|AWARD PAPER: DR. ANIL MALHOTRA AWARD PAPER
|Year : 2019 | Volume
| Issue : 1 | Page : 40-46
Psychometric properties of the Hindi-translated version of the “Assessment of Recovery Capital” scale at a tertiary level de-addiction center in North India
Aniruddha Basu1, Surendra Kumar Mattoo2, Debasish Basu2, BN Subodh2, Suresh Kumar Sharma3, Fazl E Roub2
1 Department of Psychiatry, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Psychiatry, Drug De-Addiction and Treatment Centre, PGIMER, Chandigarh, India
3 Department of Statistics, Centre for Systems Biology and Bioinformatics, Panjab University, Chandigarh, India
|Date of Submission||28-Nov-2018|
|Date of Acceptance||01-Dec-2018|
|Date of Web Publication||27-Mar-2019|
Dr. Aniruddha Basu
Department of Psychiatry, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
Source of Support: None, Conflict of Interest: None
Background/Objectives: The concept of “recovery capital” with regard to substance use draws upon the personal, social, cultural, and human resources in an individual to undergo recovery. However, lack of any structured instrument for its assessment in the local context necessitated the translation of the English self-assessment version of “Assessment of Recovery Capital” (ARC) scale to Hindi and the study of its psychometric properties. Methodology: In a cross-sectional study at a tertiary-level de-addiction center in Northwestern India, in the initial phase, forward translation to Hindi followed by expert panel back-translation, pretesting and cognitive interviewing were done. Thereafter, it was administered on 200 respondents of whom 100 were active alcohol-dependent or other illicit/pharmaceutical opioid-dependent users and another 100 dependent respondents were abstinent from such substances for the last 1 year. Results: Cognitive interviewing determined its face validity, whereas principal component analysis established a single-factor structure. It was shown to have good internal consistency (Cronbach's alpha = 0.86) and test-retest reliability (rho = 0.93, P < 0.001). Concurrent validity was established by comparing with the World Health Organization quality of life-BREF (P < 0.01), whereas predictive validity by significant area under the curve value of 82% and optimum cutoff of 41.5 (sensitivity: 81%, specificity: 71%) in the receiver operator characteristic curve. Divergent validity was established by lack of any significant positive correlation with the Addiction Severity Index (version 5.0). Conclusion: Hindi ARC has acceptable psychometric properties as a monitoring instrument for “recovery-oriented” de-addiction services. However, this needs to be studied in different settings with different substances longitudinally for its final validation.
Keywords: Hindi, instrument, recovery
|How to cite this article:|
Basu A, Mattoo SK, Basu D, Subodh B N, Sharma SK, Roub FE. Psychometric properties of the Hindi-translated version of the “Assessment of Recovery Capital” scale at a tertiary level de-addiction center in North India. Indian J Soc Psychiatry 2019;35:40-6
|How to cite this URL:|
Basu A, Mattoo SK, Basu D, Subodh B N, Sharma SK, Roub FE. Psychometric properties of the Hindi-translated version of the “Assessment of Recovery Capital” scale at a tertiary level de-addiction center in North India. Indian J Soc Psychiatry [serial online] 2019 [cited 2019 Jun 18];35:40-6. Available from: http://www.indjsp.org/text.asp?2019/35/1/40/254987
| Introduction|| |
The global burden due to alcohol and other drug use disorders is huge and as per the World Health Organization (WHO) estimates in the year 2016, the worldwide estimate is at 2 billion alcohol users and 185 million drug users. In India, the situation is also quite grave with the National Mental Health Survey showing that the prevalence of alcohol and illicit drug use disorders is 4.6% and 0.6%, respectively. This huge population burden is further aggravated by the fact that substance use disorders (SUDs) are chronic illnesses with relapsing-remitting nature. Hence, the question of “recovery” always remains doubtful. For alcohol, the concept of recovery is, however, not new, and since the 19th century, it had been upheld by different Christian evangelist societies and sociopolitical organizations which epitomized in the great Prohibition in the US in the 1930s and culminated in the Alcoholics Anonymous movement.
Systematic studies for studying the outcome of SUD have been there for the last half a century. Longitudinal decadal follow-up studies by Valliant, the famous Vietnam Veterans study by Robbins, and subsequently, systematic studies such as the Drug Abuse Treatment Outcome studies have shown that “recovery” is a reality., For alcohol dependence in 5-year follow-up, about 30%–40% were abstinent and for opioid dependence on methadone maintenance at 5 years up to 25%–28% were abstinent., Longitudinal studies involving community-based cohorts have yielded a better outcome. However, among incarcerated individuals, as shown in a 33-year follow-up by Hser et al., the outcome is poorer with high rates of relapse.
Apart from the longitudinal cohort studies which have mainly studied the outcome, qualitative studies have tried to study the nature of “recovery.” It has been seen that “recovery” in SUDs is an individual's unique experience and the outcome is varied, the reasons being the differential ability of the individual to cope through the journey to “recovery.” These led Cloud and Granfield to propose the concept of “recovery capital” which draws upon the social and personal resources of the individual to undergo “recovery.” It is the sum total of one's resources that can be brought to bear on the initiation and maintenance of substance use and cessation. Qualitative research conducted among persons who have undergone natural recovery yielded the concept of “recovery capital” which is composed of social, cultural, physical, and human domains. To understand the importance of “recovery capital,” Laudet and White conducted an important study among recovering persons (n = 312), mostly inner-city ethnic minority members whose primary substance had been crack or heroin and were interviewed twice at 1-year interval in New York City. Participants were classified into one of four baseline recovery stages: under 6 months, 6–18 months, 18–36 months, and over 3 years. Multiple regression findings supported the ability of “recovery capital” to predict the outcome. From similar other studies, it had been concluded that “recovery capital” is directly correlating with sustained recovery, higher quality of life (QOL), and lower stress in the long term. Hence, considering its importance in predicting the outcome, an objective measurement of “recovery” capital is required.
Recently, worldwide “recovery” orientation has been a paradigm shift occurring in SUD treatment services. Furthermore, the concept of “whole person recovery” has been proposed in the Draft National Demand Reduction Policy, 2013 introduced by the Ministry of Social Justice and Empowerment, Government of India (currently under reconsideration by the ministry). Since the concept of “recovery” is unique in different sociocultural settings, hence an individualized objective instrument suited to the local context is required. To the best of our knowledge, no such instrument for measuring recovery for SUDs exists in the Indian context.
In the absence of a comprehensive instrument for measuring recovery, a scale for measuring “recovery capital” can be indirectly used to assess “recovery” as seen in both qualitative and quantitative studies. The English Assessment of Recovery Capital (ARC) scale developed by Groshkova et al. is useful for assessment of “recovery capital,” and rather than deficit-based assessment, it assesses the social, physical, human, and cultural strength in an individual by means of 10 items, namely: “substance use and sobriety, global health (psychological), global health (physical), citizenship/community involvement, social support, meaningful activities, housing and safety, risk-taking, coping, and life functioning.” The ARC has acceptable psychometric properties with a single underlying factor structure as assessed by principal component analysis (PCA), high Cronbach's alpha and acceptable concurrent and predictive validity.
Hence, for better understanding the potential of an individual to undergo “recovery” in a manner suited to the local context, the ARC scale needed to be translated to different Indian languages, and subsequently, validation needs to be done. Hence, the aim of this study was to develop a Hindi version of the English ARC scale. In this regard, the objectives were an initial translation as per standard procedures and its applications on persons with alcohol and opioid dependence in different stages of substance use ranging from active use to sustained abstinence.
| Methodology|| |
A cross-sectional study was conducted at the Drug De-addiction and Treatment Centre, Department of Psychiatry, PGIMER, Chandigarh, in two phases:
- Phase I – the English version of ARC scale was translated to the Hindi
- Phase II – Hindi ARC was administered on 200 respondents.
Phase I – Translation of Assessment of Recovery Capital scale to Hindi
For the translation purposes, the following process as recommended by the World Health Organization was followed, namely:
- Forward translation
- Expert panel back-translation
- Pretesting and cognitive interviewing
- Final version.
The first author, who is fluent in Hindi and experienced in working with Hindi speaking patients with SUD, translated the scale emphasizing conceptual rather than literal translations, as well as the need to use natural and acceptable language for the broadest audience. Translator avoided the use of any jargon, difficult to understand terms that might be considered offensive to the target respondents.
For this step, a bilingual (both English and Hindi) expert panel (not directly associated with this study) was consulted. The goal was to check whether the original instrument and the forward translation were compatible conceptually. The expert panel suggested alterations to some words and expressions. All the suggestions were incorporated and the revised version was prepared.
The instrument was back-translated to English by an independent translator (not associated with this study), who is well versed in English and who had no knowledge of the original instrument. Again here, as in the first step, the translation was judged conceptually rather than literally.
Pretesting and cognitive interviewing
In total, 10 pretest respondents who were opioid dependent (from a heterogeneous socioeconomic and educational background) were administered the translated Hindi version of instrument and were systematically debriefed by audio recording in-depth interviews conducted by the first author.
Final translated version of Assessment of Recovery Capital scale
Most of the changes suggested were incorporated in the final Hindi version.
Phase II – Application of the Hindi version of the Assessment of Recovery Capital scale
This instrument was applied on a total of 200 consenting patients/respondents with alcohol and/or opioid dependence (both illicit and pharmaceutical) recruited through purposive sampling:
- One hundred respondents with current active use (last 1 month) of alcohol and or opioid of any type (“illicit” or “out of prescription opioid”)
- One hundred respondents abstinent from alcohol and/or opioid of any type (“illicit” or “out of prescription opioid”) or any other illicit drug use for last 1 year.
All the respondents had the following inclusion and exclusion criteria:
- Male respondents between 18 and 65 years of age
- Respondents with alcohol/opioid dependence diagnosed as per the International Classification of Diseases, 10th Edition (ICD-10)
- Able to understand and read Hindi.
- Severe mental illness
- Serious medical comorbidity
- Moderate or severe withdrawal/intoxication on any substance as per the clinical assessment.
Apart from Hindi ARC, these 200 respondents were assessed with the following instruments:
- Sociodemographic profile sheet and clinical profile sheet: Specifically devised for the purpose of this study, it records the clinical details and substance use history
- Mini International Neuropsychiatric Interview: It is a well-known brief-structured diagnostic interview of psychiatric disorders that can be administered in 15–20 min. Its reliability for various psychiatric disorders ranges from good to excellent (kappa = 0.51–0.90). It was used to screen the study participants for psychiatric comorbidities
- WHOQoL-BREF (Hindi version): It evaluates subjectively the respondent's health and living conditions where the 26 items are clubbed into four domains of QoL, namely physical health, psychological health, social relationships, and environment. Furthermore, there is an additional measure for general well-being
- Addiction Severity Index: It is a reliable and valid semi-structured clinical or research interview which evaluates patients with SUD in the following areas, namely, medical, employment, drug and alcohol use, legal, family/social, and psychological domains.
In another group of 27 male respondents (18–65 years) recruited through convenience sampling who have been diagnosed as alcohol and/or opioid dependence as per the ICD-10 and who were clinically evaluated to rule out any serious withdrawal symptoms, major medical, or serious psychiatric comorbidity, Hindi ARC was applied twice within a gap of 1 week.
Institute ethical committee approved the study. Furthermore, permission was obtained from the original authors of the instrument for the purpose of translation and validation.
Statistical analysis was conducted using the IBM SPSS Statistics for Windows, Version 21.0. (Armonk, NY: IBM Corp.) released 2012. The sociodemographic and clinical data were analyzed after testing their normality. An initial exploratory factor analysis was done by PCA. Cronbach's alpha and test-retest correlation coefficients were calculated. ARC domain and total scores were correlated with the WHOQoL-BREF domain scores and Addiction Severity Index (ASI) composite scores. The sensitivity and specificity of ARC as an indicator of recovery (abstinent for at least 1 year) and its optimal cutoff scores were determined and receiver operating characteristic (ROC) curve was plotted. ARC scores were compared between the opioid dependence group abstinent for 1 year on opioid substitution therapy (OST) and the group which had been drug free. All the tests were significant at P < 0.05 and two-tailed tests were applied.
| Results|| |
Sociodemographic and clinical profile
The mean age and years of education were 32.51 ± 10.72 years and 12.46 ± 2.29 years, respectively. Among the individuals with substance dependence currently abstinent for the last 1 year (n = 100), 56 (56%) were predominantly opioid dependent not on OST, 22 (22%) were predominantly opioid dependent currently stabilized on OST, and 22 were predominantly alcohol dependent currently abstinent. Mean ARC domain and total scores of the whole sample (n = 200) have been tabulated and this may be the norms for a similar clinical population [Table 1].
|Table 1: Assessment of Recovery Capital norms-mean with standard deviation, test-re-test mean with standard deviation, correlation coefficient|
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PCA revealed that 46.21% of the variation could be accounted for by the first linear factor [Table 2]. Favorable Kaiser–Meyer–Olkin measure of sampling adequacy (0.9) and Bartlett's Test of Sphericity (<0.01) supported the appropriateness of the PCA which extracted one factor, and this is similar to the factor structure of the original English ARC scale.
|Table 2: Loadings of Assessment of Recovery Capital subscales on a single factor (n=200)|
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Internal consistency was calculated as Cronbach's alpha value of 0.86. As shown in [Table 3], there were no major changes in Cronbach's alpha with successive item deletions. The test-retest reliability of ARC has been calculated by Spearman's correlation between initial scores and subsequent scores done on respondents after a gap of 4–7 days. All the domains had correlations that are statistically significant (P < 0.01) as shown in [Table 1].
Statistically significant correlations have been found between the related domains of Hindi ARC scale and Hindi WHOQOL-BREF as shown in [Table 4], thereby establishing the concurrent validity. On the other hand, [Table 5] showed lack of positive correlation between the measures of ARC and ASI in all the domains in the actively substance-using group (who have used any “illicit,” “out of prescription” opioid or alcohol in the last 1 month), thereby establishing the divergent validity.
|Table 4: Correlations between Assessment of Recovery Capital and World Health Organization quality of life BREF (n=200)|
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|Table 5: Correlations between Assessment of Recovery Capital and Addiction Severity Index among the active users only (n=100)|
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Receiver operating characteristic curve
It has an area under the curve value of 0.82 (95% confidence interval 0.76–0.88) which is statistically significant at P < 0.001. Furthermore, using sensitivity and specificity values for different cutoff points of ARC total score, according to the ROC curve in [Figure 1], an optimal cutoff level of 41.5 yielding maximum sensitivity of 81% and specificity of 71% for predicting recovery (defined as at least 1 year of abstinence) was obtained. This also established the predictive validity of the instrument.
|Figure 1: Receiver operating characteristic curve of Assessment of Recovery Capital total score and recovery (n = 200)|
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Comparison between abstinent groups
Hindi ARC when applied on the abstinent individuals with opioid dependence could differ significantly between the opioid-free group (for 1 year) and the group on OST with respect to the total ARC score (P < 0.01) [Table 6]. Among the domains of ARC, the global physical health domain showed statistically significant difference between drug-free individuals and the group on OST.
|Table 6: Comparison of Assessment of Recovery Capital between opioid-free recovery and opioid substitution therapy (n=22)|
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The average time required was between 5 and 10 min (not tabulated).
| Discussion|| |
In this study, the Hindi version of the ARC scale was developed through translation as per the WHO rules and validity and reliability was established. This was easy to administer and acceptable among respondents with at least primary school level knowledge of Hindi at a tertiary level de-addiction setting in Northwestern India.
There was a single underlying factor of recovery capital with factor analysis identifying a single dimension accounting for 46% of the variance and loadings for each of the subscales ranging from 0.52 to 0.76. The Cronbach's alpha reliability value of 0.86 was high (>0.7), thereby indicating acceptable internal consistency. There was also high statistically significant test-retest reliability in this instrument. Among the different measures of validity, face validity assessment was done by cognitive interviewing 10 respondents. The standard WHO procedure was followed and the translated version was acceptable to the respondents with minor modifications. However, other detailed procedures of content validation such as expert review or quantitative measures such as “Content Validity Ratio” calculations were not undertaken.
Apart from these, different types of criterion validity such as concurrent validity and predictive validity were evaluated. The concurrent validity was assessed by correlating with the WHOQOL-BREF. Although the latter is not the gold standard for the evaluation of “recovery capital,” yet it has been shown to be positively correlating with ARC scores in previous studies. Furthermore, the fact that ARC scores were not having any significant positive correlations with the active substance use corroborated its divergent validity.
The fact that the study could differentiate between OST and “drug-free” recovery has implications. For example, in a previous study from India, many of the patients found that the OST is a “form of bondage.” Hence, the “final drug-free state” is the most desirable goal of recovery considering patients perspective. Although currently recovery and OST are mutually inclusive, hence OST should be part of the recovery goals for opioid users for whom it is indicated in short-to-medium term (months to years) as per standard guidelines. However, for monitoring the process of attainment of recovery goals in the long term which is often the final “drug-free state” in most of the Indian patients, an instrument such as ARC may be very helpful.
This study had several differences with the original study by Groshkova et al. The optimal cutoff for maximal sensitivity (81%) and specificity (71%) in this study was 41.5 which is different from the original English study having a cutoff of 27.5 with high sensitivity of 92% and specificity of 69%. Other differences were that while the total Hindi ARC score in this study is 40.39 ± 7.75 that in the original study was 31.25 ± 11.54. These differences may be due to different methodologies, for example, the patient populations which includes the setting, sample size, substance used, recruitment methods, other sociodemographic, and cultural differences.
Major limitations of this study are social desirability bias and the lack of corroboration of self-report. Social desirability bias could have been dealt with by statistical means or by applying a scale like the Marlowe–Crowne social desirability scale. Other limitations are inherent in the assessment of any abstract concept like “recovery” by a questionnaire-based assessment. Another related controversy may be related to its factor structure which came out to be a single linear factor. This is quite surprising given that the concept of recovery capital is a multidimensional construct. Furthermore, the question remains that whether 1 year is adequate for the assessment of recovery and many definitions have considered minimum duration to be up to 5 years. Furthermore, this study was done only in tertiary care which limits its generalizability.
In view of these limitations, the Hindi ARC and the study methodology requires some modifications. As an example, the item related to “availability of education or teaching” may not be relevant to the Indian context. Furthermore, it did not include religiosity, spiritual concepts related to recovery which needs to be added as it has been shown to be important in the Indian context. In this regard, it may be said that an underlying theoretical model for recovery capital unique to the Indian context needs to be derived and from which an instrument may be devised. Future studies should include women or adolescents. As per feedback by the respondents, some of the questions were vague like duration of abstinence – this needs improvement in the future studies. Reverse questions need to be included in future for further improving psychometric properties of this instrument. Prospective validity also needs to be assessed.
In spite of some limitations, the Hindi version of the ARC has been shown to have good psychometric properties in substance-dependent population in North India. This study needs to be extended in multiples centers and also in treatment and nontreatment settings, thereby establishing its final validity. Furthermore, this instrument may help in improving the OST from a mere drug dispensing to a comprehensive recovery-oriented service.
| Conclusion and Implications|| |
ARC has been translated in a Hindi-speaking North Indian population and its psychometric properties have been established. This instrument could be used in the development of recovery-oriented services for SUDs in the future.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al
. National Mental Health Survey of India, 2015-16: Summary. Bengaluru: National Institute of Mental Health and Neurosciences; 2016.
McLellan AT, Lewis DC, O'Brien CP, Kleber HD. Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. JAMA 2000;284:1689-95.
Galanter M, Kaskutas LA. Research on Alcoholics Anonymous and Spirituality in Addiction Recovery: The Twelve-Step Program Model Spiritually Oriented Recovery Twelve-Step Membership Effectiveness and Outcome Research. New York: Springer Science & Business Media; 2008.
Vaillant GE. A 20-year follow-up of New York narcotic addicts. Arch Gen Psychiatry 1973;29:237-41.
Robins LN. The sixth Thomas James Okey Memorial Lecture. Vietnam veterans' rapid recovery from heroin addiction: A fluke or normal expectation? Addiction 1993;88:1041-54.
Hser YI, Evans E, Grella C, Ling W, Anglin D. Long-term course of opioid addiction. Harv Rev Psychiatry 2015;23:76-89.
Gossop M, Marsden J, Stewart D, Kidd T. The National Treatment Outcome Research Study (NTORS): 4-5 year follow-up results. Addiction 2003;98:291-303.
Hser YI, Hoffman V, Grella CE, Anglin MD. A 33-year follow-up of narcotics addicts. Arch Gen Psychiatry 2001;58:503-8.
White WL. Addiction recovery: Its definition and conceptual boundaries. J Subst Abuse Treat 2007;33:229-41.
Cloud WA. Qualitative Study of Heroin Addiction and Recovery: Implications for Social Work Practice; 1988. Available from: http://www.hdl.handle.net/1811/32508
. [last accessed on 2017 Dec 21].
Cloud W, Granfield R. Conceptualizing recovery capital: Expansion of a theoretical construct. Subst Use Misuse 2008;43:1971-86.
Laudet AB, White WL. Recovery capital as prospective predictor of sustained recovery, life satisfaction, and stress among former poly-substance users. Subst Use Misuse 2008;43:27-54.
Sterling R, Slusher C, Weinstein S. Measuring recovery capital and determining its relationship to outcome in an alcohol dependent sample. Am J Drug Alcohol Abuse 2008;34:603-10.
Peele S. Addiction as a cultural concept. Ann N Y Acad Sci 1990;602:205-20.
Groshkova T, Best D, White W. The assessment of recovery capital: Properties and psychometrics of a measure of addiction recovery strengths. Drug Alcohol Rev 2013;32:187-94.
Saxena S, Chandiramani K, Bhargava R. WHOQOL-Hindi: A questionnaire for assessing quality of life in health care settings in India. World Health Organization quality of life. Natl Med J India 1998;11:160-5.
McLellan AT, Kushner H, Metzger D, Peters R, Smith I, Grissom G, et al.
The fifth edition of the addiction severity index. J Subst Abuse Treat 1992;9:199-213.
DeVellis RF. Scale Development: Theory and Applications. California: SAGE; 2012.
Lawshe CH. A quantitative approach to content validity1. Pers Psychol 1975;28:563-75.
Laudet AB, Savage R, Mahmood D. Pathways to long-term recovery: A preliminary investigation. J Psychoactive Drugs 2002;34:305-11.
Prakash S, Balhara Y. Perceptions related to pharmacological treatment of opioid dependence among individuals seeking treatment at a tertiary care center in Northern India: A descriptive study. Subst Use Misuse 2016;51:861-9.
Goyal S, Amberkar A. Clinical practice guidelines for the management of opioid use disorders. In: Basu D, Dalal PK, editors. Clinical Practice Guidelines for the Assessment and Management of Substance Use Disorders. India: Indian Psychiatric Society; 2014. p. 286-349.
Crowne DP, Marlowe D. A new scale of social desirability independent of psychopathology. J Consult Psychol 1960;24:349-54.
Betty Ford Institute Consensus Panel. What is recovery? A working definition from the Betty Ford Institute. J Subst Abuse Treat 2007;33:221-8.
Morjaria-Keval A. Religious and spiritual elements of change in Sikh men with alcohol problems: A qualitative exploration. J Ethn Subst Abuse 2006;5:91-118.
Nunnally JC, Bernstein IH. Psychometric Theory. Michigan: McGraw-Hill; 1994.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]