Development and validation of the Personal Recovery Scale (ReConnect) for Mental Health in Ethiopia

Development and validation of the Personal Recovery Scale (ReConnect) for Mental Health in Ethiopia | Research Square Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development and validation of the Personal Recovery Scale (ReConnect) for Mental Health in Ethiopia Wubalem Fekadu, Atalay Alem, Laura Asher, Awoke Mihretu, Tessa Roberts, and 11 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8604727/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 31 Aug, 2026 Read the published version in International Journal of Mental Health Systems → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose To develop and validate a mental health personal recovery measure for people with mental health conditions (MHCs) in Ethiopia that is grounded in their recovery journey. Methods The study stages were: reviewing existing measures; qualitative exploration of the concept in Ethiopia (n = 25 interviews); expert workshops (n = 3 involving 28 experts); cognitive interviewing for semantic and content validity (n = 20); pilot study for item reduction and exploratory factor analysis (n = 213) and parallel analysis to determine the dimensional structure (n = 213); and assessment of construct (confirmatory factor analysis) and construct validity in an independent sample (n = 401), and test-retest reliability in a sub-sample (n = 48). Construct validity was assessed against symptom severity and disability. Results Participants gave greater emphasis to social recovery than self-actualisation or empowerment; hence, no existing measures had face validity. We piloted 26 items from existing measures and 19 newly developed items. The draft measure was unidimensional, explaining 71% of variance, and had item-test correlations > 0.58. Item reduction resulted in 20-item scale, ReConnect (Recovery and Connection Scale). In the validation study, ReConnect was unidimensional with acceptable goodness of fit indices and test-retest reliability and correlated significantly with symptom severity and functioning. Conclusion ReConnect is a valid and reliable measure of personal recovery in Ethiopia. It has potential applicability to other similar settings where the community has a greater role in the recovery journey. Personal recovery Measure Severe Mental Health Conditions non-western setting Figures Figure 1 Figure 2 Introduction Conceptualising recovery from mental health conditions (MHCs) merely by looking at the presence or reduction of symptoms has been challenged ( 1 ). Especially in the last 20 years, there has been a growing interest in personal recovery ( 2 ). Personal recovery refers to the pursuit of a meaningful and fulfilling life despite ongoing challenges, unlike clinical recovery, which emphasizes symptom reduction and functional improvement ( 3 ). Subjective experiences, including hope, identity, meaning, and empowerment, are central to individuals’ quality of life and long-term well-being ( 4 , 5 ). It also enables mental health services to align care with service users’ values and goals ( 4 ). CHIME (connectedness, hope and optimism about the future, identity, meaning in life, and empowerment) is the most cited framework in mental health personal recovery ( 6 ). It was developed from a narrative synthesis of 97 articles, all of which were from high-income countries. The CHIME framework has been used to design recovery-oriented mental health services that aim to deliver personalized, strengths-based care that is responsive to an individual’s unique strengths, circumstances, needs, and preferences ( 7 , 8 ). However, existing conceptual frameworks such as CHIME have been developed primarily within Western cultural contexts, which may limit their cross-cultural applicability. Culturally specific values, elements such as what constitutes a meaningful life and the nature of identity are likely to vary across different cultural settings( 9 , 10 ). Indeed, there have been several critiques regarding the applicability of personal recovery concepts to minority ethnic groups in high-income countries and non-western cultures ( 11 , 12 ). A global study across 28 countries found that cultural factors significantly influenced the implementation of Recovery Colleges, which provide education, social support, and skills for people with MHCs and their carers. Using Hofstede’s cultural dimensions, the study showed that countries with Western, educated, industrialized, rich, and democratic (WEIRD) characteristics achieved higher fidelity to the model, which adds to the need for cultural adaptations ( 13 , 14 ) Many scales have been developed to measure the concept of personal recovery; most are patient-reported outcome measures (PROMs), while some assess the recovery orientation of services ( 11 , 15 , 16 ). However, only a few have undergone robust psychometric testing ( 15 , 17 ). The most widely used scales are the Recovery Assessment Scale (RAS) ( 16 ) and Recovery Assessment Scale-Domains and Scale (RAS-DS) ( 18 ). Efforts have been made to develop measures that are valid for other cultural settings ( 19 ), but there have not been any rigorous validation studies on the psychometric properties to support their uptake ( 17 ). Developing a culturally relevant measure of personal recovery is crucial for countries like Ethiopia, where recovery processes such as social reciprocity and collective identity differ from widely used frameworks like CHIME. This need is especially pressing as efforts to expand access to mental health care continue ( 20 ). In this study, we aimed to develop and validate a contextually relevant recovery scale for people with severe MHCs in Ethiopia. Methods We followed the COSMIN Reporting guideline for studies on the measurement properties of PROMs ( 21 ). The current study of personal recovery measurement is part of the groundwork for a large community-based study on recent-onset psychosis in Ethiopia ( 22 ). The study had six phases: ( 1 ) reviewing existing measures; ( 2 ) secondary analysis of qualitative data; ( 3 ) expert consensus meetings and development of a beta version of ReConnect; ( 4 ) cognitive interviewing; ( 5 ) a pilot study of the ReConnect beta version and final adaptation based on the findings; and ( 6 ) a validation study of the final ReConnect. ( 1 ) Reviewing existing measures We conducted a literature review to identify existing PROMs for personal recovery and to gather evidence regarding their psychometric properties and validity in diverse cultural settings. We searched PubMed and Global Health databases. Additionally, we examined the references of the relevant articles we found in our initial searches. We combined terms for personal recovery (personal recovery, subjective recovery, recovery process) and measurement (scale, measure, PROM, tool). We included studies that fulfilled the following criteria: Studies involved people with severe MHCs Research articles that used PROM for personal recovery Reported at least one psychometric property of the measure ( 2 ) Secondary analysis of qualitative data We analysed translated English transcripts from an existing dataset of 25 qualitative interviews with 13 individuals diagnosed with schizophrenia in a rural setting in south-central Ethiopia. These interviews were conducted both before and after a one-year community-based rehabilitation intervention, with the specific aim of exploring experiences of recovery in this setting ( 23 , 24 ). We used thematic analysis ( 25 ) including both deductive and inductive coding to identify concepts of recovery journeys and a meaningful life. We also reviewed relevant previous qualitative evidence from Ethiopia collected for a related study ( 26 , 27 ). Expert consensus meetings Two initial expert meetings were organised. The first meeting was held online and included international experts (n = 8) in the field. These experts had either conducted studies on personal recovery or developed similar measures for different settings (India, South Africa, UK, and some of them were involved in multicountry studies). The second meeting (n = 10) was held in Ethiopia in Amharic and included people with lived experience of severe MHCs, caregivers, psychiatrists, a clinical psychologist, a social worker, and a psychometrician. During the meetings with experts, we presented the findings from the review of existing measures and qualitative analysis. Discussions centred on whether any existing measures adequately captured important concepts of personal recovery in Ethiopia, which items of existing measures (mainly from RAS and RAS-DS) were relevant or could be adapted, and where new items were needed. The procedure we followed was an open consensus discussion, where ideas were shared, and decisions were reached collectively without formal ranking or anonymity. Cognitive interviewing We conducted cognitive interviews with 20 individuals diagnosed with severe MHCs. The cognitive interviews were conducted in Amharic aiming to understand how respondents interpret and answer questions/items through verbalising their thought processes and understanding of each of the items while responding, allowing researchers to identify potential issues with clarity or comprehension ( 28 ). Specifically, we assessed the extent to which items were understandable, relevant, and acceptable. Based on the findings, we reworded items to form the beta version of the ReConnect (with 45 items). Pilot study We then conducted a pilot study of Amharic ReConnect (beta), described below. Setting The pilot study was conducted at Butajira General Hospital, located approximately 132 km south of Addis Ababa. This general hospital serves the town of Butajira (89,824 population) and a large rural population from the surrounding area (approximately 311, 794) (Central Statistics Agency, 2022 projection). The hospital primarily offers outpatient psychiatric services, but in 2023, it opened an inpatient psychiatric service. The service is staffed mainly by psychiatric nurses and non-specialist doctors; a psychiatrist from a nearby district visits once per week to provide supervision and review of inpatient care. Inclusion criteria We included people with a diagnosis of severe MHCs receiving care at the OPD of Butajira hospital. We excluded people with a diagnosis of substance-induced psychosis or brief psychotic disorder. Sample and recruitment The target sample size was 225, so that there would be five participants per variable for conducting exploratory factor analysis. Participants were approached by data collectors while waiting to be seen, informed about the study and invited to participate. In a random sub-sample (n = 52), the ReConnect (beta) was re-administered two weeks later to evaluate test-retest reliability. Data collection The data were collected by experienced lay data collectors who received further training for two days on the administration of the ReConnect (beta version). We also gathered information on gender, age, educational level, residence, diagnosis and duration of illness. Data analysis We conducted descriptive statistics (frequency, percentage, mean, standard deviation, median, interquartile range, skewness and kurtosis) to examine the distribution of each of the items. Test-retest reliability for each item was assessed using intra-class correlation coefficients (ICC), a 2-way mixed-effects model ( 29 ). ICC values ≥ 0.50 were considered acceptable ( 30 ). We conducted an exploratory factor analysis (with maximum likelihood extraction and varimax rotation) ( 31 ) to examine the dimensional structure of the measure. In addition, parallel analysis was conducted to identify the factor structure of the scale. The results of the exploratory factor analysis and parallel analysis were then presented to the expert group in Ethiopia, which provided input on which items to retain. These processes led to the final version of the ReConnect (with 20 items), which was then assessed in the validation study. Validation study Setting The validation study was conducted at Amanuel Mental Specialised Hospital. This is a tertiary referral hospital in Addis Ababa and is the only specialised hospital for mental health care in the country. The hospital has 280 beds ( 32 ). We conducted the validation study at this hospital because the population is more diverse than that of the general hospital, as it receives referrals from across the entire country. Sample The target sample size was 400 to allow us to conduct confirmatory factor analysis and IRT analyses. This was based on a rule of thumb of needing approximately 10 participants per scale item ( 33 ). We recruited people with severe MHCs from outpatient attendees. We also selected a random sub-sample of 50 participants to re-assess after two weeks to examine test-retest reliability. Data collection As for the pilot study, potential participants were approached by the research team while waiting for their consultation. We continued the recruitment until we reached the target sample size. Informed consent was obtained from all participants. Experienced data collectors administered the questionnaires in a private room. The following measures were administered during the interview in Amharic (the official language): Demographic characteristics (gender, age, education, residence). Clinical characteristics (diagnosis, illness duration, treatment duration). ReConnect final version The Brief Psychiatric Rating Scale, expanded version (BPRS-E)( 34 ) The World Health Organization Disability Assessment Scale 2.0 (WHODAS) ( 35 ). We assessed symptom severity and functioning to examine the correlation with the ReConnect, since there is a lack of gold standards to measure personal recovery. Other recovery measures have been shown to correlate with symptom severity, though the concept is distinct ( 36 ). BPRS-E is a widely used 24-item observer-rated scale assessing symptom severity across four domains: positive symptoms, negative symptoms, anxiety and depressive symptoms, and manic excitement or disorganization. BPRS-E has been used in previous Ethiopian studies and shown to have sensitivity to change ( 37 – 39 ). WHODAS 2.0 measures the ability to execute daily activities over the previous month. We used the 12-item version of WHO, administered by the interviewer ( 40 ). The WHODAS 2.0 was validated in Ethiopia among people with severe MHCs ( 41 ). Data analysis We used Stata version 18 ( 42 ) to analyse the data. To assess construct validity, we performed confirmatory factor analysis (CFA) ( 43 ) using the dimensional structure of the scale found in the pilot study. The overall model fitness was measured with comparative fit index (CFI), Tucker-Lewis index (TLI) and root mean square error of approximation (RMSEA) ( 44 ). Model fit was evaluated using CFI and TLI values ≥ 0.90 and RMSEA ≤ 0.08 as indicators of acceptable fit. We assessed divergent validity by calculating Pearson's correlation coefficient (r) ( 45 ) to examine the association between the ReConnect score and scores on the WHODAS-2.0 and BPRS-E. Internal consistency was evaluated using Cronbach's alpha ( 46 ). Test-retest reliability for each item was assessed using ICC coefficients ( 29 ). Ethical considerations Ethical approval was obtained from the Institutional Review Board of the College of Health Sciences, Addis Ababa University (Ref. 001/22/Psy; 12th January 2022) and the Research Ethics Committee of King’s College London (Ref. HR/DP-21/22-26183; 5th April 2022). Written informed consent was obtained from all participants. Results Reviewing existing measures We identified 17 measures of recovery from the systematic review (Supplementary File 1). The RAS ( 47 , 48 ) and RAS-DS ( 18 , 49 ) had strong psychometric properties and had been used across different cultural settings ( 14 , 50 – 53 ). We found three measures of personal recovery that were developed in LMICs: Indonesia, South Africa, and Turkey ( 19 , 52 , 54 ). Secondary analysis of qualitative data We identified seven interconnected domains of how participants conceptualised recovery and what was important for a satisfying and meaningful life: Being cured : individuals' expectations of achieving a cure from their condition and desire for a ‘cure’, rather than being on a journey to recovery. Being able to work : ability to engage in meaningful work such as farming and other employment. Better living standards : desire for improved living conditions (housing, financial stability, and access to necessities). Fulfilling adult roles : aspirations related to fulfilling adult responsibilities, such as getting married and starting a family. Fulfilling social responsibilities : a sense of purpose from being useful to one’s community for example by helping others. Social inclusion : being socially connected, accepted, and included in different aspects of community life. Being mentally free : free from stress, excessive thinking, and other mental burdens. The participants also mentioned the processes to reach these desired recovery outcomes. Analyses of the findings of the qualitative data are published elsewhere ( 55 ). Expert consensus meetings The existing measures, especially items from RAS and RAS-DS of personal recovery, were mapped onto the qualitative findings. None of the existing measures adequately covered important aspects of recovery in the Ethiopian context. However, some of the items in existing scales were relevant or were considered important by the expert group, even if not prominent in the qualitative study findings. The experts recommended extracting relevant items from the RAS and RAS-DS or adapting RAS/RAS-DS items and developing new items specific to the Ethiopian setting. We used the four response categories from the RAS/RAS-DS (untrue to completely true). This resulted in 45 items (20 identical to the original RAS/RAS-DS items, six adapted from RAS/RAS-DS items and 19 newly developed items). These items were further reviewed by the expert groups. Experts gave feedback that some items measured functioning rather than personal recovery, so they were amended. We revised some items to make them time-sensitive and changed them from self-administered to interview-administered because many of the participants could not read or write. Cognitive interviewing The 48 items were then assessed using cognitive interviewing. The major change was adding the statement “Thinking about yourself and your life at this moment” at the beginning of each domain. This was needed because participants tended to talk about their perception of other people's conditions rather than referring to themselves. The final revised 45 items were then assessed in the pilot study. Pilot study We recruited a total of 213 individuals with severe MHCs (Table 1 ). The median age of participants was 35 (Interquartile Range (IQR); 27, 47) years. Just over half (56.3%) were males. The median duration of illness was nine years (IQR: 4,12). Twenty-two percent of the participants had secondary education or above. Just over half (54%) were from rural settings. Table 1 Participant characteristics Characteristics Pilot study n (%) (N = 213) Validation study n (%) (N = 401) Sex Male 120 (56.3) 242 (60.4) Age Median (IQR) 35 ( 27 , 47 ) 36 ( 30 , 45 ) Residence Rural 114 (53.5) 61 (15.2) Urban 99 (46.5) 340 (84.8) Education Unable to read and write 49 (23.0) 11 (2.7) No formal education 26 (12.2) 12 (3.0) Primary level 91 (42.7) 151 (37.7) Secondary level 37 (17.4) 137 (34.2) Higher education 10 (4.7) 90 (22.4) Diagnosis Schizophrenia-spectrum psychotic disorders 135 (63.4) 278 (69.3) Bipolar disorder (with psychotic features) 55 (25.8) 101 (25.2) Major depression (with psychotic features) 23 (10.8) 22 (5.5) Duration (years) Median (IQR) 9 ( 4 , 12 ) 10 5, 16) Descriptive statistics and reliability The item level mean responses ranged from 1.09 (“You have ways of handling the side effects of medication”) to 2.14 (“You know that there are mental health services that help you”). The skewness and kurtosis results showed a normal distribution. The scale had good item-item (0.52–0.83) and item-test correlations (> 0.58) (Table 2 ). Internal consistency was excellent (alpha = 0.98) with an indication of conceptual repetitions. Table 2 Pilot study item level response distribution (N = 213) and test-retest (N = 48) Thinking about yourself and your life at this moment… Untrue (%) A bit true (%) Mostly true (%) Completely true (%) Mean Skewness Kurtosis ICC 1. You try to live your life in a way that prioritises your health 6.57 25.35 40.85 27.23 1.89 -0.36 2.34 0.46 2. You do things that are important to you 7.98 26.29 42.25 23.47 1.81 -0.32 2.36 0.28 3. You do things that are valuable and helpful to others 13.15 37.56 33.33 15.96 1.52 0.05 2.19 0.34 4. You make an effort to work 5.63 28.64 38.03 27.70 1.88 -0.26 2.19 0.59 5. There is something you can contribute to family life 11.74 41.31 25.35 21.60 1.57 0.14 2.01 0.53 6. You do things that help your community 23.00 40.85 24.88 11.27 1.24 0.33 2.25 0.66 7. You make an effort to participate in social events 18.78 33.80 30.99 16.43 1.45 0.06 2.01 0.73 8. You make an effort to look after your personal hygiene 4.69 20.66 37.09 37.56 2.08 -0.57 2.43 0.79 9. You can handle it if you get unwell again 28.17 28.17 26.76 16.90 1.32 0.18 1.80 0.47 10. You can help yourself become better 10.33 33.33 34.74 21.6 1.68 -0.09 2.11 0.52 11. You can handle what happens in your life 21.60 41.78 24.88 11.74 1.75 0.32 2.27 0.60 12. You have a purpose in life 9.39 28.17 40.38 22.07 1.44 -0.25 2.27 0.59 13. If people really knew you, they would like you 16.43 37.09 32.86 13.62 1.75 0.08 2.17 0.38 14. You feel that something good will eventually happen 9.86 26.29 43.19 20.66 1.95 -0.31 2.36 0.41 15. You are the person most responsible for your own improvement 5.63 22.54 42.72 29.11 1.95 -0.44 2.48 0.20 16. You are hopeful about your own future 7.04 24.88 39.91 28.17 1.89 -0.38 2.32 0.44 17. You know when to ask for help 17.37 41.31 33.80 7.51 1.31 0.10 2.37 0.70 18. You know what helps you get better 12.68 39.91 38.03 9.39 1.44 0.01 2.44 0.61 19. You can learn from your mistakes 9.86 35.21 34.27 20.66 1.65 -0.05 2.13 0.58 20. Difficulties in life happen for a reason 12.21 31.46 33.8 22.54 1.67 -0.13 2.05 0.45 21. You have hopes for your family 7.04 24.41 40.85 27.70 1.89 -0.39 2.36 0.66 22. If you keep going, things can get better 8.92 25.82 37.09 28.17 1.85 -0.34 2.19 0.55 23. You can live a life like others in your community 12.21 32.39 32.86 22.54 1.66 -0.11 2.02 0.54 24. Getting back to your previous functioning seems possible 9.39 27.23 37.09 26.29 1.80 -0.29 2.16 0.74 25. Even though you still have symptoms, you can still manage to do things 8.45 30.99 41.78 18.78 1.71 -0.18 2.35 0.55 26. You can identify the early warning signs of becoming unwell 23.00 20.66 36.62 19.72 1.53 -0.17 1.82 0.63 27. You have your own plan for how to stay or become well 15.96 38.97 32.86 12.21 1.41 0.11 2.25 0.53 28. There are things that you can do that help you deal with unwanted symptoms 23.47 39.91 29.58 7.04 1.20 0.22 2.26 0.70 29. You know that there are mental health services that help you 3.76 12.68 49.30 34.27 2.14 -0.73 3.31 0.54 30. Although your symptoms may get worse, you know you can handle it 23.00 35.21 27.70 14.08 1.33 0.20 2.03 0.74 31. Your symptoms interfere less and less with your life 13.62 33.80 40.85 11.74 1.51 -0.11 2.32 0.61 32. Your symptoms seem to be a problem for shorter periods of time each time they occur 26.29 35.21 29.58 8.92 1.21 0.23 2.10 0.82 33. You have ways of handling the side effects of medication 29.58 39.44 23.47 7.51 1.09 0.43 2.33 0.59 34. Going through so many things, you have learned how to survive 10.80 36.15 37.09 15.96 1.58 -0.02 2.27 0.64 35. You can manage stress in your life 31.92 36.62 21.60 9.86 1.09 0.48 2.25 0.71 36. You have people that you can count on 16.43 27.70 33.80 22.07 1.62 -0.15 1.95 0.72 37. Even when you don’t care about yourself, other people do 16.43 24.88 41.78 16.90 1.59 -0.25 2.14 0.74 38. You have friends that can depend on you 34.27 26.76 28.17 10.80 1.15 0.30 1.88 0.73 39. You feel ease about your family situation 3.76 23.47 41.78 30.99 2.00 -0.39 2.37 0.68 40. It is important to have supportive neighbours and relatives 7.98 28.64 41.31 22.07 1.77 -0.25 2.33 0.83 41. Your community gives you the place you deserve 22.54 38.50 30.99 7.98 1.24 0.18 2.22 0.67 42. Your neighbours can depend on you 23.47 42.25 23.47 10.80 1.22 0.38 2.32 0.72 43. You seek to keep harmony in the family 3.76 23.94 44.60 27.70 1.96 -0.35 2.45 0.54 44. It is important that others recognise when your illness improves 6.10 30.52 44.13 19.25 1.77 -0.18 2.43 0.63 45. You contribute to community life as much as you can 21.13 39.91 32.86 6.10 1.24 0.11 2.27 0.62 In the test-retest reliability analysis, most of the items had ICC values > 0.50. Five items had ICC values ranging from 0.40 to 0.50. Four items had ICC values less than 0.40: “You are the person most responsible for your own improvement” (ICC = 0.20), “You do things that are important to you” (ICC = 0.28), “You do things that are valuable and helpful to others” (ICC = 0.34), and “If people really knew you, they would like you” (ICC = 0.38) (Table 2 ). Exploratory factor analysis The KMO test result was 0.96, which shows the adequacy of the sample. The Bartlett's Test of Sphericity also indicated that the data is appropriate for factor analysis (chi-square = 7516.153, df = 990 and p-value < 0.0001). The factor loadings ranged from 0.55 (“It is important to have supportive neighbours and relatives”) to 0.83 (“You can learn from your mistakes”) and (“You can help yourself become better”) (Table 3 ). Although four potential factors had an Eigenvalue greater than one, all the items had the highest loadings for the first factor (> 0.51) (Table 3 ). The factor explained 71% of the variance, which indicated a dominant factor. The scree plot also indicated one dominant factor (Fig. 1 ). Table 3 Item-factor loading of exploratory factor analysis Thinking about yourself and your life at this moment… Loading 1. You try to live your life in a way that prioritises your health 0.60 2. You do things that are important to you 0.69 3. You do things that are valuable and helpful to others 0.65 4. You make an effort to work 0.73 5. There is something you can contribute to family life 0.69 6. You do things that help your community 0.70 7. You make an effort to participate in social events 0.63 8. You make an effort to look after your personal hygiene 0.61 9. You can handle it if you get unwell again 0.80 10. You can help yourself become better 0.83 11. You can handle what happens in your life 0.73 12. You have a purpose in life 0.82 13. If people really knew you, they would like you 0.62 14. You feel that something good will eventually happen 0.77 15. You are the person most responsible for your own improvement 0.74 16. You are hopeful about your own future 0.76 17. You know when to ask for help 0.51 18. You know what helps you get better 0.75 19. You can learn from your mistakes 0.83 20. Difficulties in life happen for a reason 0.73 21. You have hopes for your family 0.69 22. If you keep going, things can get better 0.80 23. You can live a life like others in your community 0.73 24. Getting back to your previous functioning seems possible 0.77 25. Even though you still have symptoms, you can still manage to do things 0.70 26. You can identify the early warning signs of becoming unwell 0.64 27. You have your own plan for how to stay or become well 0.73 28. There are things that you can do that help you deal with unwanted symptoms 0.68 29. You know that there are mental health services that help you 0.57 30. Although your symptoms may get worse, you know you can handle it 0.75 31. Your symptoms interfere less and less with your life 0.68 32. Your symptoms seem to be a problem for shorter periods of time each time they occur 0.63 33. You have ways of handling the side effects of medication 0.59 34. Going through so many things, you have learned how to survive 0.72 35. You can manage stress in your life 0.71 36. You have people that you can count on 0.61 37. Even when you don’t care about yourself, other people do 0.64 38. You have friends that can depend on you 0.69 39. You feel ease about your family situation 0.65 40. It is important to have supportive neighbours and relatives 0.55 41. Your community gives you the place you deserve 0.68 42. Your neighbours can depend on you 0.68 43. You seek to keep harmony in the family 0.66 44. It is important that others recognise when your illness improves 0.68 45. You contribute to community life as much as you can 0.67 The parallel analysis also showed that the scale and the items performed well (Fig. 2 ). The parallel analysis also indicated a four-factor (Eigenvalues) structure. However, the items did not load enough to form four, three, and two-factor structures, which suggested a unidimensional structure. We presented the results to an expert meeting and decided to delete the items as there was conceptual repetition. With the item performance and local relevance, the expert group selected 20 items for the final version of the ReConnect to be tested for validity. Out of the 20 items, half were new items and half were from the existing measures. However, seven out of the ten items from the existing measures were reworded. Validation study A total of 401 individuals participated in the validation study; 60.4% were men, and most were urban residents. Over half (56.6%) had received at least a secondary education. The median illness duration was 10 years (IQR; 5, 16) years) (Table 1 ). Descriptive statistics and reliability The item level mean responses ranged from 1.16 (“You do things that help your neighbours”) to 2.10 (“If you keep going, things can get better”). The skewness and kurtosis results showed a normal distribution. The scale performed well with item-item correlations (0.31–0.67). Item-test correlations ranged from 0.45 (“You can identify the early warning signs of becoming unwell”) to 0.65 (“You know what helps you get better”) (Table 4 ). Internal consistency was excellent (alpha = 0.92). In the test-retest reliability analysis (n = 48), the ICCs ranged from 0.62 (“You can identify the early warning signs of becoming unwell”) to 0.88 (“You feel ease about your family situation”) (Table 4 ). Table 4 Item-level response of the validation study Thinking about yourself and your life at this moment… Untrue A bit true Mostly true Completely true Mean Skewness Kurtosis ICC 1. You try to live your life in a way that prioritises your health 8.98 30.67 25.94 34.41 1.86 -0.26 1.86 0.76 2. You do things that are important to you 9.48 36.41 27.68 26.43 1.71 -0.04 1.92 0.63 3. You make an effort to discharge your responsibility 9.48 35.16 27.68 27.68 1.74 -0.08 1.90 0.67 4. There is something you can contribute to family life 21.70 33.67 24.19 20.45 1.43 0.14 1.84 0.82 5. You do things that help your neighbours 27.68 40.40 20.45 11.47 1.16 0.47 2.29 0.64 6. You can handle it if your illness gets worse 33.17 34.41 17.96 14.46 1.14 0.51 2.10 0.84 7. You are hopeful about your own future 6.73 28.68 31.92 32.6 1.91 -0.31 2.03 0.76 8. You know what helps you get better 8.48 36.66 29.68 25.19 1.72 -0.03 1.97 0.63 9. If you keep going, things can get better 2.74 25.19 31.17 40.90 2.10 -0.45 2.03 0.77 10. You can live a life like others in your community 10.22 37.91 25.19 26.68 1.69 0.01 1.87 0.74 11. You can identify the early warning signs of becoming unwell 18.95 34.91 24.44 21.70 1.49 0.11 1.86 0.62 12. You know you can use the available mental health services 22.19 31.17 24.44 22.19 1.47 0.09 1.77 0.80 13. Though you still have symptoms, you can still manage to do things 9.73 38.15 27.93 24.19 1.67 0.03 1.96 0.81 14. Going through so many things, you have learned how to survive 8.73 30.42 34.16 26.68 1.79 -0.21 2.07 0.71 15. You can manage stress in your life 28.68 38.15 19.95 13.22 1.18 0.45 2.17 0.83 16. You have people that you can count on when needed 9.23 26.43 23.94 40.40 1.96 -0.44 1.91 0.70 17. You have people that can depend on you 27.43 33.42 20.45 18.70 1.30 0.30 1.86 0.76 18. You feel ease about your family situation 7.23 26.68 26.68 39.40 1.98 -0.43 1.98 0.88 19. Your neighbours give you the place you deserve 17.96 35.16 26.68 20.20 1.49 0.09 1.92 0.73 20. Your progress is also noticed by other people 12.47 31.17 31.42 24.94 1.69 -0.14 1.97 0.72 Confirmatory Factor Analysis The unidimensional structure of the measure was confirmed in the validation study sample. The results of the CFA showed that the path coefficients ranged from 0.51 (“You make an effort to discharge your responsibility”) to 0.85 (“You can identify the early warning signs of becoming unwell”), indicating significant relationships between the items and the underlying construct. All items showed significant correlations. The overall model fitness was acceptable with a chi-square value of 536.47 (p < 0.0001), CFI of 0.88, TLI of 0.89, RMSEA of 0.066, and SRMR of 0.05. Construct validity The linear correlation between ReConnect and BPRS-E was weak and negative (r =-0.28), indicating that an increase in symptom severity was significantly associated with a lower ReConnect score (p = < 0.001). The linear correlation between ReConnect and WHODAS 2.0 was moderate and negative (r =-0.54). Higher scores on WHODAS 2.0 (indicating worse functioning) were associated with lower scores on ReConnect, indicating lower personal recovery. Discussion We developed and validated the Recovery and Connection Scale (ReConnect) for mental health, combining adapted items from existing measures and new items derived from local conceptualisation of recovery in Ethiopia. ReConnect can be considered the first rigorously tested personal recovery measure designed for a low-income, non-Western context. Unlike widely used instruments such as the RAS and RAS-DS, which are rooted in Western individualistic paradigms, ReConnect integrates culturally salient dimensions of recovery, particularly social connectedness, family roles, and community participation. The conceptualization of the recovery journey among people with MHCs in South Africa and Turkey also differed from the CHIME framework ( 11 , 19 , 54 ). For instance, in this study, the importance of how others perceive one's progress, such as the statement, “My progress is also noticed by other people”, was not highlighted in other contexts. In Ethiopia, in common with other non-Western countries with low economic resources, societal interconnectedness can be an important asset, especially in the absence of an established social security system ( 56 ); on the other hand, it might be the source of stigma and discrimination ( 56 ) which might negatively affect the person’s recovery journey ( 57 ). The role of culture and religion in recovery conceptualization was highlighted in various studies. In a review of studies from LMICs, social relationships were identified as facilitators of recovery, while spirituality has emerged as both a facilitator and an indicator of recovery ( 51 ). Culture was also considered a significant factor influencing recovery ( 13 ), which suggests that contextual adaptation in non-Western settings. The psychometric properties of the ReConnect indicate good potential for utility in clinical as well as research settings. The responses were normally distributed, though there were some item-level differences. Despite most participants receiving care, the scale-level distribution did not skew to the right, manifested by high scale score or frequent responses of 'mostly true' or 'completely true' across most items. Right skewness was reported for functioning measures in Ethiopia ( 38 ). The items also demonstrated acceptable item-item correlation, suggesting they are relatively homogeneous while still capturing unique variance. Additionally, the scale showed good item-total correlations, indicating that the items collectively measure the same underlying construct ( 58 ). The unidimensional nature of the 45-item- and 20-item scales was not surprising. Most existing scales, although they reported measuring more than one domain of personal recovery, also reported one dominant underlying construct: personal recovery ( 15 ). All the items had higher loading on the dominant factor (0.51–0.83) than the other possible constructs. This indicated that total scale score can be used in research studies. During the test-retest reliability assessment conducted over the two-week interval, the ICC values ranged from 0.62 to 0.88 (moderate to good level of reliability). This indicates that the new scale is a consistent measure over a two week time frame ( 59 ). There was a weak correlation between personal recovery and symptom severity. Studies in other settings reported mixed findings, some reported a weak correlation ( 60 ) while others reported a strong correlation ( 54 ). A distinguishing feature of the personal recovery construct is that it is not constrained to recovery measured by reduced symptom severity. A weak correlation with symptom severity and a moderate correlation with functioning support the validity of ReConnect as a measure of personal recovery. The moderate correlation with the WHODAS-2.0 indicates that the new ReConnect assesses a construct related to functioning, as expected, while maintaining conceptual distinctiveness from functioning. In China, a weak association between personal recovery and functioning was reported ( 61 ), while in Turkey, there was a strong correlation ( 54 ). In the Netherlands, personal recovery was explained by factors other than disability and functioning ( 62 ). Though we followed a rigorous process in developing the items, piloting, and validating the scale, there are limitations to consider. First, the average duration of illness among participants was ten years, which may not fully capture the conceptualizations of personal recovery among individuals with recent-onset illness. Secondly, the small proportion of participants diagnosed with major depressive disorder (MDD) with psychotic features may limit the measure’s generalizability to this population. Additionally, we excluded individuals with substance-induced psychosis, which might further narrow the scope of the measure’s applicability. Thirdly, the validation study involved a greater proportion of participants from urban areas. Nevertheless, the hospital receives referrals from all over the country, which may provide a geographical representation of the nation. Finally, we were not able to examine the predictive validity of the ReConnect in this study, but will be able to do so in our longitudinal study of recent onset psychosis in Ethiopia, SCOPE ( 63 ). The convergent validity will be assessed with the hope to recovery item in SCOPE. The conceptual relevance of the construct measured by the ReConnect will also be further explored in a qualitative study nested in the SCOPE project. Conclusions Based on a rigorous process, the new ReConnect was found to be a valid and reliable measure of mental health personal recovery in Ethiopia. The measure could be used in clinical settings or research studies to foreground the perspectives of people with lived experiences of mental health conditions on their recovery journey. The ReConnect has potential applicability to other similar settings where the community has a greater role in the recovery journey. Declarations Declaration of interest None Funding This study was funded by Wellcome grant 222154/Z20/Z. The funder had no role in the design, data collection, analysis, interpretation of results, or writing of the manuscript Author Contribution CH, AF, AA, ST, WF, TR, and LA conceived the study. WF, CH, AF, AA, ST, LA, TR, AM, AM, DK, AM, CL, EM and MB contributed to the design and analysis of the studies. WF drafted the manuscript. All authors revised the manuscript and approved the final manuscript. Acknowledgements Anneliese de Wet and Sumeet Jain, participated in the two online expert meetings. We appreciate their expertise and the time they dedicated to this effort. CH, AA, LA and EM receive support from the National Institute for Health and Care Research (NIHR) through the NIHR Global Health Research Group on Homelessness and Mental Health in Africa (NIHR134325), using UK aid from the UK Government. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. CH also receives support from Wellcome Trust grant 223615/Z/21/Z. For the purposes of open access, the author has applied a Creative Commons Attribution (CC BY) licence to any Accepted Author Manuscript version arising from this submission. Data Availability Data can be obtained from the coordinating author upon reasonable request. References Slade M. Personal Recovery and Mental Illness: A Guide for Mental Health Professionals. Cambridge University Press; 2009. Van Eck RM, Burger TJ, Vellinga A, Schirmbeck F, de Haan L. The relationship between clinical and personal recovery in patients with schizophrenia spectrum disorders: a systematic review and meta-analysis. Schizophr Bull. 2018;44(3):631–42. Leamy M, Bird V, Le Boutillier C, Williams J, Slade M. 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Supplementary Files Supplementaryfile1.docx Cite Share Download PDF Status: Published Journal Publication published 31 Aug, 2026 Read the published version in International Journal of Mental Health Systems → Version 1 posted Editorial decision: Revision requested 10 Apr, 2026 Reviews received at journal 10 Apr, 2026 Reviews received at journal 05 Apr, 2026 Reviewers agreed at journal 26 Mar, 2026 Reviewers agreed at journal 12 Mar, 2026 Reviewers invited by journal 26 Feb, 2026 Editor assigned by journal 15 Jan, 2026 Submission checks completed at journal 15 Jan, 2026 First submitted to journal 14 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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