Translation and psychometric validation of the Mental Illness: Clinicians’ Attitudes Scale (MICA-4) to assess attitudes of primary care physicians in Pakistan

Abstract Background Negative and stigmatizing attitudes towards people suffering from mental disorders among healthcare providers often act as a barrier to mental healthcare access. To assess these attitudes in primary care physicians (PCPs), a robust, culturally tailored psychometric tool is crucial. This study aimed to translate and psychometrically validate the MICA-4 to assess negative attitudes among PCPs in Pakistan. Methods We recruited two independent samples of PCPs (n=191, n=329) using non-probability sampling. Three bilingual mental health professionals forward-translated the scale, which was then independently reviewed and back-translated. Cognitive interviews were conducted (n=15 PCPs) to assess comprehension and clarity, for the final version to be used in the study. EFA was conducted on Sample 1 to examine the underlying factor structure of the Urdu MICA-4 items. CFA was then performed on Sample 2 to cross-validate the factor structure identified in Sample 1. Internal consistency and convergent validity were also assessed. Results A three-factor solution was retained, including Views (seven items), reflecting clinicians’ general evaluative perspectives toward mental illness and professional roles; Stereotypes (five items) representing generalized beliefs and disclosure-related concerns regarding individuals with mental illness, and Stigma (three items) capturing social distancing and perceived threat-related attitudes. The Comparative Fit (CFI = .958) and the Tucker-Lewis Index (TLI = .946) indicated good fit. Three items (9, 13, and 12) were removed due to weak loadings (< .40). Composite reliability (ω) indicated adequate internal consistency for the Views (ω = .70) and Stereotypes (ω = .74) factors, and lower for stigma (ω ≈ .53). Convergent validity was modest (.40 to .44). Conclusion The findings support the cautious use of Urdu MICA-4 in Pakistani primary care settings. The variability in the factor structure of the scale across cultures raises a practical implication for its dissemination. When item-level instability repeatedly emerges across contexts, permitting limited, evidence-based refinement may strengthen measurement stability and comparability, as well as its reliability in diverse healthcare settings.