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Table of Contents
Year : 2018  |  Volume : 15  |  Issue : 1  |  Page : 5-9

Assessment of treatment adherence in persons with mental illness: Testing of a Tool

1 Assistant Professor, Department of Psychiatric Nursing, LGBRIMH, Tezpur, Assam, India
2 Professor and HOD, Department of Psychiatric Nursing, LGBRIMH, Tezpur, Assam, India

Date of Web Publication10-Jul-2019

Correspondence Address:
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2231-1505.262507

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Maintaining adherence to prescribed treatment adherence is one of the issues in caring a person with mental illness. Treatment adherence can be measured by the patients’ interview or/and observation by the care givers. An objective measure of treatment adherence is equally important with self report especially for the patients requiring long term treatment. The present study aimed to develop a valid and reliable checklist to measure the treatment adherence of person with mental illness. Method: An 18-item checklist was constructed following the scientific tool development process. Content validity was established with validity index. The psychometrics of the checklist was evaluated with 110 family members of persons suffering from mental illness on their observation of treatment adherence of their patients. A standardized tool namely Medication Adherence Rating Scale (MARS) was also applied to the patients with mental illness to measure the same construct. Results: The statistical analysis showed good internal consistency of the constructed checklist. The chronbach’s alpha was found to be 0.789 and reliability with spearman brown prophency formula was 0.834. All the items except item no. 5, 7, 15 and 16 are significantly correlated with total score indicating sensitivity of the tool. There was significant correlation ( r=0.590, p=0.000) between the score of the constructed treatment adherence checklist and the score of MARS indicating good construct validity of the checklist. Conclusion: The constructed treatment adherence checklist was found to be valid and reliable to use in the research studies by considering its acceptable psychometrics.

Keywords: Treatment Adherence, Mental Illness, Assessment Tool

How to cite this article:
Ahmed N, Baruah A. Assessment of treatment adherence in persons with mental illness: Testing of a Tool. Indian J Psy Nsg 2018;15:5-9

How to cite this URL:
Ahmed N, Baruah A. Assessment of treatment adherence in persons with mental illness: Testing of a Tool. Indian J Psy Nsg [serial online] 2018 [cited 2022 Oct 6];15:5-9. Available from: https://www.ijpn.in/text.asp?2018/15/1/5/262507

  Background Top

With the advancement in medical science, successful treatment for mental illness has come to exist in reality. Now days, psychopharmacological agents along with the various other physical and psychosocial treatments are used to treat the mental illness. However, in reality, effective treatment for mental illness is a big challenge. Various studies showed that adherence is the prime issue in this regard. Meta analysis showed that 41.2% to 49.5% patient with schizophrenia1 and 10% to 60% patients with mood disorders2 are non-adherent to their treatment. Inadequate adherence to treatment hampers in its efficacy and contributes to numbers of negative consequences. Hence the mental health professionals have to deal with this major issue promptly and the first step in dealing with adherence problems is assessment or measurement of treatment adherence. Accurate estimation of treatment adherence will provide better evidence on its predictors, consequences and interventions to improve treatment adherence.

Treatment adherence is not just complying with the physicians’ ‘advice but also taking active participation in the treatment process. For the care purpose, adherence can be measured from the patients interview or/and observation by the care givers. There are both subjective and objective tools available to measure the treatment adherence, however none of them is gold standard3. Self reports are commonly used to measure the treatment adherence, although objective measure is equally important especially for the patients mental illness requiring long term treatment. Also the evidences suggest to use multiple measurements for better adherence assessment[4],[5]. There are objective tools like pill count, electronic monitoring, secondary data base etc. However there is no valid and reliable tool that measure treatment adherence from the observation of direct care giver at home.

There is paucity of culturally appropriate objective tool to measure the treatment adherence of persons with mental illness who needs treatment for prolong period. Keeping these in view, a treatment adherence checklist was developed with the objectives of

1) selecting the items for the tools,

2) establishing the validity of the constructed tool and

3) establishing the reliability of the constructed tool.

  Methodology Top

Development of Treatment Adherence Checklist (TAC) Step 1: Item pool and item selection:

An extensive review of literature related to treatment adherence of persons with mental illness was performed by the researcher before tool development. A two part tool was constructed with the help of the literature reviewed and the clinical experience of the researcher. The first part of the tool consist a checklist with 18 items and the second part had five structured questions enquiring qualitative information about the reasons of non-adherence. The quantitative items includes about regularity, correct dose, missed dose, regularity in check-up, follow related instructions, willingness for treatment continuation, and intake of medication without prescription. The items were written in English language in the form of interrogative sentence. Every item has two answers option namely ‘yes’ and ‘no’. The grammatical correction was made by a language expert. The desired option for each items carry one score. The checklist to be rated by the family member or significant other who is taking care of the patient for at least one month.

Step 2: Establishing validity: Content validity was checked by seven experts in the field of psychiatric nursing, psychiatry, clinical psychology and psychiatric social work. All items had validity index of 80-100% and hence all the items were included in the tool. Reliability of the English version tool was established by split-half method with twelve subjects and it was found to be 0.843.

Step 3: Translation to local language: The validated tool was 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. It took 4-6 minute to complete the questionnaire. The subjects did not find any difficulty in understanding the items.

Step 5: Reliability testing: Internal consistency was measured with split-half and Chronbach’s alpha method. Sensitivity was assessed by item discrimination. Item difficulty was assessed for each item. Construct validity was assessed with Pearson’s correlation with a standardized measure of treatment adherence.

The process of testing of reliability of TAC

Setting: The study was conducted at OPD of LGB Regional Institute of Mental Health, Tezpur, a tertiary mental health care institute in North-East India.

Sample and Sampling Technique: Total 110 numbers of subject duos comprising the persons diagnosed as any of the psychotic illness as per ICD-10 criteria (F20-F39) and their family members who attended OPD of LGB Regional Institute of Mental Health, Tezpur were included in the study. The subjects who can read and understand Assamese were selected with convenience sampling technique.

Tools: The socio-demographic data were collected with a structured data sheet and the treatment adherence was assessed with a standard ten item Medication Adherence Rating Scale (MARS) developed by Thompson et al.6 and the structured Treatment Adherence Checklist(TAC). The MARS has a good construct validity along with Internal consistency and stability of the tool was found to be 0.75 and 0.72 respectively7.

Data Collection Procedure: With the formal permission from the authority of LGBRIMH, Tezpur, the participants were selected during the OPD registration of patients coming for follow-up. The persons with mental illness diagnosed as any psychotic illness (F20-F39) and their family members were identified during registration process from the OPD registration system. The patients and their family members who can read and write Assamese were selected for the study. The participants were explained about the research study and written consent was obtained. Data collection was done after the routine check-up with psychiatrist and collection of medicines.

  Result Top

Data were analyzed as per the objectives of the study. 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.

  Sample Characteristics Top

The socio-demographic and clinical data of persons with mental illness are given in [Table 1] and socio-demographic data of family members of persons with mental illness is given in [Table 2] in concrete level whereas the data collected in continuous level are depicted in [Table 3].
Table 1: Description of selected socio-demographic and clinical variables of persons with mental illness in terms of frequency and percentage. n=110

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Table 2: Description of selected socio-demographic variables of family member of persons with mental illness in terms of frequency and percentage n=110

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Table 3: Description of selected variables of persons with mental illness and their family members in terms of range, mean and standard deviation n=110

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Description of treatment adherence score: The scores of treatment adherence measured with MARS and the TAC are given in [Table 4].
Table 4: Description of treatment adherence scores of persons with mental illness in terms of range, mean and standard deviation n=110

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Item difficulty: Item difficulty was assessed for each of the items. Item no.[5],[7],[9],[15],[16], and[18] were found to be scored by more than 80% of the respondents. All the items were included in the tool by considering the importance shown during the validity process.

Internal Consistency: Internal consistency of the tool TAC was established by split-half method. The Spearman-Brown Prophecy was used to find the internal consistency making both odd-even and 1st and 2nd half of the tool items. Chronbach’s alpha was also computed for the same as given in [Table 5].
Table 5: Internal consistency of the Treatment Adherence Checklist

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Sensitivity: The sensitivity of the TAC was established by item discrimination. Item discrimination was assessed by finding correlation between the each item score with the total score of the tool. All the items were found to have significant discrimination (r>0.2, p<0.05) accept item no.[5],[7],[15] and[16] as shown in [Table 6].
Table 6: Correlation between the each item score with the total score of the tool

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Construct validity: Construct validity of the structured tool was established by assessing correlation between the score of already standardized MARS and the score of TAC as described in [Table 7].
Table 7: Correlation between MARS and Treatment Adherence Checklist score n=110

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  Discussion Top

The present study aimed to develop a feasible, valid and reliable checklist to assess objective treatment adherence in persons with mental illness by the family members or the care giver. The analysis and result demonstrate that the developed checklist is fairly feasible, valid and reliable in assessing treatment adherence of persons with mental illness. The developed checklist has good content validity as none of the item had validity index less than 80%. The treatment adherence was also assessed with a standardized tool namely MARS which has a good internal consistency of 0.75 by Cronbach’s alpha method, Stability of 0.72 by test-retest method, inter-rater reliability of 0.93 and also a good construct validity established by using multitrait-multimethod matrix8 . The result of the current study showed a significant positive correlation (p=0.00) between the scores of MARS and Treatment Adherence Checklist demonstrating good construct validity of the developed checklist. For most of the purpose, reliability coefficient more than 0.70 is considered satisfactory.8 In the present study, the items were divided into odd and even numbers and also into first half and second half to calculate internal consistency. The reliability was found to be more than 0.70 Spearman Brown-Prophecy formula and Chronbach’s alpha in both the splits pair. The results indicate good internal consistency of the developed checklist. The result in [Table 6] indicates that a considerable number of items (22%) in the developed tool are not sensitive in measuring treatment adherence of persons with mental illness which may be due to the methodological biases. The adherence issues in the said non-sensitive items would have been more applicable to neurotic clients however, the study included only the patients diagnosed as psychotic illnesses. These items were also included in the tool by considering importance of content validity.

  Conclusion Top

Non-adherence to treatment is the vital issue related to treatment of persons with mental illness, which can be dealt with proper assessment and specific interventions. Use of this Treatment Adherence Checklist would provide a better understanding of non-adherence and lay the groundwork for intervention aimed to improve treatment adherence in person with mental illness. The developed tool i.e. Treatment Adherence Checklist is found to have good validity and considerable reliability, however, the stability of the developed tool need to be established in the future research. A large scale research may be conducted to establish the psychometric properties and standardize the tool.

  References Top

Lacro JP, Dunn LB, Dolder CR, Leckband SG, Jeste DV. Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: a comprehensive review of recent literature. J Clin Psychiatry. 2002 Oct;63(10):892-909.  Back to cited text no. 1
Lingam R. Scott J. Treatment non-adherence in affective disorders. Acta Psychiatr Scand. 2002 March;105( 3):164-172  Back to cited text no. 2
Lam WY, Fresco P. Medication adherence measures: an overview. Biomed Research International. [internet] 2015 [cited 2016 Aug 21]. Available from: http://dx.doi.org/10.1155/2015/217047  Back to cited text no. 3
Velligan D, Sajatovic M, Riley WT, Safren S, Lewis-Fernandez R, Weiden P, Ogedegbe G, Jamison J. Methodological challenges in psychiatric treatment adherence research. Clin Schizophr Relat Psychoses.2010 Apr;4(1):74-91. doi:10.3371/CSRP.4.1.6  Back to cited text no. 4
Sajatovic M, Velligan D, Widen PJ, Valenstein M, Ogedegbe G. Measurement of psychiatric treatment adherence. Psychosom Res. 2010 December ; 69(6): 59 1 -599. doi:10.1016/j.jpsychores.2009.05.007.  Back to cited text no. 5
Thompson K, Kulkari J, Sergejew AA. Reliability and validity of a new medication adherence rating scale(MARS) for the psychoses. Schizophrenia research 2000;42:241-247  Back to cited text no. 6
Fialko L, Garety PA, Kuipers E, Dunn G, Bebbington PE, Fowler D. et al. A large scale validation study of Medication Adherence Rating Scale (MARS). Schizophr Res. 2008 Mar;100(1-3):53-59 DOI: http://dx.doi.org/10.1016/j.schres.2007.10.029  Back to cited text no. 7
Polit DF, Hungler BP. Nursing Research Principles and methods, 6th ed. Philadelphia:Lippincott  Back to cited text no. 8


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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