presentation - Society for the Study of Addiction

Testing an Instrument to Measure Multidimensional Treatment
Entry Pressures in Patients Undertaking Methadone Maintenance
Authors: David M Greenwell, Hazel Watson, Angus McFadyen, Dave Johnson, Susan Kerr
Glasgow Caledonian University, NHS Highland
A number of studies have identified patients who have entered addictions
treatment as a result of perceived pressures Brecht et al. (1993) Wild et al.
(1998) Gregoire and Burke (2004) Marlowe et al. (1996). Marlowe et al. (2001)
Stevens et al. (2006) Schaub et al. (2010) proposed a model of perceived
treatment entry pressures which emanate from a range of life domains. These
pressures can be either negative or positive and external or internal.
Life Domains:
The life domains from which the pressure emanate are either familial, financial,
legal, medical, psychiatric or social.
Negative vs. Positive:
Negative pressures comprise
escape or avoidance of
aversive consequences.
Internal vs. External: Internal
pressures are those in which
the reinforcement is in the
persons control.
This is a measure of the stability of an instrument over time (Burns
and Grove, 2005). If the STEP-UP is stable then the same scores
should be obtained with the same people when the test is
administered on separate occasions. The test-retest reliabilities of the
individual items in the questionnaire were analysed using the sign
test and the weighted Kappa statistic. The test-retest reliabilities of
the subscales of the STEP-UP were analysed using t-tests and
intraclass correlation coefficients.
Positive pressures comprise the
attainment of a positive reward.
This relates to the degree to which the questions in each section of
the questionnaire, or in the whole questionnaire, are measuring the
same dimension. Asking several questions to measure one particular
facet reduces the risk that single idiosyncratic responses will have an
undue effect on the measure (Anthony, 1999).
The internal
consistency of the subscales of the STEP-UP was analysed using the
Cronbach’s alpha coefficient.
External pressures are those in
which the reinforcement is in
someone else’s control.
Crossing the type of reinforcement with the type of mediation yields four
categories of treatment entry pressure:
externally mediated
Self improvement:
internally mediated
positive reinforcement
Crossing these with the life domains produces 24 possible types of treatment
entry pressure such as family coercion or social approbation.
The Survey of Treatment Entry Pressures of the University of Pennsylvania
(STEP-UP), comprises 120 items, in 20 subscales. It was designed to
measure these treatment entry pressures, however no psychometric data on
the instrument was available. This study was carried out to examine the testretest reliability, the internal consistency and the content validity of the STEPUP in a sample of patients undertaking methadone maintenance treatment.
This concerns the degree to which the items on a scale adequately
cover the theory under investigation (Streiner and Norman, 2003). To
assess the content validity of the STEP-UP the opinion of experts
working in the field was sought and their comments were examined
with reference to relevant literature (Streiner and Norman 2003). This
analysis focussed on the relevance of the items in the STEP-UP to
the concept multidimensional treatment entry pressures, whether any
of the items were superfluous; whether the questions were easy to
understand or, if not, which caused difficulty.
The analyses of the test-retest reliability and internal consistency of
the STEP UP resulted in the deletion of 51 items from the
questionnaire. The analysis of the content validity of the resulted in
further modification to the questionnaire through the deletion of some
items and the rewording of others. The layout of the questionnaire
was also changed to make it an easier instrument to complete. This
resulted in a substantially modified questionnaire comprising 46
The questionnaire was administered to 26 patients who had been undertaking
MMT for a period of not less that six weeks in two drug services in the West of
Scotland. The STEP-UP was administered to each participant on two
occasions, the test and the retest. The mean interval between the test and the
retest was 21 days. This was consistent with test-retest intervals identified in
the literature (Burns and Grove 2005).
This work resulted in the further development of an instrument to
measure multidimensional treatment entry pressures in people
accessing drug problems treatment in the UK. The small sample did
not permit an examination of the validity of the construct of
multidimensional treatment entry pressures. Future studies should
test the reliability and validity of the instrument with larger samples
and with samples drawn from different populations.
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