International Journal of Nursing Studies 51 (2014) 927–933
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Development and preliminary testing of the Schizophrenia Hope Scale, a brief scale to measure hope in people with schizophrenia Kwisoon Choe * Department of Nursing, College of Natural Sciences, Kunsan National University, Gunsan, South Korea
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 June 2013 Received in revised form 30 August 2013 Accepted 19 October 2013
Background: Hope has received attention as a central component of recovery from mental illness; however, most instruments measuring hope were developed outside the mental health field. To measure the effects of mental health programs on hope in people with schizophrenia, a specialized scale is needed. Objective: This study examined the psychometric properties of the newly developed 9item Schizophrenia Hope Scale (SHS-9) designed to measure hope in individuals with schizophrenia. Design: A descriptive survey design. Setting: Participants were recruited from three psychiatric hospitals and two community mental health centers in South Korea. Participants: A total of 347 individuals over age 18 with a DSM-IV diagnosis of schizophrenia, schizoaffective, or schizophrenia spectrum disorders (competent to provide written informed consent) participated in this study; 149 (94 men, 55 women) completed a preliminary scale consisting of 40 revised items, and 198 (110 men, 88 women) completed the second scale of 17 items. Methods: Scale items were first selected from extensive literature reviews and a qualitative study on hope in people with schizophrenia; the validity and reliability of a preliminary scale was then evaluated by an expert panel and exploratory factor analysis. The remaining 9 items forming the Schizophrenia Hope Scale (SHS-9) were evaluated through confirmatory factor analysis. Results: The SHS-9 demonstrates promising psychometric integrity. The internal consistency alpha coefficient was 0.92 with a score range of 0–18 and a mean total score of 12.06 (SD = 4.96), with higher scores indicating higher levels of hope. Convergent validity was established by correlating the SHS-9 to the State-Trait Hope Inventory, r = 0.61 (p < 0.01). Divergent validity with the Beck Hopelessness Scale was also established, r = 0.55 (p < 0.01). Exploratory and confirmatory factor analysis resulted in a 1-factor solution, with the essential meaning of hope accounting for 61.77% of the total item variance. Conclusion: As hope has been shown to facilitate recovery from mental illness, the accurate assessment of hope provided by the short, easy-to-use Schizophrenia Hope Scale (SHS-9) may aid clinicians in improving the quality of life of individuals with schizophrenia. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Hope Mental health Reliability and validity Scale development Schizophrenia
* Tel.: +82 10 2569 1750; fax: +82 63 469 1991. E-mail address: [email protected] 0020-7489/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijnurstu.2013.10.018
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What is already known about the topic? Hope is viewed as a facilitating factor in recovery and rehabilitation from mental illness. Even though 32 hope scales have been developed, there are few valid and reliable tools for measuring hope in people with severe mental illness. What this paper adds A valid and reliable hope scale was developed for people with schizophrenia; its properties include essential meanings of hope from their perspective. This study produced a concise, easy-to-use 9-item instrument, the Schizophrenia Hope Scale (SHS-9) that could be of great value in measuring the effectiveness of nursing interventions on hope in mental health treatment settings. 1. Introduction Hope is considered to be an important factor in recovering from mental illness (Van Gestel-Timmermans et al., 2010) and is believed to improve the quality of life of people with schizophrenia (Hasson-Ohayon et al., 2009). However, it has been reported that people with schizophrenia have significantly less hope than the general population (Landeen and Seeman, 2000; Landeen et al., 2000). The diagnosis of schizophrenia, implying a life-time of psychosis and hospitalization, is certainly a cause for despair and loss of hope among people with this illness (Littrell et al., 1996). Recently, insight into mental illness, internalized stigma, and depression were also considered to be a cause of hopelessness in people with schizophrenia (EhrlichBen Or et al., 2013; Sharaf et al., 2012). Given that hope is important to people with schizophrenia, various interventions to support it have been implemented in psychiatric settings (Cheavens et al., 2006; Schrank et al., 2012a). However, when conducting a study of hope, clinicians or nursing researchers unfortunately face the difficulty of identifying an appropriate hope scale to assess their patients with schizophrenia. Today, even though 32 hope scales have been identified across various disciplines and applications (Schrank et al., 2008), few valid and reliable tools exist for measuring hope in people with severe mental illnesses (Schrank et al., 2012b). Attributes of hope are complex and multidimensional; thus, the emphasis on each attribute in hope scales would differ according to the situation and the context of the target population. One reason to insist upon the development of a hope instrument specific to people with schizophrenia is that hope reflects personal experience. For example, hope in persons with terminal cancer is related to ameliorating physical symptoms such as pain at the end of life (McClement and Chochinov, 2008), while individuals with psychiatric disorders hope for an untroubled life, the restoration of family relationships, and close interpersonal relationships (Noh et al., 2008). Hope in people with schizophrenia has
more emotional and spiritual meanings, that is, meaning in life, happiness, anticipation of a better future, and the energy to live (Noh et al., 2008). The Snyder Hope Scale, Herth Hope Index, and Miller Hope Scale are the most frequently used with psychiatric patients. Although these tools are reported to have good reliability and validity, none have been validated for people with severe mental illness (Schrank et al., 2012b). Moreover, these three tools overlap considerably and focus on each attribute separately (Schrank et al., 2012b). The Snyder Hope Scale adopted a more narrow definition of hope as the mainly motivational concept of goal orientation. Consequently, it focuses on cognitive appraisals of the ability to generate the means to achieve goals, and excludes other possible emotional and spiritual aspects of hope (Schrank et al., 2012b). The Herth Hope Index (Herth, 1991) was developed to assess hope in elderly patients with cancer and their families during the last phases of the disease. It is likely that the nature of hope differs between people with cancer who face impending death and those with mental illness who continue to be concerned with daily life. The Miller Hope Scale (Miller and Powers, 1988) was based on critical elements of hope revealed in a comprehensive literature review and an exploratory study of hope in survivors of critical illness. Although the definition of hope in the Miller Hope Scale is more comprehensive than that in the Snyder and Herth instruments, this scale still focuses on hope in persons who survived a critical physical rather than mental illness. Furthermore, it is unfeasible for people with mental illness due to its high number of items (Schrank et al., 2012b). Accordingly, the use of existing scales to measure hope in people with schizophrenia may result in a misunderstanding of hope in this population because it is not certain that these scales accurately measure the properties of hope specific to individuals with mental disorders. Therefore, there is a clear need for a high-quality instrument to measure hope in people with schizophrenia. This instrument could serve as a valuable measurement of hope in the context of evidence-based empirical research in the mental health field as well as an effective clinical assessment of recovery. This study aimed to develop a valid and reliable instrument to measure hope consisting of essential meanings of hope from the perspective of people with schizophrenia. Therefore, the specific research question is as follows: what is the reliability and validity of the newly developed measurement of hope in people with schizophrenia?
2. Methods 2.1. Design A descriptive survey design was used to develop an instrument to measure hope in people with schizophrenia. This study was conducted in three phases: instrument development (phase 1), piloting scale (phase 2), and final Schizophrenia Hope Scale (phase 3).
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2.2. Participants and ethical considerations
2.5. Data analysis
Patients were recruited from three psychiatric hospitals and two community mental health centers in South Korea. Inclusion criteria were a DSM-IV diagnosis of schizophrenia, schizoaffective or schizophrenia spectrum disorders, above 18 years of age, and competency to provide written informed consent. This research was reviewed and approved by the Institutional Review Board of Kunsan National University Bioethics Committee. All participants voluntarily consented to participate. All procedures were carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki). A total of 347 individuals participated in this study; 149 (94 men, 55 women) completed a preliminary scale consisting of 40 revised items and 198 (110 men, 88 women) completed the second scale of 17 items.
Statistical analyses were performed using SPSS version 17.0 and AMOS programs. Descriptive statistics were calculated to summarize the sample characteristics and the subjects’ responses on the questionnaires. An exploratory factor analysis and a confirmatory factor analysis were performed to evaluate the construct validity of the Schizophrenia Hope Scale. The scale’s internal consistency was established using Cronbach’s alpha and Pearson’s correlation coefficients were calculated to examine the relationships among the three scales; Schizophrenia Hope Scale-9 (SHS-9); Beck Hopelessness Scale, and State-Trait Hope Inventory. For all analyses, p < .05 was considered statistically significant.
2.3. Validating instruments
3.1. Instrument development (phase 1)
Since the Beck Hopelessness Scale and the State-Trait Hope Inventory were used in studies of hope in psychiatric populations, these scales were chosen in this study.
Forty items were selected for the scale from concept clarification research (Choe et al., 2005), a qualitative study (Noh et al., 2008), and an extensive literature review on hope in people with schizophrenia. An expert panel of professionals with extensive experience (over 10 years) working with people with schizophrenia was assembled, consisting of four psychiatric head nurses and one psychiatrist. These professionals address the issue of hope with their patients, and have specifically interviewed them on the subject. The panel evaluated content validity, assigning each item a rating ranging from 0 (not appropriate) to 2 (very appropriate). The average score was above 1 (appropriate) for each of the 40 items; all items were included in the first preliminary scale. Following a pilot study of 15 patients, some wording was changed to aid readability.
2.3.1. Beck Hopelessness Scale The Beck Hopelessness Scale (Beck et al., 1974) is a 20item questionnaire that asks participants to endorse statements as true or false as applied to them in order to measure negative thinking about the future. Individual items are summed; total scores can range from 0 to 20, with higher scores indicating higher levels of hopelessness. A Korean-language version of the Beck Hopelessness Scale was used, the psychometric soundness of which was established by Shin et al. (1990). The average score for participants in this sample was 6.44 (SD = 4.28), and the internal consistency alpha coefficient was 0.82. 2.3.2. State-Trait Hope Inventory The State-Trait Hope Inventory, developed based on a comprehensive literature review (Farran et al., 1995), consists of two identical 20-item 5-point Likert scales that measure the state and trait dimensions of hope. Total scores can range from 20 to 100, with higher scores indicating higher levels of hopefulness. A Korean-language version of this inventory was used, the psychometric soundness of which was established by the authors of this study. The average score for this sample was 67.99 (SD = 11.80), and the internal consistency alpha coefficient was 0.85. 2.4. Data collection Data collection was conducted by self-reported questionnaires administered face-to-face with participants. For reliable data collection, the author met with the patients to explain the purpose and procedures of this study. In the event that a patient could not read the questionnaires due to blurred vision, the author administered the scales verbally and recorded the patient’s responses.
3. Results
3.2. Piloting the scale (phase 2) 3.2.1. Reliability and validity of the first preliminary scale (40 items) A preliminary scale consisting of the 40 revised items was administered to 149 persons with schizophrenia (94 men, 55 women). The sample size appropriate to validate an instrument under development is at least four times the expected number of total items on the final instrument (Nunnally and Bernstein, 1994). The expected total number of items of the hope instrument in this study was less than 20; thus, a sample size of 149 people was considered to be appropriate. Each item was rated on a 3point Likert scale (0: disagree; 1: agree; 2: strongly agree), yielding a final score range of 0–80. The 3-point Likert scale is a simple but discriminate assessment tool that considers the cognitive abilities of persons with schizophrenia. Correlations between items and total scale score ranged from 0.486 to 0.806. Principal factor analysis to evaluate construct validity revealed five factors with an eigenvalue above one. The factor loadings of all 40 items were above 0.4. Cronbach’s alpha for the preliminary scale was 0.97, and for the five factors as follows: Factor I (the essential
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meaning of hope), 0.96; Factor II (what hope is for), 0.93; Factor III (support systems for hope), 0.81; Factor IV (spiritual dimensions of hope), 0.84; and Factor V (not classified), 0.18. Factor I of the preliminary scale measured the fundamental meaning of hope and included 17 items. The eigenvalue of Factor I was 19.956 and accounted for 48.9% of the total item variance. 3.2.2. Reliability and validity of the second preliminary scale (17 items) The second preliminary hope scale consisted of the 17 items included in Factor I (the essential meaning of hope). This second preliminary scale was completed by 198 persons with schizophrenia (110 men, 88 women) who had not completed the first preliminary scale. Rasch analysis showed that the mean square infit and outfit statistic of all 17 items ranged between 0.5 and 1.5; thus, exploratory factor analysis could be performed for the 17 items. As a result of exploratory factor analysis, factors with eigenvalues greater than one were extracted. Maximum likelihood factor analysis with oblimin rotation resulted in a 1-factor solution. Items with factor loadings greater than 0.60 and communalities greater than 0.50 were selected, but the validity of three items (6, 14, and 15) was low; these items were deleted. For the remaining 14 items, the Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy was 0.936; a minimum KMO score of 0.50 is considered acceptable to reliably use factor analysis. To examine the correlation between the items, Bartlett’s test of sphericity (BTS) was conducted. The BTS score was 2077.880 (p < 0.001), indicating that the correlation matrix between the variables is not the unit matrix and that factor analysis is appropriate for the variables. A total of 57.1% of the variance was explained by the 1-factor solution. Cronbach’s alpha coefficient for Factor I was 0.94. All participants completed the 17-item second preliminary version of the Schizophrenia Hope Scale and two validating
instruments, the Beck Hopelessness Scale and the StateTrait Hope Inventory. 3.3. The final Schizophrenia Hope Scale (phase 3) To select the most valid and reliable items, confirmatory factor analysis was performed for the 14 items of the second preliminary scale. Goodness-of-fit was improved by deleting five items (5, 8, 13, 16, and 17), leaving nine items in the final version, the Schizophrenia Hope Scale (SHS-9). The results of exploratory factor analysis of the second preliminary hope scale and the final SHS-9 are displayed in Table 1. The Schizophrenia Hope Scale (SHS-9) is a 9-item scale in 3-point Likert format (0: disagree; 1: agree; 2: strongly agree). The range of possible scores is 0–18, with higher scores indicating higher levels of hope. The final Schizophrenia Hope Scale was administered to 198 people with a DSM-IV diagnosis of schizophrenia, schizoaffective, or schizophrenia spectrum disorders. Participants’ characteristics are presented in Table 2. Participants were 22–67 years old, with a mean age of 43.44 (SD = 8.21), and a mean duration of illness of 12.54 years (SD = 8.66). The average score for this sample was 12.06 (SD = 4.96), with an internal consistency alpha coefficient of 0.92. The alpha coefficients decreased when any of the items were deleted, indicating that the SHS-9 is a reliable instrument. The nine items of the SHS-9 are presented in Table 1. Convergent validity was evaluated by comparing the scores of the Schizophrenia Hope Scale (SHS-9) with the State-Trait Hope Inventory. Pearson’s correlations between the two instruments indicated a moderate positive correlation, r = 0.61 (p < 0.01), supporting the convergent validity of the Schizophrenia Hope Scale (Table 3). Divergent validity of the Schizophrenia Hope Scale (SHS-9) was measured by Pearson’s correlations between the Schizophrenia Hope Scale and the Beck Hopelessness
Table 1 Exploratory factor analysis of the preliminary hope scale and the final Schizophrenia Hope Scale (SHS-9). Items
Model 1 Factor loading
Q1 There is a better future ahead of me. Q2 I will be happy in the future. Q3 I am getting better every day. Q4 My future is bright. Q5 I set my goals and try to achieve them. Q6 I have a lot of time to experience life. Q7 I am excited about my life now. Q8 I have a strong will to live. Q9 I plan my future. Q10 I am confident about my life. Q11 I am confident about my future. Q12 My life is meaningful. Q13 I have a dream. Q14 I now live with passion and strength. Q15 If I overcome difficult situations, my life will be better. Q16 I overcome sadness and frustration. Q17 I feel confident about myself. Eigenvalue % Of variance Cronbach’s a h2: index of communality coefficients.
.713 .790 .736 .751 .728 .582 .826 .711 .777 .779 .795 .742 .714 .668 .634 .726 .722 9.092 53.483 .973
Model 2 h2 .508 .624 .541 .563 .530 .329 .682 .506 .603 .607 .632 .551 .509 .446 .402 .527 .521
Factor loading
Final Model h2
Factor loading
h2
.718 .804 .744 .765 .743
.516 .646 .554 .586 .552
.736 .835 .770 .775
.541 .698 .593 .600
.823 .710 .778 .778 .796 .740 .715
.677 .503 .605 .605 .634 .548 .611
.834
.695
.769 .794 .810 .744
.591 .631 .656 .553
.729 .723
.532 .532
7.883 57.095 .942
5.559 61.766 .922
K. Choe / International Journal of Nursing Studies 51 (2014) 927–933 Table 2 Sample characteristics (N = 198). n (%)
Variables Gender Male Female Age (years) Duration of illness (years) Marital status Never married Married Separated Divorced Widowed Education Never attended Elementary school Middle school High school College Graduate school Religion Protestant Catholic Buddhist Other None
110 (55.6) 88 (44.4) M (SD) 43.44 (8.21) 12.54 (8.66) 112 32 16 25 8
(58.0) (16.6) (8.3) (13.0) (4.1)
2 17 24 89 59 5
(1.0) (8.7) (12.2) (45.4) (30.1) (2.6)
106 18 24 16 32
(54.1) (9.2) (12.2) (8.1) (16.3)
M: mean; SD: standard deviation.
Scale. Results indicated a moderate negative correlation between the two scales, r = 0.548 (p < 0.01), confirming the divergent validity of the Schizophrenia Hope Scale (Table 3).
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Construct validity of the Schizophrenia Hope Scale was confirmed by principal component analysis with extraction and direct oblimin rotation. Maximum likelihood factor analysis with oblimin rotation resulted in a 1-factor solution. One factor consisting of nine items with eigenvalues > 1 was extracted; it accounted for 61.77% of the total item variance. The results of the confirmatory factor analysis for the Schizophrenia Hope Scale were acceptable. The x2 value was significant (x2 = 88.662, p < .001), and the comparative fit index, normal fit index, goodness-of-fit index, and root mean square residual were 0.941, 0.919, 0.908, and 0.021, respectively, indicating that the structure of the Schizophrenia Hope Scale accurately represents the data for hope. The standardized estimates of the items ranged from 0.49 to 0.66 (Fig. 1). 4. Discussion This study was conducted to develop an instrument to measure hope in people with schizophrenia; the Schizophrenia Hope Scale (SHS-9) was thus created. As the scale was developed based on a concept clarification, the findings of qualitative researches, and literature reviews on hope in people with schizophrenia, this tool is unique in that it includes the meaning of hope from the perspective of this population. As a result of this study, reliability and validity of the newly developed Schizophrenia Hope Scale have been established. In the first phase, the researcher developed a hope instrument consisting of 40 items. Then,
Table 3 Correlations among the instruments (N = 198). Possible range of scores
SHS-9 BHOP STHI
0–18 0–20 20–100
Range
0–18 1–19 38–100
M SD
12.06 4.96 6.44 4.28 67.99 11.80
Correlations SHS-9
BHOP
STHI
1.0 .548* .606*
1.0 .755*
1.0
SHS-9: Schizophrenia Hope Scale-9; BHOP: Beck Hopelessness Scale; STHI: State-Trait Hope Inventory; M: mean; SD: standard deviation. * p < 0.01
Fig. 1. CFA Model for the SHS-9 standardizied estimates.
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content validity was ensured through expert-review and patient feedback. In the second phase, principal factor analysis to evaluate construct validity revealed five factors with an eigenvalue above 1, and the factor loadings of all 40 items were above 0.4. Internal consistency was very high (a = 0.97). The preliminary scale composed of 40 items on five factors became 17 items on one factor. Among the five factors, only 17 items on Factor I (the essential meaning of hope) were included in the next phase because 13 items on Factor II (what hope is for) and 3 items on Factor III (support systems for hope) addressed theoretically different elements in the dynamics of hope. Factor IV (spiritual dimensions of hope) was also excluded because its items referenced faith in God, prayers to God, and so on. These items would limit its use in nonreligious individuals. The two items on Factor V (‘‘I can overcome difficulties well’’ ‘‘I want to be free’’) were also removed due to very low internal consistency (a = 0.18). As a result of exploratory factor analysis of the second preliminary scale (17 items), a 1-factor solution was confirmed and three items with low validity were removed. For the remaining 14 items, KMO and BTS scores were acceptable for factor analysis, and a total of 57.1% of the variance was explained by the 1-factor solution. Internal consistency for Factor I was very high (a = 0.94). In the last phase, through exploratory and confirmatory factor analyses, eight items were removed from the total 17 items on Factor I step by step; finally, construct validity and internal consistency of the final model of the SHS-9 (9 items) were tested. Cronbach’s alpha was 0.92 for the SHS9, indicating good reliability. One factor was extracted, and the variance explained 61.77% of the total scale. Convergent validity was demonstrated by correlating the final SHS-9 to the State-Trait Hope Inventory (r = 0.61). Divergent validity with a negative correlation of the SHS-9 to the Beck Hopelessness Scale (r = 0.55) also supported the construct validity of the SHS-9. These two scales were chosen because they had been used in previous studies of hope in psychiatric populations. The eight deleted items included ‘‘I set my goals and try to achieve them’’ (Q5) and ‘‘I have a dream’’ (Q13) were removed, showing a major difference between the Snyder Hope Scale and the Schizophrenia Hope Scale (SHS-9). The components of the Snyder Hope Scale (Snyder et al., 1991) are goal-oriented, while the components of the final SHS-9 focus more on the emotional and spiritual aspects of hope. The remaining nine items of the SHS-9 address the emotional meaning of hope (‘‘better’’ (Q1, Q3), ‘‘happy’’ (Q2), ‘‘bright’’ (Q4), ‘‘excited’’ (Q7), and ‘‘confident’’ (Q10, Q11)), and the spiritual meaning of hope (‘‘my life is meaningful’’ (Q12)). Although ‘‘I plan my future’’ (Q9) is included in the final model, this is more general than concrete strategies to achieve goals, compared to the Snyder Hope Scale. The essential meaning of hope in the remaining nine items is defined as positive expectations for the future, confidence in life and the future, and meaning in life. In the Miller Hope Scale (Miller and Powers, 1988), hope is characterized by looking forward to a good future and the expectation of a positive outcome. In the Herth Hope Index
(Herth, 1991), future orientation and positive expectancy are similar to the positive expectation component of the Schizophrenia Hope Scale. Future reference is an inevitable aspect of hope. Interestingly, renewing a sense of possibility or positive expectations for the future is one of the definitions of social recovery in people with schizophrenia (Hopper, 2007). Among the items of the SHS-9, ‘‘confidence in life and the future’’ (Q10, Q11) was revealed as an important property of hope for people with schizophrenia. However, ‘‘I feel confident about myself’’ (Q17) was not included in the final model. Hopeful participants in this study felt confident about life and their futures, but they did not feel confident in themselves. ‘‘I have a strong will to live’’ (Q8) and ‘‘I now live with passion and strength.’’ (Q14) were also excluded. Low confidence and lack of will may reflect their low self-esteem. For this reason, two items on overcoming difficulties (Q15, Q16) may be deleted. Meaning in life is a key element of hope, although only one item on meaningful life remained in the final model of the SHS-9. The Miller Hope Scale (Miller & Powers, 1988) also describes purpose and meaning in life as critical elements of hope. Hope is intimately connected with questions of meaning and values (Fitzgerald, 1979). Qualitative studies of hope in people with mental disorders have revealed that determinants of hope revolve around meaning in life (Schrank et al., 2012a). The search for meaning is a primary force in human life (Fitzgerald, 1979). Thus, people with schizophrenia who have hope live life with energy. Recapturing meaning in life is an essential element in the process of recovery from severe mental illness (Ehrlich-Ben Or et al., 2013). In summary, the essential meaning of hope in the SHS-9 consisted of positive expectations for the future, confidence in life and the future, and meaning in life. These three meanings of hope are the very core elements of the concept of hope for people with schizophrenia. Of course, these three elements of hope may not be different from those for people without mental illness; however, until now there have been few hope scales that combine these three core elements in a single instrument. Finally, there are some limitations associated with this study. The test-retest reliability of the scale was not validated; this will need to be analyzed in a future study. Further testing of this Schizophrenia Hope Scale (SHS-9) across diverse study populations would help to validate its use in other regions. 5. Conclusion The Schizophrenia Hope Scale is a new self-report instrument with adequate psychometric properties to measure hope in persons living with schizophrenia. This scale is significant for representing the subjective meaning of hope from the perspective of people with schizophrenia and for allowing simpler quantification of the construct of hope in this population. Moreover, the Schizophrenia Hope Scale facilitates further exploration of the antecedents and correlates of hope in people with schizophrenia and provides a sound basis for future research on hope in this population.
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Acknowledgements Conflict of interest: None. Funding: This research was supported by Kunsan National University. Ethical approval: This research was approved by the Institutional Review Board of the Kunsan National University Bioethics Committee. Appendix A. Schizophrenia Hope Scale (SHS-9) – English version Directions: Read the following 9 items and check [H] the response that applies to you for each item. There is no right or wrong answer. Respond to all items, but do not spend too much time thinking about your answers. You must check only one response from the three responses (Disagree, Agree, or Strongly Agree). Disagree
Agree
Strongly Agree
1. There is a better future ahead of me. 2. I will be happy in the future. 3. I am getting better every day. 4. My future is bright. 5. I am excited about my life now. 6. I plan my future. 7. I am confident about my life. 8. I am confident about my future. 9. My life is meaningful.
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Contents lists available at ScienceDirect
International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
Development and preliminary testing of the Schizophrenia Hope Scale, a brief scale to measure hope in people with schizophrenia Kwisoon Choe * Department of Nursing, College of Natural Sciences, Kunsan National University, Gunsan, South Korea
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 June 2013 Received in revised form 30 August 2013 Accepted 19 October 2013
Background: Hope has received attention as a central component of recovery from mental illness; however, most instruments measuring hope were developed outside the mental health field. To measure the effects of mental health programs on hope in people with schizophrenia, a specialized scale is needed. Objective: This study examined the psychometric properties of the newly developed 9item Schizophrenia Hope Scale (SHS-9) designed to measure hope in individuals with schizophrenia. Design: A descriptive survey design. Setting: Participants were recruited from three psychiatric hospitals and two community mental health centers in South Korea. Participants: A total of 347 individuals over age 18 with a DSM-IV diagnosis of schizophrenia, schizoaffective, or schizophrenia spectrum disorders (competent to provide written informed consent) participated in this study; 149 (94 men, 55 women) completed a preliminary scale consisting of 40 revised items, and 198 (110 men, 88 women) completed the second scale of 17 items. Methods: Scale items were first selected from extensive literature reviews and a qualitative study on hope in people with schizophrenia; the validity and reliability of a preliminary scale was then evaluated by an expert panel and exploratory factor analysis. The remaining 9 items forming the Schizophrenia Hope Scale (SHS-9) were evaluated through confirmatory factor analysis. Results: The SHS-9 demonstrates promising psychometric integrity. The internal consistency alpha coefficient was 0.92 with a score range of 0–18 and a mean total score of 12.06 (SD = 4.96), with higher scores indicating higher levels of hope. Convergent validity was established by correlating the SHS-9 to the State-Trait Hope Inventory, r = 0.61 (p < 0.01). Divergent validity with the Beck Hopelessness Scale was also established, r = 0.55 (p < 0.01). Exploratory and confirmatory factor analysis resulted in a 1-factor solution, with the essential meaning of hope accounting for 61.77% of the total item variance. Conclusion: As hope has been shown to facilitate recovery from mental illness, the accurate assessment of hope provided by the short, easy-to-use Schizophrenia Hope Scale (SHS-9) may aid clinicians in improving the quality of life of individuals with schizophrenia. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Hope Mental health Reliability and validity Scale development Schizophrenia
* Tel.: +82 10 2569 1750; fax: +82 63 469 1991. E-mail address: [email protected] 0020-7489/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijnurstu.2013.10.018
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What is already known about the topic? Hope is viewed as a facilitating factor in recovery and rehabilitation from mental illness. Even though 32 hope scales have been developed, there are few valid and reliable tools for measuring hope in people with severe mental illness. What this paper adds A valid and reliable hope scale was developed for people with schizophrenia; its properties include essential meanings of hope from their perspective. This study produced a concise, easy-to-use 9-item instrument, the Schizophrenia Hope Scale (SHS-9) that could be of great value in measuring the effectiveness of nursing interventions on hope in mental health treatment settings. 1. Introduction Hope is considered to be an important factor in recovering from mental illness (Van Gestel-Timmermans et al., 2010) and is believed to improve the quality of life of people with schizophrenia (Hasson-Ohayon et al., 2009). However, it has been reported that people with schizophrenia have significantly less hope than the general population (Landeen and Seeman, 2000; Landeen et al., 2000). The diagnosis of schizophrenia, implying a life-time of psychosis and hospitalization, is certainly a cause for despair and loss of hope among people with this illness (Littrell et al., 1996). Recently, insight into mental illness, internalized stigma, and depression were also considered to be a cause of hopelessness in people with schizophrenia (EhrlichBen Or et al., 2013; Sharaf et al., 2012). Given that hope is important to people with schizophrenia, various interventions to support it have been implemented in psychiatric settings (Cheavens et al., 2006; Schrank et al., 2012a). However, when conducting a study of hope, clinicians or nursing researchers unfortunately face the difficulty of identifying an appropriate hope scale to assess their patients with schizophrenia. Today, even though 32 hope scales have been identified across various disciplines and applications (Schrank et al., 2008), few valid and reliable tools exist for measuring hope in people with severe mental illnesses (Schrank et al., 2012b). Attributes of hope are complex and multidimensional; thus, the emphasis on each attribute in hope scales would differ according to the situation and the context of the target population. One reason to insist upon the development of a hope instrument specific to people with schizophrenia is that hope reflects personal experience. For example, hope in persons with terminal cancer is related to ameliorating physical symptoms such as pain at the end of life (McClement and Chochinov, 2008), while individuals with psychiatric disorders hope for an untroubled life, the restoration of family relationships, and close interpersonal relationships (Noh et al., 2008). Hope in people with schizophrenia has
more emotional and spiritual meanings, that is, meaning in life, happiness, anticipation of a better future, and the energy to live (Noh et al., 2008). The Snyder Hope Scale, Herth Hope Index, and Miller Hope Scale are the most frequently used with psychiatric patients. Although these tools are reported to have good reliability and validity, none have been validated for people with severe mental illness (Schrank et al., 2012b). Moreover, these three tools overlap considerably and focus on each attribute separately (Schrank et al., 2012b). The Snyder Hope Scale adopted a more narrow definition of hope as the mainly motivational concept of goal orientation. Consequently, it focuses on cognitive appraisals of the ability to generate the means to achieve goals, and excludes other possible emotional and spiritual aspects of hope (Schrank et al., 2012b). The Herth Hope Index (Herth, 1991) was developed to assess hope in elderly patients with cancer and their families during the last phases of the disease. It is likely that the nature of hope differs between people with cancer who face impending death and those with mental illness who continue to be concerned with daily life. The Miller Hope Scale (Miller and Powers, 1988) was based on critical elements of hope revealed in a comprehensive literature review and an exploratory study of hope in survivors of critical illness. Although the definition of hope in the Miller Hope Scale is more comprehensive than that in the Snyder and Herth instruments, this scale still focuses on hope in persons who survived a critical physical rather than mental illness. Furthermore, it is unfeasible for people with mental illness due to its high number of items (Schrank et al., 2012b). Accordingly, the use of existing scales to measure hope in people with schizophrenia may result in a misunderstanding of hope in this population because it is not certain that these scales accurately measure the properties of hope specific to individuals with mental disorders. Therefore, there is a clear need for a high-quality instrument to measure hope in people with schizophrenia. This instrument could serve as a valuable measurement of hope in the context of evidence-based empirical research in the mental health field as well as an effective clinical assessment of recovery. This study aimed to develop a valid and reliable instrument to measure hope consisting of essential meanings of hope from the perspective of people with schizophrenia. Therefore, the specific research question is as follows: what is the reliability and validity of the newly developed measurement of hope in people with schizophrenia?
2. Methods 2.1. Design A descriptive survey design was used to develop an instrument to measure hope in people with schizophrenia. This study was conducted in three phases: instrument development (phase 1), piloting scale (phase 2), and final Schizophrenia Hope Scale (phase 3).
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2.2. Participants and ethical considerations
2.5. Data analysis
Patients were recruited from three psychiatric hospitals and two community mental health centers in South Korea. Inclusion criteria were a DSM-IV diagnosis of schizophrenia, schizoaffective or schizophrenia spectrum disorders, above 18 years of age, and competency to provide written informed consent. This research was reviewed and approved by the Institutional Review Board of Kunsan National University Bioethics Committee. All participants voluntarily consented to participate. All procedures were carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki). A total of 347 individuals participated in this study; 149 (94 men, 55 women) completed a preliminary scale consisting of 40 revised items and 198 (110 men, 88 women) completed the second scale of 17 items.
Statistical analyses were performed using SPSS version 17.0 and AMOS programs. Descriptive statistics were calculated to summarize the sample characteristics and the subjects’ responses on the questionnaires. An exploratory factor analysis and a confirmatory factor analysis were performed to evaluate the construct validity of the Schizophrenia Hope Scale. The scale’s internal consistency was established using Cronbach’s alpha and Pearson’s correlation coefficients were calculated to examine the relationships among the three scales; Schizophrenia Hope Scale-9 (SHS-9); Beck Hopelessness Scale, and State-Trait Hope Inventory. For all analyses, p < .05 was considered statistically significant.
2.3. Validating instruments
3.1. Instrument development (phase 1)
Since the Beck Hopelessness Scale and the State-Trait Hope Inventory were used in studies of hope in psychiatric populations, these scales were chosen in this study.
Forty items were selected for the scale from concept clarification research (Choe et al., 2005), a qualitative study (Noh et al., 2008), and an extensive literature review on hope in people with schizophrenia. An expert panel of professionals with extensive experience (over 10 years) working with people with schizophrenia was assembled, consisting of four psychiatric head nurses and one psychiatrist. These professionals address the issue of hope with their patients, and have specifically interviewed them on the subject. The panel evaluated content validity, assigning each item a rating ranging from 0 (not appropriate) to 2 (very appropriate). The average score was above 1 (appropriate) for each of the 40 items; all items were included in the first preliminary scale. Following a pilot study of 15 patients, some wording was changed to aid readability.
2.3.1. Beck Hopelessness Scale The Beck Hopelessness Scale (Beck et al., 1974) is a 20item questionnaire that asks participants to endorse statements as true or false as applied to them in order to measure negative thinking about the future. Individual items are summed; total scores can range from 0 to 20, with higher scores indicating higher levels of hopelessness. A Korean-language version of the Beck Hopelessness Scale was used, the psychometric soundness of which was established by Shin et al. (1990). The average score for participants in this sample was 6.44 (SD = 4.28), and the internal consistency alpha coefficient was 0.82. 2.3.2. State-Trait Hope Inventory The State-Trait Hope Inventory, developed based on a comprehensive literature review (Farran et al., 1995), consists of two identical 20-item 5-point Likert scales that measure the state and trait dimensions of hope. Total scores can range from 20 to 100, with higher scores indicating higher levels of hopefulness. A Korean-language version of this inventory was used, the psychometric soundness of which was established by the authors of this study. The average score for this sample was 67.99 (SD = 11.80), and the internal consistency alpha coefficient was 0.85. 2.4. Data collection Data collection was conducted by self-reported questionnaires administered face-to-face with participants. For reliable data collection, the author met with the patients to explain the purpose and procedures of this study. In the event that a patient could not read the questionnaires due to blurred vision, the author administered the scales verbally and recorded the patient’s responses.
3. Results
3.2. Piloting the scale (phase 2) 3.2.1. Reliability and validity of the first preliminary scale (40 items) A preliminary scale consisting of the 40 revised items was administered to 149 persons with schizophrenia (94 men, 55 women). The sample size appropriate to validate an instrument under development is at least four times the expected number of total items on the final instrument (Nunnally and Bernstein, 1994). The expected total number of items of the hope instrument in this study was less than 20; thus, a sample size of 149 people was considered to be appropriate. Each item was rated on a 3point Likert scale (0: disagree; 1: agree; 2: strongly agree), yielding a final score range of 0–80. The 3-point Likert scale is a simple but discriminate assessment tool that considers the cognitive abilities of persons with schizophrenia. Correlations between items and total scale score ranged from 0.486 to 0.806. Principal factor analysis to evaluate construct validity revealed five factors with an eigenvalue above one. The factor loadings of all 40 items were above 0.4. Cronbach’s alpha for the preliminary scale was 0.97, and for the five factors as follows: Factor I (the essential
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meaning of hope), 0.96; Factor II (what hope is for), 0.93; Factor III (support systems for hope), 0.81; Factor IV (spiritual dimensions of hope), 0.84; and Factor V (not classified), 0.18. Factor I of the preliminary scale measured the fundamental meaning of hope and included 17 items. The eigenvalue of Factor I was 19.956 and accounted for 48.9% of the total item variance. 3.2.2. Reliability and validity of the second preliminary scale (17 items) The second preliminary hope scale consisted of the 17 items included in Factor I (the essential meaning of hope). This second preliminary scale was completed by 198 persons with schizophrenia (110 men, 88 women) who had not completed the first preliminary scale. Rasch analysis showed that the mean square infit and outfit statistic of all 17 items ranged between 0.5 and 1.5; thus, exploratory factor analysis could be performed for the 17 items. As a result of exploratory factor analysis, factors with eigenvalues greater than one were extracted. Maximum likelihood factor analysis with oblimin rotation resulted in a 1-factor solution. Items with factor loadings greater than 0.60 and communalities greater than 0.50 were selected, but the validity of three items (6, 14, and 15) was low; these items were deleted. For the remaining 14 items, the Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy was 0.936; a minimum KMO score of 0.50 is considered acceptable to reliably use factor analysis. To examine the correlation between the items, Bartlett’s test of sphericity (BTS) was conducted. The BTS score was 2077.880 (p < 0.001), indicating that the correlation matrix between the variables is not the unit matrix and that factor analysis is appropriate for the variables. A total of 57.1% of the variance was explained by the 1-factor solution. Cronbach’s alpha coefficient for Factor I was 0.94. All participants completed the 17-item second preliminary version of the Schizophrenia Hope Scale and two validating
instruments, the Beck Hopelessness Scale and the StateTrait Hope Inventory. 3.3. The final Schizophrenia Hope Scale (phase 3) To select the most valid and reliable items, confirmatory factor analysis was performed for the 14 items of the second preliminary scale. Goodness-of-fit was improved by deleting five items (5, 8, 13, 16, and 17), leaving nine items in the final version, the Schizophrenia Hope Scale (SHS-9). The results of exploratory factor analysis of the second preliminary hope scale and the final SHS-9 are displayed in Table 1. The Schizophrenia Hope Scale (SHS-9) is a 9-item scale in 3-point Likert format (0: disagree; 1: agree; 2: strongly agree). The range of possible scores is 0–18, with higher scores indicating higher levels of hope. The final Schizophrenia Hope Scale was administered to 198 people with a DSM-IV diagnosis of schizophrenia, schizoaffective, or schizophrenia spectrum disorders. Participants’ characteristics are presented in Table 2. Participants were 22–67 years old, with a mean age of 43.44 (SD = 8.21), and a mean duration of illness of 12.54 years (SD = 8.66). The average score for this sample was 12.06 (SD = 4.96), with an internal consistency alpha coefficient of 0.92. The alpha coefficients decreased when any of the items were deleted, indicating that the SHS-9 is a reliable instrument. The nine items of the SHS-9 are presented in Table 1. Convergent validity was evaluated by comparing the scores of the Schizophrenia Hope Scale (SHS-9) with the State-Trait Hope Inventory. Pearson’s correlations between the two instruments indicated a moderate positive correlation, r = 0.61 (p < 0.01), supporting the convergent validity of the Schizophrenia Hope Scale (Table 3). Divergent validity of the Schizophrenia Hope Scale (SHS-9) was measured by Pearson’s correlations between the Schizophrenia Hope Scale and the Beck Hopelessness
Table 1 Exploratory factor analysis of the preliminary hope scale and the final Schizophrenia Hope Scale (SHS-9). Items
Model 1 Factor loading
Q1 There is a better future ahead of me. Q2 I will be happy in the future. Q3 I am getting better every day. Q4 My future is bright. Q5 I set my goals and try to achieve them. Q6 I have a lot of time to experience life. Q7 I am excited about my life now. Q8 I have a strong will to live. Q9 I plan my future. Q10 I am confident about my life. Q11 I am confident about my future. Q12 My life is meaningful. Q13 I have a dream. Q14 I now live with passion and strength. Q15 If I overcome difficult situations, my life will be better. Q16 I overcome sadness and frustration. Q17 I feel confident about myself. Eigenvalue % Of variance Cronbach’s a h2: index of communality coefficients.
.713 .790 .736 .751 .728 .582 .826 .711 .777 .779 .795 .742 .714 .668 .634 .726 .722 9.092 53.483 .973
Model 2 h2 .508 .624 .541 .563 .530 .329 .682 .506 .603 .607 .632 .551 .509 .446 .402 .527 .521
Factor loading
Final Model h2
Factor loading
h2
.718 .804 .744 .765 .743
.516 .646 .554 .586 .552
.736 .835 .770 .775
.541 .698 .593 .600
.823 .710 .778 .778 .796 .740 .715
.677 .503 .605 .605 .634 .548 .611
.834
.695
.769 .794 .810 .744
.591 .631 .656 .553
.729 .723
.532 .532
7.883 57.095 .942
5.559 61.766 .922
K. Choe / International Journal of Nursing Studies 51 (2014) 927–933 Table 2 Sample characteristics (N = 198). n (%)
Variables Gender Male Female Age (years) Duration of illness (years) Marital status Never married Married Separated Divorced Widowed Education Never attended Elementary school Middle school High school College Graduate school Religion Protestant Catholic Buddhist Other None
110 (55.6) 88 (44.4) M (SD) 43.44 (8.21) 12.54 (8.66) 112 32 16 25 8
(58.0) (16.6) (8.3) (13.0) (4.1)
2 17 24 89 59 5
(1.0) (8.7) (12.2) (45.4) (30.1) (2.6)
106 18 24 16 32
(54.1) (9.2) (12.2) (8.1) (16.3)
M: mean; SD: standard deviation.
Scale. Results indicated a moderate negative correlation between the two scales, r = 0.548 (p < 0.01), confirming the divergent validity of the Schizophrenia Hope Scale (Table 3).
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Construct validity of the Schizophrenia Hope Scale was confirmed by principal component analysis with extraction and direct oblimin rotation. Maximum likelihood factor analysis with oblimin rotation resulted in a 1-factor solution. One factor consisting of nine items with eigenvalues > 1 was extracted; it accounted for 61.77% of the total item variance. The results of the confirmatory factor analysis for the Schizophrenia Hope Scale were acceptable. The x2 value was significant (x2 = 88.662, p < .001), and the comparative fit index, normal fit index, goodness-of-fit index, and root mean square residual were 0.941, 0.919, 0.908, and 0.021, respectively, indicating that the structure of the Schizophrenia Hope Scale accurately represents the data for hope. The standardized estimates of the items ranged from 0.49 to 0.66 (Fig. 1). 4. Discussion This study was conducted to develop an instrument to measure hope in people with schizophrenia; the Schizophrenia Hope Scale (SHS-9) was thus created. As the scale was developed based on a concept clarification, the findings of qualitative researches, and literature reviews on hope in people with schizophrenia, this tool is unique in that it includes the meaning of hope from the perspective of this population. As a result of this study, reliability and validity of the newly developed Schizophrenia Hope Scale have been established. In the first phase, the researcher developed a hope instrument consisting of 40 items. Then,
Table 3 Correlations among the instruments (N = 198). Possible range of scores
SHS-9 BHOP STHI
0–18 0–20 20–100
Range
0–18 1–19 38–100
M SD
12.06 4.96 6.44 4.28 67.99 11.80
Correlations SHS-9
BHOP
STHI
1.0 .548* .606*
1.0 .755*
1.0
SHS-9: Schizophrenia Hope Scale-9; BHOP: Beck Hopelessness Scale; STHI: State-Trait Hope Inventory; M: mean; SD: standard deviation. * p < 0.01
Fig. 1. CFA Model for the SHS-9 standardizied estimates.
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content validity was ensured through expert-review and patient feedback. In the second phase, principal factor analysis to evaluate construct validity revealed five factors with an eigenvalue above 1, and the factor loadings of all 40 items were above 0.4. Internal consistency was very high (a = 0.97). The preliminary scale composed of 40 items on five factors became 17 items on one factor. Among the five factors, only 17 items on Factor I (the essential meaning of hope) were included in the next phase because 13 items on Factor II (what hope is for) and 3 items on Factor III (support systems for hope) addressed theoretically different elements in the dynamics of hope. Factor IV (spiritual dimensions of hope) was also excluded because its items referenced faith in God, prayers to God, and so on. These items would limit its use in nonreligious individuals. The two items on Factor V (‘‘I can overcome difficulties well’’ ‘‘I want to be free’’) were also removed due to very low internal consistency (a = 0.18). As a result of exploratory factor analysis of the second preliminary scale (17 items), a 1-factor solution was confirmed and three items with low validity were removed. For the remaining 14 items, KMO and BTS scores were acceptable for factor analysis, and a total of 57.1% of the variance was explained by the 1-factor solution. Internal consistency for Factor I was very high (a = 0.94). In the last phase, through exploratory and confirmatory factor analyses, eight items were removed from the total 17 items on Factor I step by step; finally, construct validity and internal consistency of the final model of the SHS-9 (9 items) were tested. Cronbach’s alpha was 0.92 for the SHS9, indicating good reliability. One factor was extracted, and the variance explained 61.77% of the total scale. Convergent validity was demonstrated by correlating the final SHS-9 to the State-Trait Hope Inventory (r = 0.61). Divergent validity with a negative correlation of the SHS-9 to the Beck Hopelessness Scale (r = 0.55) also supported the construct validity of the SHS-9. These two scales were chosen because they had been used in previous studies of hope in psychiatric populations. The eight deleted items included ‘‘I set my goals and try to achieve them’’ (Q5) and ‘‘I have a dream’’ (Q13) were removed, showing a major difference between the Snyder Hope Scale and the Schizophrenia Hope Scale (SHS-9). The components of the Snyder Hope Scale (Snyder et al., 1991) are goal-oriented, while the components of the final SHS-9 focus more on the emotional and spiritual aspects of hope. The remaining nine items of the SHS-9 address the emotional meaning of hope (‘‘better’’ (Q1, Q3), ‘‘happy’’ (Q2), ‘‘bright’’ (Q4), ‘‘excited’’ (Q7), and ‘‘confident’’ (Q10, Q11)), and the spiritual meaning of hope (‘‘my life is meaningful’’ (Q12)). Although ‘‘I plan my future’’ (Q9) is included in the final model, this is more general than concrete strategies to achieve goals, compared to the Snyder Hope Scale. The essential meaning of hope in the remaining nine items is defined as positive expectations for the future, confidence in life and the future, and meaning in life. In the Miller Hope Scale (Miller and Powers, 1988), hope is characterized by looking forward to a good future and the expectation of a positive outcome. In the Herth Hope Index
(Herth, 1991), future orientation and positive expectancy are similar to the positive expectation component of the Schizophrenia Hope Scale. Future reference is an inevitable aspect of hope. Interestingly, renewing a sense of possibility or positive expectations for the future is one of the definitions of social recovery in people with schizophrenia (Hopper, 2007). Among the items of the SHS-9, ‘‘confidence in life and the future’’ (Q10, Q11) was revealed as an important property of hope for people with schizophrenia. However, ‘‘I feel confident about myself’’ (Q17) was not included in the final model. Hopeful participants in this study felt confident about life and their futures, but they did not feel confident in themselves. ‘‘I have a strong will to live’’ (Q8) and ‘‘I now live with passion and strength.’’ (Q14) were also excluded. Low confidence and lack of will may reflect their low self-esteem. For this reason, two items on overcoming difficulties (Q15, Q16) may be deleted. Meaning in life is a key element of hope, although only one item on meaningful life remained in the final model of the SHS-9. The Miller Hope Scale (Miller & Powers, 1988) also describes purpose and meaning in life as critical elements of hope. Hope is intimately connected with questions of meaning and values (Fitzgerald, 1979). Qualitative studies of hope in people with mental disorders have revealed that determinants of hope revolve around meaning in life (Schrank et al., 2012a). The search for meaning is a primary force in human life (Fitzgerald, 1979). Thus, people with schizophrenia who have hope live life with energy. Recapturing meaning in life is an essential element in the process of recovery from severe mental illness (Ehrlich-Ben Or et al., 2013). In summary, the essential meaning of hope in the SHS-9 consisted of positive expectations for the future, confidence in life and the future, and meaning in life. These three meanings of hope are the very core elements of the concept of hope for people with schizophrenia. Of course, these three elements of hope may not be different from those for people without mental illness; however, until now there have been few hope scales that combine these three core elements in a single instrument. Finally, there are some limitations associated with this study. The test-retest reliability of the scale was not validated; this will need to be analyzed in a future study. Further testing of this Schizophrenia Hope Scale (SHS-9) across diverse study populations would help to validate its use in other regions. 5. Conclusion The Schizophrenia Hope Scale is a new self-report instrument with adequate psychometric properties to measure hope in persons living with schizophrenia. This scale is significant for representing the subjective meaning of hope from the perspective of people with schizophrenia and for allowing simpler quantification of the construct of hope in this population. Moreover, the Schizophrenia Hope Scale facilitates further exploration of the antecedents and correlates of hope in people with schizophrenia and provides a sound basis for future research on hope in this population.
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Acknowledgements Conflict of interest: None. Funding: This research was supported by Kunsan National University. Ethical approval: This research was approved by the Institutional Review Board of the Kunsan National University Bioethics Committee. Appendix A. Schizophrenia Hope Scale (SHS-9) – English version Directions: Read the following 9 items and check [H] the response that applies to you for each item. There is no right or wrong answer. Respond to all items, but do not spend too much time thinking about your answers. You must check only one response from the three responses (Disagree, Agree, or Strongly Agree). Disagree
Agree
Strongly Agree
1. There is a better future ahead of me. 2. I will be happy in the future. 3. I am getting better every day. 4. My future is bright. 5. I am excited about my life now. 6. I plan my future. 7. I am confident about my life. 8. I am confident about my future. 9. My life is meaningful.
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