Attitudes towards disabled persons scale in Nepali: development and validation

INTRODUCTION

Attitudes always symbolize an individual’s opinions that is comprised of behavioural, affective, and cognitive responses.¹ Attitude can range from extremely positive to extremely negative. Attitude of people reflect the quality of life of the person with disability. Attitudes can indicate how we feel and how we relate with each other as human beings in our society. Attitudes concerning people with disabilities can initiate from the fear of the unknown or from previous experiences with individuals who are disabled.² Attitudes have a utilitarian function, which means that they reduce the penalties for punishment and hence maximize the rewards that an individual can achieve. In addition, attitudes also help defend one’s own image thereby raising our self-esteem. Also, they help the individual attain meaning to the beliefs and perceptions that they hold. They also influence our behaviour as human beings. Disability can be defined as the restriction or inability (resultant from impairment) to perform an activity in a manner that can be considered normal for any human being.³

People without any kind of disability try to maintain distance from people with disabilities. Such people will not appreciate the individual with a disability because they consider them to be abnormal or dumb; attitudes like these can be caused due to a lack of social acceptance, social interaction among other factors. This kind of attitude provokes discrimination and prevents maximum enrichment of person with disability and social interaction.⁴ The subject of attitudes toward disability has received wide attention from psychologists, physicians and rehabilitation personnel over the past 70 years.⁵ In spite of continuous advocacy regarding the attitudes of individuals towards individuals with disabilities in the United States, public awareness is still mostly negative.⁶ For persons with disabilities, research has highlighted the fact that these negative attitudes do interfere with their work environment, affecting their self-esteem and health care.⁶ Review of literature suggests that negative attitudes towards individuals with disability are improving globally. On the contrary, attitudes towards close relationships with people with disabilities indicate that they are still not completely integrated in society which necessitates attention as they can slow down the progress towards non-discrimination and equality.⁷

Attitudes towards disabled persons (ATDP) scale by Yuker, Block and Young is a useful tool to assess the attitude of individuals towards disability.⁵ ATDP is used to measure the overall attitude of the individual towards person with disability. There are a lot of negative social stigmata regarding person with disability. This can be only minimized by educating the society regarding disability. ATDP scale can be used to find the positive and negative attitude of the people. It can be used to improve attitudes of individuals toward person with disability. Many researchers indicate that both the general public and persons with disability believe that everyday interactions and public education about disability will improve understanding and acceptance of disabled people.⁸ Nepal is a developing country in South Asia which lies in between India and China. Their official language- Nepali is spoken by about 20 million people in Nepal.⁹ Also, Nepali is spoken in north-east India and various parts of Bhutan. The Indian constitution recognizes Nepali as a major language in India due to its widespread use in the states of Sikkim and parts of West Bengal. In Bhutan, though Dzongkha is the national language, Nepali is commonly spoken and used as a lingua franca throughout the nation.¹⁰ The National Census 2011 by Government of Nepal reported that 1.94% of the total population of Nepal is living with some kind of disabilities, whereas 3.6% claimed by the National living standard survey report (NLSS). However, both figures are quite low as compared to the 15% disability prevalence rate claimed by WHO and World Bank in the World Report on Disability.¹¹ Approximately 80% of people with disabilities live in developing countries.¹² Nepal has The Disabled Welfare and Protection Act, 1982 AD to protecting the rights of persons with disability. However, the attitude of general population towards person with disability has not been studied. There is hardly any literature regarding the attitude of common people towards person with disability in Nepal.

Also, little is known of the attitudes of colleagues and supervisors towards the employees who are disabled. Information of such attitudes could be beneficial in designing training programs for future rehabilitation personnel.¹³ ATDP scale (Form A), is a 6-point Likert scale which can be used to assess the overall attitudes of participants towards individuals with disabilities. The current interest was to translate and validate ATDP in Nepali. The internal consistency of the translate scale was determined. In addition, it was also attempted to determine the differences in ATDP score across gender.

METHODS

This was a qualitative cross-sectional observational study. The study done period was from 2019 April to 2019 June at local community of Kathmandu, Nepal. The sampling method was convenient random sampling as of survey in the community. The following steps were performed for translation.

Instrument

ATDP scales (form A, B and C) are available for clinical use. In the present study, ATDP-O test (attitudes towards disabled persons-form O) was translated to Nepali. This scale was used to measure attitude of general people toward person with disability. The ATDP-O contains twenty items with a Likert-type format representing extent of agreement or disagreement. The scales ranges from +3 (agree very much) to -3 (disagree very much). The score ranges from 0 to 120, with higher score suggestive of more positive attitude on the part of participant. This test can be completed in about fifteen minutes.⁵

Procedure

Translation and adaptation

The World Health Organization (WHO) Guidelines were used for translation of all the above mentioned materials into Nepali. This guideline includes five different stages: 1) forward translation; 2) expert panel review; 3) backward translation; 4) pre-testing and cognitive interviewing and 5) final version.

Stage 1: Forward translation

In this step, two native Nepali speakers having good command over English were asked to translate. First translator was an experienced audiologist and speech language pathologist. The second translator was an experienced English teacher having widespread familiarity with the local culture. Two translators were sitting together with the aim of clarifications regarding disability related terms to support forward translation. Translator framed sentence more than one. The translator attempted to use easy word or phrase which was conceptually equivalent.

Literal translations, technical word, terms which are offensive, unfamiliar word and extended sentences with many clues were avoided. Sentence was framed in simple, concise and clear language such that it is understood by most of the common population. The first author along with two translators compared the multiple translated statements obtained in stage one and finalized the one with simple, more colloquial and clear statement.

Stage 2: Expert panel

The expert panel included experienced English teacher, experienced audiologist and an experienced linguist with minimum 12 year of experience. Previous translator and author were present along with panel members. All the members on this panel were Nepali-English bilinguals.

The panels invigilated the entire translations and recognized errors, if any. The errors comprised of inappropriate words/phrases or items that didn’t represent the concept as they were intended to. Those questions were then modified through mutual agreement. A total of 7 changes were incorporated in this stage.

Stage 3: Back-translation

In this stage, experienced Masters in arts (MA) English teacher was assigned to translate back the questions of stage 2 to English within 20 days. This helped in spotting the inaccuracies seen in forward translation. The same expert panel committee was involved in this process. They emphasized on the conceptual/cultural correspondence and not simply linguistic equality. Discrepancies noted were discussed by the expert panel and further work was restated as many times as needed until a satisfactory version was obtained and agreed upon.

Stage 4: Pre-testing and cognitive interviewing

It is also important to administer the stage 2 translated versions to the targeted population. A total of 32 adults (16 males and 16 females) were involved in this stage and were not involved in main study.

In this stage, participants were interviewed systematically by asking to repeat the statement in their own words then they heard a particular term or phrase and also asked about any word that they found offensive or couldn’t comprehend. This was done to find consistency of statement on questionnaire.

Stage 5: Final version

The final version of the questionnaire in the target language was the result of all the repetitions described above. This is considered as final version of our Instrument.

Stage 6: Documentation

In this stage, all the version of Instrument which underwent different stage was documented which include initial forward translation, summary of expert panel, and back-translation and summary of problem faced during pretesting the instrument and final version. The summary of the translation procedure used in the study is described in Figure 1.

Participants

114 Native Nepali speakers (41 males and 73 females) who have minimum education of high school level were included in the study. The mean age of the participants was 30.42 (standard deviation=8.7) the participants were selected by convenience sampling. They were enrolled from urban area in Kathmandu, Nepal. The participants were asked to fill the Nepali version of ATDP scale individually. Informed consent was obtained from all the participants of the study.

Data analysis

The raw data range from -3 to +3 obtained from each component of translated ATDP was subjected to statistical analysis using Statistical Package for Social Sciences (SPSS)21.0 (SPSS Inc. Chicago).

Ethical approval

Approval was taken from ethical approval committee of the institute and the testing was done using non-invasive procedures. The objectives and procedures of the study were explained to the participants before evaluation and informed consent was taken from them.

RESULTS

The mean ATDP score obtained for the translated version of the scale was determined. The mean ATDP score was 48.82 (SD=12.49) and the score ranged from 24 to 84. The ATDP scores were also determined for each gender separately. The results showed that the mean ATDP score was 50.8 (SD=13.53) and 47.6 (SD=11.81) for males and females as shown in Figure 2.

Shapiro Wilks test of normality suggested that the data was not normally distributed (p<0.01). Hence, non-parametric Mann Whitney U test was done to compare differences in ATDP score across gender. The results of Mann Whiteny U test suggested that there was no significant difference (Z=-1.208, p>0.05) in ATDP score for across gender.

The internal consistency of the test was determined using Cronbach alpha. The Cronbach’s alpha score was 0.61 suggesting good internal consistency. This indicates that the translated ATDP scale in Nepali can be used as tool as an efficient tool to measure attitude toward person with disability.

DISCUSSION

The present study involved translation and validation of Attitudes towards persons with disability scale from English to Nepali. The translation to Nepali is important as the attitudes vary across the culture, society, and race.¹³ The success of translated instrument depends on linguistic competence, professional knowledge and cultural experience of the translators. In present study, a team was involved with the aim to produce the best possible translated version of the scale. Special care was taken while making the team to ensure agreement and compatibility between experts within the team, as some experts try to rule over others, while expressing their insights.¹⁴

In the present study, it was found that there was no significant difference in mean ATDP score in males and females which is similar to other studies on US and Japanese students.¹⁵ This indicates that attitude towards disability doesn’t dependent on gender. However, the cultural differences and variations in economic and literacy status can affect the attitudes towards persons with disabilities. Attitudes are brief and change from person to person, from group to group and even within groups over time. The negative attitude towards disability can be an obstacle to education, freedom, transport, access to public services, social contact and convenience outside the home. Public education could help challenge the discrimination and stigmata associated with disability. Speculation in public awareness campaigns could help tackle the everyday negative attitudes that disabled people encounter.⁸ Positive attitude can be shape from an early age so school curriculum should include education on disability.

The results of the study also showed that ATDP scores obtained by individuals speaking Nepali was less compared to individuals from Japan and USA.^16,17

The cross cultural study by Nakamura suggested that there is no significant difference in ATDP score between Japanese students and American students.¹⁶ Japan and USA are developed countries and may not have differences in attitudes. However, in a developing country like Nepal has low ATDP score could be due to low socio-economic condition, lack of awareness of disability and negative stigmata presents in Nepali society. Government of Nepal should consider this as baseline and take necessary steps to improve the attitude of individuals in Nepal towards persons with disability. There should be appropriate awareness programs regarding individuals with disability in schools, colleges and offices for positive and barrier free life for persons with disability.

The present study attempted to translate and validate ATDP scale to Nepali using standard procedures. The results of the study showed that the translated version of ATDP has good internal consistency. The results of the study also showed that there was no significant difference in attitudes across gender. The scores obtained by Nepali individuals were lower compared to Japanese and Americans. The cultural differences, lack of awareness, reduced literacy, and low socio-economic status could have led to lower scores on ATDP. The translated ATDP-O can be used as a valid instrument to investigate the attitudes of different groups in Nepali speaking population. This is simple in language and can be administered by any educated person with minimal instruction. This can be used by government and other organization to check the status of society and person’s attitude toward persons with disability. This can guide the Government to develop appropriate policies and create awareness towards the needs of persons with disability. This can be used in Nepal and can provide useful facts as well as an opportunity for cross-cultural judgments and can be easily administer to those who know Nepali.

The limitation of this study is that it depends on self-reported attitudes. Roby and colleagues pointed that interviewees may not essentially have the motivation or ability to record their reliance about people with disabilities correctly.¹⁸ The study population represent only single pocket area which cannot be generalized view of the community so need a large scale study.

CONCLUSION

The present study indicates that the translated and validated version of ATDP scale in Nepali language can be used as a standard tool in assessing attitudes towards person with disability in Nepal.

ACKNOWLEDGEMENTS

We would like to thank Dr. Pabina Raymajhi for the guidance in preparation of manuscript.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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