Translation and content analysis of the Instrument “Opening Minds Scale for Healthcare Practitioners (OMS–HC)” for the assessment of stigma towards mental illness in health care professionals in Chile

ABSTRACT

Introduction: People who suffer mental illnesses frequently experience stigma from health care professionals. That is why it is urgent to have proper assessments aimed to evaluate stigma and address it. This document describes the process of language translation and content validation in Chile of the “Opening Minds Scale” for the assessment of stigma against people with mental illnesses in Healthcare Practitioners (WHO–HC), originally developed in Canada.

Methods: Language translation and content validation analysis were performed, including English–Spanish translation and reverse translation by a professional translator, item triangulation by researchers, and content validity analysis of the translated questionnaire by expert evaluation based on the Content Validity Index (CVI), including 10 experts in academy, research, and one expert by experience on Mental Health. Items rated with CVI 0.51–0.99 were considered acceptable.

Results: From the total of 20 items of the questionnaire, two were rated with a CVI lower than acceptable, specifically related to the constructs "hope" and "compassion", part of the theoretical framework of Recovery, the questionnaire is based on. The two items were re–evaluated including original authors to adapt them seeking, trying to keep fidelity to the foundational constructs, by means of an iterative process with experts.

Conclusions: The translation of the document “Opening Minds Scale for Healthcare Practitioners (WHO–HC)” is hereby presented. It has been adapted into Spanish –in Chile– with of content validation, consisting of 20 items for the evaluation of stigma towards people with mental illness in health professionals, enabling the development of new studies to analyze criterion validity, and the exploration of feasibility and utility locally.

INTRODUCTION

According to the WHO (World Health Organization), prevalence of mental disorders is still increasing, with significant effects on people´s health, and significant consequences on social/economic stratum, apart from human rights implications ⁽¹⁾. Mental disorders have severe implications not only related with their clinical aspect, but these extend to social/cultural scenarios. Among such implications, it is possible to find stigma phenomenon. Stigma may be understood as a set of negative traits a social group has with others groups, as these have some type of differential trait to be easily identified ⁽²⁾. Stigma, as a phenomenon linked to health, has been a topic of discussion and relevant theoretical development. Frequently, people who have mental disorders experience stigma from other people who do not have mental disorders, or from others groups, such as health professionals ^(3,4) because of beliefs on mental disorder deemed as dangerous, inadequate or unpredictable people ⁽⁵⁾. This is how people with mental disorders tend to be treated only according to his/her diagnosis, thus creating a segregation or disrespect and preventing to really learn about his/her actual social identity more widely ⁽⁶⁾. This is also translated into abolition of other immediate health needs ⁽⁷⁾. Likewise, people with mental disorders refer to feel rejection, to be discouraging advices, and scornful comments ⁽⁸⁾. Because of the aforementioned, it is necessary to understand stigmatization processes and the relationship among their components in order to avoid it. Opening Minds started in 2007 as an initiative of the Mental Health Commission of Canada, aimed to improve mental health system and to address attitudes and behavior of Canadian people regarding mental health problems specifically related with stigma. In this context the questionnaire “Opening Minds Scale for Healthcare Practitioners (OMS–HC)” was developed in order to evaluate stigma towards people with mental disorders in health professionals ^(9.10). OMS–HC has been translated, content validated, and construct in several countries and it has been used to evaluate stigma in college professional students from health areas ^(11,12).

This work is aimed to describe the processes of translation, and cultural adaptation in Chile of the OMS–HC questionnaire, as part of the research project CP201805 "Stigma to mental disorders in the academic community of Universidad Central". It was made with the authorization and cooperation of the program “Opening Mind”, Canada, authors of the instrument.

MATERIAL AND METHOD

Validation of the document translation was made by following Trochim guidelines ⁽¹³⁾, who states that validity analysis of translation involves to determine if the operationalization into items is a proper glimpse of the construct, assuming the researcher has a good/comprehensive definition of this and may compare the instrument against that definition. Translation validity is subdivided into two other types: face validity, content validity. After the validity analysis of the translation, the next step is validity analysis of the criterion (predictive / concurrent / convergent / discriminating validity). Such model was used to carry out translation and analysis of face validity of the content. Figure 1 describes the methodology used.

Figure 1. Stages in the translation and validity analysis of the content

Source: Made by the Team

The instrument was translated into Spanish by two research team members, to be further triangulated, by mans of consensus, in to a preliminary version of the instrument into Spanish. Later, such version was subject to inverted translation (Spanish–English) by a professional translator who also performed the translation of the instrument from the original language (English–Spanish). With that information ready at the stage of translation, the research team triangled –by agreement– every item, thus creating the version of the instrument to be subject to content validity evaluation by experts. This process, as per Lawshe guidelines ^(14,15), by using the Content Validity Index (CVI), with 10 experts(as) from the research area, the academy, an experienced expert in mental health. By using a digital form, every expert evaluated the 20 items of the instrument. Each of the following categories was assigned to every one – unnecessary, useful, or essential. The inquiry to experts also addressed some aspects regarding intelligibility of the items statements of the questionnaire. ICV calculation for every item was made by using the following formula:

Being ne the number of experts who have valued the item as essential and N is the total number of experts who have valued the item. IVC ranges between +1 –1, being the positive scores those stating a better content validity. Items having an IVC range between 0.51–0.99 were defined as acceptable.

This study deals with the first phase of the research project CP201805 "Stigma towards mental disorders in the academic community of Universidad Central", which was approved by the Scientific Research Ethics Committee of the Universidad Central de Chile, on December 14th , 2018.

RESULTS

Based on the experts´ evaluation, Table # 1 shows the scores for Content Validity Index, as per item

Table # 1. Content Validity Index for each Item, as per expert´s assessment

It was observed that items 1, 11, 20 got an IVC lower than acceptable. Item 1 was initially translated as: I feel more comfortable/helping a person who has a physical disease, rather than helping a person who has a mental disorder. Considering the questionnaire evaluates professional perception, such translation was modified to: I feel more comfortable/assisting a person who has a physical disease, rather than assisting a person who has a mental disorder, mentioning the work with PEM more explicitly (explain the Acronym). Adaptation of items 11 and 20 involved deepening theoretical constructs of the instrument, with participation of the original authors. Item 11, original in English, says: “It is the responsibility of health care providers to inspire hope in people with mental illness”. On its part, original item 20 says: I struggle to feel compassion for a person with a mental illness. The literal translation of the terms “hope” “compassion” as “hope” “compassion” (in Spanish) got a low IVC by the experts(as), which could be explained by the connotation of both concepts. For instance, the concept of “compassion” is related with paternalist altruism. On its part, the idea of “hope” may have a connotation that hinders its feasibility in the relationship between health professionals and patients. In its original expression, both concepts come from the reference framework of Recovery, which states operational definitions for both. Considering such framework, in order to remain as faithful to the base construct as possible, trying to get the best cultural adaptation, the following new statements were made:

Item 11: Health professionals have the responsibility to tell people who have a mental disorder that his/her life is going to be better.

Item 12: It is hard for me to feel empathy for what a person with mental disorder lives.

DISCUSSION

As this is a socio–cultural phenomenon, generation of constructs and stigma evaluation instruments require some research processes which allow to model in a culturally sensitive manner such attributes ^(16,17). The aforementioned is specially relevant in the study of the stigma towards people with mental disorders, given also the social/cultural implications that mental health and psychiatry have. In this context, this work is aimed to describe the content validity translation process of a questionnaire which allows to approach stigma evaluation towards people with mental disorders. The pertinence to detail the initial process of its validation including the translation and the content validity analysis lies in highlighting how the translation of constructs is not limited to its language aspect, but it has a higher complexity and involves methodological decisions. For instance, the constructs “hope” “compassion”, that represent key dimensions of the base theoretical model (Recovery), had significant hindrances in its literal translation, due to the idiosyncratic designations the concepts of “hope” “compassion” have in mental health and psychiatry contexts, which involved an agreed interpretation analysis, relevant for avoiding terms which could not be understood and hence, interfere the instrument validity in the Chilean context. Cultural adaptation processes are relevant, but usually, these are not explicitly/starkly considered in the validity analysis of instruments, as the immediate analysis of the validity criterion is usually underestimated ⁽¹⁸⁾.

This study makes the adaptation of the instrument “Opening Minds Scale for Healthcare Practitioners (OMS–HC)” available for evaluation of the stigma towards people with mental disorder in health professionals, to be used for professionals or researchers, and opening opportunities to start interventions aimed to decrease the stigma in health professionals in the mental health area. For instance, there is an interesting development of the instrument, as part of the methodology for evaluating attitudes in health undergraduate students, facilitating the review of the curricula and the optimization of its approach to these aspects, during training of future professionals of the area ^(11,12).

A strength of the validity content analysis made is that among the experts inquired, we received input from an experienced academic expert, i.e. a person who has experience in psychiatry diagnosis: therefore, based on his appraisal and experience as a user of mental health services, he stated very relevant comments about the constructs and terms used. The inclusion of experienced experts is a highly recommended strategy in research and knowledge transference in mental health and psychiatry ^(19,20). Even though this study included only one round of questions for the experts, various pieces of literature recommend to perform more queries, thus stating a process iterative. However, triangulation and methodological decisions of the research team were achieved by means of meetings with the original authors of the questionnaire, which allowed to have more reliable access to understand the purpose of the problematic constructs and their theoretical base, thus facilitating the agreement on the adaptations to be made.

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