Chapter 5 Methodology Methodology
5.3. Instrument
5.3.1. Concerns and adaptation of the instrument
The Attitudes and Beliefs about Mental Health Problems: Professional and Public Views’ Questionnaire was originally designed for a population greatly different from that of South Africa. The researcher in this study was therefore concerned that this questionnaire may not entirely meet or reflect the language and cultural context of the current study population. This necessitated the adaptation of this questionnaire to the South African context. Several changes
were made to the questionnaire during adaptation, which will be discussed in this section.
In the first part of the questionnaire, the consent form was changed to introduce the researcher, the aim of the study, and broad areas of enquiry that are covered in this study. In the section enquiring about demographic information, items asking participants if they were widowed or living with a partner were added to the questions related to marital status. Items eliciting information about the district in which participants lived, their race, their highest level of education attained, their religious affiliation and language spoken were also modified to reflect the South African context.
It has already been stated that the original questionnaire used vignettes covering four mental illnesses namely depression, schizophrenia, social phobia and PTSD. In the second part of the questionnaire, only two diagnoses included in the original questionnaire, depression and schizophrenia, were retained for this study.
However, the details of the vignettes were adapted from Goldney et al. (2005) and Jorm et al. (1997). The third vignette used in this study depicted the symptoms of someone who meets the diagnostic criteria for alcohol dependency, and this was adapted from Link et al. (1999). To substantiate the selection of diagnosis for each vignette, depression has been found to be among the most prevalent DSM disorders in numerous studies conducted in South Africa (Stein et al., 2008; Williams et al., 2008). In large epidemiological surveys, the lifetime prevalence of major depressive disorder was found to be about 10 per cent of the general population (Joska, 2007). In a nationally representative household survey conducted in South Africa between 2002 and 2004, Tomlinson et al. (2009) found the lifetime prevalence of major depression to be 9.7%, with the prevalence being significantly higher among females than males.
Regarding the choice of the second vignette, schizophrenia is a complex syndrome that inevitably has a devastating effect on the lives of the person affected and their family members (Barlow & Durand, 2011) and has a significant impact on health services and the economy of the country (Baumann, 2007). Its prevalence appears to be in the 0.5% - 1.5% range of the adult population worldwide (Jordaan, 2010), and the incidence is remarkably similar across the world, in both developed and developing nations (Baumann, 2007). A vignette used in this study for schizophrenia was also adapted from Link et al. (1999).
With respect to the third vignette, substance related disorders are highly prevalent among the South African population and are a serious concern. Recent
data on the prevalence of alcohol use and abuse shows that 9.9% of females and 27.6% of males in South Africa can be considered to be alcohol dependent (Thom, 2007). According to Williams et al. (2008), the estimated prevalence of substance abuse in South Africa is at least twice as high as that in other WHO World Mental Health countries. A vignette describing a person suffering from alcohol dependence was therefore also taken from Link et al. (1999) to be used in the questionnaire employed in thus study.
In order to make the vignettes of this study more relevant to the South African sociocultural context, the following additions were made to them. Firstly, the names of the characters presented in the vignettes of the original DSM questionnaire were Jenny for the female character, and John for the male character. In this study, these names were replaced by Zanele and Bheki for the female and male characters, respectively. Secondly, for the vignette depicting someone suffering from schizophrenia, the voices were made to be specifically that of the character’s grandmother who had passed away 10 years ago. Visual hallucinations of the grandmother were also added to the vignette. The rationale behind this decision was to make the character more culturally relevant to the South African population, since the ancestors play an important part within African cosmology.
Furthermore, in the depression vignette, a suicidal behaviour was added in an attempt to strengthen the clinical nature of the vignette to participants. No changes were made to the alcohol dependency vignette. Care was taken to ensure that the language used in these vignettes and the whole questionnaire was easy, accessible, and common to South Africans in general. Appendix A shows the three vignettes used in this study. To control for stereotypes associated with certain gender roles, the names Zanele and Bheki were assigned to all three vignettes.
However, the results of this study are presented according to diagnosis assigned to a vignette, not by vignette gender.
Once the modification of the vignettes was completed, and even prior to the completion of the adaptation process of the entire questionnaire, diagnoses presented in these vignettes were confirmed by requesting three clinical psychologists with more than three years of clinical experience to read and provide a diagnosis for each vignette. They all correctly diagnosed these vignettes.
Vignettes used in this study have been used previously in studies of mental health literacy abroad (Fisher & Goldney, 2003; Jorm et al. 1999; Jorm et al. 2006; Link et al. 1999). Vignettes in general have also been used in numerous studies of this
nature in Australia (Mccan et al., 2009, Marie & Miles, 2008, Scott & Chur-Hansen, 2008), South Africa (Samouilham & Seabi, 2010), Israel (Levav et al., 2004) and Germany (Schomerus et al., 2009).
Questions contained in the third part of the questionnaire that aim to elicit participants’ knowledge, attitudes and perceptions of mental illness remained largely unchanged. A few changes made to this part of the questionnaire however included adding a prognostic question, for example, what do you think is the cause of Zanele’s problem/s? In other Likert type questions where a list of possible answers is provided, some items common to the South African cultural context were added. For example, sangoma (diviner), nyanga (herbalist) and umthandazi (faith healer) were added on the list of different professionals who could possibly help the character depicted in the vignette. Some items added to the questionnaire in the current study were derived from previous studies of mental health literacy (Barlett, Travers, Cartwright & Smith, 2006; Marie & Miles, 2008; van
`t Veer et al., 2006). Examples of specific questions contained in the questionnaire are provided in the next chapter when reporting on the results of the study. A complete copy of a questionnaire used in this study is attached as Appendix B.
The questionnaire, in general, was adapted to the South African language spoken by the participants to reduce the likelihood of ambiguity. The whole questionnaire was written intentionally in an easy and ‘free from jargon’ English.
The researcher in this study had anticipated that, since the study was a community survey, some participants may be more likely to be comfortable completing the questionnaire using their mother tongue. The vignettes and the complete questionnaire were, therefore, translated into isiZulu. This was done by adhering to Babbie and Mouton (2001), Flisher, Ziervogel, Chalton and Robertson (1993), as well as Rosnow and Rosenthal’s (1996) suggested translation guidelines. Two experienced isiZulu translators with a university postgraduate qualification (Honours Degree) in Psychology were asked to translate the questionnaire. The first one translated the English questionnaire into isiZulu and then the other back-translated the isiZulu version into English without having seen the English version. After this forward and back translation, these translators had a meeting with the researcher where both the translated and back-translated versions were compared with the initial English version of the questionnaire. Where discrepancies in these translations were noted, they were resolved through discussion and consensus among translators.
The main challenge experienced and acknowledged by these translators was the lack of uniform isiZulu words for medical and psychiatric terminology.
Where no equivalent isiZulu words could be thought of this was resolved through making use of different words that constitute a sentence that still conveys the essence of the meaning contained in the word. Once the two translators and the researcher were satisfied with this process, both the English and isiZulu versions of these questionnaires were presented to one of the supervisors of this study, who has extensive experience in the translation of psychological concepts into isiZulu, for a final check and editing. Copies of the isiZulu versions of the vignettes are attached as Appendix C, while Appendix D comprises the complete copy of the isiZulu questionnaire used in this study.