Cross-cultural validity of the Pediatric Symptom Checklist – Youth Report (PSC-Y) in five Global South countries: Implications for equitable child mental health screening

Abstract

Background Despite a high global burden of mental health disorders in childhood and adolescence, access to adequate care remains limited, particularly in low- and middle-income countries . Valid and reliable self-report instruments are essential for early identification and equitable care, yet measurement invariance as a prerequisite for valid group comparisons remains understudied. The Pediatric Symptom Checklist (PSC) is a brief, open-access screening tool with practical advantages for global use. This study examined the factor structure and measurement invariance of the 35-item PSC youth self-report (PSC-Y) across five Global South countries. Methods We analyzed baseline data from 5,810 children and adolescents (age 6–18 years) participating in school based randomized controlled trials in Ghana, Tanzania, Uganda, Haiti, and Pakistan. Using confirmatory factor analysis (CFA) and exploratory structural equation modeling (ESEM), we tested competing models (unidimensional, three factor, second-order, bifactor). Multi-group CFA examined measurement invariance across countries. Within each of the five countries, we tested invariance across gender and across age groups in each of the three African countries where both primary and secondary students were represented, using school level as a proxy for developmental stage. Multiple Indicators Multiple Causes (MIMIC) models served as sensitivity analyses. Results A strong general factor emerged across all countries (omega hierarchical > 0.90). Configural invariance was supported across countries, but metric invariance failed, with items related to empathy, rule-breaking, and anger expression showing differential functioning. Full metric, scalar, and strict invariance were achieved across gender in all five countries. The Tanzania and Uganda samples demonstrated full invariance across school level as a proxy for age, while Ghana required partial invariance after freeing five items (e.g., empathy, fighting). MIMIC models supported these findings. Conclusions The PSC-Y exhibits a strong general factor across diverse Global South settings, supporting total score use for screening within countries. However, because metric invariance was not established across countries, cross country comparisons of PSC-Y scores are not methodologically defensible. Within countries, full gender invariance validates direct comparisons between boys and girls. Findings underscore the need for ongoing local validation and cultural contextualization for advancing equitable global mental health research and practice.