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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 10  |  Issue : 4  |  Page : 210-218

Adoption and validation of the adolescent stress questionnaire for Indian high school students


1 Department of Psychiatric Nursing, Father Muller College of Nursing, Mangalore, Karnataka, India
2 Department of Community Medicine, Father Muller Medical College, Mangalore, Karnataka, India
3 Father Muller Medical Research Centre, Mangalore, Karnataka, India

Date of Submission17-Apr-2019
Date of Decision22-Aug-2019
Date of Acceptance27-Sep-2019
Date of Web Publication18-Nov-2019

Correspondence Address:
Dr. Manjeshwar Shrinath Baliga
Mangalore Institute of Oncology Pumpwell, Mangalore - 575 002, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INJMS.INJMS_42_19

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  Abstract 


Introduction: Adolescent stress questionnaire (ASQ) – a 58-item inventory covering broad range of adolescent distress was developed and validated for Australian adolescents. The present study reports a modification of the ASQ for the Indian context. Methodology: Initially, a focus groups study was carried out with 8 adolescents and 8 experts to understand the relevance of the subject and domain contents of ASQ using the original ASQ. Later content validation was done by the experts in the field for the modified ASQ. The modified version was administered to (n = 20) adolescents for pilot testing. In the next stage, the scale was given to 153 adolescents and readministered to the same samples after 1 week. Statistical analysis was done to ascertain the internal consistency, component factor, and test–retest reliability as per the standard analysis. Results: During stage one, 38 questions were retained which were more relevant to Indian context. The internal consistency of 6 subscales was ≥8 and measuring 0.89 for overall questionnaire. The test–retest reliability measured 0.96 for the overall scale (P < 0.0001) for each domain. During the confirmatory factor analysis, above half (20 of 38) of the items confirmed high correlations with their component scale, with factor loadings P < 0.5. Conclusion: The modified ASQ had acceptable internal consistency and test–retest reliability. Further testing with adolescent students living in other parts is recommended to provide a more complete assessment of the questionnaire.

Keywords: Adolescent, psychiatric status rating scales, stress, surveys and questionnaires


How to cite this article:
D Souza OL, Suresh S, Baliga MS. Adoption and validation of the adolescent stress questionnaire for Indian high school students. Indian J Med Spec 2019;10:210-8

How to cite this URL:
D Souza OL, Suresh S, Baliga MS. Adoption and validation of the adolescent stress questionnaire for Indian high school students. Indian J Med Spec [serial online] 2019 [cited 2019 Dec 14];10:210-8. Available from: http://www.ijms.in/text.asp?2019/10/4/210/271223




  Introduction Top


Adolescence, which is a period in human growth and development which ranges from 10 to 19 years,[1] is a highly sensitive period due to physical and sexual maturation,[2] pressure for social integrity, emerging adult responsibilities, conflicts with peers, and academic performance.[3],[4] Lack of social support from family, friends, and peers could have a negative impact on the health and academic performance.[5],[6] Psychosocial problems among adolescents are clearly linked to stress and stress-related problems,[7],[8] leading to psychosomatic problems like aches and pains, nervousness and fatigue,[9] and mental health problems like depression and anxiety.[10]

According to the United Nations Children's Fund, in 2011, 21% of India's population (253 million) was adolescents.[11] The pressure to do exceedingly well induces an undue stress, resulting in emotional instability and psychological stressors even leading to suicide.[12] In most cases, school-related distress exhibiting symptoms of depression, anxiety, school refusal, phobia, physical complaints, irritability, weeping spells, and decreased interest in school work is shown to be the major cause for the stress.[13],[14] Historically, most Indian parents never considered stress in adolescent as a major factor. However, things are now changing, and in the recent past, parents have been bringing their children for psychological counseling to mitigate the problem and develop remedial coping skills.

Adolescent stress questionnaire (ASQ), a 58-item inventory covering broad range of adolescent distress through subjective stress loading, lists the stressors experienced by the adolescents which was developed and validated for Australian adolescents.[15] Byrne et al. state that “the ASQ is not a measure of symptomatic distress though it does assess subjective stressor load.” The ASQ covers broad range of perceived adolescent stresses. The self-worth of students in the Indian society is mostly determined by good academic performance, and not by vocational and/or other individual qualities[13] stressed on by the original ASQ. Thus, there is a need of a questionnaire standardized for the Indian population. The current study aimed to modify the ASQ and establish the reliability and validity of the modified ASQ in Indian context. To the best of our knowledge, this is the first attempt to develop a version of ASQ best suited for the Indian adolescent population.


  Methodology Top


A prospective study was conducted in 3 high schools in Mangalore, Karnataka affiliated with the Karnataka State Education Board. The study was devised after obtaining ethical clearance from the Institutional Ethics Committee. All study procedures adhere to the principles outlined in the Declaration of Helsinki of 1975 that was revised in 2000 for research involving human subjects. Written informed consent was obtained from all willing participants and parents of adolescents participating in the study. Permission was also taken from the school authorities.

The original ASQ comprising of 58 items is one of the highly referred questionnaires to assess stress in adolescents. The questionnaire was formulated with Australian adolescents after reliability and validity of the items.[16] The scale is then rated on a 5-point Likert scale where 1 = not at all stressful (or is irrelevant to me); 2 = a little stressful; 3 = moderately stressful; 4 = quite stressful; and 5 = very stressful. The ASQ importantly measured the adolescents' exposure to the stressors for the past 1 year. The ASQ was developed to address the requirement for systematic research of adolescent stress in the early 21st century. The adoption and validation of the ASQ for Indian high school students was done in accordance to standard procedure and is depicted in [Figure 1]. Consent was taken from the author for modification of the scale in Indian context.
Figure 1: Procedure used for tool validation

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Focus group

In the initial stage, a focus group interview was conducted using a standard procedure. Two groups were formulated each consisting of the experts from diverse fields. Each focus group consisted of 8 members with diverse age and mixed gender. The first focus group consisted of adolescent schoolgoing students (12–14 years) from the schools; the study was conducted with equal number of male and female representatives. The second group consisted of school teachers, parents, psychologists, sociologist, psychiatric doctors, and nurses. These professions were chosen due to their significant amount of interaction with adolescents and involvement in their care and well-being. The experts included child psychologists, clinical psychology nurse, psychiatrists, pediatricians, bioethicist, school teachers, statisticians, and social science researchers.

The original ASQ was handed over to the members of the focus group with a request on which questions and domains were important for the local Indian conditions. Each items included were analyzed for its relevance to the Indian context. A focal group discussion was then conducted, and the opinions of all experts were considered, and the subscale, the pertinent questions, and grading were finalized. Both the sessions were conducted by a trained psychiatric nurse trained in facilitating discussion among the students and the focal group members. The inputs and suggestions offered by the students and experts were noted. Item wording was done keeping in mind the ability of the Indian adolescents so that they were consistent with contemporary language used by adolescents [Table 1] and [Figure 2]. Finally, 38 items were retained in the modified ASQ for further statistical analysis. The items were then reworded as recommended in the focus interviews. Focus groups explicitly questioned overlap of certain items in the original ASQ and deletion of certain items which the focus group members thought were believed to overlap or were not relevant to Indian context. In addition, only four instead of the five choices were kept as this facilitated easy comprehension by the adolescents.
Table 1: Details on the original adolescent stress questionnaire and the questionnaire modified as suggested by the focus group discussion

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Figure 2: Development of india-ASQ from the original ASQ

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Content validity

Content validity was undertaken to ascertain the content of the questionnaire obtained after the focus group interview. After the focus group interview, the 38-item scales were given to child psychologists, clinical psychology nurse, psychiatrists, pediatricians, bioethicist, school teachers, statisticians, and social science researchers and were requested to review the draft of 38-item modified ASQ. Each reviewer independently rated the relevance of each item on the modified stress questionnaire using a 4-point Likert scale (1 = not relevant, 2 = somewhat relevant, 3 = relevant, and 4 = very relevant). The content validity index was used to estimate the validity of the items.[17]

Final draft of modified ASQ consisted of 38 items from the following subscales that is stress of home life - 7 items (max score = 28.18%); stress of school performance - 6 items (max score = 24.15%); stress of attendance - 3 items (max score = 12.8%); stress of peer pressure - 6 items (max score = 24.15%); stress related to body image - 2 items (max score = 8.5%); stress of teacher interaction - 7 items (max score = 28.18%); stress due to future uncertainty - 2 items (max score = 8.5%); stress of school or leisure conflict - 3 items (max score = 12.8%); and stress of financial pressure and emerging adult responsibility - 2 items (max score = 8.5%). The scale was rated using 4-point rating scale as not at all stressful/is irrelevant to me (Score 1); a little stressful (Score 2); moderately stressful (Score 3); and very stressful (Score 4). No negative worded items were included in the scale. The scale was administered to 20 adolescents for language modification and pilot testing.

Reliability statistics

Once the modified ASQ was completely formulated, it was administered to 153 adolescents after taking written informed consent from students, parents, and school authorities. Students from the 3 schools with mean age 13.08 ± 0.42 and age ranging from 12 to 14 years were the study volunteers. Adolescents were selected by random sampling stratified by gender, geographical location, age, and socioeconomic status. The 20 adolescents who were part of the pilot study were not included in the final study. The measures were explained to the students in simple language, and they were then asked to fill the modified ASQ scale along with the demographic pro forma independently.

Internal consistency

To check the accuracy, precision, equivalence, and homogeneity, the investigator administered the questionnaire to 153 students studying in 3 schools in Mangalore. Reliability of the modified ASQ was tested using internal consistency. Cronbach's alpha was the test used to find the internal consistency of the items. Commonly accepted rule of thumb is 0.7 or higher.

Test–retest reliability

A sample of 153 adolescent students from 3 schools with mean age 13.08 ± 0.42 (range from 12 to 14) years were selected for the study. The scale was readministered to the adolescent students after 1 week.

Factor analysis

The confirmatory factor analysis (CFA) was performed with the help of the first-order model, taking into consideration the individual items as manifest variables and the 9 component scales as first-order factors using Analysis of a moment structures (AMOS) and rest of the analysis was done using SPSS version 23 (Armonk, NY: IBM Corp, USA). Model evaluations were carried out using three “goodness of fit” indices: Chi-square is reported as an absolute fit index, while Bentler's comparative fit index (CFI) and Root Mean Square Error of Approximation (RMSEA) are reported as comparative indices.

Correlation matrix

Correlation matrix was devised from the pretest scores of the modified ASQ using Pearson correlation.


  Results Top


The details on the development and validation of the questionnaire are described in [Table 1], [Table 2], [Table 3], [Table 4] and [Figure 1]. In [Table 1], the details on the original ASQ and the questionnaire modified as suggested by the focus group discussion are enlisted with the reason for the changes as suggested by the focus group panel.
Table 2: Item content and results of the first-order confirmatory factor analysis of modified adolescent stress questionnaire

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Table 3: Results for the internal consistency and test-retest reliability analysis of modified adolescent stress questionnaire scores

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Table 4: Correlation matrix for adolescent stress questionnaire

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Internal consistency

The validated questionnaires consisting of 38 questions in 9 domains were administered to 153 students of studying in 3 schools in Mangalore. Reliability of the modified ASQ was tested by using internal consistency [Table 3]. Cronbach's alpha was the test used to find the internal consistency of the items. The modified ASQ has shown 9 internally reliable dimensions of adolescent stress. These are in agreement to the available literature on adolescent stressor experience. However, the dimension stress of body image yielded comparatively low internal consistency. The internal consistency of 6 subscales was ≥8 which was found to be good. For the subscales such as the school performance, attendance, school, or leisure conflict, it was between 0.7 and 0.8, which were in the range of acceptable values.

Test–retest reliability

To test the test retest reliability, the modified ASQ scale was readministered to the adolescent students after 1 week. Test–retest reliability and the intraclass correlation at 95% confidence interval were found to be good for all scales at two points of time [Table 3]. The original ASQ is thus suggested to have potential for the measurement of adolescent stress in both research and clinical contexts.

Factor analysis

The results of the first-order CFA are presented in [Table 2]. The variables demonstrated high mutual correlations between the factors (slightly above half of the correlations were ≥0.5). The error variances of the individual items were set as free parameters, while the variances of the latent factors were fixed at 1.0 in the model. The standardized factor loadings obtained represent the correlation between the observed variables and the extracted factors. Standardized loadings above 0.4 indicated an acceptable correlation and loadings above 0.5 indicated a good correlation; loadings below 0.4 were indicative of a poor correlation.

Items such as getting up early in the morning to go to school; pressure to fit in with friends; changes with your physical appearance with growing up; satisfaction with how you look; disagreements between you and your teacher; difficulty with some subjects; living at home; getting up early in the morning to go to school; and obeying the rules at school had a factor loading below 0.4 indicating a poor correlation, while four items had acceptable factor loadings between 0.4 and 0.5. Slightly above half (20 of 38) of the items confirmed high correlations with their component scale, with factor loadings >0.5. The component scales correlated highly with the summary score, with factor loadings >0.6.

For Bentler's CFI, a threshold of >0.80 was considered to indicate a good fit, and for RMSEA, values <0.05 or <0.08 were representative of a good or acceptable fit, respectively. The models' absolute fit index Chi-square was 5112.11 (df = 1474, P < 0.001). The comparative model fit indicates Bentler's Confirmatory Fit Index (CFI) and The Root Mean Square Error of Approximation (RMSEA) were 0.845 and 0.0544, indicating a poor and acceptable fit, respectively, of the theoretical model of the ASQ in the data. Even though the items are loading poorly in the domain stress in body image, they are found to be statically significant.

Correlation matrix

Mutual correlations between the modified ASQ scales (9 subscales) showed medium correlations [Table 4]. Most of the areas were statistically significant. Few of the areas showed positive correlation, however statistically not significant.


  Discussion Top


The current study investigated the reliability and validity of modified ASQ in the Indian context. The original ASQ had 10 dimensions which consisted of various stressful experiences of the adolescents.[18] The ASQ has been tried for on the Greek and European adolescents and found to be having an acceptable internal reliability and construct validity.[19],[20],[21]

In this India-specific modified ASQ, we have 38 items divided into 9 domains. The questions were considered after a focal group discussion with experts and parents and considering relevant local study area-specific stressors. Some of the important changes include not including the stress of romantic relationship (fifth domain with four items); the principal reason was that unlike in some other population, the concept of romantic partner is not very prevalent in the study area (in children between the age of 12 and 14).

The other important aspect was that from the domain stress of financial pressure, the 2 questions were retained of 4 from the ASQ. In addition, in the domain of stress emerging of adult responsibility in the original ASQ, the 3 items were excluded because it was not relevant to Indian context. This was done keeping in mind the fact that in India, parents take care of the educational needs of children and young adults (till they start earning). The questions that were not relevant were not included. In addition, in the domain of stress of home life, the argument with mother, father, and sibling were clubbed into one item which was disagreements at home.

The most important aspect we considered in this questionnaire was creation of a domain on stress related to body image. This domain had two questions (changes with your physical appearance with growing up and satisfaction with how you look) and was carved out of the original questionnaire from the domain of stress of peer pressure. This was done because a change in physical appearance and development of secondary sexual characteristics is a major stressor in the Indian adolescents, and this was emphasized by the focal group experts and adolescents. In addition, lack of attention from teachers (question 31) was a question added because in the focal group discussion, the experts felt it to be required as most students in the age group merit the attention from teachers for better academic growth. In India, a teacher takes class for students of 60–80, and it is almost impossible for them to focus and give attention to each and every student.


  Conclusion Top


The present study shows that the ASQ scale is relevant to Indian context when modified in accordance to the local conditions. The modified ASQ contains domains that are address locally specific stressors of Indian adolescents. The present study demonstrated an acceptable internal reliability (Cronbach's alpha) for Indian adolescent sample. In addition, the test–retest reliability was found to be very good. However, medium correlation was found between the 9 subscales of the questionnaire. The biggest drawback of the study is that this study was done with schoolgoing children (12–14 years) and from a highly conservative area of India. Furthermore, questions relating to romantic relationships were excluded as the focal group did not find it appropriate for the study group of 12–14 years in Indian context and needs to be considered if studies are planned with late adolescent group (17–19 years) of students. But then, the study adds to the current knowledge in the area and also acts as a lead for future research in the area. Future studies should be aimed at validating the English questionnaire with young adolescent population (>15 years) and also with other Indian state languages.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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