Estudio de traducción al español y evaluación psicométrica de una escala para medir el estigma internalizado en pacientes con trastornos mentales graves / Study of translation into Spanish and psychometric properties of a measure to evaluate internalized stigma among patients with severe mental disorders

ABSTRACT

Introduction Mental illness is one of the most stigmatized health problems. The stigma related to mental health disorders can be experienced from two different perspectives i) social stigma (perpetrated by the general population) and ii) personal stigma (internalized by the affected). Research on stigma and discrimination among patients with mental health problems has been centered on the social viewpoint, that is, what the general population sets over people who suffer the condition. Nonetheless, the investigation that focuses on the way people with psychiatric illness experience adverse reactions (i.e. rejection) has received little attention and hence been poorly assessed. Until now there was no internalized stigma measuring instrument, validated in Mexican population, nothing that could allow us to score the level of stigma perceived by these patients. Thus, the objectives of the present study were to translate into Spanish the internalized stigma scale (ISS) created by King et al., and to evaluate its basic psychometric properties among Mexican patients with severe mental disorders. The ISS has 28 items to answer in a five-point Likert scale, ranging from «strongly agree¼ to «strongly disagree¼, to assesses stigma through three different sub-scales i) discrimination, ii) disclosure, and iii) positive aspects of mental illness. The discrimination subscale contains items that refer to the negative reactions of other people, including acts of discrimination by health professionals, employers and police; the disclosure subscale includes questions regarding embarrassment or feeling bad about the illness and managing disclosure to avoid discrimination. Finally, the positive aspects subscale asks about how patients accept their illness and perceive themselves as less affected by stigma. A higher score means greater stigma, due the answer to items that explore positive aspects of mental illness are reversed. Method Subjects: One hundred severe mentally ill Mexican subjects were included in the study. All of the patients had been receiving psychiatric attention at the Mental Health Integral Attention Center, Long stay division of the Mental Health Institute in Jalisco (Instituto Jalisciense de Salud Mental), which is part of the health office of such State. They all had at least two years of diagnosis and treatment. None was suffering an acute process of the illness at the moment of administration of the instruments. Measures and procedure The ISS was translated into Spanish by translation-back- translation method and then administered by a psychiatrist together with the global assessment functional scale (GAF) and the clinical global impression scale (CGI). Data analysis: Cronbach's alpha and varimax rotation factor analysis were employed in order to examine internal consistency and construct valididty of the main components of the scale. Results From the total one hundred patients that integrated the studied sample, 67 (67%) were males; most of them single (62%) and unemployed (70%). The most commonly diagnosis was schizophrenia (47%); the time of illness was between 2 and 44 years, while the duration of the treatment was 1 to 44 years. Along the evolution of the illness, 81 (81%) had been hospitalized due to the psychiatric condition at least once. The mean functional global assessment score was 58.4, and the mean score in the CGI scale was 3.78 points. Regarding the management, 89% (n= 89) were under treatment with some kind of antipsychotic; the most used kind were first generation ones (n= 68, 68%), particularly haloperidol, either in immediate release or intramuscular depot presentations. ISS score was drawn and compared to the one obtained for the original English version; both measurements were alike (60.15 vs. 62.6, respectively). Each of the subscales in the ISS also showed similar results respect the ones obtained in the original version (discrimination 27.6 vs. 62.6; disclosure 22.1 vs. 29.1 and positive aspects 10.3 vs. 8.8, respectively). Additionally, the Spanish version of the ISS has shown a proper internal consistency with Cronbach's alpha scores higher than 0.60 in all of the sub-scales; the whole being similar to the ones identified for the original version of the measurement (Spanish version discrimination subscale=0.83, disclosure=0.76 and positive aspects= 0.60; Original version discrimination subscale= 0.87, disclosure= 0.85 and positive aspects=0.64). The unidimensional construct of the instrument showed a 0.87 Cronbach's alpha, being highly reliable. Regarding the factor validity, three main components were obtained confirming the original structure. The first factor (discrimination) explains 25.46% of the variance, the second (disclosure), 10.08%, and the last one (positive aspects) explains 7.24%. Conclusions The present study reports the psychometric data of ISS-Spanish version among severe mentally ill patients. We demonstrated that is a measure with appropriate internal consistency for the whole version as well as for all the sub-scales; it has, in addition, factor validity. Thus, it is possible to state that now we count with a valid and reliable instrument to assess internalized stigma of mental illness to be used for the evaluation of Mexican population with clinical and research purposes.

RESUMEN

Introducción Se ha demostrado que la enfermedad mental es una de las condiciones que generan más estigma. El estigma producido por los trastornos psiquiátricos se puede experimentar desde la perspectiva social y la personal (estigma internalizado). La forma en que las personas con padecimientos psiquiátricos experimentan las reacciones adversas de los otros ha sido poco estudiada. Hasta ahora no existía una escala validada en la población mexicana que permitiera la medición del estigma percibido por este tipo de pacientes. El objetivo del presente trabajo fue traducir al español y determinar la consistencia interna y la validez factorial de la Escala de estigma de King et al. Método Sujetos Se incluyeron 100 pacientes mexicanos con diagnósticos de trastornos mentales graves y persistentes (TMSP) que reciben atención en el Centro de Atención Integral en Salud Mental de Estancia Prolongada del Instituto Jalisciense de Salud Mental (SALME), con un mínimo de dos años de evolución y que no se encontraran cursando con un episodio agudo de su enfermedad. Instrumentos y procedimiento Se aplicó la escala de estigma internalizado de King et al. (EEI) y las escalas de evaluación de la actividad global (EEAG) y de impresión clínica global (CGI). Análisis de datos Se evaluó la consistencia interna de la EEI mediante el coeficiente alpha de Cronbach y la validez de constructo con base en un análisis factorial de componentes principales con rotación varimax. Resultados La muestra estuvo integrada por 100 pacientes, 67 (67%) eran hombres, mayoritariamente solteros (62%) y desempleados (70%). La mayoría contaba con un diagnóstico principal de esquizofrenia (47%); el tiempo de enfermedad y de tratamiento fue de dos a 44 años y de uno a 44 años, respectivamente. El 81% había sido hospitalizado en una institución psiquiátrica al menos en una ocasión. Respecto al funcionamiento global, la media fue de 58.4 puntos, y la puntuación promedio del CGI fue de 3.78. El 89% (n=89) se encontraba medicado con algún tipo de antipsicótico, más frecuentemente típico (n= 68, 68%). El promedio del nivel de estigma obtenido se comparó con el puntaje de la validación de la escala original; dichos valores fueron muy similares (60.15 y 62.6, respectivamente). La versión en español de la EES se caracterizó por una adecuada consistencia interna, con alphas superiores a .60 en todas las sub-escalas. La evaluación unidimensional del constructo resultó altamente confiable, con un coeficiente de 0.87. Se obtuvieron tres factores principales congruentes con la versión original, lo que da prueba de su validez. Conclusiones El presente estudio es el primero en reportar las propiedades psicométricas de la versión en español de la EES en pacientes mexicanos con trastornos mentales graves y persistentes. Con base en nuestros hallazgos es posible concluir que la EES-español cuenta con una adecuada consistencia interna total y en todas las sub-escalas; además da prueba de validez factorial, por lo que es posible recomendarla para su uso con fines clínicos y/o de investigación.