Argumento

The languages utilized for this study were Hausa and English. All questionnaires were translated from English to Hausa language and translated back to English using the back-iterative translation method to ensure accuracy of translation and that the meanings of the original items remained unaltered. The translators were drawn from the Languages and Linguistics Department of University of Maiduguri.

41

The following instruments were used for the collection of data;

(1) Sociodemographic Questionnaire.

(2) Index of Self-esteem Questionnaire (ISE).

(3) Fertility Adjustment Scale (FAS).

(4) General Health Questionnaire-12 (GHQ-12).

(5) Hospital Anxiety and Depression Scale.

4.9.0 The Sociodemographic Questionnaire (Appendix III)

This is a Questionnaire drawn by the researcher that elicited vital sociodemographic data of the respondents which include their ages, marital status, occupation, educational status, living condition, type of marital arrangement (monogamy, polygamy), parity, past

psychiatric history, family history of mental disorder, and self-reported physical illness.

4.9.1 Index of Self Esteem (ISE) Questionnaire (Appendix IV)

The ISE is a 25-item inventory that is designed to measure the sum total of the self-perceived and self-evaluative component of self concept which is held by the person (Hudson, 1982). Self-esteem is a term used in psychology to reflect a person’s overall evaluation of his or her own worth. Self-esteem encompasses believes, (for example I am competent or I am incompetent) and emotions such as triumph, despair, pride and shame.

A person’s self-esteem may be reflected in their in their behaviour, such as assertiveness, confidence or caution. Psychologist usually regards self-esteem as enduring personality characteristic. Self-esteem is distinct from self-confidence and self-efficacy, which involves

42

believes about ability and future performance (Wikipedia).The instrument was developed for individuals above 12 years of age and can be completed in about 10 minutes. The instrument is usually self-administered and the administration could be done either individually or in groups after establishing adequate rapport with the clients. For the purpose of this research, the questions were read out to the subjects and their responses recorded.

There are two sets of items that are scored either directly or in the reverse manner.

For the direct scoring, the values of the numbers shaded in the relevant items are added together to give the cumulative score. For example, if in items 6,7,8,9,10, and 11 the numbers shaded are: 3,2,5,4,1, and 2 respectively, then the total score for the six (6) items is 17.

For the reverse scoring system, the values of the numbers shaded in the relevant items are changed from1, 2, 3, 4, and 5 to 5, 4, 3, 2, and 1 respectively and the reversed values of the numbers shaded in the relevant items are added together. For example, if in items 13, 14, 15, 16, 17 and 18 the numbers shaded are 3, 2, 5, 4, 1, and 2 respectively, the scores for the items are reversed to 3, 4, 1, 2, 5, and 4. These are then added together to give the total of the reversed items.

For the purpose of clarity, the Direct Score Items are: 1, 2, 8, 9, 10, 11, 12, 13, 16, 17, 19, 20, and 24. While the Reverse Score Items are: 3, 4, 5, 6, 7, 14, 15, 18, 21, 22, 23, and 25.

43

After computing the scores as outlined above, the results of the direct score and reversed score items are then added to obtain the overall score. Finally, 25 is subtracted from the client's overall score to obtain the ISE Score.

In terms of its psychometric properties, Hudson et al, (1984) has demonstrated that the ISE has good-to-excellent internal consistency, and content, concurrent, construct, and factorial validity. Hudson (1992) reported a norm score of 30 among 1,745 male and female American subjects while Onighaiye (1996) reported a norm score of 30.89 among 80 Nigerian male subjects and a norm score of 32.04 among 80 female subjects. In terms of its reliability, Hudson (1992) obtained an alpha coefficient of 0.93 and a two-hour test-retest co-efficient of 0.92. Onighaiye (1996) obtained the following coefficients of validity by correlating the ISE with the stated tests as shown: with the Symptoms Check List 90 (SCL-90) by Derogalis et al (1973) in Scale C- Interpersonal Sensitivity = 0.46; and Scale D- Depression = 0.38. Its discriminant validity with the Ego Identity Scale (EIS) by Tan et al, (1977) was 0.42.

The ISE measures how poor a client's self esteem is. For the purpose of this study, the Nigerian norms mean scores were used for interpreting the results of the clients. Here a norm score of 32.04 reported by Onighaiye (1996) among Nigerian females were used for the interpretation of the results. Scores higher than the norms indicate that the clients have low self esteem while, the lower a score is below the norm, the higher the client's self esteem.

4.9.2 Fertility Adjustment Scale (FAS) (Appendix V)

44

The FAS was developed from pilot work and it is perceived as a clinical tool that could be used to assess psychological reactions to, and outcomes of, fertility problems. The scores on the FAS are normally distributed and are similar for both men and women. Overall, the results suggest that the FAS is a reliable measure (Glover et al, 1999).

FAS is a 12-item self-administered questionnaire developed by Glover et al in 1999. It has a short duration of administration. These items are expected to provide an indication of the extent to which individuals had considered, or come to terms with, the possibility of life with and without a child. The items cover the range of cognitive, emotional, and behavioural responses to fertility problems. The items are scored on a 6-point Likert scale ranging from 1 indicating always disagree to 6 indicating always agree.

A total score is derived by summing the scores on the individual items, where indicated, positive items are reverse-scored. A high score on the FAS questionnaire represents an indication of poor adjustment while a low score indicates good level of adjustment. The minimum possible score is 12 and the maximum score 72. FAS has a high internal

consistency with Cronbach’s alpha (0.86) and a test retest reliability of 0.88, it also has a good degree of validity (Glover et al, 1999).

For the purpose of this study, the mean (SD) of 39.2 +11.2 reported by Glover et al, was adopted as the reference value. Mean score +SD greater than the reference value is

considered maladjustment while values lower than that were considered good adjustment.

45

Though the FAS has not been widely used in Nigeria, it has good face validity. The questions represent in general what may be expected in a female population.

Furthermore, since the ISE, a self-esteem inventory has been validated in Nigeria, the ISE provides a concurrent validity check on the FAS. The ISE and FAS scores were compared for the same individuals.

4.9.3 General Health Questionnaire-12 (GHQ-12) (Appendix VI)

The GHQ is a self- report psychiatric screening instrument (Goldberg and Hiller, 1979). It was developed from a pool of 140 items that are believed to cover aspects of adjustment and felt distress. These concepts include depression and unhappiness, anxiety and felt psychological disturbance, social impairment and hypochondriasis. The original version consisted of 60 items, but there are successive shorter versions of 30, 28, and 12. The 30 item GHQ has been extensively used for research in Nigeria (Morakinyo, 1979; 1994;

Aghanwa, 1992, Aghanwa and Morakinyo 1997)

The GHQ 12, which was used in this study, has been shown to perform more efficiently than longer versions when used as part of a general survey (Goldberg and Williams, 1988;

Graetz, 1993). It has also been found useful as a screening tool in urban primary care settings (Gureje and Obikoya, 1990; Gureje et al. 1992)

Although the GHQ 12 is widely used as a uni-dimensional instrument, two or three factors have been identified in previous studies (Martin et al, 2005; Campbell et al, 2003;

46

Werneke et al, 2000).The most common factors that have been identified are those for anxiety, depression and social dysfunction. Nevertheless, using them separately does not offer many practical advantages in differentiating clinical groups or identifying association with clinical or health- related quality of life variables (Gao et al, 2004).

The scale asks whether the respondent has experienced a particular symptom or

behaviour recently. Each item is rated on a four-point scale (less than usual, no more than usual, rather more than usual, or much more than usual.). The GHQ 12 gives a total score of 36 or 12 based on the selected scoring method. The most common scoring methods are bi-modal (0-0-1-1) and Likert scoring styles (0-1-2-3). Comparison between the

conventional bi-modal (0-0-1-1) scoring methods and the Likert scoring style (0-1-2-3) showed very similar screening properties.(Younes et al, 2009)

In terms of its psychometric properties, the sensitivity ranges between 71% to 75% and its specificity ranges between 73% and 76%. The test-retest reliability of the GHQ-12, as expressed by Pearson’s r and intra-class correlation coefficient is satisfactory irrespective of the scoring method used (Giccinelli et al, 1993). In a review of 17 published research studies on GHQ-12 by Goldberg et al in 1997 it was found that the most common cut off scores 2/3 (a score of 2 or less indicating the absence of a mental disorder and a score of 3 or greater indicating the presence of a disorder). In Nigeria, investigators have shown that score of greater or equal to 3 yielded the best sensitivity and specificity rate for identifying persons with mental distress (Amoran et al, 2005; Gureje and Obikoya, 1990).

47

In this study, the GHQ-12 was used as a uni-dimensional instrument and conventional bi-modal (0-0-1-1) scoring system was adapted with a cut off score of 3 or more (maximum score 12).

4.9.4 Hospital Anxiety and Depression Scale (HADS) (Appendix VII)

The Hospital Anxiety and Depression Scale (HADS) of Zigmond and Snaith (1983) was designed to screen for the presence of mood disorders in medically ill patients. It Is appropriate for use in either community or hospital settings. To distinguish between psychiatric presentations and physical illness, the items focus predominantly on subjective disturbance of mood rather than on physical signs and symptoms. The depression

subscale is oriented towards the core symptoms of anhedonia rather than on sadness.

There is good evidence that anhedonia symptoms are sensitive indicators of depression in the medically ill. Items on suicidal ideation, guilt feelings and hopelessness are not

included. It consists of two scales, one assessing depression (consisting of 7 items) and the other assessing anxiety (consisting also of 7 items). Each of the 14 items are scored on a four-point Likert scale (ranging from 0 to 3, with varying degree of response) that applies to the previous week. The HADS is easily administered as a self-report measure or via interview and usually takes three to five minutes to complete. A total score (out of a possible 21) for each subscale is then calculated. The subscale scores are then interpreted as follows: 0-7, normal; 8-10, mild mood disturbance; 11-14, moderate mood disturbance;

and 15-21, severe mood disturbance.

Moorey et al, (1991) found a high internal consistency (Cronbach's alpha of 0.90) using the depression subscale in a population of 575 patients with recently diagnosed cancer. Snaith

48

and Zigmond (1994) reported a test-retest reliability of 0.92 of the depression sub-scale in a study involving healthy respondents. Razavi et al, (1990) reported a correlation of at least 0.70 between the HADS' Depression subscale and the Montgomery and Asberg Depression Rating Scale (MADRS) in a sample of 133 patients treated either in Cancer or Internal Medicine Units. Aylard et al, (1987) also found a correlation of 0.77 between the HADS and MADRS among 41 primary care outpatients diagnosed with mood disorders.

The HADS has been validated for use among Nigerian population (Abiodun, 1994) and has been extensively used in other studies such as in assessing the psychological condition of a cohort of Nigerian Diabetic Subjects (Akinlade and Ohaeri, 1996) as well as in the

assessing the prevalence of depression among HIV- positive subjects in Kano, North-central, Nigeria (Shehu, S. (2006).