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Psychometric Properties of the Herth Hope Index in Adolescents

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Article  in  Journal of Nursing Measurement · February 2007

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Journal of Nursing Measurement, Volume 15, Number 1, 2007

Psychometric Properties of the Herth

Hope Index in Adolescents and
Young Adults With Cancer
Celeste R. Phillips-Salimi, MSN, RN, CPON
Joan E. Haase, PhD, RN
Indiana University, Indianapolis

Eileen Kae Kintner, PhD, RN

Michigan State University, East Lansing

Patrick O. Monahan, PhD

Faouzi Azzouz, MS
Indiana University, Indianapolis

The Herth Hope Index (HHIndex), originally developed for adults, was examined for
appropriateness in two studies of adolescents and young adults with cancer—those at
various stages of treatment (N = 127) and those newly diagnosed (N = 74). The internal
consistency reliability (Cronbach’s alpha) of the index was .84 and .78, respectively, in the
two samples. Construct validity was supported by discriminant correlations in the moder-
ate to low range between the HHIndex and measures of uncertainty in illness and symptom
distress, and by moderate convergent correlations with measures of resilience (self-esteem,
self-confidence, and self-transcendence) and quality of life (index of well-being). A four-
step factor analysis procedure was done, and confirmatory factor analysis suggested that a
one-factor solution best fit the data in this population. Findings indicate that the HHIndex
is a reliable measure of hope in adolescents and young adults with cancer. Evidence of
discriminant and convergent validity in measuring hope in adolescents and young adults
with cancer was also generated. Further exploration of the HHIndex factor structure in
adolescents and young adults is needed.

Keywords: adolescents; young adults; cancer; hope; instrumentation

H
ope is recognized as an important variable that affects both the experience and the
outcomes of dealing with cancer. Some researchers have postulated that hope is a
prerequisite for effective coping and decision making and has a protective function
against the physiological and psychological stress of illness (Enskar, Carlsson, Golsater, &
Hamrin, 1997; Lai et al., 2003; Molassiotis, Van Den Akker, Milligan, & Goldman, 1997).
In adolescents and young adults with cancer, hopefulness may affect their sense of well-
being and commitment to treatment (Hinds, 1988; Hinds & Martin, 1988; Hinds et al.,
1999). Hope is also a protective factor for enhancing resilience and quality of life in ado-
lescents and young adults with cancer (Haase, Heiney, Ruccione, & Stutzer, 1999).

© 2007 Springer Publishing Company 3

4 Phillips-Salimi et al.

Over the past three decades, there has been an increasing scientific interest in the
concept of hope; however, research efforts have been hampered by the lack of adequate
instruments to measure hope (Farran, Herth, & Popovich, 1995; Herth, 1991; Hinds, 1984;
Miller & Powers, 1988; Nowotny, 1989; Owen, 1989). In response to this need, several
psychometrically sound measures for measuring hope in the adult cancer population were
developed (Herth, 1991, 1992; Miller & Powers, 1988; Nowotny, 1989). One cannot
assume that scales used with adults are appropriate for children or adolescents/young
adults. Currently, the Hopefulness Scale for Adolescents (HSA) is the only scale specifi-
cally designed to measure hope in adolescents and young adults (Hinds & Gattuso, 1991).
The HSA has shown adequate reliability and validity in a number of published studies
(Cantrell & Lupinacci, 2004; Connelly, 1998; Hinds et al., 2000; Hinds et al., 1999;
Mahat & Scoloveno, 2001; Mahat, Scoloveno, & Whalen, 2002; Ritchie, 2001; Yarcheski,
Mahon, & Yarcheski, 2001; Yarcheski, Scoloveno, & Mahon, 1994). However, the HSA
has not been tested in the adult population and therefore may not be useful to measure
hope in adolescents and young adults with cancer as they transition into adult cancer
survivors.
To examine survivorship issues of children, adolescents, and young adults diagnosed
with cancer across time and to compare hope across populations of adolescents, young
adults, and adults, there is a need to examine whether measures of hope used with adults
are also psychometrically appropriate for adolescents and young adults with cancer.
The advantages of a scale that has evidence of reliability and validity with both adults
and adolescents would include the ability to (a) measure hope across developmental stages,
(b) measure changes in hope as adolescents and young adults transition into adult survivors,
and (c) compare hope scores among adolescents, young adults, and adults with cancer.
One promising scale to measure hope in adolescents and young adults is the Herth
Hope Index (HHIndex). The HHIndex was initially developed for adults and, if found
to be reliable and valid in adolescents and young adults, may help address measurement
issues in survivors of cancer. The purpose of this article is to report reliability and validity
evidence for the HHIndex in measuring hope in adolescents and young adults with cancer.
The results reported here were obtained from larger studies on resilience and quality of life
in adolescents and young adults with cancer.

BACKGROUND AND CONCEPTUAL FRAMEWORK

Hope, often viewed as elusive and abstract (Dufault & Martocchio, 1985; Farran et al., 1995),
is described in nursing literature as a multidimensional concept (Dufault & Martocchio,
1985; Haase, Britt, Coward, Leidy, & Penn, 1992; Herth, 1990a; McGee, 1984; Morse
& Doberneck, 1995; Nowotny, 1989; Owen, 1989), an energizing force (Dufault &
Martocchio, 1985; Haase et al., 1992; Nowotny, 1989; Owen, 1989), having a future
orientation toward reality-based goals and desirable outcomes (Dufault & Martocchio,
1985; Haase et al., 1992; Herth, 1990a; Hinds, 1984; Hinds & Martin, 1988; Morse &
Doberneck, 1995; Nowotny, 1989; Owen, 1989), and related to a relationship to others and
God, as well as being personally significant (Dufault & Martocchio, 1985; Hinds, 1984;
Hinds & Martin, 1988; Herth, 1990a; Morse & Doberneck, 1995; Nowotny, 1989; Owen,
1989). The concept of hope has been studied across the lifespan from early childhood
(Hinds, 1984; Snyder et al., 1997) to the oldest of the old (Dufault & Martocchio, 1985;
Herth, 1990b).
Herth Hope Index 5

Historical Perspectives of the Measures of Hope

According to Herth (1991), the first instruments to measure hope (Erickson, Post, & Paige,
1975; Gottschalk, 1974) were based on a narrow conceptualization of hope as an expecta-
tion of goal attainment (Stotland, 1969). Stotland’s unidimensional theory of hope was
broadened as researchers began to explore hope both in adults considered relatively well
and in those chronically ill. Obayuwana and colleagues (1982) identified multidimensional
aspects of hope and developed the Hope Index Scale. This instrument was later criticized
for not accurately reflecting the theoretical framework supposedly used for item selection
(Herth, 1991; Miller & Powers, 1988).
Other multidimensional measures of hope emerged in the mid- to late 1980s: the
Miller Hope Scale (Miller & Powers, 1988) and the Nowotny Hope Scale (Nowotny,
1989). However, Herth (1991) argued that these measures excluded the more global non-
time-specific focus of hope identified by Dufault and Martocchio (1985) and Hinds and
Martin (1988). Thus, an instrument was still needed that could capture both the time-
specific and the global dimensions of hope and that could be used both with adults who
were well and with adults who were ill (Herth, 1991).
Hinds pioneered the study of hope in adolescents. Using grounded theory methods, Hinds
generated a specific definition of hopefulness from well and ill adolescents. Adolescent
hopefulness was defined as “the degree to which an adolescent possesses a comforting or
life-sustaining, reality-based belief that a positive future exists for self and others” (Hinds,
1988, p. 85). Hinds and Gattuso (1991) developed the HSA. Currently, this 24-item visual
analog scale is the only scale specifically designed to measure hope in adolescents and
young adults.

Development of the HHIndex

Herth (1991) initially developed a longer hope scale, titled the Herth Hope Scale
(HHScale). The primary purpose in developing the HHScale “was to capture the multi-
dimensionality of hope, in contrast to earlier measures that had viewed hope in terms of
goal attainment” (p. 41). The HHScale was designed to measure both the time-specific
and the global dimensions of hope and to measure hope in adults with acute, chronic, or
terminal conditions in various clinical settings. The HHScale was based on Dufault and
Martocchio’s (1985) model of hope. Herth chose this particular model because “it com-
bines philosophic, theologic, sociologic, psychologic, and nursing perspectives of hope”
(p. 40). Dufault and Martocchio’s (1985) model was based on clinical data collected over
a 2-year period on 35 elderly (65 years or older) cancer patients. Dufault and Martocchio
(1985) defined hope as a “multidimensional dynamic life force characterized by a con-
fident yet uncertain expectation of achieving a future good, realistically possible and
personally significant” (p. 380). Dufault and Martocchio identified two spheres of hope:
generalized hope and particular hope. Generalized hope refers to a sense of some vague
beneficial future that extends beyond the limits of time. Therefore, generalized hope is not
linked to a particular concrete or abstract object of hope. In contrast, particularized hope
is concerned with a particularly valued outcome that is time specific.
In addition to spheres, Dufault and Martocchio (1985) identified six dimensions of
hope. Herth (1991) combined the six dimensions into three domains that guided the
item generation for the HHScale: (a) cognitive-temporal, (b) affective-behavioral, and
(c) affiliative-contextual. Herth hypothesized that at least one sphere and one dimension
of hope are always present, but the amount and focus may vary.
6 Phillips-Salimi et al.

In 1992, Herth developed a shorter version of the HHScale because one of the limi-
tations for the clinical usefulness of the scale was the number of items. According to
Jacobson (1989), “completing scales that are lengthy and contain sensitive material may
increase stress during the time of illness” (as cited in Herth, 1991, p. 48). The shorter ver-
sion was titled the Herth Hope Index. The purpose of the adaptation was “to capture the
multidimensionality of hope as represented on the HHScale, to reflect clearly the unique
dimensions of hope in the clinical populations, and to reduce the number and complex-
ity of items and so render the tool more clinically useful” (Herth, 1992, p. 1252). The
HHIndex has been used in more than 40 published research studies and 15 doctoral disser-
tations, and it has also been translated into at least three other languages: Chinese, Korean,
and Swedish (Benzein & Berg, 2003; Chen & Wang, 1997; Chen, 2003; Hsu, Lu, Tsou, &
Lin, 2003; Lee, 2001; Lin, Lai, & Ward, 2003).

Format of the HHIndex

Twelve items from the HHScale were selected to create the HHIndex. Parallel to the
HHScale, the HHIndex was developed with three subscales. Each subscale represents one
of the three combined domains of the conceptual model, defined as follows: (a) “temporal-
ity and future (cognitive-temporal dimension), defined as the perception that a positive,
desired outcome is realistically probable in the near or distant future; (b) positive readiness
and expectancy (affective-behavioral dimension), defined as a feeling of confidence with
initiation of plans to affect the desired outcome; and (c) interconnectedness (affiliative-
contextual dimension), defined as the recognition of the interdependence and interconnect-
edness between self and others and between self and spirit” (Herth, 1992, p. 1253). HHIndex
items use a Likert scaling format. Each item on the HHIndex is scored on an ordinal scale
from 1 to 4, with a score of 1 indicating “strongly disagree” and a score of 4 indicating
“strongly agree.” Total scores can range from 12 to 48, with higher scores representing
higher hope. Items are ordered so that no two consecutive items are from the same subscale
and no more than two consecutive items are keyed in the same direction (Herth, 1992).

Psychometric Evaluation of the HHIndex

Herth (1992) was initially tested the HHIndex in a convenience sample of 172 adults (70 acutely
ill, 71 chronically ill, and 31 terminally ill patients). Internal consistency was estimated by
a Cronbach’s coefficient alpha of .97 with a 2-week test–retest reliability of .91 (Herth,
1992). Concurrent criterion-related validity was supported by demonstrating moderate to
high correlations between the HHIndex and the original HHScale (r = .92), the Existential
Well-Being Scale (r = .84), and the Nowotny Hope Scale (r = .81). Divergent validity was
evidenced by finding a moderate correlation (r = –.73) between the HHIndex and an instrument
to measure hopelessness. Construct validity was supported through the factorial isolation
of the same three factors used in the HHScale: (a) temporality and future, (b) positive
readiness and expectancy, and (c) interconnectedness (Herth, 1992).

Use of the HHScale and HHIndex for Adolescents

and Young Adults With Cancer
Our decision to use the HHIndex in studies with adolescents and young adults was based
on a program of research to develop and test the Adolescent Resilience Model (ARM)
(Haase, 1987; Haase et al., 1999). The ARM was developed through a series of qualitative
Herth Hope Index 7

and quantitative studies in adolescents and young adults with chronic illnesses, especially
those with cancer. Within the ARM, hope is hypothesized to serve as an individual pro-
tective factor that enhances resilience and quality of life. The HHIndex was selected to
support the evaluation of the ARM through a systematic decision-making process of using
qualitative research findings to develop or select instruments (Haase et al., 1999). This
decision process guided ARM instrument selection so that the instruments would reflect
the qualitatively derived concepts specific to adolescents and young adults with cancer and
other chronic illnesses. Haase and colleagues used the process to select a hope measure
using the two theme clusters of hope and hope-fostering strategies found in Haase’s phe-
nomenological study (Haase, 1987). These clusters were compared for congruence with
existing theories of hope and several hope instruments. In the initial work, the subscales of
the HHScale had the best qualitative correspondence with themes in the phenomenological
study. In addition, the wording of most of the items was reflective of the phrasing used
to describe hope by adolescents and young adults. As a result of this decision process,
Haase and colleagues selected the HHScale to measure hope in adolescents and young
adults with chronic illnesses (asthma, cystic fibrosis, or cancer) in their first model evalu-
ation study. In that study, the 30-item HHScale had a Cronbach’s alpha of .91 for both
the entire sample (N = 73) and the subset with cancer (n = 39). Most items revealed an
item-to-total correlation above .40; however, five items showed an item-to-total correla-
tion less than .30 in either the entire sample or the sample with cancer. The discriminant
validity correlation between the HHScale and Mishel’s Uncertainty in Illness Scale was
.32 and .51, respectively, for the entire sample and the cancer sample. The convergent
validity correlations for the entire sample and the cancer sample were .60 and .63 with the
Reed Self-Transcendence Scale, .45 and .58 with the Nowotny Confidence subscale and
.40 and .44 with the Rosenberg Self-Esteem Scale. The shorter HHIndex, published after
this study, was used in the subsequent studies reported here (referred to in this article as
Study 1 and Study 2) in order to reduce the response burden on the adolescents and young
adults with cancer.

METHODS

Sample, Setting, and Procedures

Information on the setting and sample for each study is presented in Table 1. Study 1 data
were collected using a convenience sample (N = 127) of consecutively admitted adolescents
and young adults with cancer (excluding those with central nervous system involvement) at
any stage of treatment, ranging from newly diagnosed to several years off treatment. Subjects
were recruited at four North American cancer centers. Study 2 data were collected using a
convenience sample (N = 74) of consecutively admitted adolescents and young adults newly
diagnosed with cancer at oncology clinics and hospital units from multiple sites within the
United States. A longitudinal design was used in Study 2, with three data collection times
starting at one month from diagnosis through one year from diagnosis. Data from the initial
data collection in Study 2 were used in this analysis.
Institutional Review Board approval was obtained for the protection of human subjects
at all sites for both studies prior to recruiting subjects. Similar procedures were used to
enroll participants in both studies. Potential subjects were identified by the clinical nurse
specialist or social worker in the outpatient clinic or the inpatient unit. An explanation of
8 Phillips-Salimi et al.

TABLE 1. Demographic Data Reported in Percent (%) by Site and Study

Study 1 (N = 127) Study 2 (N = 74)
Data Collection Site % %
Arizona—Tucson 8.7 23.0
British Columbia—Vancouver 7.1 —
California—Los Angeles 59.8 13.5
Indiana—Indianapolis 0.0 14.9
Oklahoma—Oklahoma City 0.0 48.6
South Carolina—Columbia 24.4 —
Missing 0.0 —
Demographic data
Gender
Male 52.8 59.5
Female 46.4 40.5
Missing 0.8 0.0
Age at data collection
10–13 18.1 25.7
14–15 20.5 41.9
16–17 27.6 25.7
18–19 21.2 5.4
20–26 11.8 1.4
Missing 0.8 0.0
Age at diagnosis
Birth–9 37.8 —
10–13 29.9 25.7
14–15 15.8 41.9
16–17 10.2 25.7
18–21 3.9 6.8
Missing 2.4 0.0
Time since diagnosis
Newly diagnosed 5.5 100.0
1 year 11.0
2–3 years 19.7
4–6 years 22.8
7–18 years 37.8
Missing 3.2
Race or ethnic background
Asian American 4.7 5.4
African American/Black 9.5 4.1
Hispanic/Latino American 27.6 13.5
Native American 2.4 6.8
Non-Hispanic White 48.0 62.2
American 3.9 2.7
Other 3.9 5.4
Missing
Herth Hope Index 9

Table 1. continued
Study 1 (N = 127) Study 2 (N = 74)
Data Collection Site % %
Religious preference
Catholic 33.9 20.3
Jewish 3.2 2.7
Muslim 0.8 —
Protestant 36.2 28.4
Other 9.5 20.3
No preference 15.8 24.3
Missing 0.8 4.1
Religious participation
Inactive 25.2 25.7
1 to 2 times per year 15.0 21.6
More than 4 times per year 22.8 16.2
Weekly year round 33.9 32.4
Missing 3.1 4.1
Annual family income
Less than $20,000 29.9 —
$20,000 to $49,000 33.1 —
Greater than $50,000 22.0 —
Missing 15.0 —

the study was given to potential participants (and parents when the adolescent was less
than 18 years of age) by the staff member or by a study coordinator. After the staff mem-
ber or study coordinator answered questions about the study, written consent/assent was
obtained and a questionnaire instrument booklet was given to the adolescent/young adult.
An incentive for completing the booklet was a monetary stipend of $10. Adolescents and
young adults were asked to complete the booklet while they were in the hospital or clinic.
Completion of the booklet took approximately 45 to 75 minutes, and participants were
encouraged to take breaks. If a participant was unable to finish the instruments during
the clinic visit or hospital stay, the booklet was taken home and returned by mail, using
a study-provided stamped and addressed envelope. If the booklet was taken home, the
adolescent/young adult was contacted by a research staff member to answer any questions
that the adolescent/young adult had.

Instruments
Evaluation of the psychometric properties of the HHIndex was guided by the ARM. The
instruments used to examine concurrent convergent and discriminant validity included
the McCorkle Symptom Distress Scale (McCorkle, 1987), Mishel Uncertainty in Illness
Scale-Revised (Mishel, 1981, 1990, 1997), Rosenberg Self-Esteem Scale (Rosenberg, 1989),
Nowotny Confidence subscale (Nowotny, 1989), Reed Self-Transcendence Scale (Reed,
1987), and the Index of Well-Being (Campbell, Converse, & Rogers, 1976).
McCorkle Symptom Distress Scale. The McCorkle Symptom Distress Scale assesses
10 symptoms such as pain, nausea, and insomnia on 5-point Likert scales (McCorkle, 1987).
Verbal anchors describe symptom intensity, with a higher score indicating distress. This
10 Phillips-Salimi et al.

scale has been tested on cancer and noncancer patients. Adequate test–retest reliability,
internal consistency, and concurrent validity of the instrument have been previously
reported (McCorkle, 1987; McCorkle & Quint-Benoliel, 1983). The McCorkle Symptom
Distress Scale used in ARM Study 1 and Study 2 had alpha coefficients of .82 and .83,
respectively.
Mishel Uncertainty in Illness Scale-Revised. The Mishel Uncertainty in Illness Scale-
Revised contains 28 items on 5-point Likert response scales (Mishel, 1981, 1990, 1997).
The scale consists of two subscales—complexity and ambiguity—with higher scores indi-
cating a high level of uncertainty. This instrument has been used in numerous studies
of chronically and critically ill adults and in several studies with adolescents. Adequate
internal consistency and construct validity have been previously reported (Mishel, 1981;
Mishel, Hostetter, King, & Graham, 1984). Results in the studies reported here support its
reliability, with alpha coefficients of .91 for both Study 1 and Study 2. For consistency in
direction, the Mishel Uncertainty in Illness Scale-Revised was reverse coded so that higher
scores indicate less uncertainty.
Rosenberg Self-Esteem Scale. The Rosenberg Self-Esteem Scale contains 10 items on
4-point Likert response scales and measures a person’s attitude toward himself or herself
(Rosenberg, 1989). It was developed in 1965 and applied to a sample of 5,024 high
school juniors and seniors from 10 randomly selected public schools in New York. The
instrument’s reliability and construct validity have been well supported, as it has been used
in various populations (Rosenberg, 1989). Alpha coefficients in the studies reported here
were .89 (Study 1) and .91 (Study 2).
Nowotny Confidence Subscale of the Nowotny Hope Scale. The Nowotny Confidence
subscale is an eight-item self-report measure of confidence in one’s own ability that uses
a 4-point Likert response format (Nowotny, 1989). Content validity was supported by
literature review and an expert panel (Nowotny, 1989). Concurrent validity of the entire scale
was supported with the Beck Hopelessness Scale (r = –.47) (Nowotny, 1989). Alpha coef-
ficients in the studies reported here were .86 (Study 1) and .90 (Study 2).
Reed Self-Transcendence Scale. The Reed Self-Transcendence Scale has 15 items on
4-point Likert response scales, assessing activities and perspectives that individuals engage
in to expand their boundaries (Reed, 1987). Initially, it was developed and tested in the
oldest of the older populations, and it demonstrated adequate reliability and criterion and
construct validity (Reed, 1987, 1989). Internal consistency was confirmed in our studies,
with alpha coefficients of .76 (Study 1) and .80 (Study 2).
Index of Well-Being. The Index of Well-Being is a nine-item semantic differential
scale (Campbell et al., 1976). Subjects are asked to rate their present life in terms of adjec-
tive extremes such as rewarding/disappointing. Item 9 is a global indicator of well-being
(completely dissatisfied or completely satisfied). The instrument has consistently been
reported as having construct validity (Campbell et al., 1976). This scale was used only in
Study 2 and had an alpha coefficient of .93.

Analysis
Reliability of the HHIndex was estimated with Cronbach’s alpha coefficient, which is a
measure of internal consistency. As a proxy for parallel-forms reliability, Cronbach’s alpha
accounts mainly for measurement error due to content sampling error (Feldt & Brennan,
1989). Estimates of test–retest reliability were not done for either study, because (a) the
stability of hope as a concept in cancer patients is not well documented and (b) multiple
Herth Hope Index 11

assessments within a 7-day period were not available. Construct validity was assessed
by (a) item-to-total correlations after deleting the item from the total, (b) discriminant/
convergent validity coefficients estimated by correlations between the hope scales and other
scales, and (c) confirmatory and exploratory factor analysis. The Cronbach alphas and item-
to-total correlations were estimated after reverse scoring the few negatively worded items.

Demographics of Sample
Demographic data for each study group are presented in Table 1. Data sets were completed
for 201 participants. Study 1 participants (N = 127) ranged in age from 11 to 26 (M = 16.4
years, SD = 2.9), and 52.8% (n = 67) were male. Study 2 participants (N = 74) ranged in
age from 10 to 21 (M = 14.8, SD = 2.0), and 59.5% (n = 44) were male. Although most of
the participants were White, other ethnic groups were fairly well represented. Most of the
participants were either Catholic or Protestant, and approximately 20% reported no reli-
gious preference. For both studies, about 25% of study participants were inactive in their
religious participation, and about 33% were fairly active. Scores on the HHIndex did not
differ significantly by age (Table 2) or by time since diagnosis (Table 3).

RESULTS

Reliability Estimates and Item-to-Total Correlations

As can be seen in Table 4, the estimates of internal consistency for the 12-item HHIndex
were acceptable at .84 (Study 1) and .78 (Study 2) on the basis of the suggested criterion
level for a coefficient alpha of .70 or above (Nunnally, 1978). The item-to-total correla-
tions were above .40 for eight items in Study 1 and nine items in Study 2. The item “I feel
scared about my future” (reverse scored) was correlated with the HHIndex total score near

TABLE 2. Comparison of Hope Across Three Age Groups (M ± SD [n])

Mean ± SD (n) <15 15–18 >18
Study 1 39.8 ± 6.0 (37) 37.9 ± 6.3 (62) 39.5 ± 4.7 (28)
Study 2 40.0 ± 6.4 (29) 40.8 ± 3.8 (42) 40.0 ± 9.6 (3)
Note. The Kruskal-Wallis Test comparing the three age groups on mean
hope score was not significant ( p = .32 for Study 1, and p = .91 for
Study 2).

TABLE 3. Comparison of Hope Across Time-Since-Diagnosis Groups

(M ± SD [n])
Mean ± SD (n) <=1 yr 1–5 yr >5 yr
Study 1 40.8 ± 4.5 (25) 39.2 ± 5.1 (47) 37.6 ± 6.9 (55)
Study 2 40.5 ± 5.1 (74) — —
Note. The Kruskal-Wallis Test comparing the three groups (of time since
diagnosis) on mean hope score was not significant ( p = .20 for Study 1).
 12

TABLE 4. HHIndex Item Analysis by Study

Study 1 Study 2
Item-to-Total Alpha if Item Item-to-Total Alpha if Item
Scale Item M SD Correlation Deleted M SD Correlation Deleted
1. Positive outlook 3.51 .67 .68 .82 3.57 .50 .75 .74
2. Short-/long-range goals 3.42 .61 .38 .84 3.44 .65 .24 .78
3. Feel all alone 3.32 .80 .45 .84 3.49 .63 .36 .77
4. Light at end of tunnel 2.97 .90 .41 .84 3.27 .83 .38 .77
5. Faith gives comfort 3.23 .80 .57 .83 3.43 .67 .47 .76
6. Scared about future 2.69 .96 .39 .84 2.84 .81 .07 .81
7. Recall happy times 3.60 .59 .33 .84 3.57 .58 .53 .75
8. Deep inner strength 3.39 .64 .61 .82 3.47 .56 .48 .76
9. Able to give/receive 3.48 .74 .53 .83 3.49 .70 .44 .76
10. Sense of direction 3.21 .80 .68 .82 3.49 .50 .41 .76
11. Each day has potential 3.24 .68 .50 .83 3.31 .53 .60 .75
12. Life has value/worth 3.51 .65 .67 .82 3.57 .53 .65 .74
Standardized Cronbach’s alpha coefficient Study 1
Standardized Cronbach’s alpha coefficient Study 2
Phillips-Salimi et al.
Herth Hope Index 13

zero in Study 2 (r = .07) and .39 in Study 1. The only other item with an item-to-total
correlation less than .40 for both Study 1 and Study 2 was “I have short-, intermediate-,
and/or long-range goals”; however, the correlation approached .40 in Study 1 (r = .38).
Three items had an item-to-total correlation less than .40 (but above .30) in one or both of
the studies: “I feel all alone” (reverse scored), “I can see a light at the end of the tunnel,”
and “I can recall happy/joyful times.”

Discriminant /Convergent Validity

Most correlations were significant, which is not surprising (Table 5). The more important
evidence for validity is whether the correlations were of the expected magnitude and direc-
tion. Construct validity was supported by discriminant correlations ranging from moderate
to low between the HHIndex and measures of uncertainty in illness and symptom distress.
Construct validity was also supported by moderate convergent correlations of the HHIndex
with measures of resilience (self-esteem, self-confidence, and self-transcendence) and quality
of life (Index of Well-Being).

Factorial Validity
Factorial validity of the HHIndex was assessed by a four-step process: (a) confirmatory
factor analysis on the original hypothesized three subscales, (b) exploratory structural
equation modeling, (c) exploratory factor analysis, and (d) respecified confirmatory mod-
eling. Structural equation modeling was conducted with the EQS 6.1 for Windows pro-
gram (Bentler, 2003), using maximum likelihood estimation on the covariance matrix from
subjects (n = 187) with complete data on the relevant variables. This data set represented
94% of the participants in both Study 1 and Study 2. Subjects excluded from the analysis
because of missing data were similar to those included with regard to health and demo-
graphic characteristics.
Step 1. A confirmatory factor analysis model was estimated as hypothesized, with
12 items specified to measure three factors. Parameter estimates appeared in order with
no special problems encountered during optimization. The results are shown in Figure 1.
The hypothesized measurement model converged in eight iterations, with the largest stan-
dardized residuals <.30. The chi-square test indicated that the hypothesized factor analysis
model could be statistically rejected, χ2(df = 51, n = 187) = 125.65, p < .00. Thus, the mea-
surement model could be rejected as a good fit with poor fit indices (Non-Normed Fit Index
[NNFI; Bentler & Bonnett, 1980] = .85, Comparative Fit Index [CFI] and Incremental Fit
Index [IFI; Bollen, 1989] = .88). The Root Mean-Square Error of Approximation (RMSEA;
Steiger Shapiro, & Browne, 1985) was .09 with a confidence interval of .07 to .11. Although
all paths from indicators to factors and all correlations between the factors were significant
( p < .00), the standardized solution revealed five of the loadings to be less than .45 and cor-
relations between the factors greater than .99, indicating the factors were redundant.
Step 2. Using theory to guide decision making to improve the model-to-data fit, the
Wald test for dropping parameters and the Lagrange Multiplier test for adding parameters
were considered. The Wald test did not indicate any parameters to be dropped; however,
the Lagrange Multiplier test offered 27 suggestions for adding paths, including cross-
loadings. In a series of sequential runs to improve the goodness of fit between the data
and the model, hypothesized paths were systematically dropped and added. Results of
the measurement model with the best fit, with five items loading above .64 ( p < .00)
 14

TABLE 5. Intercorrelations and Level of Significance Between Mean Scores

Scale 1 2 3 4 5 6 7 8 9
1. HHIndex (12 items) — .93c –.40c –.42c –.22b .33b .57c .58c .62c
2. Adapted HHIndex (7 items) — –.36c –.36c –.20b .26a .57c .59c .58c
3. Uncertainty—complexity — .70c .22b –.38b –.41c –.38c –.42c
4. Uncertainty—ambiguity — .45c –.45c –.42c –.34c –.48c
5. Symptom distress — –.37b –.28c –.27c –.36c
6. Index of Well-Being — .49c .64c .27a
7. Nowotny Self-Confidence — .51c .53c
8. Reed Self-Transcendence — .48c
9. Rosenberg Self-Esteem —
ap < .05. b p < .01. c p < .001.
Phillips-Salimi et al.
Herth Hope Index 15

Figure 1. Confirmatory factor analysis model of HHIndex estimated as hypothesized with 12 items
specified to measure three factors.

on a single factor, are displayed in Figure 2. With parameters appearing in order and no
special problems encountered during optimization, the model converged in four iterations.
The largest standardized residuals were less than .07. The chi-square test indicated that
the hypothesized factor analysis model was approaching statistical acceptance, χ2(df = 5,
n = 187) = 12.02, p = .03, indicating that the data fit the model. In addition, the NNFI was
.96, and the CFI and IFI were .98, indicating a very good fit. The RMSEA was .09 with a
90% confidence interval between .02 and .15.
16 Phillips-Salimi et al.

Figure 2. Best fit structural equation model of the HHIndex with five items.

Step 3. Exploratory factor analysis was performed on the HHIndex (also using the
combined samples from Studies 1 and 2) using the principal component method of factor
extraction and squared multiple correlations as prior communalities (Table 6). The number
of factors suggested by the data was assessed with the scree plot. Varimax rotation was
performed to interpret factor loadings. We selected Varimax rotation because our goal was
to identify clinically meaningful factors that were relatively distinct from one another. The
first five eigenvalues (% variance in parentheses) were 3.91 (89%), 0.65 (15%), 0.29 (7%),
0.17 (4%), and 0.15 (3%). Thus, the scree plot suggested two factors, and perhaps a weak
third factor. Because Herth hypothesized three factors a priori, we ran the three-factor solu-
tion in addition to the two-factor solution reported in Table 6.
The result for the three-factor solution was not satisfying: Several items cross-loaded
on multiple factors despite the attempt by Varimax to rotate to simple structure, and three
items (2, 4, and 7) loaded less than .40 on all three factors. Interestingly, the only two
items to load convincingly on Factor 3 (.63 for item 3, and .56 for item 6) were the only
two reverse-scored items. The two-factor solution revealed a clearer assignment of items to
factors (Table 6). However, in the two-factor solution, the following problems were noted:
(a) item 4, “I can see a light at the end of the tunnel,” loaded less than .40 on both factors;
(b) items 9, 10, and 12 cross-loaded somewhat on both factors; and (c) again, the only two
items to load convincingly on Factor 2 were the only two reverse-scored items. Therefore,
Herth Hope Index 17

TABLE 6. Exploratory Factor Analysis

Item Description Factor 1 Factor 2
1 I have a positive outlook toward life. .67* .36
2 I have short-, intermediate-, and/or long-range goals. .50* –.08
3 I feel all alone. .15 .64*
4 I can see a light at the end of the tunnel. .38 .25
5 I have a faith that gives me comfort. .55* .27
6 I feel scared about my future. .06 .56*
7 I can recall happy/joyful times. .44* .08
8 I have deep inner strength. .67* .14
9 I am able to give and receive caring/love. .45* .32
10 I have a sense of direction. .52* .43*
11 I believe that each day has potential. .59* .20
12 I feel my life has value and worth. .65* .38
Note. Performed on Study 1 and Study 2 combined (n = 187). Values greater
than .40 are flagged by an *.

regarding interpretation of linear factor-analytic models, the data appeared unidimensional

from both statistical and substantive standpoints. That is, a one-factor solution made more
sense than the two- or three-factor solutions.
Step 4. Following exploratory factor analyses, a final respecified confirmatory model
was tested using Structure Equation Modeling, with seven indicators measuring a single
factor. The results are presented in Figure 3. With parameters appearing in order and no
special problems encountered during optimization, the model converged in five iterations.
The largest standardized residuals were less than .096. The chi-square test indicated that
the hypothesized factor analysis model could be statistically accepted, χ2(df = 14, n = 187)
= 19.02, p = .16, indicating that the data fit the model. In addition, the NNFI was .97, and
the CFI and IFI were .98, indicating a very good fit. The RMSEA = .04 with a 90% con-
fidence interval between .00 and .09.

DISCUSSION

We examined the psychometric properties of the HHIndex in measuring hope in adoles-

cents and young adults with cancer. This instrument has been widely tested and used in the
adult population. The results of our study indicate that the HHIndex is reliable and shows
some evidence of construct validity in adolescents and young adults. These findings are
important because the HHIndex can be used to measure hope across developmental stages
and to measure changes in hope as adolescents and young adults transition into adult
cancer survivors. Furthermore, the HHIndex can be used to compare hope scores among
adolescents, young adults, and adults.
The item-to-total correlations revealed that some of the items may need further explora-
tion. For example, the item “I feel scared about my future” had an item-to-total correlation
of .39 in Study 1; however, in Study 2 the correlation was .07. This item may have had a
lower correlation in Study 2 because the adolescents and young adults were all newly diag-
nosed, and this difference may be the result of the struggle to cope with a new diagnosis of
a life-threatening disease, the experience of hospitalization, and the reactions of parents,
18 Phillips-Salimi et al.

Figure 3. Final respecified confirmatory model with seven indicators measuring a single factor.

extended family, and friends as they were all beginning to assimilate the meaning of the
diagnosis. The literature indicates that assurances by providers, adaptation of family and
friends, and the development of effective coping strategies may serve to decrease adoles-
cents’ and young adults’ fears over time (Ritchie, 1992; Weekes & Kagan, 1994).
Evidence of discriminant and convergent validity for the HHIndex was supported by
the significant correlations in the predicted direction with the selected ARM variables.
All but one of the correlations were significant. The only nonsignificant correlation found
was between hope and symptom distress in Study 2. We hypothesized that this correlation
would be low in the negative direction, which is why we labeled it a discriminant correla-
tion coefficient. However, we expected that this and all correlations would be significantly
greater than zero. When thinking about why the Study 2 correlation may not have been
significant compared with Study 1, it may again be because all the participants in Study 2
were newly diagnosed and may not have experienced the cumulative effect of the treat-
ment-related side effects. The score used to examine symptom distress is cumulative.
Though adolescents and young adults who are newly diagnosed may have some symptom
Herth Hope Index 19

distress, items on the scale are usually associated with treatment-related side effects rather
than disease-related symptoms. Thus, it is possible that adolescents and young adults who
have been treated over time experience more symptoms and thus their scores would reflect
greater symptom distress. However, this finding contradicts the results of another study
that indicated a pattern of gradual decrease in symptom distress during the first six months
of treatment for adolescents and young adults with cancer (Hinds, Quargnenti, & Wentz,
1992). It is difficult to evaluate this contradiction because statistical evidence that sup-
ported the Hinds and associates study finding was not reported. Thus, further information
and additional studies would help clarify why these contradictory findings exist. These
findings also suggest a need for further research on the patterns of relationships between
hope and symptom distress in adolescents and young adults with cancer over time.
The factor structure of the HHIndex supports other research that has shown that there
may be developmental differences in hope in adolescents and young adults with cancer
compared with adults (Hinds et al., 1999). In this study, it is clear that the one-factor solu-
tion best fits the data on adolescents and young adults with cancer. The literature suggests
that adolescents and young adults may not differentiate the three components of hope
in the same way that adults do, as specified by Herth’s measures. For example, regarding
temporality and future orientation, research indicates that adolescents and young adults
are more likely to focus on present-oriented hopes (Hinds et al., 1999). That is, adoles-
cents and young adults with cancer may still be developing a future orientation. Further
research is needed on the developmental differences relative to the conceptualization of
hope in adolescents and young adults with cancer and the potential patterns of change in
hope across the cancer experience trajectory. The links among developmental competence,
coping, and hope found in other studies of adolescents and young adults with cancer and
other chronic illnesses (Ritchie, 2001; Sawin, Buran, Brei, & Fastenau, 2003) should be
explored further.
Regarding the use of negative items that loaded on a separate factor, there has been
some discussion in the literature that hope and hopelessness are not polar opposites (Farran
et al., 1995), so items that are reverse scored may be measuring a very different concept.
The reverse-scored items “I feel all alone” and “I am scared about my future” may not
preclude the presence of hope. Frequently, adolescents and young adults express a feeling
of being alone or different, but they may not be without hope.
On the other hand, the methodology literature suggests that when unidimensional attitu-
dinal scales contain bipolar constructs (e.g., items 3 and 6 on the HHIndex are worded in
the negative direction), secondary dimensions may arise purely because data may conform
more closely to an unfolding model (in which observed variables are quadratically related
to latent variables) than to a linear factor-analytic model (Coombs & Kao, 1960; van
Schuur & Kiers, 1994; van Schuur & Kruijtbosch, 1994). Future research needs to be done
to fit HHIndex data using a graded unfolding model to examine which model fits better.
A larger sample may also be warranted for a clearer distinction of the model.
To our knowledge, this study is the first to examine the factorial structure of the
HHIndex in adolescents and young adults with cancer. To replicate the findings of this
study, we suggest that future factor analysis be done with other adolescent and young
adult samples using all 12 items of the HHIndex. Twelve items compared to seven items
is not really a significant additional burden. In addition, further research can then be done
to determine whether the 12-item, the revised 7-item, or some other group of items from
the HHIndex is the most appropriate version of the HHindex for adolescents and young
adults with cancer.
20 Phillips-Salimi et al.

Limitations
For both Study 1 and Study 2, a convenience sample was used. Although participants were
not randomly sampled, no potential participants were systematically excluded. Participants
were typical adolescents and young adults with cancer who are seen in hospitals. Therefore,
the samples were likely to be reasonably representative of their respective populations (i.e.,
adolescents and young adults across the diagnosis, treatment, and survivor continuum
in Study 1, and adolescents and young adults newly diagnosed with cancer in Study 2).
Nevertheless, it should be emphasized that the results here generalize only to those popula-
tions. The use of the HHIndex in other populations would require reliability and validity
assessment specifically for those populations.

CONCLUSION

With the findings of this study, the brief HHIndex is an easy-to-administer instrument
with evidence of internal consistency and discriminant and convergent validity in measur-
ing hope in adolescents and young adults with cancer. However, the hypothesized factor
structure of the HHIndex does not correspond with the data obtained from adolescents and
young adults in our sample. The question remains as to whether there are developmental
differences in perspectives of hope among adolescents, young adults, and adults. Until this
question is further explored, we recommend continued use of the full index and the further
exploration of the factor structure. The advantage of using an instrument with evidence
of reliability and validity in both adolescent/young adult and adult populations would be
to examine how hope changes over time and across developmental stages. Additionally,
the HHIndex could be used to compare hope scores among adolescents, young adults, and
adults. Further psychometric testing is recommended to explore the dimensions and pat-
terns of hope in adolescents and young adults across the cancer trajectory.

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Acknowledgments. This study was funded by the NIH/NINR R29 NR03882–01A1 (PI: Joan E.
Haase, PhD, RN). Additionally, this research project was supported in part by the American Cancer
Society Doctoral Scholarship in Cancer Nursing, the National Research Service Award (NRSA) Pre
Doctoral Fellowship (NR 07066) T32 Training Grant, and a Research Incentive Fellowship spon-
sored by the IUPUI Graduate Office of Indiana University.

Correspondence regarding this article should be directed to Celeste R. Phillips-Salimi, MSN, RN,
CPON, Indiana University School of Nursing, 1111 Middle Drive, NU 338, Indianapolis, IN 46202.
E-mail: cephilli@iupui.edu
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

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