Measuring changes in self-concept: a qualitative evaluation of outcome questionnaires in people having acupuncture for their chronic health problems

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Measuring changes in self-concept: a qualitative evaluation of outcome questionnaires in people having acupuncture for their chronic health problems
Received: 27 July 2005
Accepted: 16 March 2006
Published: 16 March 2006
Charlotte Paterson
BMC Complementary and Alternative Medicine 2006
BioMed Central

MRC Health Services Research Collaboration, Department of Social Medicine, University of Bristol. Bristol, UK

Abstract

Background
Changes in self-concept are an important potential outcome for many interventions for people with long-term conditions. This study sought to identify and evaluate outcome questionnaires suitable for quantifying changes in self-concept in people with long-term conditions, in the context of treatment with acupuncture and Chinese medicine.

Methods
A literature search was followed by an evaluation of three questionnaires: The Wellbeing Questionnaire W-BQ12, the Patient Enablement Instrument (PEI), and the Arizona Integrative Outcome Scale (AIOS). A convenience sample of 23 people completed the questionnaires on two occasions and were interviewed about their experience and their questionnaire responses. All acupuncturists were interviewed.

Results
Changes in self-concept were common and emerged over time. The three questionnaires had different strengths and weaknesses in relation to measuring changes in self-concept. The generic AIOS had face validity and was sensitive to changes in self-concept over time, but it lacked specificity. The PEI was sensitive and specific in measuring these changes but had lower acceptability. The sensitivity of the W-BQ12 was affected by initial high scores (ceiling effect) and a shorter timescale but was acceptable and is suitable for repeated administration. The PEI and W-BQ12 questionnaires worked well in combination.

Conclusion
Changes in self-concept are important outcomes of complex interventions for people with long-term illness and their measurement requires carefully evaluated tools and long-term follow-up. The literature review and the analysis of the strengths and weaknesses of the questionnaires is a resource for other researchers. The W-BQ12 and the PEI both proved useful for this population and a larger quantitative study is planned.

Background
Relevant, comprehensive, and valid outcome measures are a pre-requisite for all experimental and observational evaluations of healthcare interventions. The choice of outcome measures is especially problematic in evaluating complex interventions, interventions for people with long-term health problems, and interventions that aim to bring about a wide range of treatment effects and behaviour change. In these situations it has been suggested that a staged process of enquiry should be instituted, and that qualitative and theoretical work may play an important part in developing research designs [1]. Qualitative methods are useful in understanding the wide range of treatment effects that may be valued in such situations; in linking these individual experiences to more theoretically based concepts; and in designing and evaluating outcome questionnaires that can be used to quantify these treatment effects. By raising descriptive qualitative findings to the level of concepts, such preliminary work may be transferable to other interventions and populations. This paper is based on a programme of primary research into evaluating acupuncture and Chinese medicine, but the wider issues of the definition and measurement of changes in self-concept are relevant to evaluating many other educational and healthcare interventions for people with long-term health problems.

Qualitative studies of people with long-term health problems that use acupuncture and Chinese medicine have identified a range of valued treatment effects and have started grouping them into categories and concepts [2-4]. In addition to changes in symptoms, medication, energy and relaxation, there are other changes that have been described by different researchers as 'improvement in psychosocial coping' [2] or 'changes in personal and social identity' [3]. There is considerable overlap in these two categories. Improvements in psychosocial coping included an increase in self-awareness, an increased sense of wholeness, balance, centredness, well-being, increases in self-efficacy and all round changes in lives; and the category of changes in personal and social identity included changes in self-awareness, self-acceptance, self-confidence, self-responsibility and self-help. In this paper the broad term of 'self-concept' is used to encompass this range of descriptors and the definition of the term 'self-concept' is explored as part of the literature search reported below. The significance of these changes in self-concept to some of the individuals studied is in accordance with a whole body of work that has investigated how people experience and adapt to the 'biographical disruption' of long-term illness (including survival from cancer) and the importance of re-negotiating and coming to terms with changing identities over time [5-7]. They are also of interest in relation to the use of social cognitive theory in health promotion interventions [8].

Previous research has suggested that changes in self-concept are not reliably measured by the generic outcome questionnaires EuroQol-5D and COOP-WONCA charts, or by the individualised problem-specific questionnaire Measure Yourself Medical Outcome Profile, MYMOP[9]. The study reported below aimed to identify and evaluate outcome questionnaires that would be suitable for quantifying changes in self-concept in people with long-term health problems who were having acupuncture and Chinese medicine for the first time. A literature search identified two questionnaires that were then evaluated, alongside a third brief generic questionnaire, using mixed methods. The method and results of the literature search are described first, followed by the details of the evaluation of the three questionnaires.

© 2006 Paterson; licensee BioMed Central Ltd.
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