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Development and validation of
“Knowledge on screening and
identification of mental illness (KSIM)
questionnaire” among primary care
nurses in India
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www.jehp.net

DOI:
10.4103/jehp.jehp_184_23 James Paul, Radhakrishnan Govindan, Monika Thakur1, Narayana Manjunatha2

Abstract:
BACKGROUND: As stated in the World Health Organization’s Mental Health Report 2022, 13%,
or almost a billion people, had a mental health issue, and 82% of these people resided in low‑ and
middle‑income countries with limited access to mental health treatments. Successful integration of
mental health services into primary healthcare depends on primary healthcare providers receiving the
proper training and information required to provide basic mental health care in the community. Primary
care nurses generally lack the confidence and skills to handle mental health issues while being in an
excellent position to screen, identify, refer, and follow‑up on a person with mental illness (PMI). The
study aimed to develop and validate the KSIM questionnaire to assess the knowledge of primary
care nurses in screening, identifying, referral, and follow‑up persons with mental health issues in
the community.
MATERIALS AND METHODS: The study was conducted based on a sequential exploratory design
in two phases: the development and the validation phases. An extensive literature search was done,
Department of Nursing, and the themes derived from the two focus group discussion (FGD) and three direct interviews, and
National Institute of the inputs from the mental health experts were used to design the KSIM questionnaire. A panel of
Mental Health and Neuro 17 experts validated the KSIM questionnaire through item‑level content validity index (I‑CVI) and
Sciences, Bangalore, scale‑level CVI (S‑CVI) for content validation, and the reliability test was done using the intraclass
Karnataka, India, correlation coefficient ICC test–retest method.
1
Psychiatry, TORENT
RESULTS: The draft version‑1 of the KSIM questionnaire showed high content validity of individual
Project, National
items (I‑CVI range: 0.82–1.00) and high overall content validity (S‑CVI = 0.95), and suggestions from
Institute of Mental Health
the experts were incorporated. The KSIM questionnaire consists of 30 multiple choice questions and
and Neuro Sciences,
10 case vignettes. The KSIM questionnaire has a very good test–retest reliability using the single
Bangalore, Karnataka,
measure two‑way mixed absolute agreement ICC value 0.97 with 95% CI.
India, 2Department of
Psychiatry, National CONCLUSIONS: Using an iterative approach, the development and validation of the KSIM
Institute of Mental Health questionnaire demonstrated high I‑CVI and S‑CVI with good ICC test‑retest reliability to assess the
and Neuro Sciences, knowledge of primary care nurses on screening and identification, referral and follow‑up of a PMI in
Bangalore, Karnataka, the community. Primary care nurses’ knowledge on how to screen for and identify people with mental
India health issues in the primary care setting can be evaluated with the help of the KSIM questionnaire,
and providing need‑based training may help to reduce the time taken for people with mental illness
Address for to receive professional help.
correspondence: Keywords:
Dr. Radhakrishnan
Govindan, Knowledge questionnaire, mental illness, primary care nurses, validation
Additional Professor
of Nursing, National
Institute of Mental Health
and Neuro Sciences,
Bangalore, Karnataka,
This is an open access journal, and articles are
India. distributed under the terms of the Creative Commons How to cite this article: Paul J, Govindan R,
E‑mail: dr.rk76@hotmail. Attribution‑NonCommercial‑ShareAlike 4.0 License, which Thakur M, Manjunatha N. Development and
com allows others to remix, tweak, and build upon the work validation of “Knowledge on screening and
non‑commercially, as long as appropriate credit is given and identification of mental illness (KSIM) questionnaire”
Received: 09‑02‑2023 among primary care nurses in India. J Edu Health
the new creations are licensed under the identical terms.
Accepted: 28‑02‑2023 Promot 2023;12:216.
Published: 30-06-2023 For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

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Paul, et al.: Knowledge on screening and identification of mental illness (KSIM) questionnaire

Introduction project received ethical clearance from the Institutional

Ethics Committee, Ref No. NIMH/DO/IEC (BEH.

A ccording to the National Mental Health Survey

2016, the prevalence of mental health disorders in
India is 10.6%, and the treatment gap varies from 60%
Sc.DIV)/2018 Dated: 17/12/2018 and approval from
the Technical Advisory Committee, DHFWS, Govt of
Karnataka with Ref No. DD/Mental Health/50/2019‑20.
for Common Mental Disorders to 90% for Substance Permission was obtained from the DHO, Ramanagara
Used Disorders. [1‑3] The mental disorders include District and the Medical officers of each PHC. The signed
Common Mental Disorders (CMD), such as depression, informed consent was obtained from all the mental health
anxiety, and somatization disorders; Substance Use experts and nurses, and confidentiality was maintained.
Disorders (SUD), such as alcohol, tobacco, and other
substance use, and Severe Mental Disorders (SMD), Development of questionnaire
such as schizophrenia and mania.[4‑6] Due to the lack of The KSIM questionnaire was developed and validated
trained professionals and significant discrepancies in under four stages:
the distribution of resources, mental health problems 1) An extensive literature search.
account for 25.3–33.5% of the global burden and have 2) Focused group discussion and in‑depth interviews
a treatment gap of 76–84% in poor and middle‑income with primary care nurses and experts.
countries, respectively.[3,7] 3) The development of the KSIM questionnaire.
4) Stabilizing the face and content validation, and
Basic community mental health treatment can be 5) Testing Reliability.
effectively provided by a variety of primary care
workers, including non‑specialist physicians, nurses, An extensive literature search
and other paraprofessionals, in low‑ and middle‑income Using various searching mesh terms such as knowledge
countries.[3,8,9] According to the National Mental Health questionnaire, identification of mental illness, primary
Survey 2016, all of India’s states should prioritize human care nurse’s role, referral, follow‑up, management of
resource management, with a particular emphasis on mentally ill, etc., an extensive search was done from
training medical professionals, nurses, and community several databases such as PubMed, PsycINFO, Science
health workers to recognize and treat mental health Direct, CINAHL, Cochrane, Scopus, and Google Scholar
problems at the primary care level.[2,8] for studies related to the knowledge of primary care nurse
in screening and identification, referral, and management
The manpower development of primary care doctors of a person with mental health issues. The researcher has
through the On‑Consultation Training program referred to 87 studies and reviewed 35 various studies
demonstrated high sensitivity and reasonably high related to the assessment of knowledge of primary care
specificity for the psychiatric diagnoses made in the nurses on handling a person with mental health issues.
primary care setting.[4] The primary care nurses are the Research studies matching the keywords, studies in the
people who reach the patients who are not attending English language, and studies with full text were included.
the PHC, and training them to identify the patients Research studies older than 20 years, except for landmark
with mental health issues at the community level studies, those other than the English language, and those
and refer them for treatment can bring a significant lacking appropriate methodology were excluded.
change. However, the PHC nurses have to address all
23 programs, and they find it very difficult to give more Focused group discussion and in‑depth interviews with
focus to psychiatry based on the currently available nurses and experts
standardized MSE and history collection format.[3,7,8] After the literature review, a draft of the KSIM
Primary care nurses generally lack the confidence and questionnaire was prepared and discussed individually
skills to handle mental health issues while being in an with several mental health experts from the
excellent position to screen, identify, refer, and follow up multidisciplinary team.
on a person with mental illness (PMI). The study aimed
to develop and validate the KSIM questionnaire to assess Two focused group discussions were done with DMHP
the knowledge of primary care nurses on screening, nurses (12 nurses) and primary care nurses (6 field nurses
identifying, referral, and follow‑up of the person with from Jigani PHC), and three in‑depth direct interviews
mental health problems. for 30 minutes each with the primary care nurses from
Gottigere PHC [Table 1] The sample size for the number
Materials and Methods of FGD and the direct interview was decided upon data
saturation during the qualitative phase. The theme
Based on the sequential exploratory design, the present analysis was done using ATLAS‑ti software, and the
study was carried out in the design, development, and major themes raised from the FGD and direct interviews
validation KSIM questionnaire [Figure 1]. This research were used to develop the KSIM questionnaire.
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Paul, et al.: Knowledge on screening and identification of mental illness (KSIM) questionnaire

Figure 1: Sequential exploratory design

Table 1: Composition of the subjects for the FGDs guideline that helps to screen the patients for mental
and in‑depth interviews illness with minimal time?
Code Designation No. of 10. What do you do for the patient’s family members if
Number Nurses you identify a person with some mental health issues?
N.O Primary Health Care Nurse (PHC and Subcenter) 06
11. How do you follow up with the patient who identified
C.N DMHP‑Community Nurse 06
with some mental health issues?
C.P DMHP‑Psychiatric Nurse 06
12. What are the assessments you would like to do during
D.I Direct Interview‑Nursing Officer 03
your follow‑up?
Total Number of Participants 21
13. How will you monitor drug compliance?
14. How will you assess the need for psycho–social
To meet the objectives of phase 1 of the study, the FGDs interventions?
and direct in‑depth interviews focused on 15. What do you do if the patient or family members
1. What common mental health problems or patients report no improvement in the conditions?
do you face during field visits? 16. What activities will you do to improve the community’s
2. Do you feel you can screen and identify patients with mental health?
mental disorders?
3. Do you feel you can attend to the families of patients Development of KSIM questionnaire
with mental disorders? Based on the review of the literature and the inputs from
4. What services are offered to people and their families the FGD and in‑depth interviews and discussions with
with mental health issues? the experts on the knowledge of primary care nurses
5. Do you think you require some guidance to help you in screening, identification, referral, and follow‑up
identify mental illness? And why? of a person with mental health issues. The KSIM
6. What are the common mental health issues you are questionnaire was developed as 30 multiple choice
addressing in the community? questions and 10 case vignettes on nurses’ knowledge
7. Do you think you will be able to screen and of screening and identification of mental illness in
identify the CMD, SMD, intellectual developmental the following five domains: 1. Causes and Prevalence
disabilities, and SUD in the community? And why? of Mental Illness, 2. Stigma and Myths about MI, 3.
8. How much time can you provide for a family to screen Screening and Identification of MI, 4. Treatment and
for mental illness during your field visit? Management of PMI, and 5. Handling Side Effects and
9. What components would you like to include in the Follow‑up [Figure 2].

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Paul, et al.: Knowledge on screening and identification of mental illness (KSIM) questionnaire

Table 2: Domains of KSIM questionnaire

Divisions–Knowledge on Min‑ Max Score Question No.
Causes and Prevalence of Mental Illness 0–5 1, 2, 3, 14, 27
Stigma and Myths about MI 0–6 4, 9, 13, 18, 20, 22
Screening and Identification of MI 0–8 7, 8, 10, 23, 24, 25, 26, 29
Treatment and Management of PMI 0–7 5, 6, 11, 12, 15, 19, 21
Handling Side Effects and Follow‑up 0–4 16, 17, 28, 30
Case Vignettes on Knowledge on Identification of Mental Disorders 0–10 CV‑1 to CV‑10
Total 0–40

Using the case vignettes‑based questionnaire, the

researcher assessed the nurses’ knowledge of identifying
Causes and
mental illness in the community. The case vignettes prevalence of
were developed based on all the mental disorders like Mental Illness
schizophrenia, mania, depression and suicide prevention,
anxiety disorder, somatization disorder, alcohol and Stigma and
tobacco addiction, and intellectual developmental Handling side Myths about
effects and Mental illness
disorder (mental retardation) and two case vignettes
follow up of PMI
with general non‑psychiatric disease conditions. The Knowledge
case vignettes were quantified based on the application domains

of knowledge in identifying the disorder using objective

questions. Each MCQ and case vignette has one
multiple‑choice question with the right answer scoring
Treatment and Screening
“1” and the wrong answer scoring “0.” The total score management and identification
for this scale is 40. It took approximately 20–30 minutes of PMI of Mental
Illness
to complete this tool [Table 2].

Validation of KSIM questionnaire Figure 2: Domains of KSIM questionnaire

The researcher approached 28 mental health experts from
three universities, three mental health institutions, two
agreement ICC was done. Thirty‑nine subjects were
medical colleges, and one community health center across
recruited for the test–retest reliability from the PHC. The
India. Out of 28, only 17 mental health professionals from
test was administered through online google forms, and
the multidisciplinary team (Psychiatrist‑5, Psychiatric
the participants filled the google form in the presence of
Nurses‑7, Primary care nurses‑3, Medical officer‑1, and
the researcher; a retest was done. After 15 days. Thirty‑two
Senior Resident in Community psychiatry‑1) had sent
subjects completed the re‑test after 15 days intervals
their comments, and the remaining 11 did not respond.
through online google forms. Seven subjects did not
The validation and data collection process took about
complete the retest, so they were excluded from the process.
ten months, from 2020–21.

The mental health expert evaluated each item of the KSIM

Results
questionnaire using a structured tool on how the contents
The study has developed the KSIM questionnaire, which
described were applicable. For Face validation of the
helps to assess the knowledge level of the primary care
questionnaire, the researcher asked each mental health
nurse to screen, identify, refer, and follow‑up the person
professional to give their opinion on appropriateness
with mental health issues, especially particular focus on
and relevancy through a 3‑point scale of 1 = completely
CMD, SMD, Intellectual Development Disorder (IDD),
meets the criteria, 2 = partially meets the criteria, and
and SUD. The ten major themes identified from the FGDs
3 = does not meet the criteria to calculate the item‑level
and direct interviews were used to frame the domain of
CVI (I‑CVI). The S‑CVI was calculated using the average
of the I‑CVI of each item of the KSIM questionnaire.[9,10] the KSIM questionnaire [Table 5].
After incorporating the suggestions from the experts,
the KSIM questionnaire was developed. The item‑wise Findings from the FGD’ and direct in‑depth
content validity index of the KSIM questionnaire and the interviews among nurses
experts’ remarks are given in Tables 3 and 4. The mean age of the participants was 32.95 (± 5.05)
years, most of which were females (85.7%). The mean
Testing reliability educational experience was 15.67 years (± 2.06), and
The reliability of the KSIM questionnaire was measured experience in psychiatry was 0.81 years (± 0.87) [Table 6].
through the single measure two‑way mixed absolute Around 52.4% of nurses completed GNM, and 6 nurses
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Paul, et al.: Knowledge on screening and identification of mental illness (KSIM) questionnaire

Table 3: Distribution of Intensive content validity index (I‑CVI) for the KSIM questionnaire
Evaluation criteria E‑1 E‑2 E‑3 E‑4 E‑5 E‑6 E‑7 E‑8 E‑9 E‑10 E‑11 E‑12 E‑13 E‑14 E‑15 E‑16 E‑17 Expert Item
Agreement CVI
Sociodemographic profile 1 1 1 1 1 1 1 2 1 1 1 2 1 1 1 1 1 15 0.88
KSIM questionnaire
Q‑1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
Q‑2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
Q‑3 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 16 0.94
Q‑4 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
Q‑5 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 15 0.88
Q‑6 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 16 0.94
Q‑7 1 1 1 2 1 1 1 1 2 1 1 1 1 1 2 1 1 14 0.82
Q‑8 1 2 1 1 1 1 2 1 1 1 1 2 1 1 2 1 1 13 0.76
Q‑9 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
Q‑10 2 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 15 0.88
Q‑11 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
Q‑12 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
Q‑13 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
Q‑14 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
Q‑15 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 16 0.94
Q‑16 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
Q‑17 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
Q‑18 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
Q‑19 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 16 0.94
Q‑20 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
Q‑21 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 16 0.94
Q‑22 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 16 0.94
Q‑23 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 16 0.94
Q‑24 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
Q‑25 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
Q‑26 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
Q‑27 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
Q‑28 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
Q‑29 1 1 1 2 1 1 1 1 2 1 1 1 2 1 1 1 1 14 0.82
Q‑30 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
Case Vignette’s
CV‑1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 16 0.94
CV‑2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
CV‑3 1 1 1 1 1 1 1 1 2 1 1 1 1 2 1 1 1 15 0.88
CV‑4 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
CV‑5 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
CV‑6 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
CV‑7 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
CV‑8 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
CV‑9 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17 1
CV‑10 1 1 1 1 3 1 1 1 1 1 3 1 1 1 1 1 1 15 0.88

were recruited for each FGD from DMHP community and quotations and interpreted by the researcher. Each
nurse, DMHP psychiatric nurse, PHCO, and 3 nursing transcript was coded similarly, and a set of codes,
officers for direct interviews [Table 1]. memos, verbatim pertaining to the codes, and texts
of relevant meaning from the verbatim were derived.
Individual case analysis Through this process, the researcher identified 40
The audio‑recorded raw data were transcribed and different codes. They were
entered into the Atlas‑ti version 8 software. The 1. Unwillingness to seek treatment in mental hospitals.
network analysis was done as described above using 2. Early identification can reduce the treatment gap
Creswell’s (2009) six steps to identify the themes and 3. Stigma and misconceptions lead to delay in availing
categories revealed through the participant’s narratives treatment.

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Paul, et al.: Knowledge on screening and identification of mental illness (KSIM) questionnaire

4. Lack of specialists in the remote areas 24. Refer to the medical officer during the home visit.
5. Lack of confidence in identifying a PMI. 25. Conformation of referral through ASHA worker.
6. Lack of motivation to do the screening and extra 26. Refer to medical officer for non‑adherence and no
work. improvement during the follow‑up visit.
7. Able to identify serious mental illness 27. Refer to the DMHP psychiatrist by the medical officer
8. Fewer opportunities during the diploma in Nursing. 28. Express the need for guidance.
9. Lack of knowledge on mental illness and its 29. Showing interest in training.
management. 30. Enhance the confidence level in handling PMI
10. Medication adherence and compliance with 31. Mental health services offered.
treatment. 32. Family and financial support.
11. Handling side effects of medication. 33. Welfare benefits and disability certification.
12. Handling expressed emotions. 34. Supply of free essential drugs in PHC.
13. Handling psychiatric emergencies 35. Home visit
14. Frustration due to the workload from various 36. Start with general questions and then move to specific
programs. questions.
15. Lack of knowledge on mental illness and its 37. Identification of common mental disorders.
management. 38. Identification of severe mental disorders.
16. Organizational and job‑related barriers. 39. Identification of substance use disorders.
17. Time constrain lead to neglect of mental health 40. Special focus on patient and family education and
aspects. counseling.
18. Personal barriers.
19. Regular follow‑up and periodic home visits. The credibility of coding is maintained by involving
20. Family education on handling person with mental two other naive researchers to code the same transcript
illness. quotations individually and then discussed the
21. Importance of drug compliance. similarities and differences found in the set of codes
22. Monitor the PMI through ASHA workers. for each quotation. It was supervised by two research
23. Teach the family about the early signs of relapse. experts, including the research guide. The revision of
codes helped to clarify and confirm the research findings.
Table 4: The I‑CVI score and experts’ comments on The major themes identified are explained in Table 5.
each item of the KSIM questionnaire
Topic I‑CVI Remarks by validators The I‑CVI calculations for the relevancy of each item
Average I‑CVI 0.93 Reframe the 5th and 18th are in Tables 3 and 4. Thirty‑three items (82%) of the
of the KSIM questions in a simple way for KSIM questionnaire were marked as relevant, and the
Questionnaire (30 easy understanding.
Questions) I‑CVI ranged from 0.76 to 1.00. Twenty‑five items had
Simplify the questions.
Average I‑CVI of 0.97 Make the case vignettes simpler
an I‑CVI = 1.00, eight a score of 0.94, four a score of 0.88,
Case Vignettes way for easy understanding. two a score of 0.82, and one a score of 0.76. Most of the
(10 Case Vignettes) Kannada translation to be done. items were considered relevant and three questions were
Average S‑CVI= 0.95 modified as per the expert’s suggestions [Table 3].
I‑CVI:‑ Item‑level Content validity Index; S‑CVI:‑ Scale‑Level Content Validity
Index The average S‑CVI of the KSIM questionnaire is 0.96,
which shows high content validity and test–retest
Table 5: Major Themes Identified during the Focus reliability of the tool is very good. It requires 15–
Group Discussion and Direct interview 30 minutes to screen the nurse’s knowledge on screening
Major Themes Identified during the Focus Group Discussion and identification, referral and follow‑up of a PMI in
and Direct interview
the community, and the comprehensive assessment
Understand the importance of mental health in primary health
care. yields specific targets or goals of raining that can be
Stigma and misconceptions about mental illness. tailor‑made to suit the nurse works in the primary health
Confidence level in identifying and managing the PMI in the care centers.
community.
Knowledge level of nurses about mental illness. For each item, the I‑CVI is computed as the number of
Skill in identifying mental illness. experts given a rating of 1 or 2, divided by the number of
Barriers in routine screening for mental illness. experts and the S‑CVI is calculated by taking an average
Role in prevention of relapse. of the I‑CVI. The S‑CVI for the KSIM questionnaire was
Referral system for a person with mental illness. 0.95, which is very close to 1; it indicated the average
Empowerment of nurses in doing follow‑up. proportion of items judged relevant across the 17
Support services available for a person with mental illness. experts = 0.95, which is very good [Table 4].[9,10]
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Paul, et al.: Knowledge on screening and identification of mental illness (KSIM) questionnaire

Table 6: Socio‑demographic data of the participants and requirements of the end users (nurses) as well
for the FGD and in‑depth interview (n=21) as feedback on how to overcome the barriers while
Variable Participant in the screening, identification and following up of a PMI
FGD and in‑depth
in the community. Most of the studies conducted by
interview mean (SD)
undergraduate or postgraduate students or professionals
Age in Years 32.95 (5.05)
Education In Years 15.67 (2.06)
use semi‑structured or unstructured tools for assessment.
Experience in Psychiatry 0.81 (0.87) Although the majority is unpublished literature, the
Variables Category Frequency (%)
non‑availability of a structured questionnaire makes the
Gender Male 3 (14.3) study’s replicability difficult in different populations and
Female 18 (85.7) large‑scale applications. Since the validity of those tools
Educational ANM 7 (33.3) is not established, the reliability of a similar result will
Qualification GNM 11 (52.4) be difficult even in a similar population.[11,13–15]
BSc Nursing 3 (14.3)
Cadre DMHP Community Nurse 6 (28.6) With any preliminary questionnaire, its design had
DMHP Psychiatric Nurse 6 (28.6) some limitations. The study’s limitations include 1)
Primary Health Care Officer 6 (28.6) the potential lack of generalisability, 2) the risk of
Nursing Officer 3 (14.3) using a self‑reported measure, and 3) the length of the
questionnaire. The KSIM Questionnaire was designed
The single measure two‑way mixed absolute agreement for the primary care nurses working in the PHC and
ICC value was calculated (for 30 subjects) for the subcenters; their generalisability to other nurses in
reliability test, and the ICC value was 0.97 with 95% a different setting is unknown and must be tested.
CI (0.94, 0.99). As this ICC value is very close to 1, it There is a risk of recall bias or inflated answers in the
indicates that the test–retest reliability of the developed self‑reported measures due to the high workload among
questionnaire is very good. the nurses. The KSIM questionnaire also takes about
15–30 minutes to complete. The KSIM questionnaire
Discussion should be viewed as a knowledge booster rather than a
competency enhancer in a therapeutic setting. Therefore,
The study has developed the KSIM questionnaire, which rather than focussing on the skill‑improving effects of a
helps to assess the knowledge level of the primary care clinical training program, the results of this paper should
nurse to screen, identify, refer, and follow up the person be viewed as translating the knowledge‑enhancing effect
with mental health issues, especially particular focus on in a clinical situation.
CMD, SMD, IDD, and substance use disorder (SUD).
The present study can be used as a basis for the
The nurses are required to screen, assess, refer to, and development of other related tools and for regular
follow up on mental illnesses in the community area.[11–13] assessment of the nurses in the wards and community
Although the majority of the nurses have pointed out areas with either slight modification or as it is. The
that nurses have inadequate knowledge about screening case vignettes given in the present studies can aid in
and assessment. One of the reasons for the same is the the development of knowledge regarding psychiatric
unavailability of holistic tools. diagnosis and the easy identification of cases.

The KSIM questionnaire is one of the first developed The next step is replication with a larger sample size to
tools, which helps the primary care nurses working improve the clinical skill‑based training of primary care
in the community setting to assess the knowledge on nurses in the primary care settings with its acceptability
screening, identification, referring, and follow‑up of a by the primary care nurses who work in real‑life
PMI. Unlike the previously designed questionnaire to community settings with the patients. The questionnaire
screen depression or anxiety, the KSIM questionnaire is should also be prepared in various local/regional
designed comprehensively to rapidly screen the mental languages for large utilization by primary care nurses. It
health knowledge on CMD, SMD, IDD, and SUD in a will be a structured tool for other researchers to conduct
primary care setting. similar studies in the future.

The KSIM questionnaire is tailor‑made, based on Conclusion

the needs and suggestions of the nurses, and further
refined by the experts from the multidisciplinary team. The KSIM questionnaire is an effective tool to assess
The major strength of the KSIM questionnaire was the knowledge of primary care nurses in screening
the qualitative strategy adopted for the development and identifying people with mental health issues at the
of the tool that took into consideration the needs primary care itself, thereby identifying the training needs

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Paul, et al.: Knowledge on screening and identification of mental illness (KSIM) questionnaire

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There are no conflicts of interest.
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8 Journal of Education and Health Promotion | Volume 12 | June 2023