was that of Tres Cantos, a new town created just under 30 years ago.
The electoral roll of 01/01/93 shows the total population as 19,563. Broken down by sex, this gives 9,680
men and 9,883 women, with a male: female ratio of 0.98. Table 1 shows the distribution by age group
and sex for the 15-65 age range used to delimit our study population.
Table 1. Distribution of the population of Tres Cantos (age-range 15-65 years), by age and sex
In order to obtain the necessary sample, the municipal electoral office was asked to draw up a random
list of 5% of the population stratified by age and sex, along with an adequate, also randomly selected list
of replacements for each stratum, to be used in the event of possible refusal. The sample so obtained
comprised 654 subjects, age-range 15-65 years, made up of 334 women (51.5%) and 320 men (48.9%).
Table 2 shows the distribution of the sample by age and sex cohort. All subjects duly completed the GHQ60 questionnaire; this was self-administered during a home interview conducted by purpose-trained
personnel, and was also used to gather other socio-demographic and general health data.
Table 2. Demographic characteristics of the sample (N=654)
Table 2 shows the demographic characteristics of the sample. Mean age was 34.8 years, with a standard
deviation of 11.96. The age and sex balance of the sample meant that the mean age proved to be
similar, if not practically equal, across the sexes, i.e., 34.71 years with a standard deviation of 11.83 for
women, and 34.89 years with a standard deviation of 11.96 for men. When broken down by marital
status, the most numerous group was made up of "Married" subjects, and the least represented groups
were "Separated" (0.3%) and "Divorced" (0.2%), with "Widowed" (1.2%) being similarly very reduced.
In all, 35.6% of the sample had a university education, with solely 1.7% of subjects being "Illiterate" or
"Sub-primary". While certain differences between the sexes were in evidence, this divergence proved
widest in the case of university graduates, with men accounting for 42% and women, 29.3%. The largest
occupational group was "Active, in full-time employment" (71.6% of men and 38.4% of women), followed
by that of "Housewife", composed totally of women. The low percentage of unemployed (4.1%), with
figures far below those for the Madrid population as a whole, can be explained by the fact that this is a
newly settled urban population, which has largely opted to move house in order to be near the
workplace. Tres Cantos lies between the so-called "Madrid Technology Park", consisting of a group of
high-technology companies lining its southern access point, and a sizeable industrial estate located at its
northern access point. Furthermore, the town has tended to be a population-catchment area for teaching
and other categories of staff employed at the nearby Autonomous University of Madrid.
Data-analysis
Factor structure of the GHQ-60
Given that our aim was to construct a real Spanish-language adaptation of the GHQ-28 in the general
Spanish population, in the process of constructing the GHQ-28 we had to follow the selfsame step-bystep methodology as that used by the authors when they developed and drew up the original version,
rather than rely on a mere translation of the same items obtained for the English population.
In order to determine whether it was possible to develop a shorter, balanced version of the GHQ, a
principal components analysis was performed, using GHQ-60 responses with Likert scoring (0-1-2-3). The
unrotated solution was first examined and varimax rotation was then applied. The number of factors to
be retained and rotated was determined by the criteria used by Goldberg and Hillier (1979).
Comparison between the results obtained by us on the one hand, and the factor structures of the original English and the
Mexican versions of the GHQ-28 and data obtained for the general rural Spanish population on the other.
The GHQ-28 items were disembedded from the GHQ-60. The results of the four analyses were then
inspected and compared.
RESULTS
Factor- structure of the GHQ-60
In the principal component analysis, 14 components with an eigenvalue greater than or equal to 1.00
were obtained, accounting for 59.9% of total variance, but only the first 6 could be readily
conceptualised. These factors accounted for 43.6% of the total variance (see Table 3).
Table 3. Unrotated principal components analysis of GHQ-60
The first principal component was a general unipolar factor. Subsequent components were generally
bipolar, with fewer items loading on each successive factor. As with the original version, when these
factors were subjected to a varimax rotation, they proved even easier to conceptualise, due to the more
equal distribution of variance. More items were loaded on each. By taking the 5 items with the highest
loads on each factor (all with loads of over 0.50), it proved possible to construct 6 five-question scales in
which no item loaded significantly on any but the assigned scale (see Table 4).
Table 4. Factor structure of the GHQ-30 version. Varimax rotation of the 6-factor solution, accounting for 43.6% of variance
A new analysis retaining 4 factors was now performed, thereby allowing for each factor to be described
with a larger number of items, i.e., the 7 with the highest loads per factor. We then proceeded to
construct four scales with seven items each (28 items in all) relating to the four factors accounting for
37.8% of total variance.
Individual analysis of the items showed that all but one loaded more than 0.48 on the chosen factor. This
sole exception was item 50, which was also the only item to register a greater load on any scale other
than that chosen. It loaded more on the first factor than on factor 4, where it was chosen as the seventh
highest load overall (see Table 5).
Table 5. Items of greatest factor load after varimax rotation of first four factors (accounting for 37.8% of variance).
In similar circumstances, the authors of the original version (Goldberg and Hillier, 1979) opted for
greater homogeneity and excluded item 49, which in their study loaded equally on two scales (B and D).
They thus obtained a version in which no item loaded significantly on any other scale. Other authors have
adopted a similar strategy. In their Mexican population study, Medina-Mora et al. (1983) found that in
the previous stage (varimax rotation of the six-factor solution) their item 36 loaded among the first five
items on two scales (C and D). Accordingly, they replaced this in one of the scales ( D) with item 28,
which had approximately the same load.
We found no factor-4 item that was similar to 50, did not load significantly on any other scale and could
thus be used to replace it, as Goldberg and Hillier had done in a similar situation. It thus became
necessary to choose a solution that had 4 scales of equal size (7 items each), or alternatively, one that for the sake of greater homogeneity- dispensed with 4 scales of equal length and instead had one with
six and another with eight items.
Given the importance of this question, we decided to pursue both possible avenues of research and leave
analysis of the results for in-depth discussion at the end. The chosen 28 items were thus subjected to a
second analysis, using varimax rotation with these alone to observe the final solution. This step was
performed twice:
1. The first time, item 50 was included among the chosen 28 comprising factor 4 (as the item with the
2.
seventh highest load on this factor);
The second time, with the aim of achieving greater homogeneity, item 50 (which showed a heavier
load on a factor other than that from which it was selected) was excluded from factor 4, and item
17 selected instead to form part of the 28 on which this analysis was based (as the item with the
eighth highest load on the first factor).
1. Final solution with item 50: GHQ-28 with four scales of 7 items each
On repeating the analysis with the twenty-eight selected items, the four factors identified accounted for
50.7% of the corresponding variance (see Table 6). All items showed a heavy load on their pre-assigned
factors except for item 50 ("lost confidence in oneself"), which continued to register a greater load on a
factor other than the original. This item, which had been chosen in the conceptualised factor as Severe
depression for the purposes of analysis, replicated its previous behaviour pattern and continued loading
more on the same alternative factor (conceptualised as Anxiety and Insomnia). In essence, the situation
was similar to that observed previously.
Table 6. Factor structure of the 28-item GHQ version (varimax rotation of the 4-factor solution, accounting for 50.7% of
variance ). Solution with four scales of 7 items, including item 50
As observed in the first unrotated analysis, a general factor accounted for 22.9% of the total variance,
thereby rendering it inevitable that the various scales would not be pure measures of the four factors.
Table 7 shows the mean factor loads for each scale on each factor.
Table 7. Mean factor loads of the 4 scales on the four factors. Solution with four scales of 7 items, including item 50 (50.7%
of variance on these factors: varimax rotation of the 28-item questionnaire)
2. Final solution with item 17: GHQ-28 characterised by greater homogeneity
When the analysis was repeated by using item 17 in place of item 50, the first four factors accounted for
50.2% of the variance (see Table 8). All the items were found to show a high load on pre-assigned
factors. Following analysis, item 17 ("Difficulty in getting off to sleep"), which had been chosen as the
eighth item in factor 1 (Anxiety and Insomnia), registered an even higher load on the same scale as
items 47 and 49, moving up to sixth place.
Table 8. Factor structure of the 28-item GHQ version (varimax rotation of the 4-factor solution, accounting for 50.2% of
variance). Most homogeneous solution with a scale of 8 items, including item 17
As in the first solution, the different scales are not pure measures of the four factors. Table 9 sets out the
mean factor loads for each scale on each factor in this second possible final solution.
Table 9. Mean factor loads of the 4 scales on the four factors. Most homogeneous solution with a scale of 8 items, including
item 17 (50.2% of variance on these factors: varimax rotation of the 28-item questionnaire)
Comparison of the factor structures of the different versions of the GHQ
After performing an unrotated principal components analysis, the British authors obtained 11 factors with
a eigenvalue greater or equal to one, accounting for 63.4 % of the variance. We obtained 14 factors in a
general urban population, accounting for 59.9% of the variance (versus 13 in Vázquez-Barquero's
general Spanish rural population study in 1988, and 14 in Medina-Mora's Mexican study in 1983).
Table 10 compares the results yielded by varimax rotation of the first six factors in our sample against
those yielded by the English version. As will be clearly observed, the greatest stability in both studies lies
in the scales that form part of the final four-factor solution, namely: "Severe depression", "Sleep
disturbances" and "Social dysfunction". Furthermore, the "Anxiety and dysphoria" scale in the English
study shares a single item (item 55) with the "Anxiety" scale in our study, and another (item 50) with
"Loss of self-esteem".
Table 10. Comparison between the factor structures of the 30-item GHQ version obtained in our sample and the English
version (varimax rotation of the 6-factor solution)
In the study by Vázquez-Barquero et al. -which was undertaken with a different objective to that of
construction of a GHQ-28- all items having a load of over 0.5 were retained, whereas in our, MedinaMora's and Goldberg and Hillier's studies the five with the highest load were retained. Although this
difference in criterion limits comparison, the 6 factors obtained by Vázquez-Barquero et al from all 60
items proved to be different to those reported in the other studies. It is noteworthy that the factor,
"Somatic symptoms", was identified in neither of the two Spanish samples, while Goldberg and Hillier
were able to differentiate 2 factors of general illness and somatic symptoms (only one factor was
observed in the Mexican data).
The results obtained in our sample compared to those of the original English version (Goldberg
and Hillier, 1979) and the Mexican study (Medina-Mora et al., 1983)
Both possible final solutions proposed in the Results section of this study differ from the Goldberg and
Hillier version in 8 items (Table 11). The Mexican study by Medina-Mora et al. differs by one more.
Despite the differences, there are greater similarities between the English version and the solution
yielded by our study, than between our results and the Mexican solution, as can be seen from Table 12:
the first two coincide in 20 items (versus 19) and combine the items of Anxiety and Sleep disturbances in
a single dimension, while in the Mexican version, "Sleep disturbances" constitutes a pure scale.
Table 11. Comparison between the two possible factor structures of the 28-item GHQ version obtained in our sample and that
of the English version (varimax rotation of the 4-factor solution)
Table 12. Comparison of items comprising the GHQ-28 in three studies. The English and Mexican versions conducted on
primary-care populations and our study conducted on general Spanish population (varimax rotation of the 4-factor solution)
DISCUSSION
On applying the same methodology to the general Spanish population as that used by Goldberg and
Hillier (1979) in developing the original scaled version , we found that shorter versions can be derived
from the GHQ-60. In this paper, 2 short versions have been included: one with 6 scales of 5 items each
(N=30), and another with 4 scales (N=28). Our study confirms the hypothesis that the questions
obtained would not be the same as those featured in the English version.
The 6 factors obtained from all 60 items proved to be different from those reported by Goldberg and
Hillier (1979). While they were able to differentiate 2 factors of general illness and somatic symptoms, we
observed only one in the Spanish data. Solely three of the five questions comprising this scale appear in
the English version, two (3 and 4) in their "General illness" factor and another (9) in "Somatic
symptoms". Moreover, the "Anxiety and dysphoria"scale in the English study shares item 55 with the
"Anxiety" scale, and item 50 with the "Loss of self-esteem" scale which is not represented in the English
version. "Sleep disturbance" coincides in 4 of five items, while "Severe depression" is exactly the same.
The remaining factor, "Social dysfunction", coincides in three of five items (28,30,36). In the shortened
28-item GHQ, only 20 items coincide with the English version. Unlike the Mexican version which features
a scale with items exclusively relating to Sleep disturbances, in the English version and our study these
are combined in a single scale along with items related to anxiety disorders. Lastly, in line with the
different philosophy used for the construction of the GHQ-28 versus other versions of the General Health
Questionnaire, it would seem wise for priority to be given to the criterion of homogeneity in the scales of
any 28-item version of the GHQ proposed designed for use in the general Spanish population (in an
attempt to ensure that such scales represent common dimensions of symptomatology). The fact that not
all the scales would have the same length becomes of secondary importance, when it is recalled that the
point at issue is the factor structure of the results of the GHQ-60 obtained in the study population. Our
version therefore highlights an aspect that differentiates it from other studies, namely, to obtain four
homogeneous scales by selecting 28 items, one of the scales must contain an additional item, with the
ultimate consequence that two scales of 7, another of 6 and a fourth of 8 items are thus obtained.
As regards variance, Goldberg was able to account for 53.5% with 6 factors obtained from 60 items, and
59% with 4 factors from 28 items, while we could account for only 43.6% and 50.2% respectively. This is
probably due to the fact that in his data the first general component accounted for 35%, while in our data
it accounted for only 22.9%.
There are three reasons that might account for the differences between the versions studied. Firstly,
there is the possibility that the statistical processing of the samples might be different, inasmuch as the
use of a factor analysis technique other than principal components analysis with varimax rotation would
necessarily yield different results (Vázquez-Barquero, 1988). This is not the case here, since the method
used both for our study and for the Mexican version of the GHQ-28 was the same as that used for the
original version. Secondly, there is the possibility that the number of items analysed might be different,
since the fewer analysed, the fewer the resulting factors (Worsley et al. 1978). However, this was not the
case either, since all the studies cited took the GHQ-60 as their starting point.
Thirdly, there are the characteristics of the samples used. Our sample totalled 654 subjects, a figure
large enough to comply with recommendations for the ideal sample size for a GHQ factor analysis, i.e., at
least five times greater than the number of variables to be examined (Goldberg and Williams, 1988). The
study design used by Goldberg and Hillier and by Medina-Mora et al. is a systematic sampling of a
general medical practice. Furthermore, in both cases the proportional number of women in the sample
was higher than that of men, given the greater demand for primary care among the former (Molina,
1998). As mentioned above however, the Tres Cantos study featured a different setting (general
population), as well as a different sampling design and sample characteristics, with a balance between
the numbers of men and women that is not reflected in the other studies.
In this regard, one must not overlook the extent to which the different nature of the sample can cause
the relationship between the factors comprising the structure to vary. Our study is unique, inasmuch as
the GHQ-28 was constructed on the basis of the general urban population while earlier studies were
conducted in a primary-care setting. In other words, the relative severity of the symptoms or moment in
the evolution of the illness ("before seeking advice about a symptom" versus "a symptom sufficiently
intense to induce one to seek advice") may explain differences in the factor structure. Similarly, sight
must not be lost of the proportional number of women making up the study samples (higher in primary-
care studies), since studies conducted on samples composed solely of women are known to register a
lower number of principal components compared to other studies (Benjamin et al. 1982; Parkes, 1982;
Hobbs et al.1983).
The practical value of this study resides in its having produced a real adaptation of the GHQ-28 based on
the general Spanish population. This adaptation places an instrument at our disposal, not only capable of
detecting possible psychiatric cases in the community but also affording guidance via its subscales.
Moreover, this study calls for further field work, aimed at replicating the development of the GHQ-28 in a
primary-care setting and, subsequently, comparing the male-female factor structures both in the general
population and in primary care. It would be interesting to corroborate whether a GHQ-28 having two
scales of 7, one of 6 and another of 8 items would also be obtained in a Spanish primary care sample.
Furthermore, the question of the number of items that should ideally comprise the scaled version of the
GHQ remains to be ascertained. It falls to subsequent predictive assessment studies to furnish the
parameters of sensitivity, specificity and percentage of misclassified subjects for this version's use in a
Spanish population.
ACKNOWLEDGEMENTS
We should like to thank Dr. Pedro Enrique Muñoz for his continued confidence and help over the 7 years
devoted to the project, "Aportaciones al desarrollo de la versión española del General Health
Questionnaire (GHQ) de Goldberg de 28 ítems" (Contributions to the development of the Spanish version
of Goldberg's 28-item General Health Questionnaire), as well as all the various professionals who
collaborated in the field work entailed in this research.
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ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN (en trámite)
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
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