Shamshunnisah Abu Bakar*, Hasanah Che Ismail**

Transcription

1 ORIGINAL ARTICLE DESIGNING A CULTURE, LANGUAGE AND ILLNESS-SPECIFIC SELF- ESTEEM SCALE IN BAHASA MALAYSIA Shamshunnisah Abu Bakar*, Hasanah Che Ismail** *Department of Psychiatry and Mental Health, Hospital Sultan Abdul Halim, Sungai Petani, Kedah 08000, Malaysia, **Department of Psychiatry, Universiti Sains Malaysia 16150, Kubang Kerian, Kelantan. Abstract Objective: Self-esteem is an important component of psychological health. In Malaysia, Rosenberg s self-esteem scale remained the single most popular utilized scale for studying global self-esteem. This study aims to design a language, culture and illness specific self-esteem questionnaire. Methods: The study consisted of 2 phases. The first phase was to generate items for the new self-esteem questionnaire (SSES) in Bahasa Malaysia. Literature review on the concept of selfesteem and its content was conducted. This was followed by expert opinion from professional care-givers. The items were qualitatively validated by healthy subjects and patients with schizophrenia from the same locality, culture and language. The second phase consists of quantitative validation of the items. Items in the new scale were analyzed based on the responses from 165 stable schizophrenia outpatients. The validated Malay version of Rosenberg Self-Esteem scale (RSES) was used concurrently as a comparison. Results: The SSES displayed good internal consistency for its two domains (Cronbach s alpha=0.88, 0.81) and test-retest reliability (ICC), ranged from 0.44 to Its construct validity was confirmed by confirmatory factor analysis. The concurrent validity of SSES and RSES using Pearson correlation was The Cronbach s alpha for the validated Malay version of RSES is Conclusion: This study presents a new self-esteem questionnaire (SSES) which has high concurrent validity with the standard RSES and confirms the reliability and validity of SSES in Malay patients with Schizophrenia. ASEAN Journal of Psychiatry, Vol.10, No.2, July Dec 2009: XX XX Keywords: Shamshunnisah Self-Esteem Scale (SSES), Rosenberg selfsteem scale (RSES), Brief Psychiatric Rating scale (BPRS), validation Introduction Self-esteem refers to an individual s sense of value or the extent to which a person appreciates himself [1]. Selfesteem is considered as the evaluative component of the self-concept, a broader representation of self that includes 1

2 cognitive, behavioral and affective components [2]. High self-esteem is characterized by tolerance and respect for others, self-motivated, capable of handling criticism and take control of their lives; whereas low self-esteem is characterized by people who wants to impress others, have doubts about their worth and acceptability, and expose themselves to failure [2,3]. Low selfesteem has been said to be a constant companion for people suffering from stigmatizing illnesses. Cross-cultural researches have suggested that self-concept varies greatly depending upon the culture one lives in, either independent self (individualist) or interdependent self (collectivist) [1, 4]. The Asian interdependent cultures consist of seeing oneself as part of an encompassing social relationship and realizing that one s behavior is determined and dependent on what one perceives to be the thoughts, feelings and actions of others in the relationships [1]. Malaysia is an Asian country, which in many ways can be considered as an interdependent culture. The Rosenberg's self-esteem theory relies on reflected appraisals and social comparisons. Rosenberg s Self-Esteem Scale (RSES) was developed to measure adolescents global feelings of selfworth, and is generally considered the standard one against which other measures of self-esteem are compared. The scale is one-dimensional in nature: one subjective experience of self-worth and was arranged in two factors structure: self-confidence and selfdepreciation. The scale test-retest correlations are typically in the range of.82 to.88 and Cronbach s alpha in the range of 0.77 to 0.88 [5]. Using the RSES cross-culturally creates two methodological concerns: (1) comprehension and/or the translation bias and (2) response bias. Statements, such as I feel that I'm a person of worth, at least on a level equal with others, have varied meanings depending on cultural norms. In some cultures, including Malaysians, modesty may be a highly valued trait, so one might disagree with the statement in order to appear humble. So far, there are no specific scales developed to measure self-esteem in the people with chronic mental illnesses. This indicates the lack of interest or effort in looking into the specific ways in which people with major mental illnesses perceived their self-worth or self-esteem. For the above reasons, an attempt is made to construct a new selfesteem scale, taking into consideration perception and views from patient with schizophrenia and their professional care-givers. The items for the new selfesteem scale were generated into the local Malay Language and pilot-tested on healthy volunteers and patients with schizophrenia in the same population. The study aims to develop a culturespecific questionnaire that would be considered important in defining the global self-value or self-worth of a person with schizophrenia. Methods Stage 1: Identifying domains, facet and items of global self-esteem. The process involved in the generation of the Shamshunnisah Self-Esteem Scale (SSES) consisted of gathering experts psychiatrists, sociologist and 2

3 psychologist opinion, focus group discussion and finally conducting a pilot study of the questionnaire. A draft of items concerning self-esteem was then generated. This draft underwent review and inputs from the immediate supervisor and then the draft was given to other 6 experts (2 psychiatrists, 2 sociologists and 2 psychologists) for comments. Subsequently a workshop was held inviting those experts and the draft was discussed and subjected to debate and further commentary. Two focus groups consisting of 10 healthy subjects and 10 stable schizophrenia patients were interviewed separately using the first draft questionnaire. The patients with schizophrenia were from those attending the psychiatric follow-up clinic. They were patients on treatment and in remission. A systematic method for obtaining information on the comprehensiveness and the evaluation of items for the questionnaire was conducted first with the healthy group, followed by the group with schizophrenia. The first draft of the SSES ( first DQ) consisted of 53 items and had two domains: self-worth and social relation or functioning (Table 1). The 53 items were each evaluated by degree of importance in defining selfesteem by a 5 points likert scale by the two focus groups. There are two ways of answering the questionnaire, that is by assessing the frequency:- 1.Tidak Pernah (Never); 2.Jarang Sekali (Rarely); 3.Kadang-kadang (Sometimes); 4.Agak Kerap (Frequently); 5.Sentiasa (Always). Total items in this mode: 20 items and the second style of answering is by assessing agreement: 1.Sangat Tidak (Strongly Disagree); 2. Tidak (Disagree); 3.Agak setuju (Somewhat agree); 4. (Agree); 5.Sangat setuju (Strongly Agree). Total items in this mode are 33 items. The questionnaire also has positively worded questionnaire (28 items) and negatively worded items (25 items). The expert s suggestion was to arrange the items randomly. This was carefully thought and suggested in order to reduce bias and to enhance the level of concentration when they were answering the questionnaire. The items were rephrased whenever appropriate, giving importance to the ease of comprehension by the patients with schizophrenia. During data analysis, the negatively worded items will be recoded and reversed on analysis. The score range will be discussed at the final stage of the questionnaire. Subsequently, a pilot study of the first stage DQ was completed using 50 stable patients with a diagnosis of Schizophrenia based on the DSM-IV classification of Mental Disorder and 100 normal subjects. Only patients with schizophrenia who experience symptoms that are relatively stable and if present at all, are almost always less severe than in acute phase. Patients can be asymptomatic and manifest nonpsychotic symptoms for example tension, anxiety, depression or insomnia or experiencing attenuated positive and negative symptoms of Schizophrenia [6]. Objective assessment to describe such patient would be those who score 0 or 1 in the BPRS psychotic symptom subscale [7]. Patients, who are cognitively intact, free from current severe concentration and attention problems, able to show coherent thinking and give relevant verbal and written responses. They should also be 3

4 able to give informed consent to take part in the study. The standardized validated Malay version of the Rosenberg self-esteem questionnaire (RSES) was also given to them at this setting [8]. (refer appendix B). The normal subjects represent a population that consisted of a good range of age, different level of education and socio-economic background and fairly equal gender. The age for normal subjects range from years old and for schizophrenia the age ranges from years old. For normal subjects: 20 were medical students, 5 were student nurses, 5 were doctors, 40 consisted of nurses and medical assistant, 30 were clinic attendants and cleaners in HUSM. To obtain test-retest reliability of the questionnaire, 50 normal subjects and 30 schizophrenic patients we asked to refill the questionnaire after one week of their initial interview. However, only 30 normal subjects and 20 schizophrenic patients returned their completed questionnaires. After the pilot study, an exploratory factor analysis was performed to determine the psychometric property of the first DQ and RSES. Refer table 1. Confirmatory factor analysis was done using the question scores of all questions. Principal component method (varimax rotation method) was used to extract 2 factors to support the theoretical assumption of the two major domains in the self-esteem questionnaire which were self-worth and social relation or functioning. The principal component matrix used has grouped the first DQ into two distinct groups: 15 items into factor 1 and 13 items into factor 2. The 23 items that could not fit into any factors were excluded. Factor 1 has 6 items with r more or equal to 0.60 and 9 items with r = 0.42 or more and less than The factor 2 has 5 items with r more or equal to 0.59 and 8 items with r = 0.41 or more and less than Refer Table 1. After careful analysis of the result and discussion, it was concluded that the factor 1 represent items that assessed self-worth and factor 2 represent items that assessed social relation or functioning. This support the original theoretical assumption made at the early stage of item generation. The eventual total items in domain self-worth were 15 and 10 items in domain social relation or functioning. Items that had high internal consistency and reliability were selected and form a new set of questionnaire. The new scale had been named as Shamshunnisah Self-Esteem Scale (SSES). 4

5 Basic flow of item generation methodology Review of literature and reading Input from experts Face validity and content validity of the questionnaire Focus groups A first draft of the questionnaire (first DQ) and Pilot Study of the first DQ Factor analysis: item s reliability and validity Generated new SSES 5

6 Table 1: Factor analysis: Construct Validity of First DQ (53 items) using principal components analysis with varimax rotation. N=150 Items a Domain 1: Self-worth A.14 I am special A.15 I am being loved by others B.17 I am capable of attracting my partner A.17 I am happy with the way I look A.13 I am a special person A.18 My life is meaningless B.22 I surely could make my partner happy B.23 I would not be able to have a good marital relationship A.3 I am proud of myself B.2 People usually like me B.19 I am not capable of getting married A.1 I love myself B.24 I am capable of having my own children B.18 I am not attractive A.19 My life is useless Domain 2 : Social relation or functioning B.6 I feel lonely B.5 I disappoint those who care about me A.2 I cannot accept the way I am A.10 I am proud of my work B.4 I am scared of not being accepted by my colleagues A.9 People look down on my work B.10 People would dislike my real self A.7 I am capable of completing my work successfully B.3 I need to pretend to make friends B.8 I am satisfied with my friendship A.24 Any impending problem would just vanished by ignoring it A.4 I don t love myself A.12 I have every right to be happy A.5 I respect myself A.6 I am a person with high self-esteem (general question on self-esteem) E 4.00E 8.21E E Factor loading Factor 1 Factor E E E Rest of the 23 items could not fit into any domain r< 0.04 r< 0.04 Stage 2: Quantitative study of selfesteem in stable outpatient Schizophrenia using SSES and RSES. The subjects were 165 stable patients with schizophrenia attending outpatient psychiatric clinics of Hospital Universiti Sains Malaysia (HUSM) and Hospital Kota Bharu, (HKB), Kelantan. The definition of the stable patient with schizophrenia was already stated in the stage 1 methodology. The study protocol was approved by the Research & Ethics Committee, School of Medical Science, Universiti Sains Malaysia. Written informed consent was obtained 6

7 from all participants after explaining the nature of the study. A single researcher, who was trained in psychiatric interview and examination, interviewed all the subjects individually. The patients were asked to fill up the form consists of 25 items of SSES and 10 items of the translated and validated Malay version of Rosenberg Self-Esteem Scale (RSES). This is a combination between an interview and questionnaire type where an interviewer is present in the same room as respondents but yet the respondents complete the questionnaire themselves. The collected data was entered and analyzed initially using the Statistical Program for Social Science (SPSS version 10) for descriptive and simple linear regression analysis (SLR). Comparison between the RSES and the SSES The SSES and the RSES are available in the appendix A and B respectively. The SSES measures one s self-worth (SW) and social relation and functioning (SF). As been mentioned early (methodology section), the SSES has 25 items in total and has 5 points Likert scale in the response. The scale ranges from , with 125 indicative of the highest score possible. The cut-off scores in SSES are: 25-74, low self-esteem; 75-99, moderate self-esteem; , high self-esteem. The SW domain has 15 items and the SF domain has 10 items. The maximum scores for the SW and the SF are 75 and 50 respectively and the minimum scores for the SW and the SF are 15 and 10 respectively.the RSES measures global self-esteem and personal worthlessness. It has 10 items and when 5 points Likert scale used, the maximum score would be 50 and the minimal score would be 10. Using the same frame of score range as SSES, the cut of scores for the RSES would be as follows: 10-29= low selfesteem; 30-39= moderate self-esteem; 40-50= high self-esteem. Result Psychometric Property of the SSES Internal consistency Cronbach s Alpha is a widely reported measure of internal consistency. Each attitude scale should have a value of about 0.6 or more [9]. The Cronbach alpha values of the domains of selfworth and social relationship and functioning are 0.88 and 0.81 respectively, reflecting a high internal consistency [9]. The Cronbach alpha for the validated Malay version of Rosenberg scale is This value is slightly better to the previous local study by Mahmood N.M et al (1999) who obtained Cronbach alpha of

8 Table 2: Reliability analysis of each domain of the SSES and the RSES (Malay version) Item Corrected item-total Correlation Internal consistency Domain self-worth A.1 A.3 A.5 A.6 A.11 B.2 A.13 A.15 A.18 A.17 A.14 B.18 B.17 B.22 B Domain social relation or functioning A.7 A.9 A.10 B.4 B.5 B.6 B.8 A.12 A.24 B.10 Rosenberg self-esteem scale items: Test-retest reliability of SSES Stable scale would produce score that has high test-retest correlation if the test is repeated after a period of time [9]. In this study, the agreement of the subjects ratings on the questions at the time point one and two, as reflected by intra-class correlation coefficient (ICC), ranged from 0.44 to 0.87, with 20 out of 25 items with ICC value below 0.75 were regarded as having fair test-retest agreement. The rest 5 items with ICC value equal to 0.75 or more were regarded to have good test-retest reliability. 8

9 Concurrent validity This requires a comparison between scores with the new questionnaire and a well established one. A high correlation between these two scales indicates concurrent validity [9]. In this study, the responses to the SSES and to the validated Malay version of Rosenberg (RSES), (Table 3) were analyzed to obtained concurrent validity. The highest correlation was found between RSES and the total SSES and the lowest in the SW. For further interest, the RSES score, SW domain score, SRF score, total SSES score were compared with the question 7of the SSES. The question 7 statement is Saya mempunyai harga diri yang tinggi. There were significant correlation between the scores of RSES, the SW, SRF domains, and the total SSES with the question 7. The correlation coefficients were found to be 0.46, 0.62, 0.40 and 0.60 respectively. Refer Table 3. Table 3: Correlation matrix (Person) of the RSES, self-worth (SW), social relation or functioning domains (SRF) and the total SSES (n=165). RSES SW SRF TOTAL SSES QUESTION 7 RSES 1.00 SW 0.64** 1.00 SRF 0.71** 0.55** 1.00 TOTAL SSES 0.77** 1.00 QUESTION ** 0.62** 0.40** 0.60** 1.00 **correlation is significant at the 0.01 level (2- tailed) Distribution of SSES and RSES scores in the schizophrenic patients The scores of SSES and RSES in patients with schizophrenia were normally distributed (Graph 1.1 and 1.2 respectively). The levels of self-esteem in patients with schizophrenia based on different tools, i.e. SSES and RSES are shown in Table 4. 9

10 Graph 1.1 Distribution SSES score in the 165 schizophrenic patients Graph 1.2 Distribution of RSES score in the 163 schizophrenic patients 10

11 Table 4. Level of self-esteem in the schizophrenic patients as measured with the SSES and RSES SSES RSES Level of selfesteeesteem N=165 Level of self- N=163 Low (25-74) 15 (9.1%) Low (10-29) 15 (9.1%) Moderate (75-99) 84 (50.9%) Moderate (30-39) 105(64.4%) High ( ) 66 (40.0%) High (40-50) 43 (26.4%) N=frequency Discussion The psychometric performance of the SSES is quite impressive both in terms of reliability and validity. The internal consistencies for the domain self-worth and social functioning or relation were high (Cronbach s alpha values of and respectively). The internal consistency for the validated Malay version of the RSES was only These Cronbach s alpha values are obviously acceptable and comparable to the value obtained in Mahmood N.M et al (1999) where the value was However, in comparison to the SSES, it shows some weakness in the homogeneity among items in the scale when used in this sample. The original RSES has Cronbach s alpha in the range of 0.77 to 0.88 [5]. The test-retest reliability coefficient of SSES assessed after one week interval ranged from 0.44 to This demonstrates acceptable stability of the instrument to measure self-esteem over time. In contrast to the general assumption that mentally ill patients have low selfesteem, using SSES this study found that 50.9% of the sample studied has moderate level of self-esteem and 40.0% of them actually have high self-esteem. Thus, only 9.1% of the sample studied reported low level of self-esteem. Even though the percentage for the moderate and high self-esteem as measured by the SSES and RSES differed, where the RSES captured larger subjects with moderate level of self-esteem (64.4% versus 50.9%), the percentage of subjects with the low level of selfesteem were about the same (9.2% versus 9.1%). This could reflect that SSES with it two domains of self-worth and social relation or functioning was more sensitive in detecting the positive self-concept in this subjects than RSES. The validity of the SSES was also demonstrated through the significant positive correlation with the standardized validated Malay version of RSES. The highest correlation was between the RSES score and the total SSES score. Moreover, question 7 of the SSES which actually means I have a high self-esteem has stronger correlation to the total score of SSES than to the RSES (0.60 versus 0.47). This could possibly means that the SSES is more sensitive in measuring selfesteem in this sample. Findings from the confirmatory factor analysis indicate that the SSES has 2 factors and this relates very well with the proposed domains of 11

12 self-esteem in the early stage of questionnaire development. This reflects the construct validity of the SSES. The SSES is a newly developed selfesteem scale and subjected to criticism. It carries some limitations which subjected to future improvement. Usually, large number of subjects is used for questionnaire development. The number of subjects (150) in this study may raise issue of validity and reliability, despite its demonstrable excellent psychometric property. Recommendation The use of standardized and validated scales in assessing important concepts in relation to self-esteem, for example, patients awareness of illness, social support, executive functioning and perceived stigma would definitely produce more attractive and sound result. This study is the first attempt at designing an illness specific self-esteem scale based on the perception and values of normal and patient populations, and could not avoid dealing with a large number of items. However, the advantage is that, the questionnaire could be tested on other patients with chronic illnesses or in healthy subjects. Validation of a shorter and user-friendly version is the next step, and should involved more subjects from patients with mental illness and healthy subjects. The phrasing of items could be revised with further similar studies. The final questionnaire from this study is however good enough to carry out a study of selfesteem in patients with schizophrenia, with the objective of finding out the association factors in relation to poor self-esteem. This result has been published in another paper (Psy On- Line, In Press). Conclusion This study resulted in a language, culture and illness specific self-esteem questionnaire with two domains: selfworth and social relationship or functioning. The 25 item-questionnaire is possibly suitable for other mental illness or subject with no mental illness, considering that it was generated and validated by taking into account responses from normal subject from the same community. References 1. Taylor, S. E., Peplau, L. A., & Sears, D. O., Social psychology. (ed.10 th ), Upper Saddle River, NJ: Prentice-Hall. 2. Wells, L. Edward and Gerald Marwell., Self-Esteem: It s Conceptualization and Measurement. Beverly Hills: C A: Sage, Wylie, R. C., The self-concept. Lincoln: The University of Nebraska Press, Flynn, H.K., Self-Esteem Theory and Measurement: A Critical Review Paper Presented at the ninety-sixth Annual Meeting of the American Sociological Association held in Anaheim, California, August 18-21, Rosenberg, M., Rosenberg scale of Self-Esteem. The Morris Rosenberg 12

13 Foundation, Department of Sociology, University of Maryland, American Psychiatric Association Guidelines., Diagnostic and statistical manual of mental disorder. (ed.4 th )1994. Washigton, DC: American Psychiatric Association. 7. Bech, P., Kastrup, M., Rafaelsen, O.J., Mini-compendium of rating scales. Acta Psychiatrica Scandinavia, :p Mahmood,N.M., Drug addiction and Recidivism. Psychological and Environmental Aspect,1999 Consultation and Research Center, North University of Malaysia. 9. Jackson, C.J., Designing And Analyzing Questionnaires And Surveys, Whurs publication. Corresponding author: Shamshunnisah Abu Bakar, Department of Psychiatry and Mental Health, Hospital Sultan Abdul Halim, Sungai Petani, Kedah. Malaysia. Received: 1 April 2009 Accepted: 20 May

14 Appendix A SSES (Shamshunnisah Self-Esteem Scale) BIL SILA TANDAKAN PADA KOTAK YANG BERKENAAN UNTUK MENANDAKAN KEKERAPAN SESUATU PERKARA YANG DITANYAKAN TENTANG DIRI ANDA SEPANJANG 1 BULAN INI. KENYATAAN-KENYATAAN 1 Saya menyukai diri saya 2 Saya bangga dengan diri saya 3 Saya menghormati diri saya 4 Saya mempunyai harga diri yang tinggi. 5 Saya dapat menyelesaikan kerja dengan baik 6 Saya berasa rendah diri jika tidak dapat melakukan kerja sebaik orang lain 7 Saya bangga dengan hasil kerja saya 8 Orang lain memandang rendah kerja yang saya lakukan 9 Saya disukai oleh orang lain 10 Saya takut tidak diterima oleh kawan-kawan 11 Saya menghampakan mereka yang mengambil berat tentang diri saya 12 Saya berasa keseorangan dalam diri ini 13 Saya berpuas hati tentang hubungan saya dengan kawan-kawan Tidak pernah 1 Jarang sekali 2 Kadang Kadang 3 Agak kerap 4 Sentiasa 5 SILA TANDAKAN PADA KOTAK YANG BERKENAAN UNTUK MENANDAKAN PERSETUJUAN ANDA BAGI SETIAP KENYATAAN SEPANJANG 1 BULAN INI. BIL KENYATAAN-KENYATAAN Sangat Tidak 1 14 Kebanyakan orang lain adalah lebih bernasib baik daripada saya 15 Saya berhak untuk bergembira 16 Saya disayangi ramai orang 17 Saya senang dengan paras rupa saya 18 Saya seorang yang berkebolehan 19 Saya tidak mungkin dapat menyumbang sesuatu yang bermakna 20 Orang akan membenci saya jika mengenali diri saya yang sebenar 21 Saya seorang yang istimewa 22 Saya tiada daya penarik Tidak 2 Agak 3 4 Sangat 5 14

15 Kenyataan-kenyataan berikut adalah mengenai perhubungan suami isteri tetapi pada yang masih bujang, bayangkan keupayaan anda dan sila tandakan pada kotak yang berkenaan. BIL KENYATAAN-KENYATAAN Sangat Tidak 1 23 Saya berupaya memikat hati pasangan hidup 24 Saya yakin dapat membahagiakan pasangan hidup saya 25 Saya tidak mampu menjalinkan perhubungan suami isteri yang baik Tidak 2 Agak 3 4 Sangat 5 Terima kasih Appendix B A Validated Malay version of RSES (Rosenberg Self-Esteem Scale) BIL KENYATAAN-KENYATAAN Sangat Tidak 1 1 Selalunya saya berpuas hati dengan diri saya 2 Adakalanya saya rasa diri saya ini tidak berguna langsung 3 Saya mengambil sikap yang positif terhadap diri saya 4 Saya selalu rasa yang saya ini seorang yang gagal 5 Saya rasa yang saya ada beberapa kualiti yang baik 6 Saya rasa saya seorang yang mempunyai nilai, sekurang-kurangnya sama seperti orang lain 7 Hajat saya ialah saya lebih menghormati diri saya 8 Kadangkala saya terfikir yang saya bukan baik selalu 9 Saya boleh melakukan tugas sama baiknya seperti orang lain 10 Saya boleh merasakan yang tidak banyak yang boleh saya banggakan Tidak 2 Agak 3 4 Sangat 5 Terima kasih 15