Pilot study of illness perception questionnaire for schizophrenia

Author: Iloka Benneth Chiemelie

Published: 29-November-2014

ABTRACT

Background: Schizophrenia is a common illness in the world which effects from 0.3% up to 1.1% worldwide. In Malaysia, it effects an average of 1,200 cases every year in Malaysia.

Objective: To examine the reliability of the translated version of IPQS and to test the feasibility of the procedures and to gather information prior to a larger study.

Method: This is an experimental research in which respondents were selected from affected hospitals and their studied in order to understand how reliable the IPQS survey is in the Malaysian context.

Result: Findings show that IPQS just as in its English version is also reliable in the Malaysian setting because respondents with high degree of awareness about their illness were attached with high degree of response to treatments.

Conclusion: The Malay version of the questionnaire is reliable to be used among Malaysian and we considered our series as a first step for a more detailed approach to the study Illness Perception.

Keywords: Schizophrenia, Illness Perception, Illness Perception for Schizophrenia (IPQS)

INTRODUCTION

One of the major challenges faced by those providing services for people with severe mental health issues is the poor level of engagement with treatment. For instance, a number of research suggest that at least half of the people that have been diagnosed with schizophrenia don’t comply with their medications regimen, and such low level of compliance will influence high rates of relapse and re-hospitalization with a general poorer outcomes (Perkins, 2002). In the forensic view, this issue is very significant because low level of compliance will influence higher rates of re-offending (e.g., Swanson et al., 2008).

A number of factors have been found to influence poor compliance with medications, which includes experiences from negative side-effects such medications, negative attitudes towards it, abuse of substances, lack of outside supports, demographics variables and impairment of cognitive reasoning (Jeste et al., 2003; Perkins, 2002; Pogge, Singer, & Harvey, 2005; Sajatovic, Valenstein, Blow, Ganoczy, & Ignacio, 2006).

While much attention have been accorded to factors such as their attitude towards medications, less attentions have been accord to their beliefs about the condition itself. In any case, a number investigations have been done with the aid of traditional construct of insight but outcomes from such studies have been mixed. Some of the have reported a decline in compliance with reduced insights t (e.g., Amador & Strauss, 1993), while others have not been able to notice such (e.g., Budd, Hughes, & Smith, 1996). The absence of a consensus in definition and resulting differences in terms of and resulting differences in terms of how the constructs are measured can offer needed explanations to such understanding (Budd et al., 1996).

The framework of the Health Belief Model (HBM) has been successful in addressing existing links between conditions and compliance (Janz & Becker, 1984). Two factors have been postulated by the model as having an influence on health behaviours that are related to people’s belief about their conditions as: Susceptibility (belief that one is vulnerable to the illness) and Severity (belief that the illness does have some level of consequences). Additionally, the results in this area has also been mixed. Some of the studies have noted that both constructs have positive correlation with better compliance with antipsychotic and/or lithium medication (Adams & Scott, 2000; Budd et al., 1996; Kelly, Mamon, & Scott, 1987), but other studies have not found any association between these consequences and constructs (Connelly, Davenport, & Nurnberger, 1982; Pan & Tantam, 1989). Another issue with this studies is differences in terms of the way the constructs are measured (Adams & Scott, 2000). There seems to be no widely accepted standards in terms of how the HBM constructs are measured as none of the studies conducted in line with such have made use of the same measure. Majority of the measures used where invented for the purpose of the study and are not known or have poor psychometric properties. Some of such studies have laid high emphasis on self-report as measure of compliance without further external validations. A common criticism has been that of exclusive focus on compliance with medications. Additionally, attentions have been given to engagement in other aspects of treatment like cognitive behaviour therapy and social activities. Within the realm of psychosis, Hall, Meaden, Smith, and Jones (2001) did view such engagements as being of different dimensions such as meeting attendance, willingness with discussion of personal issues, the extent of therapeutic relationship and undertaking designated tasks.

In the same wing, another theoretical framework has been provided for exploring the influence of beliefs about a condition of patients and such ideology is provided in the Common Sense Model (CSM) of self-regulation of health behaviour (Leventhal, Brissette, & Le-venthal, 2003). This model was created within the field of physical health. In this model, people are seen as common sense scientists that try to understand their illness by presenting a representation of what it is all about, and adopting such views to guide their behaviour in order to fill up existing spaces in terms of their current health status and desired health status.

In the area of qualitative research that have been done on physical health, six dimensions of such representativeness has been proposed as: Identity (what the patient believes about the symptoms and actual diagnosis), Timeline (what is believed about the temporal cause of such illness, Cause (belief about the aetiology of the illness), Control / Treatment Control (belief about how the condition can be treated) and Control / Personal Control (belief that the patient can influence the illness through his or her own actions), Consequences (belief about the impact that such illness will have on the customer, and Coherence (to what extent the person belief that he or she understands the condition). In order to measure all the dimensions discussed above, the Illness Perception       Questionnaire (IPQ) and the Illness Perception Questionnaire-Revised (IPQ-R) (Moss-Morris et al., 2002) have been created as the right tool for conducting such measurement. Contrasting with researches that have adopted the construct of insight and/or the HBM, increased adoption of this questionnaire has offered needed consensus on the right tool for measuring the constructs within the CSM framework.

Based on earlier understanding, it has been noted that the model proposes that the representation of illness does have direct influence on the behaviour of the individual who is undergoing responses to the illness because attempts are made in order to narrow existing gaps between current situations and desired outcome. In the realm of physical health research, many of the IPQ/IPQ-R have been found to have relational effects on treatment engagement. Taking Cooper, Lloyd, Weinman, and Jackson (1999) as an example, the researchers discovered that a patient’s attendance at a cardiac rehabilitation program does influence two control dimensions (treatment and personal) positively. In a study conducted on patients that were recently hospitalized with cardiac diseases, Stafford, Jackson, and Berk (2008) made the discovery that  high scores on the dimension of consequences does have subsequent predictive power on adherence to recommendations on changes in lifestyle that are geared towards preventing such illness. Searle and Murphy (2000) conducted another but related study, and came with the reports that beliefs that the conditions will be long-lasting (on the dimension of timeline) does predict some of the aspects of adherence to recommendations that are offered by a homeopathic practitioner.

Recent studies have explored how the CSM can be applied to people with severe mental difficulties. Lobban, Barrowclough, and Jones (2004, 2005) made use of the IPQ-R for people with schizophrenia and produced some encouraging results in the area of reliability and validity analyses. Their 2005 paper also conducted an investigation on the relationship between IPQS and Drug Attitude Inventory. The later study was conducted to assess attitudes towards anti-psychotic medications and it was found to be correlated with compliance to medication (Hogan, Awad, & Eastwood, 1983). The treatment of control dimension does have significant positive correlation with scores obtained in this inventory, which is a clear indication that those who have more positive beliefs about medication are more likely to believe that their illness can be treated. Those who have more positive believe about their medications were also found to be more likely to attribute their symptoms to mental health issues (identity dimensions) as well reporting reduced understanding of their conditions (coherence dimension).

The work of Lobban et al. (2005) has expanded an understanding on the present studies by investigating the possibilities of the IPQS dimensions being associated with actual engagement of treatment, instead of attitudes towards medications. Participants in this study included people suffering from psychosis and detained in a secured setting. In the view of countering criticism that previous researches have focused greatly on compliance with medications, the present study made use of methods of engagement within the range of available therapies and treatments. Both self-report and staff-report were adopted in order to reduce overreliance on self-report. Based on the basic study of Lobban et al. (2005) as well as researches conducted on physical health, it was hypothesized that better engagement in treatment will result to the belief that the conditions are long-lasing and reoccurring (measured by timeline); does have a more severe impact (measured by consequences), can be influenced by the actions of patients (measured by control), is not easily understandable (measured by coherence), and that the symptoms can be attributed to mental health difficulties (measured by identity).

METHODS

Sample

This study took place at Hospital Permai, Johor. Total population in the hospital is 830 and 545 in-patients were qualified for the study. There are 365 males and 180 females. Prior to a larger trial, sample size involving 30 patients was interviewed consists of 20 males and 10 females. Random sampling were used get the patients for this study. The mean age of participants is 34 years old with a standard deviation of 10.9 and the mean duration of their present period of residence in the institution is 3 years with a standard deviation of 4.0. All the participants have been in the institution for at least 6 months and they all had prescription for antipsychotic medication during the time of the study.

Materials

IPQS has an adequate sensitivity and specificity. It has been translated to Malay language. The translation process was followed according to the MAPI translation steps and guidelines. The questionnaire has composed of 81 questions which consists of the following subscales: identity, timeline acute, timeline cyclical, consequences, personal control, personal blame, treatment control, illness coherence, emotional representation. Identity and causes are calculated separately as there are not included as one of the subscales.

Participants took part by completing the IPQS (Lobban et al., 2005) as well as 24-item shorter version developed by the University of Rhode Island Change Assessment (URICA) (DiClemente & Hughes, 1990). The URICA was modified in order to align it with the mental health context and the only construct adopted in the analysis is the Action subscale. The purpose of the subscale is to measure the extent at which participants viewed that they are taking necessary steps towards addressing their mental health issues. The six items gathered information about participant’s perception of engagement on a general level (for instance, “I am taking active steps to change my mental health issues” and ‘I am working very hard to change”). The assumption for such assertion is that this general views will be sensitive to behavioural engagements such as participants attendance to sessions without prompting, and their willingness to discuss personal issues in the therapy. Participants completed the questionnaire in the presence of a researcher and were accorded necessary assistance when they called for it. One member of the nursing staffs new the residents very well this staff completed the Service Engagement Measure (SEM) (Hall et al. 2001); which is a 12-item measures that is designed to be used for people with severe mental health difficulties and it covered aspects such as compliance with medications, attendance of appointment and openness when discussing personal issues.

Participants’ criterion

In order to ensure that participants in this study fall within the category of individuals who are targeted for the research, a number of criterion was set as a measure of whether or not a participant can be taken into consideration in the study and these criterion include: the participant must be diagnosed with schizophrenia, must have schizoaffective disorder or psychosis, must be fluent in English and/or Malay; must not have any major cognitive impairment, and must not have any kind of symptom, behaviour or attitude in their state of mind that have result to distress or put the participant in any danger to his/herself or that of others participating in the study. The unit staffs were given the responsibility of judging whether or not these criterions have been meet.

RESULTS

The mean, standard deviation, Crombach’s alpha and range are provided in the table 1 below for each of the measures used in this study. The table showcase high scores for both the URICA and SEM in terms of gender engagement. Higher timeline scores shows that the conditions will last for a long time (likely to be acute or chronic) or possibly relapse (cyclical); consequences shows that respondents believe that they will have greater negative impact; treatment and personal control shows believe in greater control of the issue; while coherence indicates believe in clear understanding of the conditions; and identify attributes the symptoms to difficulties with mental health. Additionally, a closer look at the findings shows that some of the attributes have scores below the standards of 0.7, which is a clear indication of poor internal consistency. The standardization study (Lobban et al., 2005) shows that in the case of this study, Treatment and Personal Control represents the least reliable subscale while Personal Control also fall below the acceptable standards. The IPQS mean score shows similarity with that reported by Lobban et al. (2005) and participants from the two units studied did not show significant difference on any of the measured. The obtained correlation between the URICA Action and SEM is only 0.28 (p=14), which is a sign of reduced validating in one or both of the measured used for the study. In any case, the table 1 below shows that both of the measured did show relatively good internal consistency.

Table 1: Descriptive statistics for the IPQS, SEM and URICA

	Mean	Std. deviation	Alpha cronbach
IPQS Subscales
Identity	26.7	6.34	0.88
Timeline acute	17.73	6.00	0.91
Timeline cyclical	11.73	3.79	0.91
Consequences	35.53	7.19	0.74
Personal control	14.13	2.13	0.56
Personal blame	11.4	3.17	0.98
Treatment control	20.50	2.76	0.49
Illness coherence	9.47	3.40	0.70
Emotional representation	27.33	6.30	0.78
SEM	41.0	7.7	0.86
URICA Action	23.1	4.7	0.85

Established correlation between the IPQS and measures of engagement are documented in table 2 below. Three of the constructs used in IPQS are found to be significantly correlated with the Action measure. Following entrance into a multiple regression analysis, these three measures accounted for 46% of the variance recorded in Action scores, F(3,26)¼9.10; p5.000, adjusted r 2¼0.46). I is important to note that none of the IPQS measures has any significant correlation with the SEM scores. Except for Coherence that recorded an opposite of what was expected, all other correlation were in the predicted directions.

Table 2: Table II. Correlations for the IPQS, SEM and URICA

	Timeline Acute/chronic	Timeline Cyclical	Consequences	Treatment Control	Personal Control	Coherence	Identity (Mental health)
URICA Action	.52** (.004)	.42* (.026)	33 (.055)	.72** (.000)	.25 (.218)	.16 (.374)	.32 (.111)
SEM	.23 (.254)	.17 (.356)	33 (.106)	24 (.166)	.22 (.249)	.25 (.137)	.25 (.142)

DISCUSSION

Evidence has been provided in this study that patient show perceive their conditions to be chronic (timeline), having potential to relapse and treatable (Treatment Control) are more likely to indicate that they have been actively involved in activities designed towards addressing their mental health issues. A significant amount of evidence has also been recorded in researches conducted with the settings of physical health that there is a correlation between engagement in treatment and both timeline (e.g., Searle & Murphy, 2000) and treatment control measures (e.g., Cooper et al. 1999). Similarly, Lobban et al. (2005) with report of a significant relationship between treatment control beliefs and positive attitude of patients towards medication and they will in turn predict the compliance with medications. Contrasting with these previous studies, there is not significance between established correlation on engagement and identity, and correlation between engagement and coherence had opposite direction with what was reported by Lobban et al., (2005).

In any case, recorded self-reports were not correlated with that of staff report on the levels of engagement. The correlation between self-report (the URICA) and staff report (SEM) on the level of engagement were not found to be significant and none of the reviewed IPQS has significant correlation with the measures in staff report. However, there is no clear reason why such is the case and it should be noted that correlation between self and other ratings of psychological states and behaviour in this study seem to be always poor (e.g., Becchi, Rucci, Placentino, Neri, & DeGirolamo, 2004) and a number of researches have raised issues with the validity of rating of medication compliance that are recorded by health-care providers (Osterberg & Blaschke, 2005), but such issues can have less significant influence when it comes to inpatient settings. The issue in this case was likely influenced by the fact that while the two measures may have entangled into a complex an underlying construct, they have been able to address these aspects differently to a considerable extent. Take for instance, the SEM did include an item in relation to compliance with medication but no specific reference was made to this by the URICA in relation to the extent at which participants have been actively addressing their health issues, and participants might have omitted consideration of their compliance to medication in this part.

Irrespective of these limitations, this study is in line with earlier findings (Adams & Scott, 2000; Budd et al., 1996; Kelly et al., 1987; Lobban et al., 2005), as it makes the suggestion that people’s belief about their mental health conditions should be explored to a further extent because it does have potential influence on their engagement with treatment. As such, it can be concluded that Malay perception of mental illness does have an influence on Malay schizophrenic patients.

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