Testing an Instrument to Measure Multidimensional Treatment Entry Pressures in Patients Undertaking Methadone Maintenance Treatment Authors: David M Greenwell, Hazel Watson, Angus McFadyen, Dave Johnson, Susan Kerr Glasgow Caledonian University, NHS Highland 1. A MULTIDIMENSIONAL MODEL OF PRESSURE TO ENTER ADDICTIONS TREATMENT 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. Positive pressures comprise the attainment of a positive reward. Whereas Internal vs. External: Internal pressures are those in which the reinforcement is in the persons control. External pressures are those in which the reinforcement is in someone else’s control. Whereas Crossing the type of reinforcement with the type of mediation yields four categories of treatment entry pressure: Coercion: externally mediated negative reinforcement Aversion: internally mediated negative reinforcement Approbation: externally mediated positive reinforcement 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. 2. THE STUDY 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 test- retest reliability, the internal consistency and the content validity of the STEP- UP in a sample of patients undertaking methadone maintenance treatment. 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). 3. TEST RE-TEST RELIABILITY 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. 4. INTERNAL CONSISTENCY 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. 5. CONTENT VALIDITY 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. 6. RESULTS 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 items. 7. CONCLUSIONS 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. References: Anthony, D. (1999). Understanding Advanced Statistics A Guide for Nurses and Health Care Researchers. Edinburgh, London, New York, Philadelphia, Sydney, Toronto. Brecht, M.L., Anglin, M.D., Wang, J.C., (1993) Treatment effectiveness for legally coerced versus voluntary methadone maintenance clients. American Journal of Drug & Alcohol Abuse. Vol. 19 (1), pp Burns. N., Grove, S.K., (2005) The practise of nursing research conduct, critique and utilization. 5th ed. St Louis, Missouri: Elsevier Saunders Gregoire, T.K. Burke, A.C. 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