Critical Analysis of Health Professional’s Attitude Toward the Homeless Inventory (HPATHI)

We recommend first reading the Critical Analysis of the Health Professionals' Attitude Toward
the Homeless Inventory (HPATHI), which covers basic descriptive and psychometric
information, including the number of items, instrument purpose, and psychometric (i.e.
validity) data and can help determine if the HPATHI meets your needs. If you are interested in
getting more detailed information about the items in the instrument or have decided to
consider using the HPATHI, we recommend reviewing the HPATHI instrument file.

Educational Objectives:
1. To describe the purpose and basic properties of the Health Professionals' Attitude
Toward the Homeless Inventory, including number of items and scales and psychometric
properties.
2. To describe the application of the Health Professionals' Attitude Toward the Homeless
Inventory to the field of health sciences education.
3. To evaluate the strengths and weaknesses of the Health Professionals' Attitude Toward
the Homeless Inventory.
4. To provide the Health Professionals' Attitude Toward the Homeless Inventory and
supplemental materials to aid in its administration.

Resource files:
• Critical Analysis of the Health Professionals' Attitude Toward the Homeless
Inventory.pdf
• HPATHI Instrument.pdf

A. Original Citation: Buck, DS, Monteiro FM, Kneuper S, Rochon D, Clark DL, Melillo A, Volk RJ.
Design and validation of the Health Professionals' Attitude Toward the Homeless Inventory
(HPATHI)”, BMC Medical Education 2005; 5(1): 2.

B. Brief Description/Purpose: The HPATHI has 19 items and three subscales: Personal Advocacy
– reflects a personal commitment to work with the homeless, Social Advocacy – reflects
society’s responsibility to care for the homeless population, and Cynicism – reflects a negative
attitude and sense of futility in working with the homeless. The response options are
presented along a 5-point Likert scale ranging from 1 - Strongly Disagree to 5 - Strongly Agree
for each item. Higher scores indicate more positive attitudes towards the homeless population.

C. Development and Psychometrics:

Background
The Health Professionals’ Attitude Toward the Homeless Inventory (HPATHI) was developed to
assess medical students’ and physicians’ attitudes toward the homeless and to measure their
level of interest and confidence in their ability to deliver healthcare services to the homeless
population. The HPATHI was developed in response to a survey measure previously developed

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in the United Kingdom, Attitudes Toward the Homeless Questionnaire (ATHQ)1 and the
Attitudes Toward Homelessness Inventory (ATHI)2. The HPATHI was developed in three phases.

Phase I: Instrument Development

In Phase 1, a Delphi study with 16 physicians and nurse practitioners, all experts in healthcare,
rank ordered a list of 24 statements, with the ability to generate additional statements. Three
iterations of rank ordering yielded a 35 item questionnaire, which constituted the first draft of
the HPATHI.

Phase 2: Pilot Administration

In Phase 2, the HPATHI was administered to 76 third-year medical students with a second
administration two weeks later to 34 of the original 76 students. For this administration, alpha
was 0.87 and test-retest reliability coefficient was 0.69. An item analysis concluded 12 of the
35 items were either repetitious or had item-scale correlations less than 0.20. Based on this
information, the questionnaire was reduced to 23 items.

Phase 3: Target Population Administration

In Phase 3, the 23 item questionnaire was administered to 160 healthcare professionals,
including primary care physicians, primary care residents, and preclinical and clinical medical
students. An exploratory factor analysis yielded three factors, which explained 39% of the
variance of the data. Four of the 23 items were either not represented in the three-factor
structure or had an adverse effect on the subscale’s reliability, thus reducing the scale to 19
items. The authors suggest the three subscales reflect the general attitudes of healthcare
providers who work with the homeless population. These include 1) a personal commitment to
work with the homeless (personal advocacy, 9 items), 2) society’s responsibility to care for the
homeless (social advocacy, 6 items), and 3) a negative attitude and sense of futility in working
with the homeless (cynicism, 4 items).

Psychometrics
Construct Validity
Construct validity was demonstrated through extreme group comparisons (by medical training
and experience with the homeless), item analyses, and a factor analysis. No significant
difference was found between preclinical medical students and healthcare professionals;
however, individuals with more than one year experience working with the homeless scored
significantly higher than those with less than one month experience. For the three subscales,
alpha ranged from .72 for social advocacy and cynicism to .75 for personal advocacy. The 19-
item version of the HPATHI achieved a Cronbach’s alpha of 0.84 and a test-retest reliability
coefficient of 0.69.

Content Validity
Content validity of the instrument was established using the Delphi method and a review of
findings from the current literature. Instrument items were initially selected and adapted from
the ATHI1 and the ATHQ,2 in addition to items developed by the instrument’s authors. Three
iterations for soliciting feedback and refining the instrument were used.
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Concurrent Validity
To establish concurrent validity, the HPATHI was correlated with a similar instrument, the
Attitudes Toward the Homeless Inventory (ATHI).2 Pearson’s correlation coefficient between
the two instruments was 0.68.

D. Additional Studies Reporting Validity Evidence: Only two studies were found reporting HPATHI use
to measure attitudinal change toward homeless persons in medical students and physicians.3-4 Both
studies used the 23-item HPATHI, rather than the 19-item version. In the first study3, participants were
second-year Family Medicine residents who completed the HPATHI and the ATHI2 before and after a
Homeless Care Clinic experience. Only 2 of the 23 items on the HPATHI demonstrated a significant
change in attitudes.

Participants in the second study4 were third year medical students rotating on the Psychiatry clerkship,
fourth year medical students rotating on the Emergency Medicine clerkship, and Psychiatry and
Emergency Medicine residents and physicians. Among the medical students, statistically significant t-
test differences were noted after participation on the Psychiatry Clerkship, but not the Emergency
Medicine Clerkship. An analysis of variance (ANOVA) determined there were statistically significant
differences between the two specialties on 7 of the 23 items.

It is interesting to note the two HPATHI items that were significant in first study3 were not significant in
the second study4. Furthermore, one of the two items with significant findings in the first study was
deleted from the final 19-item scale because it was not represented in the three-factor structure.

E. Application to Health Sciences Education and Health Sciences Education Research:

To date, the HPATHI has only been used with medical students, residents, and physicians;
however, it is feasible the instrument could be appropriate for use in other health science
related disciplines, particularly nursing since nurse practitioners were involved in the Delphi
process.

F. Commentary:
The construct the HPATHI is purporting to measure, attitudes toward caring for the homeless, is
an important construct for medical educators to know and understand. This construct is similar
to healthcare professionals’ attitudes toward caring for the underserved, which has been
written about considerably.5-7 The homeless and the underserved populations include people
who are sick, and according to Wear & Kuczewski,8 need physicians without negative attitudes
toward patients based on social or economic status. The HPATHI is a potential tool for
exploring attitudes that may be a reflection of physician training and education.

The psychometric properties of the HPATHI were critiqued using a set of guidelines published in
the healthcare literature for testing validity and reliability.9 Medical educators interested in
using the instrument should consider the following:

• Content validity was established through the use of experts, current findings from the
literature, and comprised three rounds of eliciting and refining opinions.
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 • The HPATHI demonstrated strong internal consistency (Cronbach alpha coefficient >
.80). This high degree of internal consistency suggests the measure may be best thought
of as a global measure of attitudes of healthcare professionals toward the homeless,
rather than one possessing three subscales for separate dimensions.
• The two week test-retest coefficient was borderline acceptable (.69) indicating 31% of
the variability in participant’s scores on the measure were due to random error or some
other effect. A value of .70 or greater for instruments used in research is preferable.
• Subsequent studies of the HPATHI do not provide strong evidence of the instrument’s
validity. Both studies3-4 reported no change in attitude as measured by the total overall
score of the HPATHI, but rather examined the instrument’s items independently, which
is not good evidence for validity. Neither study reported any additional information
regarding the three subscales.
• There is no evidence to support the consequential validity of the instrument, i.e., no
evidence to suggest there are consequences to the healthcare professional’s attitudes
the HPATHI is said to measure.
• Medical educators who use this instrument might want to consider how the profession
and society can benefit from its use. The use of a test is said to have consequential
validity to the extent that society benefits from that use of the test.
• The HPATHI title suggests the instrument is appropriate for a wide-range of healthcare
providers; however, the studies to date have only included medical students, residents,
and physicians. While nurse practitioners (unknown how many) were involved in the
Delphi process, additional studies are needed in other healthcare fields.
• More validation research is needed on the 19-item version of the instrument. The
studies described in this critical analysis were on the 23-item version. No studies were
found using the 19-item HPATHI.
• It is recommended that healthcare educators interested in using the HPATHI consider
administering a pre/post survey and add a control group to the study. Those in another
discipline may want to conduct a literature review to assure that items within the
HPATHI are equally relevant and acceptable in the target population. They may also
want to determine whether items group together similarly to the items in the original
study. Factor congruence across different disciplines is an indicator there is similar
interpretation of the items.

G. Additional Citations:
1. Buck, DS, King, BT. Medical student self-efficacy and attitudes toward homeless
patients. Virtual Mentor. 2009;11(1):32-37.
2. Kingree JB, Daves WF. Preliminary validation of the attitudes toward homelessness
inventory. J Community Psychol. 1997;25(3):265-88.
3. Woodhead EL, Sperry JA, Bower EH, Fitzpatrick KM. Attitude change following a
homeless clinic experience. Fam Med. 2009;41(2):83-4.
4. Morrison A, Roman B, Borges N. Psychiatry and Emergency Medicine: Medical student
and physician attitudes toward homeless persons. Acad Psychiatry. 2012;36(3):211-15.

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 5. Crandall SJ, Volk RJ, Cacy D. A longitudinal investigation of medical student attitudes
toward the medically indigent. Teach Learn Med. 1997;9:254-260.
6. Wayne S, Timm C, Serna L, Solan B, Kalishman S. Medical students’ attitudes toward
underserved populations: Changing associations with choice of primary care versus non-
primary care residency. Journal of Health Care for the Poor and Underserved.
2010;21:438-447.
7. Crandall SJ, Reboussin BA, Michielutte R, Anthony JE, Naughton MJ. Medical students’
attitudes toward underserved patients: A longitudinal comparison of problem-based
and traditional medical curricula. Adv Health Sci Educ Theory Pract. 2007;12:71-86.
8. Wear D, Kuczewski MG. Medical students’ perceptions of the poor: What impact can
medical education have? Academic Medicine. 2008;83(7):639-645.
9. DeVon HA, Block ME, Moyle-Wright P, Ernst DM, Hayden SJ, Lazzara DJ, Savoy SM,
Kostas-Polston E. A psychometric toolbox for testing validity and reliability. Journal of
Nursing Scholarship. 2007;39(2):155-164.

H. Author’s Information:
Sheila M. Crow, PhD
Assistant Dean for Curriculum & Faculty Affairs
Associate Professor of Pediatrics
University of Oklahoma School of Community Medicine
4502 East 41st Street, Suite 2B38
Tulsa, OK 74135
Office phone: (918) 660-3095
Email: Sheila-crow@ouhsc.edu.