SW. Sri. Med. Vol. 16. pp. 1591 to 1593. 1982 Prtnted in Great Britain. All rights reserved

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RESEARCH NOTE

MEASUREMENT AND ANALYSIS OF KNOWLEDGE AND ATTITUDES TOWARD EPILEPSY AND PERSONS

WITH EPILEPSY*

RICHARD F. ANTONAK and PATRICIA R. RANKIN

University of New Hampshire. Education Department. Merrill Hall, Durham, NH 03824 U.S.A.

Abstract-The Scale of Knowledge and Attitudes Toward Epilepsy and Persons with Epilepsy (ATPE) was developed as a contemporary. brief. easy to administer and score, psychometrically sound instru- ment, The 32 item scale consists of 25 statements from which an attitude score is derived and 13 statements from which a knowledge score is derived. Data were collected and analyzed which indicate satisfactory item characteristics, scale reliability and internal consistency. Scale development supports the content validity of the scale. while data from multiple regression and factor analyses support its construct validity. The scale should be useful for the investigation of questions concerning the formation. structure. correlates and modification of knowledge and attitudes regarding epilepsy and persons with epilepsy

Although the results of periodic nationwide polls [l]

demonstrate an improvement in attitudes and en- lightened knowledge about epilepsy. children and adults with epilepsy continue to be stigmatized and discriminated against [2]. Recent research [3-S] pro- vides ample support for Wright’s [6] contention that “for many persons with epilepsy. society’s attitude is more devastating than the disorder itself” (p. 3).

In Arangio’s [2] analysis, the stigma of epilepsy consists of a cluster of such deeply discrediting attri- butes as criminal tendencies, sexual deviance and insanity. This stigma leads to discrimination against persons with epilepsy in the form of eugenic marriage laws. insurance restrictions. exclusion from school and denial of employment opportunities. Rejected by society and deprived of essential life opportunities. the person with epilepsy may internalize maladaptive be- haviors (i.e. live dor~rr to expectancy) which confirm the prejudice and misunderstanding of the non-epilep- tic person and reinforce discriminatory attitudes and behaviors. The stigma of epilepsy self-perpetuates a vicious cycle similar to the stigma attached to other differences among people. such as race, religion, or physical attractiveness.

To break this cycle. authors call for educational programs to dispel myths. correct misunderstandings. and change attitudes among medical professionals [7]. educators [S], rehabilitation counselors [9]. employers [lo] and the general public [l]. Although the design of attitude change studies has improved considerably,. the instruments used to measure knowl- edge and attitudes toward epilepsy continue to be psychometrically crude. Typically. they are designed for a specific research situation without formal valida-

*Copies of the scale. along with the more detailed Tech- uictrl Rcpwr .Vo. I. are available from Dr Richard F. Antonak. Education Department. University of New Hampshire. Durham. NH 03824. U.S.A.

tion or scale ana.lyses. Rapid and profound change in rehabilitation and special education practice has intensified the interest of researchers in the measure- ment of knowledge and attitudes of various popula- tions toward epilepsy; that research demands a useful and psychometrically sound instrument. The purpose of this paper is to describe the development and psychometric characteristics of a new scale to measure knowledge and attitudes toward epilepsy and persons with epilepsy.

METHOD

SC& development

Definition of the scale’s item content was ac- complished by reviewing previously published investi- gations of the attitudes of various groups of subjects toward persons with epilepsy (e.g. [3. S-lo]) and ana- lyzing open-ended interviews with experts in neuro- logy, rehabilitation and special education. A pool of 106 items was edited to yield a set of 76 items which were evaluated by a panel of ten experts representing school administration. special education, vocational rehabilitation, pediatrics, neurology, nursing. health administration, occupational therapy, higher edu- cation and the New Hampshire Epilepsy Foundation. A set of 38 items was retained which were judged unambiguous, and which elicited relatively extreme favorable or unfavorable evaluations by the experts. This included a subset of 14 knowledge items which elicited loo”, truth value agreement.

Half the number of statements were worded so that an agree response would indicate a favorable atti- tude (or correct response), while the other half were worded so that a disagree response would indicate a favorable attitude (or correct response). The 38 state- ments were randomly arranged on a Likert-format scale on which the respondent rates each statement on a 6-point continuum. ranging from -3 to signify ‘I

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1592 Research Note

disagree v’ery much’ through +3 to signify ‘I agree very much’. A weighted sum of the item responses provides a measure of the respondent’s global attitude with a high score indicating a favorable attitude. The knowledge items are dichotomously scored according to the expect-derived key.

Sump/e

Data were obtained from a sample of 253 individ- uals (50 males and 203 females) enrolled in a variety of undergraduate and graduate courses offered by the University of New Hampshire. Of this sample, 122 were undergraduate majors in a variety of degree pro- grams (e.g. occupational therapy, home economics, psychology, communications disorders. etc.), 87 were graduate students in various majors (e.g. developmen- tal disabilities, communication disorders, rehabilita- tion counseling, reading, special education, etc.) and 44 were non-matriculated professionals enrolled in courses for continuing education purposes. The mean age of the sample was 26.41 years (SD = 7.62, range from 19 to 62 years).

RESULTS

Preliminury um~l_ws

The results of detailed item [ll], scale [12], and factor analyses of the responses of the 253 subjects to the 38 items were examined, and a decision to delete six items from the scale was reached. The final version of the scale contains 32 items (16 positive and 16 negative) of which 2.5 are scored as attitude items (12 positive and 13 negative), 13 are scored as knowledge items (7 positive and 6 negative) and 6 are scored as both knowledge and attitude items (3 positive and 3 negative).

Detailed analyses revealed satisfactory item charac- teristics in all cases. The mean item value for the posi- tively and negatively worded attitude items was 2.23 and -2.35. respectively. The mean item to total scale correlation (corrected for redundancy) was 0.43 (range from 0.29 to 0.56). The mean item difficulty and dis- crimination index for the 13 dichotomously scored knowledge items were 0.86 and 0.39, respectively.

The mean attitude score was 131.75 (SD = 12.76, SE; = 0.80) with a slight negative skew to the distri- bution of scores (skewness = - 1.24. kurtosis = 1.41). The value of the shared common variance was calcu- lated to be 0.57. which indicates a tendency for the respondents in this sample to select the extreme re- sponse options.

The value of the corrected SpearmanBrown split- half reliability coefficient was 0.81 with a standard error of measurement (SE,,,,,,,) of 5.56. The coefficient alpha internal-consistency homogeneity index based upon item variances was 0.87.

The mean knowledge score was I 1.24 (SD = 1.74. SE; = 0.11. skewness = - 1.06, kurtosis = 0.65). The value of the Kuder-Richardson formula-20 reliability estimate was 0.59 (SE,,,,,,, = 1.1 I), while the coefficient alpha internal-consistency homogeneity index was 0.97.

An iterative principal-factors analysis of the atti- tude item correlation matrix yielded three non-trivial factors which accounted for 68”,, of the variance m the attitude scores. These three factors were rotated to a terminal solution using the varimax criterion.

The first attitude factor. accountine for 70”,, of the common variance. was labeled Prejudical Stereotypes. The six items loading on this factor characterize epi- leptic persons as insane. dangerous and a threat to other children and spouses. The second factor accounted for 16”; of the common variance and was labeled Behavioral Misconceptions. The SIX items loading on this factor suggest that epileptic persons are accident prone. do not make good spouses. par- ents or offspring, are prone to criminal behavior and prefer life in isolated communities of their epileptic peers. The last factor accounted for the remainrng variance (14YJ and was labeled Behavioral Optimism. The six items loading on this factor state positive views of the educability, employability, personal skills and social adaptability of persons with epilepsy.

Factor analysis of the knowledge item correlation matrix yielded five non-trivia) factors. The Hurst facto1 accounted for 19”,, of the common factor variance. The seven items with significant loadings on this factor express optimistic views of the personal com- petence of persons with epilepsy. The remaining factors accounted for very little vartance.and were not readily interpretable.

Demographic and experiential data collected in- cluded the respondent’s age. sex. educational level attained and professional specialization. Four cate- gories for this last characteristic were defined: (a) regular service providers (RSP) (e.g. teachers. adminis- trators), (b) special service providers (SSP) (e.g. special educators), (c) ancillary service providers (ASP) (e.g. occupational, physical, and speech therapists. nurses. etc.). and (d) non-human service providers (NHSP) (e.g. physics majors. accountants). Analyses of vari- ance of mean attitude and knowledge scores showed females to have a significantly higher mean attitude score (F = 6.68. d.f. = 1.251. P -C 0.01). but no signifi- cant sex difference in the mean knowledge scores was found.

The attitude scores were significantly correlated with both age (r = 0.13. P < 0.05) and educational level (r = 0.18. P < 0.01). The knowledge scores were also significantly correlated with both age (r = 0.13. P < 0.05) and educational level (r = 0.14. P < 0.051. The special service providers in this sample recorded the most favorable attitudes (r = 0.15) and accurate knowledge (r = 0.13) about epilepsy.

Forward-inclusion stepwise multiple regression analyses showed that the educational level of the re- spondent was the best predictor of both attitude score and knowledge score. Taken together with the results of the factor analyses. these regression results provide evidence for the scale‘s construct validity. Additional data concerning the discriminant. concurrent. and predictive validity of the ATPE scale are being col- lected.

Research Note 1593

DISCUSSION

The ATPE scale was developed in response to a need for a contemporary, brief. easy to use, psycho- metrically sound instrument to measure knowledge and attitudes about epilepsy and persons with epi- lepsy. The results of the analyses reported here indi- cate that the ATPE has good item properties and is reliable and valid.

In particular. the ATPE has strong content validity and is easy to administer and score. The 25 attitude and 13 knowledge items have satisfactory character- istics; the corrected Spearman-Brown coefficient (0.81) and alpha coefficient (0.87) demonstrate the atti- tude subscale’s reliability and homogeneity; the KR-20 estimate (0.59) and alpha coefficient (0.97) demonstrate the knowledge subscale’s reliability and homogeneity. Factor analysis of the attitude state- ments yielded three interpretable factors labeled Pre- judical Stereotypes. Behavioral Misconceptions and Behavioral Optimism. The specificity and reliability of these factors must be demonstrated before rec- ommendations for their use in profile analysis can be made. The factorial structure of the ATPE which emerged from these data conforms to recommen- dations [13] that scales which proport to measure attitudes toward disabled persons demonstrate a mul- tidimensional structure.

Some support for the construct validity of the ATPE was found in the analyses of the relationship of scale scores with respondent demographic and exper- iential characteristics. However, additional discrimin- ative validity analyses are required with samples of respondents who differ substantially in age. training and experience with persons with epilepsy. Neither predictive validity nor concurrent validity of the ATPE can be reported yet. although data for such analyses are currently being collected.

In order to dispel the myths of epilepsy and break the stigma which the public has associated with it, teachers. rehabilitation counselors and other human service professionals must develop sound education programs to convey accurate information and pro- duce positive attitudes. Although public attitudes toward epilepsy have become more positive in the last 25 years. there remains a significant gap between con- temporary medical and psychological knowledge

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REFERENCES

about epilepsy and epileptic persons, and the knowl- edge and attitudes of not only the general public, but also professional educators, counselors and phys- icians. The ATPE is offered as a psychometrically sound measure of knowledge and attitudes toward epilepsy and persons with epilepsy which should prove useful in research and evaluation studies designed to narrow that gap. Additional research is encouraged to provide information regarding the val- idity and utility of the ATPE scale.

Caveness W. F. and Gallup G. H. Jr A survey of public attitudes toward epilepsy in 1979 with an indication of trends over the past thirty years. Epilepsia 21. 509-5 18. 1980. Arangio A. J. Behind the Stigma q/ Epilepsy. Epilepsy Foundation of America. Washington, DC 1975. Gage H. S. The Problems of Epilepsy as Viewed hi

Purenrs and Patients. Epilepsy Foundation of America. Washington, DC 1972. Panda K. C. and Bartel N. R. Teacher perception of exceptional children. J. spec. Educ. 6, 261-266. 1972.

Harasymiw S. J., Home M. D. and Lewis S. C. A long]- tudinal study of disability group acceptance. Rrhuhil. Lit. 37, 98-102. 1976. Wright G. N. (Ed.) Rehabilitation and the problem of epilepsy. In Epilepsy Rehabilitation. Little-Brown. Boston, 1975. Braham S.. Houser H. B.. Cline A. and Posner M. Evaluation of the social needs of nonhospitalized chor- nically ill persons. J. chron. Dis. 28. 401-419. 1975. Martin J. W. Attitudes toward epileptic students in a city high school system. J. Sch. H/t/l 44, 144145. 1974. Studde E. W. Evaluation of short-term trainIn for rehabilitation counselors: Effectiveness of an insiitute on epilepsy. Rehahil. ~‘own. Bull. 16, 146154. 1973.

Sands H. and Zalkind S. S. Effects of an educatlonal campaign to change employer attitudes toward hiring epileptics. Epiledsia 13. 87-96. 1972. intonak R. i. ITEM3: A general purpose FORTRAN 10 test scoring and item analysis program. Behu~,. Res.

Met/t. Instrum. Il. 81-82. 1979. Antonak R. F. A FORTRAN program to analyze sum- mated rating scales. Am. Srarisr. 34 (I ). 59. 1980. Antonak R. F. Drwlopmenr and Psj,chomerric Analysis of the Scale of’ Attitudes Too\vard Disahled Persons.

Technical Report No. 1. University of New Hamp- shire. Durham, NH, 1981.