|Year : 2020 | Volume
| Issue : 2 | Page : 141-145
Psychometric properties of the hindi version of beliefs about voices questionnaire-revised
Amrita Choudhary, Jay Kumar Ranjan, HS Asthana
Department of Psychology, Banaras Hindu University, Varanasi, Uttar Pradesh, India
|Date of Submission||03-Sep-2019|
|Date of Decision||11-Nov-2019|
|Date of Acceptance||09-Dec-2019|
|Date of Web Publication||27-Jun-2020|
Dr. Jay Kumar Ranjan
Department of Psychology, Banaras Hindu University, Varanasi, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: The cognitive model of auditory hallucinations posits that the beliefs or appraisal of the voices plays an important role in the determination of consequent reactions. These beliefs are explored effectively through “Beliefs About Voices Questionnaire-Revised (BAVQ-R).” However, Hindi adaptation and psychometric evaluation of this tool are yet to be done. Hence, the present study aimed at translating the BAVQ-R in Hindi language and assessing the psychometric properties of the same. Methodology: The original version was translated in Hindi language using translation–back-translation method. This translated version of BAVQ-R was then administered to 51 schizophrenia patients with a history of active auditory hallucinations. All the participants were selected from Central India Institute of Mental Health and Neuro Sciences, Rajnandgaon (Chhattisgarh), using purposive sampling technique. Initially, the informed consent was taken from the patients, followed by the administration of the Hindi version of BAVQ-R and Psychotic Symptom Rating Scale (PSYRATS). Finally, the psychometric properties, e.g., internal consistency reliability, divergent validity, and convergent validity were calculated. Results: The internal consistency reliability was within the range of 0.6–0.94, as indicated by Cronbach's alpha. The divergent validity was high as malevolent voices and engagement feelings and behavior towards the voices were negatively correlated (r = −0.56, P < 0.01), and benevolent voices significantly negatively correlated with resistance feeling and behavior towards the voices (r = −0.74, P < 0.01). Convergent validity was measured by correlating the subscales of BAVQ-R with the dimensions of PSYRATS. Pearson's correlation indicated significant associations between the dimensions of the two scales. Conclusion: The Hindi version of BAVQ-R has good psychometric properties. The tool has good internal consistency along with high divergent and convergent validity.
Keywords: Auditory hallucination, Beliefs About Voices Questionnaire-Revised (Hindi), hallucinatory beliefs, schizophrenia
|How to cite this article:|
Choudhary A, Ranjan JK, Asthana H S. Psychometric properties of the hindi version of beliefs about voices questionnaire-revised. Indian J Soc Psychiatry 2020;36:141-5
|How to cite this URL:|
Choudhary A, Ranjan JK, Asthana H S. Psychometric properties of the hindi version of beliefs about voices questionnaire-revised. Indian J Soc Psychiatry [serial online] 2020 [cited 2020 Aug 8];36:141-5. Available from: http://www.indjsp.org/text.asp?2020/36/2/141/288116
| Introduction|| |
Auditory hallucinations are the most common symptom of schizophrenia, and its nature is multidimensional and heterogeneous. Hallucinatory experiences are not only eccentric and perplexing but also very personal and subjective. Some patients experience them as extremely disturbing, while others find it amusing and enduring. The content of hallucination is linked to ones' belief related to the hallucinatory voices. Therefore, the patients who consider it negative find difficulty in concentrating and communicating with the external world. The distress related to the voices has also been linked with feelings of powerlessness, inferiority complex, low self-esteem,, and attributed power of the voices. On the other hand, the patients who believe that the voices are beneficial often do not seek professional help. Therefore, compliance with the demands and advice of the voices depends on the appraisal of hallucinatory voices. This epistemology can be explained through the ABC cognitive model of hallucinations, wherein “A” is the activating event, i.e., auditory hallucinations, “B” is the belief, i.e., interpretation or appraisal, and “C” is the consequence of the hallucination.
Based on the cognitive model of auditory hallucinations, it can be inferred that the beliefs about the voices play a mediating role in the consequent reaction to the voices. There are tools that measure the presence of hallucinations and its related contents, such as psychotic symptom rating scale (PSYRATS) and Brief Psychiatric Rating Scale. However, Beliefs About Voices Questionnaire-Revised (BAVQ-R) is the only tool that measures the interpretation or appraisal of the hallucinatory voices. The original BAVQ comprised the constructs, viz., malevolence, benevolence, resistance feeling and behavior, and engagement feeling and behavior. Malevolent beliefs about voices lead to fear and resistance, while benevolent beliefs lead to positive affect and engagement behavior. BAVQ was revised in 2000, namely BAVQ-R, which additionally comprised omnipotence and positive affect and engagement behavior.
The BAVQ-R has been translated and validated in French language. However, the Hindi adaptation of the tool is yet to be done. Hence, the present study aimed to translate BAVQ-R in Hindi language and to assess its psychometric properties further. The ABC cognitive model of hallucinations is the soul of cognitive therapy for managing hallucinations and delusions in schizophrenia and other psychotic patients. The analysis of belief or appraisal system of hallucination will help the mental health professionals in cognitive therapeutic case formulation of Hindi-speaking schizophrenia patients.
| Methodology|| |
The present study was carried out on the in-patients of Central India Institute of Mental Health and Neuro Sciences (CIIMHANS), Rajnandgaon, Chhattisgarh. The patients who met the following inclusion criteria were included for the study: (a) patients diagnosed with schizophrenia disorder (F.20.0) according to ICD-10 DCR, (b) had a history of active auditory hallucinations, (c) 18–55 years of age range, (d) both male and female patients, and (e) able to read and comprehend Hindi language. Patients with a family history of mental illness, comorbidity of any other significant physical, neurological, and psychiatric conditions such as a history of substance abuse, mental retardation, and epilepsy were excluded. Patients who had undergone electroconvulsive therapy (ECT) in the last week were also excluded. During the 45-day period of data collection, there were 132 patients with psychosis in the in-patient department, of which 96 were diagnosed with schizophrenia with a history of active auditory hallucinations. Based on the inclusion and exclusion criteria, 18 patients were excluded because of their chronic duration of illness, 13 patients were non-cooperative, and nine patients denied sharing information about their hallucinatory voices. Therefore, a total of 56 patients were taken for the collection of data. Meanwhile, five had undergone ECT; therefore, they were also excluded from the study. Finally, the psychometric evaluation of the Hindi version of BAVQ-R was conducted on 51 patients.
- PSYRATS–auditory hallucination (PSYRATS-AH) subscale: The PSYRATS-AH is part of a larger semi-structured interview developed for quantification of the multidimensional features of the psychotic symptoms of hallucinations and delusions. It is often used for gathering additional information regarding hallucinations and delusions of schizophrenia and psychotic patients. It comprised 11 items to measure 11 dimensions of auditory hallucinations, namely duration, location, frequency, amount and degree of negative content, controllability, and amount and intensity of distress. Each item is scored on a 5-point Likert scale (0–4) based on the severity of voices. The inter-rater and concurrent validity of the scale are high, and its internal consistency reliability ranges from 0.63 to 0.76
- BAVQ-R: The BAVQ-R is a 35-item measure of people's beliefs about auditory hallucinations and their emotional and behavioral reactions. There are five subscales in the questionnaire, viz., malevolence, benevolence, omnipotence, resistance, and engagement feelings and behavior. The items are measured on a four-point Likert scale. The mean Cronbach's alpha for the five subscales ranges from 0.74 to 0.88, along with high construct validity.
The permission had been taken from the author of the BAVQ-R regarding Hindi translation and psychometric validation of the tool. After that, the original version of BAVQ-R was given to three bilingual mental health professionals for Hindi translation. Of the three translations, the most suitable translation was selected and given to another three bilingual mental health professionals for back-translation. These back-translated statements were compared with the original BAVQ-R, and necessary modifications were made wherever applicable. The BAVQ-R did not have any culturally-sensitive item; therefore, cultural adaptation of any item was not required. Patients with schizophrenia were selected on the basis of the above-mentioned inclusion and exclusion criteria for the assessment of psychometric properties. Initially, the written informed consent was taken from the patients, and the socio-demographic details were recorded. After successful rapport establishment, the Hindi-translated version of BAVQ-R along with PSYRATS was administered. In addition, it was noted if any patient had any difficulty in understanding any particular word or phrase during the administration of the translated tool. Finally, obtained responses were statistically analyzed for the estimation of the psychometric properties, i.e., reliability and validity of Hindi-translated version of BAVQ-R.
A series of Cronbach's alpha was calculated for each subscale of BAVQ-R to measure internal consistency reliability of the translated instrument. Divergent validity was estimated by calculating the correlation coefficients among the different subscales of BAVQ-R. Convergent validity was also calculated by computing correlation coefficient between the scores of BAVQ-R and PSYRATS-AH.
| Results|| |
The present study was conducted on 51 patients of schizophrenia; among them, 45% were males and 55% were females. Majority of the participants (66.8%) were educated above higher secondary. 19.61% and 11.76% of participants had received secondary and primary level of education, respectively. The mean age of participants was 32.94 ± 13.84 years.
Reliability and validity
Internal consistency reliability was calculated for each subscale of BAVQ-R, and the Cronbach's alpha coefficients were found to be uniformly high for each subscale ranging from 0.6 to 0.94 (as indicated in [Table 1]. To measure the divergent validity, correlations among different subscales of BAVQ-R were computed [Table 2]. The findings of the present analysis indicated a significant negative correlation between malevolence and engagement feelings and behavior (r = −0.56, P < 0.01) and between benevolence and resistance feelings and behavior (r = −0.74, P < 0.01). It can be inferred from the findings that patients' negative beliefs related to voices led to resistance behavior and positive beliefs headed to engagement behavior. Similarly, the omnipotence subscale was also positively correlated with malevolence (r = 0.65, P < 0.01) and resistance feeling and behavior (r = 0.54, P < 0.01). This implies that patients who considered voices as powerful show resistance behavior. All other subscales had significantly negative correlations.
|Table 1: Internal consistency across the subscales of the Beliefs About Voices Questionnaire-Revised|
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|Table 2: Correlations between the subscales - construct validity of the Beliefs About Voices Questionnaire - Revised|
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The convergent validity was measured by assessing the relationship between the subscales of BAVQ-R – Hindi version – and PSYRATS-AH. The results indicated that there were significant correlations between the dimensions of both the scales. For instance, the benevolence belief was significantly and positively correlated with distress (r = 0.59, df = 49, P < 0.01) and negatively correlated with amount of negative content (r = −0.59, df = 49 P < 0.01), degree of negative content (r = −0.59, df = 49, P < 0.01), intensity of distress (r = −0.49, df = 49, P < 0.01), and controllability of the voices (r = −0.31, df = 49, P < 0.05) [Table 3]. Therefore, the patients who had voices with less negative content both in terms of degree and amount, considered these voices as benevolent. The belief regarding malevolence of the voices was significantly positively correlated with frequency (r = 0.37, df = 49, P < 0.01), duration (r = 0.37, df = 49, P < 0.01), perceived location (r = 0.31, df = 49, P < 0.05), amount of negative content (r = 0.93, df = 49, P < 0.01), degree of negative content (r = 0.93, df = 49, P < 0.01), amount of distress (r = 0.48, df = 49, P < 0.01), and intensity of distress (r = 0.45, df = 49, P < 0.01) [Table 3]. It is evident from the findings that the patients who experienced voices with higher degree and amount of negative content also reported malevolent beliefs about the hallucinatory voices. The belief regarding the strength of the voices, i.e., omnipotence, was found to be significantly and positively associated with frequency (r = 0.38, df = 49, P < 0.01), duration (r = 0.51, df = 49, P < 0.01), amount of negative content (r = 0.63, df = 49, P < 0.01), degree of negative content (r = 0.61, df = 49, P < 0.01), amount of distress (r = 0.37, df = 49, P < 0.01), and intensity of distress (r = 0.37, df = 49, P < 0.01) [Table 3]. It can be inferred that voices were perceived as powerful by the patients when they occurred frequently for longer durations with higher degree and amount of negative content, and consequently, the voices caused greater intensity of distress. The engagement feeling and behavior subscale was significantly negatively correlated with duration (r = −0.28, df = 49, P < 0.05), loudness (r = −0.29, df = 49, P < 0.05), amount of negative content (r =−0.49, df = 49, P < 0.01), degree of negative content (r = −0.45, df = 49, P < 0.01), amount of distress (r = −0.60, df = 49, P < 0.01), intensity of distress (r = −0.53, df = 49, P < 0.01), and controllability of the voice (r = −0.30, df = 49, P < 0.05) [Table 3]. Therefore, only those participants endured the voices that had negative content in terms of less amount, degree, and duration. Finally, the resistance feeling and behavior subscale has significantly positive association with frequency (r = 0.38, df = 49, P < 0.01), duration (r = 0.36, df = 49, P < 0.01), amount of negative content (r = 0.79, df = 49, P < 0.01), degree of negative content (r = 0.78, df = 49, P < 0.01), amount of distress (r = 0.66, df = 49, P < 0.01), intensity of distress (r = 0.63, df = 49, P < 0.01), and controllability of the voice (r = 0.32, df = 49, P < 0.05) [Table 3]. Voices are negative in nature along with higher severity are also resisted by the patients.
|Table 3: Correlations between the subscales of the Beliefs About Voices Questionnaire-Revised and Psychotic Symptoms Rating Scale-Auditory Hallucination Subscale|
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| Discussion|| |
The present study was conducted to translate the BAVQ-R in Hindi and assess the psychometric properties of the translated tool in Indian setting. A number of earlier studies have demonstrated the clinical utility of this test, especially with schizophrenia population.,,
Internal consistency method has been used to assess the reliability of the BAVQ-R. Findings of the present study indicate that Cronbach's alpha scores are on the acceptable range (0.6–0.94). The internal consistency reliability of the French version of BAVQ-R also ranges from 0.64 to 0.83. Thus, it can be inferred that the Hindi-translated version of the BAVQ-R is a reliable tool for measuring hallucinatory beliefs of schizophrenia patients.
Correlation coefficients between the subscales have been calculated to measure divergent validity. As the behavioral response to the hallucinations is related to the appraisal or interpretation of the hallucination,,,, the findings of the present study are consistent with the findings of previous researches as, if the patients find the voices to be negative (malevolent), then they develop a tendency to avoid, refrain, and resist hallucinatory voices (resistance). Similarly, when the hallucinatory voices were found to be positive or beneficial (benevolent), the patients did not resist the commands and indulged with voices (engagement). Therefore, it can be inferred that subscales of the Hindi version of BAVQ-R measure what it intend to measure. The present findings are consistent with earlier research.,
According to the ABC cognitive model, the hallucinatory experiences precede the belief formation process and these beliefs are dependent on the content of the voices. The dimensions of the PSYRATS-AH quantify the multidimensional features of hallucinatory experiences, especially the items related to type of content and its degree. Therefore, it can be speculated that it is an appropriate tool to assess the convergent validity of the Hindi version of BAVQ-R. The correlation coefficients between the dimensions of the PSYRATS and the subscales of Hindi version of BAVQ-R were found to be high. Hence, it can be said that the translated tool has high convergent validity.
The Hindi version of BAVQ-R would have great diagnostic as well as therapeutic importance, especially in cognitive therapy-based case formulation of schizophrenia patients. Although the translated version has good psychometric properties, it has certain limitations. The test–retest reliability of the tool could not be calculated because it was not feasible to collect the data on the same patients after a certain period of time. Second, the sample size of the present study was relatively small, which also limits the generalizability of the findings. Majority of schizophrenia patients available to be included in the study sample did not want to disclose information about their hallucinations; therefore, the sample size of this study is relatively small. As large numbers of patients experienced command type of hallucinations, denied the occurrence of hallucinations, abiding by the hallucinatory voice. The non-significant relationship between the various dimensions can also be attributed to the aforementioned limitations.
| Conclusion|| |
The Hindi version BAVQ-R is an effective measure of hallucinatory beliefs for Hindi-speaking schizophrenia patients. It has good psychometric properties as internal consistency reliability, and convergent and divergent validity are in high range. This tool will be very useful for Indian mental health practitioners in their clinical as well as future research endeavors.
We are thankful to Dr. Pramod Gupta, Psychiatrist and Director, CIIMHANS, Rajnandgaon (Chhattisgarh), and Lokesh Kumar Ranjan, Psychiatric Social Worker, CIIMHANS, Rajnandgaon (Chhattisgarh), for their assistance in procuring data from patients with schizophrenia.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.r
| References|| |
World Health Organization. Report of the International Pilot Study of Schizophrenia. Switzerland: World Health Organization; 1973.
Waters F, Allen P, Aleman A, Fernyhough C, Woodward TS, Badcock JC, et al
. Auditory hallucinations in schizophrenia and nonschizophrenia populations: A review and integrated model of cognitive mechanisms. Schizophr Bull 2012;38:683-93.
Chadwick P, Birchwood M. The omnipotence of voices. A cognitive approach to auditory hallucinations. Br J Psychiatry 1994;164:190-201.
Romme MA, Escher AD. Hearing voices. Schizophr Bull 1989;15:209-16.
Fannon D, Hayward P, Thompson N, Green N, Surguladze S, Wykes T. The self or the voice? Relative contributions of self-esteem and voice appraisal in persistent auditory hallucinations. Schizophr Res 2009;112:174-80.
Smith B, Fowler DG, Freeman D, Bebbington P, Bashforth H, Garety P, et al
. Emotion and psychosis: Links between depression, self-esteem, negative schematic beliefs and delusions and hallucinations. Schizophr Res 2006;86:181-8.
Birchwood M, Gilbert P, Gilbert J, Trower P, Meaden A, Hay J, et al
. Interpersonal and role-related schema influence the relationship with the dominant 'voice' in schizophrenia: A comparison of three models. Psychol Med 2004;34:1571-80.
Johns LC, Kompus K, Connell M, Humpston C, Lincoln TM, Longden E, et al
. Auditory verbal hallucinations in persons with and without a need for care. Schizophr Bull 2014;40 Suppl 4:S255-64.
Birchwood M, Chadwick P. The omnipotence of voices: Testing the validity of a cognitive model. Psychol Med 1997;27:1345-53.
Chandwick P, Lees S, Birchwood M. The revised Beliefs About Voices Questionnaire (BAVQ-R). Br J Psychiatry 2000;177:229-32.
Curtis L, Zanello A, Ba MB, Mohr S, Huguelet P. Validation of the “Beliefs about Voices Questionnaire-Revised (BAVQ-R).” In: French Speaking Switzerland. 4th
Biennial Schizophrenia International Research Conference/Schizophrenia Research 153. Switzerland: Geneva University Hospitals; 2014.
Chadwick PD, Birchwood MJ, Trower P. Cognitive Therapy for Delusions, Voices and Paranoia. Oxford, England: John Wiley and Sons; 1996.
Haddock G, McCarron J, Tarrier N, Faragher EB. Scales to measure dimensions of hallucinations and delusions: The psychotic symptom rating scales (PSYRATS). Psychol Med 1999;29:879-89.
Jones C, Hacker D, Meaden A, Cormac I, Irving CB, Xia J, et al
. Cognitive behavioural therapy plus standard care versus standard care plus other psychosocial treatments for people with schizophrenia. Cochrane Database Syst Rev 2018;11:CD008712.
Ranjan JK, Prakash J, Sharma VK, Singh AR. Manifestation of auditory hallucination in the cases of schizophrenia. SIS J Projective Psychol Ment Health 2010;17:76-9.
Wykes T, Reeder C. Cognitive Remediation Therapy for Schizophrenia: Theory and Practice. London: Routledge; 2006.
Chadwick P, Birchwood M. The omnipotence of voices. II: The Beliefs About Voices Questionnaire (BAVQ). Br J Psychiatry 1995;166:773-6.
[Table 1], [Table 2], [Table 3]