- CHAPTER 3

METHODOLOGY

> Sample 9 Tools and variables 9 Procedure adopted

9 Consolidation of data 9 Statistical techniques used for analysis

> Method of analysis

Numerous psychological correlates have been hypothesised to play a role in cardiovascular

diseases. A methodology has to be used to identify these factors to collect data on each

factor and decide the hierarchy of importance. Methodology in general refers to the

techniques of securing knowledge regarding the universe. Methodology is a universally

significant step in any research because the fruitfulness and validity of the information that is

secured in the study depends largely upon the authenticity and perfection of itsmethodology.

This chapter gives details regarding the sample selected for the study and the tools used.

Details of administration of the test materials and the procedure followed are separately

presented.

3.1 SAMPLE

Selection of the sample is a crucial step in any research study. In order for the results to

provide valid conclusions the sample should be adequate and representative. The adequacy

of the sample is determined by the size, and the representativeness is determined by its

similarity to the population of the study.

Three groups of respondents were selected for the present study. The first group includes

cardiovascular patients. Cardiovascular disease is a broad area and it is not possible to

examine it as a single unit. Hence, eight cardiac disease types have been included in this

category, viz.; Myocardial Infarction (MI), Angina (AN), Cardiac Surgery (CS), Essential

Hypertension (EH), Arrhythmia (ARR), Atherosclerosis (ATH), Endocarditis (EN) and

Pericarditis (PE). Fifty patients each from these cardiac disease types were selected on the

basis of the diagnosis of expert cardiologists, to constitute the cardiac disease group.

The second group of the study sample is a non-cardiac patient group. Fifty patients with

diseases other than cardiovascular diseases were randomly selected to be included in this

group. Care has been given to exclude patients with or having the history of cardiovascular

disease from this group. The third group of the sample comprised a control group of fifty

normal individuals. Care has been given to exclude individuals with a history of any major

illness.

-40- There are several methods available for selecting a sample size. The population for the

present study is very large and considering the time and cost involved, it was decided to fix

the sample size as 50 in each of the groups. Care has been taken to see that the selected

individuals form a representative sample of the total population.

The cardiac and non-cardiac patients were selected from different hospitals in the state of

Kerala. Purposive sampling technique was used for this purpose. A purposive sample isone,

which is arbitrarily selected for the reason that there is ample evidence of its representative

nature.

3.1.1 Age

Age has a major role in moulding the individuality of any individual. Generally, people have

specific behaviour patterns at different age levels. To a great extent, the behaviour of an

individual is influenced by his age. The details regarding the age of the selected subjects in

each of the disease category are presented in table 3.1.

Table 3.1 Distribution of the sample with regard to age

1 - 3 0 Groups / 30-39 I 40-49 1 50-59 1 60-69 70 +

Nwmal

Non-cardiac Patient

Myocardial Infarction

Angina

Cardiac Surgery -~ ~~~ - .~~~

Essential Hypertension ~ . . ~ . ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~

Arkyhmia -

Alhefeselwesis

Endocarditis

Pericardilis

Column total 78 92 120 I10 82 18

-41- Sample distribubon with respect to age in different groups show that the majority of the

Myocardial Infarctlon patlents fall under the age group 50-59 and 60-69 and the Angina and

Endocarditis patients in the range 50-59. Most of the cardiac surgery, essential hypertension,

and pericarditis patients were in 40-49 age range. Similarly the arrhythmia patiintscome in

30-39 group and Atherosclerosis patients in 30-49 age group.

3.1.2 Sex, religion and place of residence wise classification of the subjects

An important aspect considered while selecting the sample was the influence of sex. There

can be differences among males and females with respect to the occurrence of

cardiovascular diseases. Hence the subjects were taken from both sexes. Similarly, to a

great extent the individual's behaviour is influenced by the religion and it may alsoaffecttheir

life style as they're by the occurrence of cardiovascular diseases. Hence the subjects are

taken considering their religion also. Considering the importance of the locale of the

residence of patients, the subjects are taken from rural as well as urban areas. Details of the

-, sex, religion and place of residence -wise classification are given in table 3.2.

Table 3.2 Distribution of the sample with regard to sex, religion and place of residence

Noncardiac patient

Total 263 237 221 228 51 292 208

42 Sample distr~butlon with respect to male and female representation in different groups

indicates that there IS a h~gher male representation in the MI, EH and PE groups. In all

the other groups the male-female representatlon 1s more or less same. Break up of the

sample with regard to place of residence show that the cardiac patient groups belong

mere to rural area Patlents from the three major religions, viz., Hindu, Christian and

Muslim have been ~ncluded in th~s study

3.1.3 Socio-economic status (SES) wise classification o f the subjects

Education, occupation and income have been found to be potential factors influencing

the adjustment and personality characteristics of an individual. Taking this aspect into

consideration, a SES-wise classification also was made. The personal data schedule

given to the subject is given in appendix 1.

Measurement of Socio-Economic Status

Many Socio-economic status scales are available for measuring the socio-economic

-, status of the subjects Soclo-economic status was computed on the basis of the needed

data for the present study with reference to the scales developed by Kuppuswamy

(1962). Pillal (1973). Nair (1976). and lyer (1977). For the present purpose, the socio-

economic status of the subjects is measured in terms of three variables viz. education,

occupation and income. The computation used by the researcher is an adapted version,

modified according to the income level of respondents at the time of administration.

Education: Classification and Weightago

On the basis of education, subjects were classified into seven categories. For subjects

C with professional or gostgracluate degrees, a score of ten is given. In the case of

subjects with Bachelor's degree like BA I BSc, a score of eight; for subjects with

education up to hlgher secondary or pre-degree, a ssore of five; for subjects who have

studied up to S.S.L.C, a score of four; subjects W ~ Q have studied up te middle school

(Standard VII), a score of two; subjects who have completed lower primary, a score of

one; and who are illiterate is given zero score,

42a Occupation: Classification and Weightage

Subjects were class~fied into six categories on occupational basis as high professional,

semi professional, skilled, semi skilled, unskilled and unemployed,

High Professiona!~

This group consists of individuals who have very high education and are engaged in

decision making process, laying down policies and executing them like doctors,

engineers, lawyers, principals of colleges, readers, professors, bank managers,

buisiness executives, university officials, heads of research organisations, heads of

departments of government, big land holders, secretaries and assistant secretaries to

government, state or district level officers, chief executive of quasi -governmental body,

etc. For this category a weightage of 10 score is given.

Semi professionals

This group consists of occupations which require college education. Here job is of

routine nature This group includes lecturers, chemists, teachers, officers at sub district

level, public health workers, superintendent of any government office, contractors, sub

inspector of police, excise inspector, sub registrars. For this category a weightage of 8 is

given.

Skilled workers

This group consists of workers who have a long period of training in semplisated tasks.

Mechanics, fitters, electricians, drivers, painters, photographers, masons, carlagnkrs,

document writers, vakil-clerks, head constables of police and village officers can be

inGluded in this category. A weightage of 7 is given for this category,

Semi skilled workers

This group includes occupations which require some training on the part of the persons-

shop keepers, attendsrs, farmers, small s6ale meghants, and pglice 68nsfablsS 68me

under this category. The weightage given to this category is 4.

42b Un skilled workers

All persons who are doing work which involves neither education nor training belong to

the unskilled group The watchman, labourers, peon and coolie belong to this category.

A score of 2 is given for this category

Unemployed

The unemployed includes persons who are unemployed irrespective of their education or

training. Zero weightage is given to this category.

Income: Classification and weightage

On the basis of monthly income also, subjects were classified into six categories. Forthe

group having monthly income of Rs 80001- and above, a score of 10 is given. For the

group having monthly income in the range of Rs 43511- to Rs 80001- ; a score of 8; for

the group having monthly income in the range of Rs 34511- to Rs 43501-, a scoreof 6; for

a group having monthly income in the range of Rs 26011- to 34501-, a score of 4; for the

group having monthly income in the range of 17511- to Rs 26001-, a score 2 is given. For

the group having monthly income of Rs 17501- and below, a score of 1 is given.

Computation of Socio - Economic Status (SES)

The details of weightage given to education, occupation and in~ome which is used for

the present purpose is given in table no 3.3a

Table 3.3a Weightage given for the measurement of Socio-economic status --

Occupation

d ree & above -.-- 8

Bre degree, pre 5

Weight age 10

2

Semi professionals Skilled workers

Income per month

Above 8000

Sem~ skilled workers blnskilled werkers Unemployed

Weigh tage 10

8 7

4 2 0

4351-8000 3451-4350

8 6

260 1-3450 1751-2688

Below 1750

4 1 2 1

42c The total of the scores obtained for the three dimensions of SES designated above

yielded a composite score for each subject. The mean value of the composite score was

found to be 16.68 and Standad Deviation (SD) value as 4.05. Using normal probability

distribution, the subjects were divided into three groups. The mean value plus one SD

was found to be 20,73, and those who scored above this was taken as high SES group.

The mean value minus one SD was found to be 12.63, and those who scored less than

the value was taken as low SES group. The subjects who scored between 12.63 and

20.73 were taken as middle SES gmu?

The table 3.3b shows the sample distribution with respect to SES. Sample distribution

with respect to SES in all the eight cardiac groups, shows that a considerably good

number of patients belong to middle socio economic group.

Table 3.3 Distribution of the sample with regard to socio-economic status

Arrhythmia ! . -~ ~- ~ -~ - -~~

I I i

I 1 22 1 1 7 i Atheroscleros~s

~~~ ~ ~-

10 1 25 1 15 - 21 I I

Endocarditis I 12 --

~

i I . ~ i lo i

Pencarditis - 1 i 7 20 f :: 15 1

1 . ~ - ~~~ ~

1 Total 125 239 136

~-~ ~- ~ ~- r-- +~. Socio Economic Status

3.2 TOOLS AND VARIABLES

I ~ ~

Low

Although cardiovascular recovery may be important to long-term cardiovascular health,

its biopsychosocial correlates have received much less attention than the correlates of

Middle High b . I I I Normal ! 7 27 i 6 I

~. --. I I / on-cardiac parlent I io 1 23 I

10

12

~ ~~ ----- I iviyoc~lrdial Infarction 1 20 -_ - . 1- Angina I I 17

~ ~ i

20

21

! Cardiac Surgery I - - - - .

12

Essential Hyuertension ! 8

26

28

12

14

43- cardiovascuiar reactivity. Hence the present study is an attempt to explore the psychological

correlates of cardiovascular disorders. Numerous psychological factors have been

hypothesised to play a role in cardiovascular diseases. To find these psychological factors,

sets of inventories were used, including a personal data schedule. The tools are

1. Personal Data Schedule

2. Stress lnventory

3. Type A Behaviour lnventory

4. Depression lnventory

5. StateTrait Personality lnventory

6. Personality lnventory

7. Generalised T Scale

8. Self-Esteem lnventory

Among the said tools, three were developed for the present purpose, they being stress -, inventory, type A behaviour inventory and depression inventory. Apart from this,

Spielberger's StateTrait personality inventory has been translated into Malayalam and

standardised for the present purpose.

3.2.1 PERSONAL DATA SCHEDULE

The information regarding the subject's personal aspects are collected using the personal

data schedule (PDS). PDS consists of a set of unstructured questions for eliciting information

like age, sex, locale, educational qualifications, occupation, nature of family, food habits,

family atmosphere, prior history of illness, hereditary factors and habits. This is expected to

give a clear understanding about the patient's personal background, which is an important

component in the present study.

3.2.2 STRESS INVENTORY - TOOL DEVELOPMENT

Defining Stress

The term 'stress' has been defined, generally in three ways (Coyne & Holroyd, 1982). First,

stress is commonly defined in terms of particular events in the environment. According to the

-44- stimulus views of stress certain events are particularly likely to produce feelings of tension or

upset the person experiencing the stimuli. Thus stress is seen as being a characteristic of

environmental stimuli. Researchers using this definition of stress have focussed their

attention on how people respond to different events believed to be stressful. This view

assumes that different people respond similarly to given events and thusthe amountofstress

that people are experiencing can be determined by assessing the events that have occurred

in their lives (Holmes & Rahe, 1967).

Stress has also been defined in terms of the reactions that people have in stressful situations.

This response definition of stress focuses on the physiological and psychological effects of

particular events. Hans Selye (1976, 1982) has argued that any time an organism is

challenged, it will exhibit a particular pattern of physiological responses, including the release

of various hormones and changes in heart rate, blood pressure, respiration and

gastrointestinal activity. These responses are essentially the same regadlessof thestimulus

., that evoked them. Hence the important features of stress are to be found in how the person

reacts, as opposed to the events to which the person has been exposed.

A third approach to stress argues that stress is best understood as a process that

incorporates both the events experienced and psychological and physiological responses to

those events (Coyne & Holroyd, 1982, Lazurus & Folkman, 1984). In this view the critical

determinant of stress is how the person perceives and responds to different events. What is

important is not the event itself, but how it is interpreted by the person. This approach to

stress introduces a psychological dimension that is missing in the other definitions. In

particular, stress is understood as a transaction between the person and the environment, in

which the person approaches the situation along with available resources for coping with

those situations.

For the present purpose, the following definition is used. "Stress is a transition between the

person and the environment that includes the person's appraisal of the challenges posed by

the situation as well as resources available for coping up with the challenges along with the

psychological and physiological responses to those perceived challengesn.

45-

The Measurement of Stress

In general stress is measured in four different but complementary ways (Baum et al, 1982).

Researchers using a stimulus definition of stress have tended to emphasise self-reports,

whereas researchers defining stress in terms of performance use psycho-physiological

andlor biochemical measures. From a process point of view none of these measures is

sufficient in itself. Rather each is useful for examining a particular apect of stress and a

complete analysis requires a combination of measures. The ultimate test of a measure is the

extent to which it is reliable and useful in predicting a given outcome.

Among measures of stress, self-report measures are by far the most commonly used. Self-

report measures are attractive to investigators because they are often straightforward in

format and easy to administer and score. For the present study it has been decided to

prepare an inventory in order to measure the level of stress in individual.

Description of Ule Stress Inventory ->

The present inventory is prepared and standardised in order to measure the level of stress in

individual, as there is no inventory available for this purpose, especially in Malayalarn. The

inventory developed has been named as Stress Inventory.

The variables selected for the stress inventory are

1. Family stress

2. Social stress

3. Personal stress and

4. Occupational stress

The review of related literature shows that the above mentioned variables have a remarkaMe

influence on patients and the present inventory is developed with a view to measure these

variables.

The stress inventory contains four subscales with 18 items each, with a total of 72 items

capable of eliciting different components of stress. The descriptions are given below.

-46-

I . Family Stress

The behaviour, needs and personality of each member of afamily, and the interaction with

other members of the family system, may produce stress. As an important variable, family

stress measures various aspects related to family life such as a lack of satisfaction with the

home atmosphere, unreasonable demands, conflict among family members, ill health of the

family members, lack of freedom and independence, uncomfortable physical facilities, etc.

2. Social Stress

Social stress can be defined as an unfavourable perception of the social event and its

dynamics. Any variable that indicates how much social upheaval a society is experiencing

can potentially be used as a measure of the stress of that society's population. In this

variable, 'social stress' measures factors related to social relationship, unemployment,

violence, noise, crowding, pollution, cramped living conditions, loneliness and isolation etc.

3. Personal Stress

Emotion tends to accompany stress, and people often use their emotional status to evaluate

their stress. Most of the time, the sources of stress arewithin the person. People are likely to

find conflict stressful when the choices involve many features, when opposing motivational

forces have fairly equal strength and when the 'ivory' choices can lead to very negative

consequences. In this variable, personal stress measures factors related to worries, anxiety,

fears, anger, sensitiveness, depression, conflicts etc,

4. Occupational Stress

Almost all people at sometime in their life experience stress that relates to their occupation.

m e n these stressful situations are minor and brief, and have little impact on the person. But

for many people, the stress is intense and continuous for long periodsof time. In any form of

paid employment there are a large number of potential sources of stress: the charateriskof

job itself, the role of the person in the organisation, interpersonal relationship atwork, career

development pressures, the climate and structure of the organisation and the problems

associated with the organisation and outside world etc. are some of the factors.

Draft Scale

The drafl scale consisted of 18 Items under each of the four subscales along with

instructions for responding. The following are the instructions given to the subject.

In our day-to-day life, we have to face different circumstances at different spheres of lie.

When we face these situations, we experience stress and tension. But the degree of stress

may vary from person to person. Some statements (events) have been given to find out the

degree of stress experienced, when you are in such a situation. Carefully read thestatements

and indicate the intensity of stress you might have experienced during the situations

described in each statement. In the response column adjacent to the statements, four

choices, viz., very high, huh, somewhat and not at all are given. Indicate yourresponse in the

response column with a ' J' mark.

Scoring

Scoring was done by using the separate keys for each variable. Four-point scale has been

used to measure the intensity of stress. There are positive and negative items in the four

subscales and score of 4,3,2 or 1 is given for a positive item and a score of 1,2,3 or 4 is given

for a negative item. The score ranges from a minimum of 18 and a maximum of 72. The draft

scale has been printed along with the instructions. The scale was named as Stress Inventory.

A copy of the draft scale is given in appendix 2.

Administration of the Draft Scale and Item Analysis

The draft scale was administered to a sample of 200 cardiac patients admitted in various

hospitals in the state of Kerala. The response column has been scored using the scoring key.

The item analysis of the stress inventory was done using the Mathew Item Analysis Table

(Mathew, 1982). This table gives item criterion correlation (Phicoefficient) arid percentageof

subjects making the keyed answer (P value), from P values at the tails of the distribution

according to the criterion.

48-

The response sheets were arranged in the order of the criterion score, which is usually the

total score of the trial form of the test itself. The response sheets were arranged in an order

and fifty response sheets each from the top and bottom were designated as 'upper tail' and

'lower tail' (the 25% of the subjects with the highest total score - upper tail, and the 25%of the

subjects with the lowest total score - lower tail). For each item, count the number of testees

giving the keyed answer (when there are four response categories, t h e m responses getting

the larger weights in scoring can be considered as Ule keyed answer) in each of the tails.

Calculated the percentages of individuals giving the keyed answer in each of the tails.

The final percentage needed for reading the item indices from the table are

(a) PI - Percentage of individuals in the lower tail marking the keyed answer, and

(b) Pu - Percentage of individuals in the upper tail marking the keyed answer.

In the table, first locate the 'PI' value of the item given as heading. Then locate the 'Pu' value

of the item along the left margin and read the corresponding 'Phi' and 'P' vdues. The required

number of items was selected from among items having the highestcorrelation value (Phi).

The details regarding the PI, Pu, Phi and P valuesoffamily stress inventory are presented as

appendix 3.

Final Scale

Out of the 72 items in the draft scale of the stress inventory, 60 items were selected for the

final scale, in which 15 items each were selected from among the four subscales. The

instructions and scoring procedures for the final scale were exactly the same as that of the

draft scale. Copy of the final scale is given in appendix 4.

Reliability

There are different methods for estimating the reliability of a test For the present test, the

test-retest method was used to find out the reliability. Test-retest method involves repetition

of a test on the same gmup immediately or after the lapse of some days, and computation of

correlations between the first and second set of scores. The correlation coefficient thus

obtained indicates the extent or magnitude of the agreement between the two sets of scores

and is often called the coefficient ot stability.

Here the reliability was established separately for the four subscales. The final tool, aflerthe

item analysis, has been administered to the subjects for collecting the data. From this, 70

subjects have been selected at random for calculating the test-retest reliability. Then, after a

week the test was again administered to the identified 70 subjects and a second score was

obtained. The correlation between these two sets of scores was calculated using Pearson

Product Moment Correlations. The reliability value coefficients of the foursubscales are 0.95

(family stress), 0.86 (social stress), 0.95 (personal stress) and 0.94 (occupational stress)

respectively. The high correlation value shows the higher rate of reliability ofstress inventory.

Validity

Validity of a test or evaluation device can be defined as the degree to which the test

measures arid what it intends to measure. There are different types of validity meant for

different purposes. For the stress inventory, it could be claimed that the scale has face

validity, as the items are prepared on the basis of the various components of stress and also

because the final scale has been prepared after item analysis.

Apart from this concurrent validity was also calculated. Concurrent validity calculated by

showing how well the test scores obtained in the newly developed inventory correspond to

already accepted questionnaireslinventory performance made at the same time. In this a

correlation coefficient between the two sets of measures was calculated as an index of

validity. For this, scores of stress inventory were validated against the concerned medical

practitioner's ratings of the patients on this aspect, using a five point rating scale. The values

of the four subscales are as follows, family stress: 0.82, social stress: 0.72, personal stress:

0.80 and occupational stress: 0.94. Hence it could be claimed that the test has high validity.

3.2.3 TYPE A BEHAVIOUR INVENTORY - TOOL DEVELOPMENT

Type A Behaviouc Concepts and Definiiions

Speculation concerning the role of behavioural and environmental factors associated with the

pathogenesis of CHD has been noted in the writings of such medical luminaries as Harvey,

1628, and Osler, 1892 (cf. Weiss et al1984) who believed that CHD was more closely related

to emotion and overwork than to other predisposing factors. It has only been within the past

25 years, hawever, that the term 'coronary prone behaviour' has come into use, refening to a

broad somewhat diffuse body of literature, which includes research on stress, significant life

events, social support networks etc. The most systematic body of evidence linking behaviour

and coronary heart disease can be attributed to the seminal work of two cardiologists,

Friedman and Rosenman (1974) who in the course of their clinical practice identified a

constellation of behaviour (Type A) consistently noted in the majority of their patients.

Friedman and Rosenman (1974) describe type A behaviour pattem as "a particular complex

of traits including excessive competitive drives, aggressiveness, impatience and hurried

sense of time urgency. Individuals displaying this pattern seem to be engaged in chronic

ceaseless and often fruitless struggle within themselves, with others, with circumstances,

with time and sometimes with life itself.

The type A behaviour pattern includes ambitiousness, aggressiveness, c o m p e t i t i ~ and

impatience and specific behaviours such as alertness, muscle tenseness, rapid and emphatic

speech, emotional reactions such as enhanced irritation, signs of anger. Type A person

differs from others with classic anxiety states, who on finding overwhelming challenges

experiences anxiety and often withdraw or seek support or counsel from others. Type A

confidently grapples with challenges while anxiety subjects' retreat from similar situations.

Persons identied as Type B is characterised by the relative absence of these behaviours

(Rosenman & Chesney, 1982). Type A behaviour is distinguishable from of stress, in that

this pattern is not a distressed response but a style of overt behaviour used to confront life

situations. Type A behaviour pattem may be elicited from pleasant or troubling situations

especially situations that are perceived as challenges (Rosenman & Chesney, 1982).

-5r- Type A behaviour pattern might be partially emerging out of certain personal or behavioural

predisposition. But it is largely elicitable on environmental challenges. That is, if the

challenges are severe enough, any person might exhibit a type A behaviour pattem. Thus it

will be seen that 'Type A behaviour is not a personality type but asetof typical behavioural

responses including both an environmental and an intrinsic component.

DeveIopment of the Type A Behaviour Scale

The scale was prepared and standardised in-order to measure the type A behaviour pattem

of the cardiac patients, as there is no scale available in Malayalam language for the purpose.

The scale measures only one variable, and it is named as Type A Behaviour. The scale

contains 18 items. Items in this scale measures the behaviour pattem of cardiac patients,

which includes ambitiousness, aggressiveness, competitiveness and impatience, emotional

reactions, hostility combined with time urgency and excessive involvement with their work.

Draft Scale

The draft scale consisted of 18 items along with instructions and response column also

provided against each statement. The following were the instmtions given to the subjects:

Some statements related to your behaviour and experiences aregiven below. Please indicate

whether it is right or wrong, for the statement, concerned. In the response column, against

each skment, two choices, 'right and 'wrong' are given. Read each statement carefully and

indicate your response with a 'J ' mark.

Administration and ltem Analysis of the D M Scale

The drafI scale was administered to a sample of 200 cardiac patients admitted in various

hospitals. Giving a score of 'one' for right and 'zero' for wrong has scored the responses.

The item analysis of type A behaviour inventory was done using the Mathew ltem Analysis

Table (Mathew, 1982). The details pertaining to the item analysis procedure is given in the

previous section of this chapter (Administration and item analysis of the stress inventory,

page 47-48). The drafI tool is presented as appendix 5 and the details of the PI, Pu, Phi and P

values of type A inventory are presented as appendix 6.

-52- Final Scale

Out of the 18 items in the draft scale, 15 were selected and included in the final scale. The

instructions and scoring procedure for the final scale were exactly the same as that of the

draft scale. Copy of the final scale presented as appendix 7.

For the present purpose, test-retest method was used to flnd out the reliability of the test The

procedure in detail was presented in the 'reliability' section of stress inventory (page 48-49).

The correlation thus obtained for the type A behaviour inventory was 0.61.

Validity

For the type A behaviour inventoly, it could be claimed that the scale has face validity,

because the items are prepared on the various components of type A behaviour pattern and

also the final scale has been prepared after item analysis. Apart from this, concurrent validity

is also calculated. For this, scores of type behaviour was validated against the ratings (five

point scale) made by the concerned medical practitioners. The correlation value thus

obtained was 0.86. Hence it could be claimed that the test has high validity.

3.2.4 DEPRESSION INVENTORY - TOOL DEVELOPMENT

Depression -Concepts

Depression is known as theS'cornrnon cold* of psychological disorders (Seligman 1973). The

word 'depressed' is widely used in our everyday vocabulary. People say they are depressed

when they are sad or upset or in a bad mood. However, a depression serious enough to be

considered a'severe mental disorder' consists of an overwhelming sadness thatimmobilises

and arrests the entire course of a person's l ie (Omstein, 1985).

Depressive disorders incotprate a spectrum of psychological dysfunction, which vary

considerably in severity, frequency and duration. At one end of the spectrum is the

experience of normal depression, a transient period of sadness and fatigue, generally

-53-

responding to clearly identifiable stressors. The moods associated with normal depression

vary in length, but usually continue no longer than two weeks. If the depressed mood

continues for a longer period of time, and growing thoughts of despair and hopelessness

develop, the problem approaches clinical depressive disorder.

Depressive disorders generally involve an unpredictable pattern of symptoms. This includes

loss of interest and pleasure, loss of appetite, decrease in energy level, sense of

worthlessness, difficulty in concentrating and thoughts about death. Other featuresthat might

be experienced by the depressed person are anxiety, phobias, over-concem about health,

fearfulness and irritability.

Description of the Depression Inventory

The present inventory was developed on the basis of the Beck's Depression Inventory and

his cognitive theory of depression. The cognitive theory proposed by Aaron Beck is based on

the relationship between thought and affect in human beings. Beck and co-workers

suggested that errors in thinking cause depression. He noted that depressed people seem to

hold a negative triad of beliefs that include

1. a view of self as unworthy and deficient

2. a view of the world as cruel and aversive, and

3. a hopeless view of the future.

The negative triads of beliefs lead to cognitive distortions in the depressed patients including

problems such as

/

1. Arbitrary influence, a conclusion drawn in absence of suflicient information

2. Selective abstraction, a conclusion on the basis of, but are of many elements

3. Overgeneralization, an overall sweeping conclusion drawn on the basis of single,

perhaps trivial events, and

4. Magnification and minimisation, or gross errors in evaluating performance.

-54- Thus depressed people tend to think in distorted ways. These distortions precipitate new

problems and exacerbate old ones, leading to a vicious circle in which depression is

continually increased.

The present inventory was designed to measure the depth of depression. Its items were

based on observations of attitudes and symptoms characteristic of depressed patients. Most

of the symptoms and attitudes associated with depression were accounted for, since the

numbers of reported symptoms were found to be associated with the depth of depression.

Some of those symptoms and attitudes are sadness, sense of failure, dissatisfaction, self-

dislike, work inhibition, sleep disturbance, loss of appetite and loss of libido.

Draft Scale

The inventory consisted of 18 items designed to measure the depth of depression.

Statements were printed in a single page along with the instructions and the response

column. The inventory measures only one variable, i.e., depression. The following

instructions were given.

"A number of statements that people use to describe themselves are given below Read each

statement and put a 'J ' mark in the appropriate space provided in the response column to

indicate how you feel. There are no right or wrong answers. Do not spend too much time on

any statement. In the response column against each statement four choices A, B, C or D-

denoting almost never, sometimes, often and almst always, respectively are given.

The scoring is done as follows. A score of 4,3,2 or 1 is given to the category A, B, C or D fora

positive statement and a score of 1,2,3 or 4 is given to the category A, B, C or D for a

negabie item respecbvely. The scores are then summed up to obtain the depression score of

an individual. The maximum score will be 72 and the minimum, 18. The draft tool is

presented as appendix 8

Administration and Item Analysis

The draft scale was administered to a sample of 200 cardiovascular patients admitted in

various hospitals in the state of Kerala. The item analysis of the depression inventory was

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done by using the Mathew Item Analysis Table (Mathew, 1982). The details regarding the

procedure were given in the previous section (47-48). The PI, Pu, Phi and P values of items

in the depression inventory are presented as appendix 9.

Final Scale

Of the 18 items in the draft scale, 15 items were selected for the final tool. The instructions

and the scoring procedures for the final scale was exactly the same as that of the draft scale.

Copy of the final scale is presented as appendix 10.

Reliability

The test-retest method was used to find out the reliability of the depression inventory. The

final tool, after the item analysis has been administered to the subjectsfor collecting thedata.

From this, 70 subjects have been selected at random for calculating the test-retest reliability.

After a week, the test was again administered to the identified 70 subjects and a second set

of scores was obtained. (Procedure in detail is presented in pages 48-49). The correlation

coefficient thus obtained for the depression inventory was 0.91. The high correlation value

shows the higher rate of reliability of the depression inventory.

Validity

To find out the validity of the depression inventory concurrent validity method is used. Forthis

the scores of depression inventory were validated against the concerned medical

practitioner's ratings of the patients on depression, using a five point rating scde. (Detzik are

presented in page 49). The correlation value thus obtained is 0.73.

3.2.5 STATE TRAIT PERSONALITY INVENTORY - MALAYALAM ADAPTATION

The State Trait Personality lnventory was developed by Spielberger et al(1979). For the

present study a Malayalam language adaptation of the State Trait Personality Inventory

(STPI) was done and used for data collection. As a first step it has been translated into

Malayalam without making any change in the structure or patkm of the original version. The

item analysis has been done and the reliability and validity coefficients w r e also found out

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State and Trait Dimensions of Personality- Concepts

Freud's danger signal theory and Cattel and Scheier's concept of state and trait anxiety as

refined and elaborated by Spielberger provided the conceptual framework of the State Trait

Anxiety Inventory (STAI). Spielberger, Gorsuch and Lushene (1970) developed the STAI for

assessing state anxiety and trait anxiety in research and clinical practice, The thearetical

importance and heuristic value of this distinction have been increasingly recognised in

anxiety research. This distiwtion provided the COtIceptUal framework for the construction of

psychometric inventories to assess anger and curiosity as emotional states and personality

traits (Spielberger 1979,1980; Spielberger et al 1979,1985). In the light of these evidence

Spielberger et al (1979) developed the STPl to provide reliable, relatively brief, self-report

scales for assessing the personality traits. Although originally developed as a research

instrument for investigating the phenomena in normal adults, the STPl hasalso been found to

be useful medical and surgical patients.

Description of the StateTrait Personality Inventory

The STPl consisted of six subscale; state and trait anxiety, state and trait curiosity and state

and trait anger. The three STPl state subscales are referred to as state anxiety, state

curiosity and state anger; each subscale consisted of 10 items. Similarly 3 STPl trait

subscales referred to as trait anxiety, trait curiosity and trait anger contains 10 items each.

Subjects respond to the STPl state items in terms of how they feel at a particular moment by

rating on a four-point scale, i.e; (a) Not at all, (b) Somewhat, (c) Moderately so and (d) Very

much so. In responding to STPl trait items, subjects indicate how they generdlyfeel by rating

on a four-point scale: 1. Almost never 2. Sometimes 3. Often, and 4. Almost always.

The scoring was done as follows: A score of 1,2,3 or 4 is given to the category a, b, cord for

a positive statement and a score of 4,3,2 or 1 is given to the category 1,2,3 or 4 for anegative

statement. To obtain the score for state and trait anxiety, state and trait curiosity and state

and trait aqer subscales, simply sum the weighted scores for the 10 items that comprise

each subscale. The possibie scores for each subscale can vary from 10 to 40.

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Subscales

STPl was developed to assess the state and trait dimensions of anxiety, curiosity and anger.

Anxiety, curiosity and anger that are being experienced at the present time were labelled as

state dimension and the degree of anxiety, curiosity and anger that a person habitually

experience was known as trait dimension.

1. State and Trait Anxiety

State anxiety was defined as a transitory emotional reaction that consists of feelings of

tension, apprehension, nervousness and worry and activation of the autonomic nervous

system. Trait anxiety refers to relatively stable individual differences in anxiety proneness,

i.e., the differences between people in the tendency to perceive stressful situations as

dangerous of threatening and to respond to such situations with elevations in the intensity.

2. State and Trait Curiosity

It measures both the trait (a person's general tendency) and the state (the intensity of feelings

at a particular moment) dimensions of curiosity. Curiosity means the desire or inclination to

know or learn about anything, ranging from what is novel or strange to a desire of knowing

what one has no right to know. Some of the factors for assessing curiosity are

inquisitiveness, studiousness, concemedness, solicitousm, mental activity etc.

3. State and Trait Anger

State anger was defined as an emotional state or condition that consists of subp3vefeelings

of irritation, annoyance, fury and rage with concomitant activation or arousal of the autonomic

nervous system. It will vary in intensity and fluctuate over time as a function of affronting

injustice or frustration resulti ng from the blocking of goal directed behaviour. The trait anger

was defined in terms of individual differences in the frequency that state anger was

experienced over time.

Draft Scale

The draft scale of the Malayalarn version of the STPl consisted of 60 items, 10 items in each

variable. It consists of 6 subscales: state and trait anxiety, state and trait curiosity and state

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and trait anger. For the present purpose, the original version of the STPl has been translated

into Malayalam without making any change. Instructions, administrations and scoring are

exactly same as of the original version, which was presented in details in the above section

(description of the STPI).

The instructions for the state scale were as follows. "A number of statements people use to

describe themselves are given below. Read each statement and then put a 'J' mark in the

appropriate space on the answer column to indicate how you feel right now. There are no

right or wrong answers. Do not spend too much time on any statement but give the answer,

which seems to describe your present feelings best".

The instructions for the trait scale are as follows: "A number of statements that people have

used todescribe themselves are given below. Read each statement and then put a'/' mark

in the appropriate space on the answer column to indicate how you generally feel. There are

no right or wrong answers. Do not spend too much time on any one statement but give the &

answer which seems to describe how you generally feel."

The draft scale was printed along with the space for responses. A copy of the draft scale is

given in appendix 1 1.

Administration and ltem Analysis

The draft scale was administered to a sample of 200 cardiac patients. The item analysis of

the STPl was done using the Mathew ltem Analysis Table (Mathew 1982). The details

pertaining to the procedure was exactly the same as that which was used in the development

of stress inventory ( page riu 47-48). PI, Pu, Phi and P values are presented as appendix 12.

Final Scale

From among the 60 items in the draft scale Malayalam adaptation of the STPI, 48 itemswere

selected for the final scale, 8 items each in the six subscales. The instruction and scoring

procedures for the final scale was exactly the same as that of the draft scale. A copy of the

final scale is given in appendix 13.

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Reliability

Spielberget's StateTrait Personality lnventory (STPI) has got higher reliability on all the six

variables. Apart from this, the test-retest method was used to find out the reliability of the

Malayalam adaptation of STPI. Procedure in details presented in the reliability section of

stress inventory (page 4849). The correlation values of STPl are presented in table 3.12.

Table 3.4 The correlation values of the original and adapted version of the STPl

. Validity

Validity was established for the original version of STPI with the parent scales, namely State

Trait Anxiety Inventory (STAI), StateTrait Curiosity lnventory (STCI) and StateTrait Anger

lnventory (STAgI). Apart from this, the Malayalam adaptation of STPl has also to find out the

concurrent validity for all the six variables. The scores of six variables were validated qainst

the ratings (five point scale) and presented in table 3.13.

Table 3.5 The correlation values of the original and adapted version of the STPI

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3.2.5 PERSONALITY INVENTORY

Eysenck Personality Inventory (EPI) developed by Eysenck was used to measure the

personality dimensions of Extroversion (E) I Introversion (I) and Neuroticism (N). A

Malayalam adaptation of the EPI constructed by Ammal(1977) was used for the present

study. The inventory has two forms (Form A and Form B) with 56 items each; 24 each in

lntroversion I Extroversion and Neuroticism scale and 8 items in the lle scale. Forthe p m t

study Form B has been used and is attached as appendix 14. The variables studied were

introversion I extroversion and neumticism.

1. Introversion / Extroversion

According to Eysenck, "The typical extrovert is sociable, likes parties, has many friends, need

to have people to talk to, and does not like reading or studying himself. Hecravesexcitement,

takes chances, often sticks his neck out, acts on the spur of the moment and is generally an

. impulsive individual, He is fond of practical jokes, always has a ready answer, and get-erally

likes change. He is carefree easygoing, optimistic and likes to laugh and be meny. He prefers

to keep moving and doing things, tends to be aggressive and loses his temper quickly. His

feelings are not kept under tight control and he is not always a reliable person.

The typical introvert is quiet, retiring sort of person, introspective, fond of books rather than

people, he is reserved and distant except to intimate friends. He tends to plan ahead, 'looks

before he leaps' and disrupts the impulse of the moment. He does not llke excitement; take

matters of evelyday life with proper seriousness and llkes a well-ordered mode of life. He

keeps his feelings under close control, seldom behaves in an aggressive manner and does

not lose his temper easily. He is reliable, somewhat pessimistic and places great value on

ethical standards.

High neumticism scores are indicative of emotional liability and over-activity. High scoring

individuals tend to be emotionally over responsive and have difficulties in returning lo normal

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state after emotional experiences. The neuroticism is widely used to refer to a personality

type which is predisposed to develop neurotic symptoms under even relatively mild stress.

Some of the traits, which correlate and make up the concept are anxiety, moodiness,

unhappiness, proneness to worry, in addition psychosomatic symptoms are frequently

reported by high neuroticism subjects.

Administration and Scoring

Each of the traits, extroversion and neuroticism are measured by 24 items and the subject

has to choose from the alternatives 'Yes' or 'No' as the response for an item. The instructions

are printed in the test booklet.

Separate stencils for scoring purposes are provided with the inventory. Scoring is done by

aligning the appropriate sconng key over the completed answer sheet, and counting one pint

for each 'I' mark appearing through the holes in the stencil. A lie scale is also included to

detect attempt to falsify responses. 'There are 8 lie items. If the lie score obtained by a subject

is five or more, the datacollected is considered invalid and hence not included for the study.

Reliability and Validity

Parallel form reliability is obtained by administering the inventory form A and form B.

Reliability is calculated separately for males and females for the two scales. Reliability

coefficients of neuroticism scale are 0.72 for males and 0.75 for females and extroversion

scale are 0.62 for males and 0.61 for females.

Validity coefficients of the inventory are obtained separately for extroversion neuroticism

against certain subscales of Mathew Temperament Scale. The values are 0.30 (E) and 0.68

(N) for males and 0.76 (E) and 0.67 (N) for females.

3.2.6 GENERALISED T SCALE

Generalised T Scale is a temperament scale, developed by Sananda Raj (1993). It consists

of stability, sociability and objectivity as variables of the scale. The salient features, which

make up a rational personality, are stability, sociability and objectivity. These three traits of

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personality are indispensablefora human being to lead a life that is efficacious, fulfilling and

hassle free in his particular social context. Stability, sociability and objectivity together

determine the degree of rationality a person exhibits in his behaviour.

Variables

1.Stability

Stability means how far a person remains relatively unchanged in his attitude, perceptions,

opinions and in all his behaviour. The different aspects measured by the subscale, 'stability'

may be summarised as emotional maturity, evenness of mood, stability in decisions, lackof

fatigue, optimism, alertness, firmness, endurance, not having the feeling of wony,

depression, guilt and anxiety, non fanaticise and un-suspiciousness.

2. Sociability

Sociability is an ability of an individual to adapt his behaviour to the changing social

environment and its demands, so that he exhibits extroverted or gregarious types of

behaviour. Various characteristics measured by the subscale 'sociability' may be

summarised as; socially active, having many friends, enthusiastic, lively, pleasant, happy-ge

lucky, positive response to criticisms, helpful and energetic.

3. Objectivity

Rational behaviour entails an objective interpretation of the realities around us, without giving

way to subjectivity. Objectivity is the scientic temperament in observing and interpreting the

world of events, realistically and reasonably. The variable 'objectivity' as used in the present

scale covers the following characteristic of temperament: realistic, punctual, systematic,

persistent, self-confident, self-controlled, analysing oneself, lack of impulsiveness,

attentiveness and concerned about morality and ethics.

Thus, the scale mainly covers information about the abovementioned three variables, viz.,

stability, sociability and objectivity. The test consists of 36 items, 12 items in each variable.

.There are positive as well as negative items in each variable. Copy of the inventory is

attached as appendix 15.

63- Administration and Scoring

The subject is instructed to select any one of the five responses viz., A, 8, C, D and E given

against each item, representing: strongly agree, agree, undecided, disagree, strongly

disagree respectively. Scoring is done as follows. A score 5,4,3,2 or 1 is given for the

responses A, 8, C, D or E for a positive item. The scoring is reversed for a negative item.

Reliability

The retest reliability of the scale was obtained on 200 subjects (100 males and 100 females)

selected randomly, repeating the test after one month of the first administation. The reliability

coefficients of the subscales were stability 0.89, sociability 0.82 and objectivity 0.91.

Validity

A temperament survey, developed by Mathew, which yields ten aspectsof temperament, was

used as a criterion scale to estimate the validity of the Generalised T Scale. The validity

coefficients for stability: 0.81, sociability: 0.74 and objectivity: 0.75.

3.2.7 SELF ESTEEM INVENTORY

Self-esteem is measured using a standardised test developed by Thomas (1984), which is

known as the self-esteem inventory. The inventory is constructed making use of the self-

reported method. All the items are in the form of self-evaluative andlor descriptive

statements. The items are expected to tap self-evaluation of the subject from awidevariety of

behavioural domains including academic, social, physical and emotional aspects. The

inventory measures only one variable, namely self-esteem.

Self-esteem is believed to be the core concept in the dynamics of a healthy personality. In -

fact the humanistic psychologists maintain that the develapmentof normal healthy personality

is geared to the development and maintenance of high level of selfesteem.

In other words self-esteem is the way one feels about oneself, including the degree to which

one possesses self-respect and self-acceptance. Self-esteem is the sense of personal worth

and competence that persons associate with their self-concepts.

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Administration and Scoring

The test material of the self-esteem inventory comprises of the instruction for the subject (20

items) and the response columns are provided. The following instructions are meant for the

subject, "Some statements related tocertain problems that we face in our day-to-day life are

given in the scale. Please indicate how far you agree or disagree with each statement. In the

response column against each statement five choices A, 6, C, D and E are given

representing strongly agree, agree, undecided, disagree and strongly disagree respectively.

Copy of the self esteem inventory is attached as appendix 16

The scoring is done as follows. A score of 5,4,3,2 or 1 is given to the category A, B, C, D or E

for a positive statement and a score of 1,2,3,4 or 5 is given to the category A, B, C, D or E for

a negative statement. The scores are then summed up to obtain the self-esteem score of an

individual. The maximum score is 100 and the minimum, 20.

Reliability and Validity

The split half reliability coefficient calculated is 0.95, after correction using the Spearmen

Brown Prophecy formula. The retest reliability obtained is 0.90. The behavioural esteem

scores (Behaviour rating form developed by Coppersmith) obtained here correlated with self-

esteem inventory and found to be 041.

In the present study 7 standardised inventories and one unstructured personal data schedule

have been used. Altogether 18 variables are studied using these inventories. The variables

are (I) family stress (2) social stress (3) personal stress (4) occupational stress (5) Type A

behaviour pattern (6) introversion I extroversion (7) neuroticism (8) stability (9) miability (10)

objectivity (1 1) self esteem (12) state anxiety (13) state curiosity (14) state anger (15) trait

anxiety (16) trait curiosity (17) trait anger and (18) depression.

3.3 PROCEDURE FOR DATA COLLECTION

The data for the present study were collected from patients in different hospitals in the state

of Kerala. Categorisation of the 8 groups of cardiovascular disease patients was made with

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the help of the concerned medical practitioners and from the case sheets provided in the

hospitals. The researcher met each patient individually to collect the required information.

Due to the peculiar nature of the illness, personal visits were possible only after aweekfrom

their date of admission in the hospitals. It took about 30 minutes to complete the set of

inventories, but sufficient time was given to the subjects depending upon the health

conditions of the patient. The inventories were read out to those patients who were either

illiterate or were not able to comprehend the items properly to secure correct and appropriate

information.

3.4 CONSOLIDATION OF DATA

The relevant data obtained from the subjects using the personal data schedule and the 7 set

of inventories were consolidated in a coding sheet, in the following way: each subject was

given an identification number and against that number the data relating to personal

information like age, sex, religion etc and the scores obtained for different variables were

entered in a single line. The data thus consolidated are subjected to analysis.

3.5 STATISTICAL TECHNIQUE USED FOR ANALYSIS

Computer facilities were used for analysing the data. The main statistical techniques used for

analysis were: Multivariate Analysis of Variance (MANOVA), Univariate Analysis ofvariance

(ANOVA), Scheffe Procedure, Discriminant Function Analysis and Chi-square . These

techniques are briefly described below.

3.5.1 Multivariate Analysis of Variance (MANOVA)

M m v a provides an opportunity to test the equality of group dispersions, viz., test of H I.

With the help of the results of the test, it would be possible to test the discriminating power of

the variables, test of H 2 (Cooley and lohnes, 1971). It may be noted here that the first test

provides a picture of the general analysis. This can be canied further (test of H 2), only when

there is group dispersion.

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3.5.2 Univariate Analysis of Variance (ANOVA)

Univariate Anova is an effective way to determine whether the means of more than two

samples are too different to attribute the sampling error. In one way analysis of variance, the

relationship between one independent and one dependent variable is examined.

3.5.3 Scheffe Procedure

A significant F does not point out which of the three mean values differ among themselves. In

such cases, the comparison of the differences between means for any two groups is done

using a rigorous method called Scheffe Procedure (Scheffe, 1957). However if the F test

does not refute the null hypothesis, there is no justification for further analysis, as differences

between pairs of means will not differ significantly, unless there are a large numberofgroups

in which case one or two might by chance equal or approach significance.

If the Anova proves the mean difference to be significant, the analysis is proceeded furtherto

find out which of the means differ significantly using the Scheffe Procedure. Scheffe test is

one of the well known multiple group comparison test.

3.5.4 Discriminant Analysis

In many situations a researcher is faced with the necessity to identify the subgroups in a

given sample or to find out the discriminating characteristics among two or more subgroups.

In a multivariate set up, this amounts to differentially weighting the predictor variables and

arriving at a composite index which will help in placing a particular case in a specific

category. Discriminant analysis is often the best-suited technique to achieve this objective.

For the present purpose, discriminant analysis is used to identify those psychological

variables which are most discriminative among the different subgroups, selected for the

study. It is expected that the results will supplement the univariate andysisdoneforthesame

purpose and will bring out a more realistic picture in the multivariate set up.

3.5.5 Chi-square

The chi-square test is an important test amongst the several tests of significance developed

bv statisticians. As a non-~arametric test. it can be used to determine if cateaorical data

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shows dependency or the two classifcations are independent. At the same time, chi-square

test is not a measure of the degree of relationship or the form of relationship between two

attributes, but is simply a technique of judging the significance of such association or

relationship between two attributes.

3.6 METHOD OF ANALYSIS

The present study is aimed to find out the psychological correlates of cardiovascular

diseases. For this, sets of psychological inventories are used, which measures 18

psychdogical variables. To make the study more fruitful and effective two type of group

comparison has been made. As a first criterion, the total sample (500) has been divided in to

three groups (Three group) viz., cardiovascular patient gmup (400), nowcardiac pabent group

(50) and normal group (50). A second criterion (ten group) was used to get a clear picture

about the different cardiovascular diseases, for this the cardiovascular patients were divided

into eight groups (50 each) based on the diagnosis and was compared with the non-cardiac

and normal group.