Volume 22, Issue 1 (Spring 2021)                   jrehab 2021, 22(1): 118-131 | Back to browse issues page

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Abolhasani M, Karbalaee Nouri A, Bakhshi E, Kheirkhah M. Assessing the Validity and Reliability of the Persian Version of the Interpersonal Problem Solving Skills Assessment Tool in Schizophrenia. jrehab 2021; 22 (1) :118-131
URL: http://rehabilitationj.uswr.ac.ir/article-1-2795-en.html
1- Department of Occupational Therapy, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
2- Department of Occupational Therapy, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. , nouri.uswr@gmail.com
3- Department of Biostatistics, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
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chizophrenia is a severe mental disorder and one of the leading causes of disability in the world [1]. The annual prevalence of schizophrenia varies but averages 15 per 100,000 [2]. Symptoms of schizophrenia include delirium, hallucinations, thought disorders, speech disorders, behavioral disorders, indifference, and sluggish emotional responses [3].
Defects in social functioning and social skills are often associated with the diagnosis of schizophrenia [76, 5, 4]. In a study conducted in Iran on 208 schizophrenia patients, 95.75% of them had social dysfunction [2, 3]. Other studies have reported social dysfunction in 50 and 87% of patients with schizophrenia [10].
Social function is a general term that refers to an individual’s ability to interact appropriately and effectively in society [11]. The ability to solve an interpersonal problem is one of the main aspects of social skills that many patients with schizophrenia suffer from [1213].
Social dysfunction is one of the debilitating and resistant aspects of schizophrenia. Social problems in adulthood can lead to severe disruption in functional role areas (such as marriage, employment, and friendship) [14]. Impairment in social functioning also affects the quality of life [15] and predicts outcomes, such as relapse, poor course of illness, and unemployment [161718].
The emphasis on improving social skills as a therapeutic goal for schizophrenia creates the need for an appropriate assessment tool with good psychometric conditions. It is necessary to have an assessment tool to determine the basic level of the individual’s skills, strengths and weaknesses, and the patient’s progress so that the therapist can provide a suitable rehabilitation program for the patient.
The Assessment of Interpersonal Problem-Solving Skills (AIPSS) tool is a role-playing tool that assesses the social skills of patients with schizophrenia based on interpersonal problem-solving [1920]. This tool was introduced by Donahue et al. in 1990 and has been translated into French [21], Turkish [22], Chinese [23], Swedish [24], and Norwegian [25] and has been used in various studies [21, 26272829, 30]. This tool appears to be a sensitive tool and reveals problems in schizophrenia that other tools cannot show [26]. AIPSS differs from other common tools in assessing social performance for the following reasons: 1. Using observational role-playing instead of self-declaration or third-party reporting; 2- Determining the current rank of the patient instead of his past performance; 3- using real-life video scenes related to the patient’s ability to solve social problems; and 4- Assessing the patient’s social perception and processing social information to plan verbal and non-verbal social actions and responses [27]. In this study, the validity and reliability of the Persian version of this tool were examined.
Materials and Methods
This research was a methodological study and the statistical population included Iranian (adult) patients with schizophrenia referring to the Razi Psychiatric Hospital in Tehran in 2019. A total of 52 individuals were selected by available sampling according to the inclusion and exclusion criteria to participate in the study.
Inclusion criteria were as follows: 1- Schizophrenia according to the fifth version of the Guidelines for Diagnosis and Statistics of Mental Disorders, which is listed in the medical record by a psychiatrist; 2- the Age of over 18 years old; 3- Having full consent to participate in the study; and 4- the lack of other disorders in their medical records. The exclusion criteria were: 1- severe visual or hearing impairment 2- severe impairment in reality testing 3- Recurrence of symptoms during the performance, and 4- Unwillingness to continue cooperation.
Persian version preparation process

A Persian version was prepared based on the International Bureau of Evaluation of Quality of Life Assessment. To reach the Persian version of the evaluation scenes, first, in a meeting with the presence of researchers, the Persian copy of the evaluation scenes obtained in the previous stage was examined for cultural adaptation and using this copy, the evaluation scenes were filmed. The film was then reviewed by 7 psychologists. To compare the two versions, a form was provided that included the following factors: environment, speech quality, non-verbal components, and verbal content. For each of these cases, the question was asked whether there was a major discrepancy between the original and the reconstructed scene. Also, for each scene, to check the cultural compatibility, a question entitled “Is the Persian version culturally applicable for the Iranian society” was included. Experts’ suggestions were used to improve the evaluation scenes.
Examining the apparent and content validity
The apparent validity of the test evaluation scenes was assessed using a survey of 7 experienced and knowledgeable experts in psychology, who examined the evaluation scenes in terms of clarity and simplicity. To determine the content validity, the Lavash method was used to calculate the Content Validity Index (CVI) and Content Validity Ratio (CVR). For this purpose, the experts rated the content of the test items in terms of relevance and necessity, and finally, the preliminary test was performed on 3 healthy people and 2 patients to clarify the ambiguous parts.
Interpersonal information questionnaire: Demographic information included education level, gender, age, marital status, and length of hospital stay in the participating hospital. This information was obtained through the subjects’ reports or their medical records.
AIPSS: This tool was designed to assess social skills in people with schizophrenia using the 1990 problem-solving model by Donahue et al. AIPSS is done using a film that consists of 14 short scenes of interaction between two actors. The scenes are used to familiarize the examiner with the testing process. There are no problems in three of these scenes, and each of the remaining 10 scenes shows a social interaction problem. The examiner stops playing the video after each scene and asks the examiner to answer a series of questions to assess the skills of receiving, processing, and sending.
Reliability check
Cronbach’s alpha coefficient was used to determine the internal consistency of the test. To measure the reliability between the evaluator, two evaluators scored 22 patients during the test, and then, the correlation coefficient within the scores was calculated. To evaluate the relative reliability of the test, 15 patients were re-tested at intervals of 2 weeks, and the correlation coefficient within the range with a 95% confidence interval was used. Data were analyzed using SPSS software version 26.
In this study, 52 patients with schizophrenia with a Mean±SD age and standard deviation of 39.92±10.32, all of whom were male. Also, the Mean±SD length of hospital stay in these patients was 49.69 days with a standard deviation of 54.14. Education 69.2% of the samples were below diploma and 30.8% were diploma and higher.
Regarding apparent validity, almost all the experts believed that the quality and clarity of the sound were not good in scenes 1 and 9; thus, the two scenes were filmed again. In other scenes, no particular problem was reported, they were approved and the test was performed without problems on 3 healthy people and 2 patients. According to 7 psychiatrists, the value of CVI and CVR for all scales was 1.
Cronbach’s alpha coefficient was used to determine the internal consistency of the test. According to Table 1, Cronbach’s alpha coefficient for different scales of the test was obtained between 0.511 and 0.821. 

As shown in Table 1, the intra-rank correlation coefficient for the two testers at different test scales ranged from 0.98 to 0.99, indicating high reliability between the test evaluators. The correlation coefficient to calculate the repeatability of the test after two weeks in 15 samples for different test dimensions was between 0.733 and 0.893 (Table 1).
Discussion and Conclusion
The validity of the test content was obtained by providing the test to 7 experts and the CVI and CVR results were equal to one. Considering that the acceptable value for CVI is 0.79 and for CVR is 0.99, the results of this study showed that this tool has an accepted content validity [31].
Cronbach’s alpha coefficient was used to determine the internal consistency of the test. According to Table 1, Cronbach’s alpha coefficient for different scales of the test was obtained between 0.511 and 0.821, which indicates the appropriate internal consistency of the test. Donahue et al. obtained Cronbach’s alpha coefficient of 0.65 - 0.78 for different scales of the test [32], which is close to our results. Leung et al. (2006) also reported Cronbach’s alpha of 0.766 for receiving and 0.982 for sending in a study on the Chinese version [23]. As mentioned, the response in each scale is influenced by the response of the previous scale, i.e. the individual’s score in each scale depends to a large extent on his success rate in the previous scale. Therefore, the scales are not completely pure in the process of processing and sending. This can be a reason for the low Cronbach’s alpha level and as a result, the internal consistency of the test.
In this study, the reliability between the evaluators was evaluated by two testers on 22 patients. According to Table 1, the correlation coefficient for all test domains was above 0.98. According to the classification, correlations less than 0.50, 0.50- 0.75, and more than 0.75 are considered weak, medium, and good, respectively, and correlations above 0.9 are excellent [33]. As a result, the reliability between the evaluators in this study was considered excellent for all scales. In the study by Donahue et al. (1990), the reliability between the evaluators was assessed on 9 samples and the kappa coefficient for different test domains was calculated between 0.76 and 0.85 [32]. In a study using the Chinese version, Leung et al. (2006) used the Pearson correlation coefficient to evaluate the reliability of the evaluators and the percentage of agreement between the two testers for different test scales ranged from 0.871 to 0.986 [23]. In a study conducted on 20 French patients with schizophrenia, an agreement between two testers in different scales ranged from 0.90 to 0.95 [21]. In a study conducted on a Swedish version by Stalberg et al., the correlation between the two testers in different test scales was reported to be between 0.74 and 0.80 [24]. The results of the mentioned studies were consistent with the present study and showed the reliability between the appropriate evaluators of the test.
To evaluate the relative reliability of the test, the test was repeated on 15 patients at intervals of 2 weeks and the correlation coefficient for different domains of the test was between 0.733 and 0.893 (Table 1), which shows good reliability for all scales. In a study conducted by Donahue et al. (1990) on 9 samples with a time interval of 2 weeks from the first test, the second test was performed, the correlation range of the retest was reported from 0.46 to 0.77 [32]. In a study using the Chinese version, Leung et al. obtained the correlation of between 0.534 and 0.681 in the test-retest reliability for different domains [23]. One of the possible reasons for the higher reliability of the test in this study compared with the mentioned studies is that the test was performed on hospitalized patients in this study, while in other studies, and the test was performed on outpatients. Outpatients can perform better in testing due to symptom control; thus, they perform better in retesting. The results of this study and the studies mentioned above showed that the test has the appropriate reliability.
Discussion and Conclusion
Given the appropriate psychological conditions and characteristics of this tool mentioned earlier and the fact that the tool measures social skills based on the problem-solving model, this tool can be a good option for psychiatrists, especially occupational therapists. Because social participation is one of the factors of acupuncture in occupational therapy [34], this test should be used in the process of teaching social skills to schizophrenia patients.
Overall, the results obtained in this study showed that the Persian version of the tool for assessing interpersonal problem-solving skills has good validity and reliability and can be used for measuring social skills in Iranian patients with schizophrenia.
The most important limitation in this study was assessing hospitalized patients and the presence of acute symptoms in these patients possibly could affect the results. On the other hand, due to the existing limitations, this study was performed only on men and patients admitted to the studied hospital (Razi). The above limitations can affect the generalizability of this tool; thus, the results of this study should be generalized with more caution. Concerning these issues, it is suggested that further studies be conducted on women using a larger sample size to provide more accurate information.

Ethical Considerations
Compliance with ethical guidelines

This study was approved by the ethics committee of the University of Social Welfare and Rehabilitation Sciences (Code: OR.USER.REC.1397.081).

The present study was extracted from Ma. thesis of the first author at the Department of Occupational Therapy, University of Social Welfare and Rehabilitation Sciences. 

Authors' contributions
Conceptualization: Milad Abolhassani, Ashraf Karbalaei Nouri; Validation: Milad Abolhassani, Mojtaba Khairkhah; Analysis, research and study: Milad Abolhassani, Mojtaba Khairkhah, Ashraf Karbalaei Nouri; Editing and finalizing: Milad Abolhassani; Supervision: Ashraf Karbalaei Nouri, Enayatullah Bakhshi; Data analysis and interpretation: Milad Abolhassani, Ashraf Karbalaei Nouri, Enayatullah Bakhshi.

Conflict of interest
The authors declared no conflict of interest.

The authors would like to thank all the patients who participated in this study, the esteemed staff of the occupational therapy department of Razi Hospital, as well as all those who participated in the preparation of the Persian version of this tool.

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Type of Study: Original | Subject: Occupational Therapy
Received: 15/06/2020 | Accepted: 29/10/2020 | Published: 1/04/2021

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