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Metrics details. The concept of hope has been measured using the Herth Hope Index HHI in different samples, but varying factor structures comprising different items from the HHI have been reported. Therefore, further testing with regard to the dimensionality of the instrument is recommended. Patients completed the item HHI, which measures various dimensions of hope using a 4-point Likert scale that ranges from 1 strongly disagree to 4 strongly agree. The internal scale validity, person response validity, unidimensionality, and uniform differential item functioning were evaluated by applying a Rasch rating scale model.
After removing these 5 items, the resulting 7-item scale demonstrated acceptable item fit to the model, acceptable unidimensionality A 7-item version of the HHI had better psychometric properties than the original item version among patients with cancer-related pain.
Registered September 25, Hope has been measured in many different patient samples [ 1 , 2 , 3 , 4 , 5 ], in family caregivers [ 6 , 7 ] and in the general population [ 8 ]. Hope is described as an important phenomenon for patients in different phases of their disease [ 2 , 9 ] as well as for their quality of life [ 10 , 11 ]. Hope is considered to be an effective coping strategy for both patients [ 12 , 13 ] and family caregivers [ 7 ] in demanding situations in life.
The HHI is a item instrument designed to measure a global, non-time oriented sense of hope. The HHI is based on a definition of hope that describes it as a multidimensional life force characterized by a confident yet uncertain expectation of achieving a future good, which to the hoping person is realistically possible and personally significant [ 15 ]. The three dimensions of the HHI are defined to be: temporality and future, positive readiness and expectancy, and interconnectedness [ 14 ].
The HHS was reduced from 30 to 12 items to make a shorter scale and still capture the multi-dimensionality of hope as presented in the HHS [ 14 , 16 ]. Factor 1 Inner sense of temporality and future consisted of items 1, 2, 6 and 11, Factor 2 Inner positive readiness and expectancy consisted of items 4, 7, 10 and 12, and Factor 3 Interconnectedness with self and others consisted of items 3, 5, 8 and 9. Interestingly, in these eight studies, one [ 20 , 21 ], two [ 6 , 8 , 17 , 19 , 22 ] or three factors [ 18 ] were identified.
These differing results may be due to the fact that the studies not only used different analytic approaches, but also used the HHI in different types of samples and in different countries.
Still, the findings indicate that there is no empirically confirmed construction of the phenomenon of hope as measured by the HHI.
One factor consisted of four items, including 1, 2, 3 and 6. The other six items loaded on the second factor. These findings suggested that positively worded items cluster together on a dominant factor as both items 3 and 6 are negatively worded and items 1 and 2 loaded on both factors [ 8 ].
The two factors were not named in this study, but three of four items in one factor were future oriented positive outlook on life, presence of goals and scared about the future. The other factor comprised the rest of the items. Benzein and Berg [ 17 ] examined the factor structure of the HHI in Swedish palliative cancer patients.
With only two items, the first factor explained only 9. One can also question whether item 4 I can see a light in the tunnel reflects religiosity.
The first factor view on life and future consisted of items 1, 2, 3, 6, 10 and 12, while the second factor self-confidence and inner strength consisted of the other six items. In a study describing the psychometric properties in cognitively intact Norwegian nursing home patients, Haugan and colleagues described different factor solutions of the HHI [ 19 ]. A two-factor model comprising 11 items excluding item 6 resulted in the best model fit. This model explained The factor structure of the HHI was examined in US patients with cognitive impairment and their family caregivers [ 6 ].
They found a two-factor solution explaining Factor 1 comprised items 2, 3, 7, 9, 10 and 12, while factor 2 comprised items 1, 4, 5, 6, 8, and Factor 2 explained only 6.
In Chinese patients with heart failure [ 18 ], a confirmatory factor analysis yielded the same three-factor solution as Herth found in her original work [ 14 ]. The percent of explained variance was not reported in the Chan et al. In Italian patients with solid and hematological malignancies on active treatment [ 21 ], a one-factor solution was found to have the best fit.
Taken together, previous studies using classical test theory approaches found varying factor structures comprising different items from the HHI. The measureable concept of hope seems to be influenced by various aspects, including both methodological approaches as well as sample-dependent characteristics. Another limitation of these prior studies using the HHI is that they are based on an assumption that the scores generated from the HHI can be treated as interval measures.
The consequences of treating ordinal data as interval have been previously described [ 23 , 24 ], and specifically in relation to the use of factor analysis [ 25 , 26 ]. The patients and their family caregivers in this study were recruited for participation in a randomized controlled trial about pain management. Only baseline data from the patients are included in this analysis. Details about the recruitment procedure and the samples are described in detail elsewhere [ 28 ].
All were outpatients who were able to read, write, and understand Norwegian. Because this study was about pain management, all patients had an average pain intensity score of 2. To ensure satisfactory physical functioning, only patients with a Karnofsky Performance Status KPS score of 50 or greater were eligible. The protocol was registered on ClinicalTrials. Medical records were reviewed for disease and treatment information, including cancer diagnosis, treatment and radiographic evidence of bone metastasis.
Patients completed a demographic questionnaire about age, gender, living arrangements, education and employment status. All patients completed the HHI after recruitment into the study. The HHI measures various dimensions of hope using a 4-point Likert scale that ranges from 1 strongly disagree to 4 strongly agree with items 3 and 6 reverse-coded.
The scale has one global score that ranges from 12 to 48, as well as single-item scores that range from 1 to 4 [ 14 ]. A higher score denotes higher levels of hope. In addition to the evidence of its validity, its reliability has also been evaluated and found to be satisfactory. Both internal consistency [ 6 , 8 , 14 , 17 , 18 , 19 , 20 , 21 , 22 ] and test-retest correlations [ 14 , 18 , 21 , 22 ] were reported to be satisfactory in different samples.
HHI items 2 and 4 were reworded in to make the meaning clearer [ 30 ]. Only two studies that did a factor analysis of the HHI as shown in Table 1 used the new version [ 21 , 22 ]. SPSS version 22 was used to calculate descriptive statistics and frequency distributions to summarize demographic and clinical characteristics as well as HHI scores. A Rasch rating scale model was selected as all the items in the HHI are scored on a similar scale. The Rasch model converts the raw scores from the HHI items simultaneously into item and person equal-interval measures using a logarithmic transformation of the odds probabilities of responses.
This computation has been described elsewhere [ 34 ]. In a similar manner, the estimated person measures are used to evaluate person response validity and the precision of the scale. Initially, a differential item functioning DIF analysis was performed in order to explore the stability of response patterns of the HHI items in relation to a number of demographic variables, to support evaluation of validity in relation to internal structure and potential unfairness in testing. It is crucial that a scale is not biased in relation to demographic characteristics, as it will otherwise compromise the measures generated, question the validity of the tool, and influence the interpretation of findings.
The psychometric properties of the HHI rating scale categories were then evaluated with the following criteria: a a minimum of 10 responses per step category, b the average measures for each step category should advance monotonically, and c outfit mean square MnSq values less than 2. Evidence of internal scale validity was then investigated by monitoring the item goodness-of-fit statistics.
The goodness-of-fit statistics indicate the degree of match between actual responses on the items and expected responses from the Rasch model. The MnSq fit statistic is preferable for item goodness-of-fit with polytomous data as it is less sensitive to sample size [ 40 ].
We chose to use a sample-size adjusted criterion [ 40 ] for item goodness-of-fit set for infit MnSq values between 0. To detect any additional explanatory dimensions in the data, a principal component analysis PCA of the residuals was also performed to evaluate the possibility of multidimensionality [ 41 ]. Evidence of person response validity was then evaluated by monitoring the person goodness-of-fit statistics.
We also evaluated the proportion of maximum and minimum scores in the HHI, as this is an indication of ceiling and floor effects, which will also compromise evidence of validity and reliability.
Lastly, in order to monitor the precision of the estimated measures, the person separation index was calculated [ 47 ]. The separation index reflects the number of statistically different performance strata that the test can identify in the sample, considering the range and precision of the individual person estimates. An index above 1. A total of patients with pain from bone metastasis were recruited from a university based cancer center and completed the baseline questionnaires including the HHI.
Of these, 12 had missing data on the HHI and were excluded from the analysis. Half of the sample The majority of the patients had breast or prostate cancer, and about a third received chemotherapy or radiation therapy. When evaluating the categorical responses from the HHI items, all set criteria were met.
However, the item goodness-of-fit statistics revealed that items 3 and 5 did not meet the criterion set for item goodness-of-fit see Table 4. By removing both these items, the next iteration revealed that items 4 and 6 also did not meet the criterion for fit and were subsequently removed.
In the third iteration, item 7 did not demonstrate acceptable goodness-of-fit to the model and was removed. The principal components analyses revealed that the first component explained When evaluating person response validity, 9 of the participants 5.
Thus, we concluded that the reduction of the HHI scale to improve unidimensionality had only a marginal effect on its ability to separate the generated person measures. As the review of literature on the HHI did not indicate any consistent findings in relation to subdomains of hope across countries or demographics, we decided to explore whether the five items that were deleted from the original item HHI scale demonstrated similar response patterns, indicating a secondary dimension within these items.
We therefore combined these five items into a new scale subdomain of the HHI. As presented in Table 4 , the findings in this 5-item scale were relatively similar to the 7-item scale, except for the unacceptably low separation index. This unidimensional 5-item scale did not separate the sample into any detectable subgroups, which indicates that these generated scale measures are not reliable to use as individual outcomes.
As a final evaluation of the HHI scale, we also evaluated the three suggested subscales in relation to the same aspects and criteria as the total scales. The findings were relatively similar across the subscales and in comparison to the HHI total scale; items 3 and 6 also demonstrated misfit in the subscales. The three subscales also demonstrated even lower levels of separation, indicating that the subscales do not separate the sample into detectable subgroups.
Our study showed that a 7-item version of the HHI, after deleting items 3 through 7, satisfied our criteria for a unidimesional scale and demonstrated evidence of internal scale validity, unidimensionality and person-response validity as well as satisfactory person-separation and person reliability Table 4.
Furthermore, none of the 7 remaining items demonstrated DIFs in relation to gender, age, or cohabitation. In addition, the two negatively worded items 3 and 6 did not fit the same construct as the 7 HHI items retained after the Rasch analyses. These findings are consistent with other empirical studies using reverse-coded items.
Abbreviated Instrument to Measure Hope: Development and Psychometric Evaluation
Rasch analysis of the Herth Hope Index in cancer patients