Development of a tool to assess the knowledge of mental illness among the family members of mentally ill

Background: Knowledge of family members or caregivers regarding mental illness plays a vital role in treatment for persons with mental illnesses. There are limited numbers of standardised tool that measure the existing knowledge of family members regarding mental illness. The present study aimed to develop a valid and reliable tool to assess the knowledge of family members regarding mental illness. Methods: A 46-item questionnaire was structured following the scientific tool development steps. Six domains, namely basic information, need of treatment, medication administration, side-effects and management, consequences of non-adherence, and psychosocial treatment were included in the tool. Content validity of the questionnaire was established by accepting more than 80% validity index for each item. To test the reliability, questionnaire was applied to 100 family members of persons with mental illnesses. Results: Statistical analyses showed good internal consistency by Chronbach’s alpha (r=0.831) and Spearman Brown-Proficiency formula (r=0.88). Score of all the six individual domains were significantly correlated with the total score of the tool indicating acceptable sensitivity. Significant correlation was found among the score of domains indicating good construct validity of the structured questionnaire. Conclusion: The constructed questionnaire can be used in research studies of related field by considering its acceptable psychometric properties.


Introduction
Mental illnesses are common non-communicable diseases. Prevalence of mental disorders is found to be 73 per 1000 population. [1] Lifetime prevalence of mental disorder is found to be 5.03% in urban population. [2] Treatment of mental illness comprises early detection, prompt treatment, rehabilitation, and prevention of relapse. Involvement of family members is essential in the treatment process. Family members have a major role in re-socialisation, vocational and social skills training of the patient. [3] Awareness regarding mental illnesses is much lesser than other non-communicable diseases. Studies showed poor knowledge of mental illness among the community people. [4,5] At the same time, negative views of mental illness was found to be widespread, with as many as 96.5% with standard deviation 0.05. [4] Negative views on mental illness are found to be prevailed in the Indian community also. [6] Study shows that the family members of person with mental illness being admitted to hospital had significant lack of information regarding nature and aetiology of mental illness. [7] The common people are unable to recognise the symptoms as a part of mental illness even though treatment process has become advanced. Knowledge of mental illness is related to insight and medication adherence. [8] Inadequate knowledge of mental illness is found to be associated with poor treatment compliance. [9,10] Better knowledge of mental illness is found to be the predictor help-seeking behaviour. [11] Knowledge regarding mental illness among the caregivers aid in early identification of symptoms and early help-seeking for the mentally ill person, and that leads to better outcome in treatment process. [12] Increased knowledge about mental illness help the family members to cope with the symptoms and solve the problems related to mental illness. Family members with inadequate knowledge about mental illness are often reluctant to seek help and which ultimately make the illness chronic.
Even though many of the research studies have intended to measure and improve the knowledge of mental illness in family members and community people, most of the studies have used the self-structured measurement tools as per the socio-cultural context of the particular population. There is no standardised valid tool to measure the existing knowledge of mental illness of family members in North-East region of India. So, it becomes imperative to develop a tool to measure knowledge of mental illness in local language by considering the belief system and sociocultural context of the region. This tool will help to identify areas of weakness in people's understanding of mental illness and will also provide useful baseline data for family education in the treatment process.

Aim
The study was aimed to develop a valid and reliable tool to assess the knowledge of family members regarding mental illness.

Objectives
1. To select appropriate items for the questionnaire assessing knowledge of family members regarding mental illness 2. To establish content validity of the tool 3. To establish reliability of the tool.

Setting
The tool was developed at LGB Regional Institute of Mental Health, a tertiary mental health care institute in North-East India.

Developing the questionnaire
The tool has been developed with the following scientific steps-

Step 1
Item pool and item selection: An extensive review of literature related to knowledge of mental illness among the public as well as the relatives was performed. With the clinical experience of the researchers along with the information from the existing literature, a total of 52 items were constructed considering the area 'Basic information' , 'Need of treatment' , 'Medication administration' , 'Side-effects and management' , 'Consequences of non-adherence' , and 'Psychosocial treatment' .
The items were written in English language in the form of interrogative sentences. Every item has three answer option namely yes, no, and do not know. The grammatical correction was made by the expert. Every correct answer for the items denote one score each.

Step2
Establishing validity: Content validity was checked by seven experts in the field of psychiatric nursing, psychiatry, psychology, and psychiatric social worker. A total number of 46 items were short listed following the expert suggestion and calculating validity index for each item. The items with validity index 80-100% were accepted for the tool. Total 11 items in the domain 'Basic information' , five items in 'Need of treatment' , nine items in 'Medication administration' , six items in 'Side-effects and management' , six items in 'Consequences of non-adherence' , and nine items were included in domain 'Psycho-social treatment' . Reliability of the tool in English language was established by split-half method in ten samples.

Step 3
The tool was than translated to Assamese language by three bi-lingual experts and also back translation was confirmed by another expert. The back translated tool was found to be almost similar with the original sentences without changing the meaning. Content validity of the translated tool was ensured.
Step 4 Tool testing: The tool was piloted with ten family members of person with mental illness. The time taken to complete the questionnaire was eight to 12 minutes. The subjects did not find any difficulty in understanding the items.
Step 5 Reliability assessment: The tool was applied to 100 family members of person with mental illness who were receiving treatment from outpatient department (OPD). A master datasheet was prepared from the collected data and analysed with the help of Statistical Package for the Social Sciences (SPSS) 16.0 version.

Analyses and result
Sample characteristics Demographic data, in nominal level, of the family members of person with mental illness are described in terms of frequency and percentage in Table 1, and the data in continuous level are described in Table 2.

Score description for the tool
The description of total scores of the six domains along with the description of the total score is shown in the Table 3.

Item difficulty
Item difficulty was assessed for the accepted 46 items. 21.7% of the items (ten items) were found to be easier, i.e. scored by more than 80% of the respondents. All the items were included in the tool by considering the importance in the validity.

Internal consistency
Internal consistency of the tool was established by split-half method. The items were divided into odd and even numbers and Spearman Brown-Proficiency formula was computed for both the group. Chronbach's alpha was also computed for the tool (Table 4).

Sensitivity
Tool sensitivity was assessed by item discrimination. Item discrimination was assessed by finding correlation between the each item score with the total score of the tool. Total 43 items among 46 items were found to be satisfactorily discriminated. Item no. 22, 23, and 25 was found to be non-discriminating among the subjects (correlation is less than 0.2). Correlation between total score and the score of six domains were computed to assess the sensitivity of the domains with the total score. The result in Table 5 shows statistically significant correlation between the total score with the score in individual domains.

Construct validity
Construction of the tool was established by the correlation between the domains. The correlation between the domains is found significant as shown in Table 6.

Discussion
The aim of the study was to develop a valid and reliable tool to assess the knowledge regarding mental illness among the population. Total 46 items were included from 52 items by considering the more than 80% validity index. The tool was administered in 100 family members of persons with mental illness. Total score range found in the respondent was from nine to 44 with mean 32.4±6.67. This indicates that the respondents' score toward higher knowledge of mental illness. The result may be due to the experience of having a person with mental illness in the family. Mukherjee et al. [13] observed the positive impact on knowledge about mental illness and attitude or reaction towards persons with mental illness in those who had personal experience or contact of persons with mental illness.
Spearman-Brown Proficiency reliability coefficient was found to be 0.88 in split-halves among odd and even items. Chronbach's alpha was found to be 0.83. As the reliability coefficients above 0.7 are considered satisfactory, [14] the results for the constructed knowledge questionnaire indicate good internal consistency.
For the present constructed questionnaire, item discrepancy was calculated. All the items, except item no. 22, 23, and 25 were found to be sensitive to the tool (r≥0.2). These less sensitive items were also included in the tool by considering the validity importance. General nutrition knowledge questionnaire developed by Parmenter and Wardle [15] had also included some item with lacked consistency by considering its content validity.
The items of the tool were divided in six domains, namely Basic information, Need of treatment, Medication administration, Side-effects and management, Consequences of non-adherence, and Psychosocial treatment. The score of all individual domains are significantly correlated with the total score which indicates the sensitivity among the individual domains.
Convergent validity is the degree to which two measures of construct are related [16] and which can be estimated by   N=Number, SD=Standard deviation using correlation coefficient. [17] The significant correlation among the score of the various domains (Table 6) indicates good convergent construct validity for the tool.

Limitations
The current study included only one group of sample which makes difficulty in construct validity. Stability of the tool was not assessed. Some items were found to be too easy for the participants, but the same items were found to be essential for the population in the setting.

Conclusion
Assessing the knowledge regarding mental illness is essential in providing psycho-education and in total management   of a person with mental illness. The 46-item questionnaire was developed to assess the knowledge of family members regarding mental illness. The psychometric properties of the tool were found to be satisfactory to accept for any research study in the same related areas.