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Validation of Hindi version of Stages of Recovery Instrument

Objectives: To translate the Stages of Recovery Instrument (STORI) and evaluate its psychometric properties, demographic, and clinical correlates among patients with schizophrenia. Materials and Methods: The English version of the scale was translated into Hindi using the World Health Organization methodology. The Hindi version was completed by thirty patients with schizophrenia on two occasions, 4–7 days apart. Another thirty patients completed both Hindi and English version within a gap of 4–7 days. In addition, 100 patients completed the Hindi version of STORI once for studying the demographic and clinical correlates of recovery. Results: Hindi version of STORI demonstrated good internal consistency (α = 0.854) for the full scale and also for all the five stages of recovery (α = 0.745 to 0.756) as described in the scale. Split-half reliability of the scale was also good, as reflected by a high Spearman-Brown coefficient (0.781) and Guttmann's split-half coefficient (0.778). All the items of the scale showed high test-retest reliability and cross-language equivalence. Correlation between different stages and correlation between the allocated stage and different stages reflected good concurrent and construct validity of the subscales described as various stages of recovery. In general, demographic and clinical variables did not have any significant correlation with stages of recovery. However, those with lower level of general psychopathology scores showed significant correlation with higher stages of recovery. Conclusions: Hindi version of STORI has good psychometric properties.


INTRODUCTION
Traditionally, schizophrenia is regarded as an inherently chronic and deteriorating condition. However, there has been a historical shift in the expectations for the course of schizophrenia. Empirical data challenge this chronic disease model and the assumption that schizophrenia has a life-long deteriorating course. In a landmark study, Harding et al. [1,2] confirmed that recovery from mental illness was possible. [1,2] Gradually, the interest in personal recovery increased and Recovery as a concept has gained increasing prominence in the delivery of mental health services to people with severe mental illness over the past three decades or so. Historically, the concept of recovery has moved away from a dominant medical model, where mental health professionals promoted "clinical recovery," which emphasized reductionist illness deficit paradigms, and narrowly defined recovery as the absence of symptoms. [4][5][6] Now, the emphasis is placed on a holistic and personal recovery. This concept has emerged from the narrative discourse of recovery provided by people who have lived satisfactory life despite having a chronic mental illness, like schizophrenia. This is now known as "personal recovery." [7] Qualitative studies based on individuals' narrative accounts highlight a number of common themes which are important in the process of recovery, which include: hope; acceptance; redefining self; a sense of identity and movement beyond the illness, living outside of illness; self-esteem; empowerment; social support systems; spirituality; establishment of meaning and purpose in life, including a positive personal and social identity; and overcoming social stigma. [8][9][10][11][12][13][14][15][16][17][18] While the qualitative studies add to the growing evidence, generalization from these studies is limited given their small sample sizes. This, therefore, calls into question the external validity of such studies. In last few years, many instruments have been designed to assess the various aspects of personal recovery. [19,20] Development of instruments to assess recovery has paved the way for quantitative studies. It is expected that understanding the concept of recovery and its correlates in a larger population can help in the generalization of the findings, improving the mental health care and organizing the services with an aim to promote recovery. Among the various instruments available for assessment of personal or psychological recovery, Stages of Recovery Instrument (STORI) is one of the popular instruments used to assess psychological recovery. Although few studies have evaluated personal recovery of patients with schizophrenia from India, [21,22] none of the studies have attempted to validate the STORI. Accordingly, this study aimed to: (1) Develop a Hindi translated version of STORI; (2) Evaluate the psychometric properties in the form of internal consistency, split-half reliability, test-retest reliability, and cross-language reliability of Hindi version of STORI; (3) to study the stage of recovery among patients of schizophrenia; and (4) to study the demographic and clinical correlates of recovery among patients with schizophrenia.

MATERIALS AND METHODS
The study was approved by the Ethics committee of the institute, where the study was conducted. The study included 160 patients with schizophrenia attending the psychiatry outpatient services of a tertiary care hospital. Written informed consent was obtained from patients before recruitment into the study. The diagnosis of schizophrenia was confirmed using Mini-International Neuropsychiatric Interview. [23] The inclusion criteria for the study were age between 18 and 65 years, duration of illness of at least 1 year, currently in clinical remission (as defined by Andreasen et al. [24] ) and must be able to read Hindi and/or English. Patients with intellectual disability and Organic Brain Syndrome were excluded from the study.
Positive and negative symptom scale was used to assess residual psychopathology. [25]

Stages of Recovery Instrument
The STORI [26] is a self-report measure for assessing stages of recovery from mental illness. It comprises 50 items, each of rated on a six-point Likert scale. The stages of recovery identified by STORI include moratorium, awareness, preparation, rebuilding, and growth. Stage 1 is moratorium (the realization that all is not lost, and that a fulfilling life is possible) which is understood as a time of withdrawal characterized by denial, confusion, hopelessness, and identity confusion. [26] Stage 2 is awareness (taking stock of strengths and weaknesses regarding recovery, and starting to work on developing recovery skills) which involves having hope for a better life where recovery is possible. It involves awareness of a sense of self-other than that as a "sick person" to emphasize a self that is capable of recovery. Stage 3 is preparation, which involves starting work on developing recovery skills. This involves identifying values, strengths, and weaknesses within one's intact self and striving to learn about mental illness and services available. This includes becoming involved in social groups and connecting to others who are in recovery. Stage 4 is rebuilding in which the person is actively working toward a positive identity, setting personally valued goals, taking responsibility for managing mental illness, and taking control of one's life despite setbacks and risks encountered. The final stage that is, Stage 5 is growth which involves living a full and meaningful life, characterized by self-management of the illness, resilience and a positive sense of self. In the final stage of the recovery process, the person may not be symptom-free but knows how to manage their illness and stay well. This involves personal resilience, self-confidence, and optimism about the future. The person develops a positive sense of self, and there is a belief that the experience has made them a better person. Stage of recovery (STORI stage) is determined based on each participant's highest mean score on the five stage subscales. When scores on two subscales are tied, the person is allocated to the higher stage. The instrument has been shown to have good internal consistency (0.88-0.94) and moderate to good concurrent validity. [26] Translation of the scale Permission was sought from the authors of the original scale before the translation of the scale. STORI was translated into Hindi by following the World Health Organization's translation back-translation methodology. For this, the English version of the scale was translated to Hindi by three bilingual mental health professionals (psychiatrists), fluent in Hindi as well as English. Then, another panel of three mental health professionals (two psychiatrists and one clinical psychologist) reviewed the Hindi translated versions and prepared a consensus Hindi version. Then, the Hindi translated version was given to ten patients for assessing the simplicity of the language and their understanding of the issues being assessed by the questionnaire. Initially, they were asked to fill the questionnaire, and this was followed by an interview with a health professional to check whether patients understood the same thing as the items were intended to convey. Based on this input, the language of the Hindi version was simplified. Following this, the available Hindi version was back-translated into English by the third set of 3 mental health professionals. The back-translated versions were reviewed, and a consensus back-translated version was prepared. The back-translated English version was compared with the original English version, and necessary changes were made for the discrepancies in the Hindi version. Finally, a Hindi version was prepared.

Procedure
Patients with a clinical diagnosis of schizophrenia attending the psychiatric outpatient services were approached and were explained about the nature of the study. Patients were recruited after obtaining written informed consent. For the cross-language equivalence, 30 patients initially completed the Hindi version and after 4-7 days completed the English version. Another 30 subjects completed the Hindi version twice with a gap of 4-7 days to establish the test-retest reliability of the scale. Another 100 patients completed the Hindi version only. Accordingly, data of 160 patients were available for the Hindi version, and this was used for factor analysis of the scale.
Statistical Package for the Social Sciences Windows version 14 (SPSS-14) (SPSS for Windows, Version 16.0. Chicago, SPSS Inc.) was used for computing the data. Initially, mean along with standard deviation and frequencies along with percentages were calculated for continuous and categorical variables, respectively. Psychometric properties were evaluated for the Hindi version of the scale. Cronbach's alpha was used to evaluate the internal consistency. Split-half reliability of the scale was evaluated using Spearman-Brown coefficient and Guttmann split-half coefficient. Kappa values along with intraclass correlation coefficients were calculated to evaluate the test-retest reliability for the scale. Intraclass correlation coefficients were also calculated to evaluate the cross-language equivalence of Hindi and English versions. Association of the stage of recovery with different demographic and clinical variables was studied using Pearson correlation coefficient and Chi-square test. Table 1 depicts the sociodemographic and clinical details of the study participants. The mean age of study participant was 35.8 (standard deviation [SD]-11.8) with a range of 18-65 years and the mean number of years of education was 11.6 (SD-3.8) with a range of 0-18 years. There was nearly equal distribution of currently married and currently single and those who were on paid jobs and those who were not on paid jobs. More than half of the patients were educated beyond matric (54.4%), from nuclear families (59.4%) and middle socio-economic status (60.6%). Nearly, two-thirds of the study participants were Hindu (70%) by religion and came from urban localities (64.4%). The mean distance of the place of residence and the hospital was 68.9 (SD-83.7) km.

Psychometric properties of the Hindi version
The internal consistency of Hindi version was found to be good with Cronbach's alpha of 0.854 suggesting good inter-item correlation. Cronbach's alpha for each stage of STORI (Stage 1: 0.746; Stage 2: 0.755; Stage 3: 0.752; Stage 4: 0.745 and Stage 5: 0.756) was also good. Split-half reliability of the Hindi version was also found to be good as indicated by a high Spearman-Brown coefficient (0.781) and Guttmann's split-half coefficient (0.778). The Cronbach's alpha values for the two parts of the scale were 0.724 for part 1 (comprising 25 items) and 0.795 for part 2 (comprising 25 items). As depicted in Table 2, intraclass correlation coefficients for 2 assessments varied between 0.914 and 0.999 for all the 50 items of the scale with P < 0.001 for all the items. Similarly, Pearson correlation coefficient for all the items was also high with P < 0.001. In terms of cross-language equivalence, the intraclass correlation coefficient and Pearson's correlation coefficient for each item of both versions (Hindi and English) was higher than 0.876 with P < 0.001 for all the items [ Table 2].

Stages of psychological recovery in patients
When the stage allocation was done, majority of the patients (N = 74) belonged to the Stage 5, and this was followed by those in the Stage 4, that is, stage of rebuilding (N = 38), Stage 3, that is, stage of preparation (N = 26) and Stage 2, that is, stage of awareness (N = 12). Least number of patients were allocated Stage 1, that is, stage of moratorium (N = 10) [ Table 3].

Relationships of various stages with each other
When the relationship of mean scores obtained on each stage was studied using correlation analysis, as shown in Table 4

DISCUSSION
This study aimed to evaluate the psychometric properties of Hindi version of STORI and to evaluate psychological recovery among patients with schizophrenia.
The Hindi version of STORI demonstrated high internal consistency (Cronbach's alpha − 0.863), for the whole scale and each stage of STORI (Cronbach's alpha ranging from 0.745 to 0.756). A Cronbach's alpha value of 0.7 for a scale is considered as a good indicator of internal consistency of the scale. Hence, it can be presumed that the Hindi version of STORI has good internal consistency and the items of the each stage assess similar characteristics. When the Cronbach's alpha values were compared with that reported for the original scale, [26] values for the Hindi version were slightly lower. The Hindi version of STORI also demonstrated good split half reliability, cross-language equivalence/ reliability and test reliability. In terms of cross-language reliability, significantly high correlation was seen between all the items of Hindi and English version, suggesting that the Hindi translated version reflected similar meaning as the English version. Similarly, all the items of the scales showed significant intra-class correlation coefficient suggesting that the concept of recovery assessed by STORI is stable over at least a short period. Construct validity of various stages was established by studying the correlation between the various stages. Stage 1 correlated negatively with Stage-5 and various stages had positive correlations between neighboring stages, suggesting continuity between different stages and at the same time reflecting the fact that Stage-1 and Stage-5 were at the opposite ends of each other. Authors of the original scale and the validation study of STORI from England have also reported an almost similar correlation between different stages of recovery. [26,27] The present study also replicates these findings and provides cross-cultural validation of the staging model proposed by the author. These findings provide evidence for the construct validity of the five stages. [8]   In this study, although, the concurrent validity of STORI was not evaluated by comparing it with another instrument, concurrent validity of various stages was evaluated by studying the correlation between allocated stage and different stages. It was evident that stage-1 had negative correlation with the allocated stage and Stage 3, 4, and 5 had positive correlation with allocated stage, with increasing strength of the correlation coefficient. These findings are very similar to that noted in the original validation study [26] and suggest that the stages as defined in STORI, although exist in continuum, but also assess stage-specific variables and provide evidence for the concurrent validity of the stages as defined in the instrument.
In this study, the majority of the patients were allocated Stage-5 (growth), followed by those in the Stage-4 (rebuilding), Stage-3 (preparation), Stage-2 (awareness) and least number of patients were allocated Stage 1 (moratorium).
In the original study, in which the authors described the development of STORI, out of 94 patients, 32 participants were allocated Stage 5, 34 to Stage 4, 13 to Stage 3, 6 participants to Stage 2 and 7 participants to Stage-1. [28] Another study from England evaluated the psychometric properties of STORI. [27] In this study too, maximum number of patients (32%) were allocated Stage-5, and another 28% were allocated Stage-4, 10% to Stage-3, 22% to Stage-2, and 8% to Stage-1. While comparing the findings of this study with the above two studies, two common themes emerge, that is, the relatively greater proportion of patients in all the studies (including the present study) were allocated to higher stages (i.e., Stage 4 or 5) and few patients were categorized into Stage-1. The minor differences across the different studies could be due to the differences in the demographic profile of the patients included in these studies. For example, in this study, two-thirds of the patients were males and about half of the sample was on paid employment. This is in contrast to the earlier study [26] in which only 48% of the subjects were males.
In this study, no significant correlation emerged between stages of recovery and various sociodemographic variables, except for negative correlation between Stage-2 and education in years. In general, previous studies also suggest a lack of relationship between recovery and demographic variables such as gender, marital status, and religion. [26,29] With regard to the age, some of the studies have shown that older age is a predictor of better recovery, [29,30] while others have found no association of age with recovery scores. [31] Findings of the present study support the latter. There is some evidence to suggest that better personal recovery is seen in people on paid employment [31] and those with higher education level. [26] The present study suggests that those with lower level of education possibly are in the higher stages of recovery.
Earlier studies which have assessed the relationship between various stages of recovery, as assessed using STORI, and duration of illness, suggest that there is no significant correlation between them. [26] This finding of the present study too supports the same. Furthermore, in the present study, no association between the stage of recovery and age of onset of illness was seen. Existing literature on this association is still unsettled, with some studies showing a negative correlation of early onset of illness with later subjective sense of recovery, whereas other studies suggest that age at onset moderates the relationship between symptoms and self-report of being in recovery. [28] Regarding the association between residual psychopathology and stages of recovery, existing literature, in general, suggests no association between the two, implying that remission in the sense of reduction or elimination of symptoms is not synonymous with self-assessment as being in a state of recovery. [28,[31][32][33] However, in the present study, a negative association was seen between the PANSS general psychopathology score and higher stage of recovery. Hence, elimination of symptoms can be considered one of   the components contributing to psychological recovery. Thus, clinicians should focus not only on the acute phase of symptom removal but also the management of residual symptoms for promoting personal recovery.

CONCLUSION
To conclude, the present study shows that the Hindi version of STORI scale has good psychometric properties. Further, this study shows that personal and psychological recovery among patients of schizophrenia is not associated with demographic and clinical variables. Lower level of residual psychopathology is associated with higher stage of recovery. However, results of the present study must be interpreted in the light of some limitations. The present study was limited to patients in clinical remission. Hence, the findings cannot be generalized to patients experiencing acute episode or those having higher level of residual psychopathology. The present study also did not evaluate the association of recovery with psychosocial variables such as stigma, social support, disability, quality of Life, and coping. Similarly, this study also did not evaluate the relationship of recovery with treatment adherence and side effects of medications. With the availability of validated Hindi version, it is expected that future studies will evaluate these associations. Understanding the association of psychological recovery with various psychosocial and treatment-related variables can help in organizing services to promote personal recovery.

Financial support and sponsorship
Nil.

Conflicts of interest
There are no conflicts of interest.