Qual Life Res (2008) 17:771–781

DOI 10.1007/s11136-008-9348-z

Comparing unidimensional and multidimensional models

of benefit finding in breast and prostate cancer
Kathryn E. Weaver Æ Marı́a M. Llabre Æ
Suzanne C. Lechner Æ Frank Penedo Æ
Michael H. Antoni

Accepted: 9 April 2008 / Published online: 24 May 2008

US Government 2008

Abstract examine if BFS domains are differentially related to

Purpose Psychosocial research with cancer patients has quality-of-life outcomes in both cancer and other medical
increasingly recognized that a large proportion report at patients.
least some positive changes or aspects of personal growth
that occur because of their illness—a construct referred to Keywords Psychological adjustment
Cancer

as benefit finding. Although theory suggests that there may Measurement
be several domains to benefit finding, measurement
instruments such as the Benefit Finding Scale (BFS) are Abbreviations
typically considered to be unidimensional. BF Benefit finding
Method This study compared single and multiple factor SRGS Stress-Related Growth Scale
models of the BFS using group confirmatory factor analysis in PTGI Posttraumatic Growth Inventory
men with prostate cancer (n = 185) and women with breast BFS Benefit Finding Scale
cancer (n = 115) who were less than 2 years postdiagnosis. SES Socioeconomic status
Results In both samples, the multiple-factor model fit the CFA Confirmatory factor analysis
data significantly better than the single-factor model, and CFI Comparative Fit Index
factor loadings were equivalent between groups. Men with RMSEA Root Mean Square Error of Approximation
prostate cancer reported greater Personal Growth benefit SRMR Standardized Root Mean Squared Residual
finding and women with breast cancer reported greater AA/BC African American/Black Caribbean
Social Relationships benefit finding. Differential relation-
ships were observed between BFS factors and
sociodemographic and disease-related variables. Introduction
Conclusion Results suggest an alternate multidimen-
sional framework for the BFS that may be generalizable Despite the many stressors and negative psychological
across cancer populations. Future research should sequela associated with cancer (see for example, [1–3]),
there is increasing recognition that some individuals view
aspects of their illness as positive or beneficial. Terms used
to describe the identification of benefits following trau-
matic experiences include benefit finding (BF), stress-
K. E. Weaver
M. M. Llabre (&)
S. C. Lechner
F. Penedo

related growth, found/discovered meaning, and posttrau-
M. H. Antoni
Department of Psychology, University of Miami, matic growth [4–8]. Cancer-related BF appears to be a
P.O. Box 24-8185, Coral Gables, FL 33134, USA relatively common phenomenon, with 50–80% of study
e-mail: mllabre@miami.edu participants identifying at least one positive life change
associated with breast [9] or lung cancer [10].
S. C. Lechner
F. Penedo
M. H. Antoni
University of Miami School of Medicine, Coral Gables, FL, BF theory suggests that positive life changes may occur
USA in several different domains. Tedeschi and Calhoun [4]

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772
propose that traumatic events must be sufficiently disrup-
tive to evoke the cognitive activities that lead to growth.
There is variability in both the domains and intensity of
negative changes reported by cancer survivors [11], sug-
gesting that BF may be most likely to occur in life domains
in which the person has experienced disruption. In their
conceptual model for understanding life crises and transi-
tions, Moos and Schaefer [12] further identify five groups
of tasks that are typically encountered during a life crisis or
transition and propose that the importance of the different
tasks varies depending on characteristics of the person and
the crisis. The extent to which one engages in each of the
tasks may influence outcomes in related areas. For exam-
ple, the success with which a person sustains relationships
with others or preserves a sense of competence and mastery
may influence perceptions of BF in related areas, i.e., social
relationships and personal strengths.
Tedeschi and Calhoun [13] identified five distinct cate-
gories of posttraumatic growth (i.e., relating to others, new
possibilities, personal strength, spiritual change, and
appreciation of life), and Park and colleagues [5] hypothe-
sized that stress-related growth encompassed three domains
(enhanced social resources, enhanced personal resources,
and new or improved coping skills). However, factor ana-
lytic studies have not always been consistent, suggesting
both unidimensional and multidimensional models of BF,
even for the same scale (see for example, [5], [14]). Com-
monly used BF measures, such as the Stress-Related
Growth Scale (SRGS) [5] and the Posttraumatic Growth
Inventory (PTGI) [13], have been used to assess BF in
medical patients; however, there are several drawbacks to
this practice. As both of these scales were validated in
samples of college students experiencing age-appropriate
stressors and traumas, they may fail to assess domains of BF
specific to medically ill populations. For instance, neither
the SRGS nor the PTGI assesses the adoption of positive
health behaviors, one of the most prevalent forms of posi-
tive change among medical patients [15, 16].
In contrast, the Benefit Finding Scale (BFS) was
developed for and validated in samples of medical patients,
specifically women with breast cancer. This measure was
adapted from Behr’s Positive Contributions Scale used
with parents of disabled children [17], and additional items
were written with the content directed toward the experi-
ence of individuals with cancer. A 17-item version of the
scale was initially developed in women with breast cancer
[18, 19], and a 22 item version with some unique items has
also been examined [20]. The 29-item version being used
by this research team assesses six BF dimensions: Accep-
tance, Family Relations, Personal Growth, World View,
Social Relations, and Health Behaviors. The Personal
Growth factor focuses on identification of new strengths or
positive qualities (i.e., patience, responsibility, strength,
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Qual Life Res (2008) 17:771–781
enhanced coping skills) and is similar to the content of the
Personal Strength factor of the PTGI and the ‘‘enhanced
personal resources’’ and ‘‘enhanced or improved coping
skills’’ domains identified by Park and colleagues [5]. The
Acceptance factor centers on the intentional acceptance of
things that cannot be changed, and the World View factor
focuses on changes in spirituality and perceptions of the
purpose of others in the world. The Health Behaviors factor
is new to the 29-item version and is not covered by other
commonly used scales. The BFS also distinguishes
between BF with respect to family relationships and more
general social relationships. This may be especially
important in cancer patients, as intimate relationships
might be strained by caregiving responsibilities or changes
in sexual functioning due to treatment side effects, result-
ing in more or less BF. Changed perceptions of family
relationships may or may not track with more generalized
perceptions of social support and closeness.
Although researchers have identified broad categories of
BF and designed questionnaires to assess several dimen-
sions (for review see [21]), in practice, BF is often treated
as a unidimensional construct. Even the PTGI, which has
five designated subscales, is often reduced to a single total
score. Some psychometric data support the single dimen-
sion approach to BF, as Cronbach’s alpha reliabilities for
the scales are often high and exploratory factor analyses
(EFA) have found that all items load strongly on a single
general factor [5, 9, 13, 18–20]. However, other EFA
analyses suggest multiple factor solutions for BF scales
used with medical and caregiving samples [22–24].
In their conceptual model, Moos and Schaefer [12]
identify personal and demographic characteristics as one of
three sets of factors affecting the resolution of a crisis.
However, the results of studies linking demographic pre-
dictors such as gender, age, socioeconomic status (SES),
education, and ethnicity with BF in cancer patients vary by
cancer type and method of assessing BF. Although results
from validation samples comprised of college students
suggest that women report greater BF than do men [5, 13],
these findings are typically not replicated in samples of
cancer patients [6, 25]. One exception was a study of mixed
cancer patients that found that women reported greater BF
for four of five domains [26]. Some research suggests that
younger cancer survivors report greater benefits than do
older survivors [6, 26, 27], with one breast-cancer study
reporting stronger associations for BF domains assessing
relationships and appreciation for life [28]. Other studies
have found no relationship between age and BF in indi-
viduals with breast cancer [9, 20, 29, 30].
Studies of cancer patients also produce conflicting
results regarding the impact of ethnicity and SES on BF. A
few studies suggest that ethnic minority and low SES
women perceive more benefits than white, non-Hispanic
Qual Life Res (2008) 17:771–781
women [18, 20]. Others find no differences between ethnic
groups [9] or no relationship between income or education
and BF [6, 25]. SES may be related to some measures or
dimensions of BF but not others [9, 28].
Due to measurement limitations in existing research,
few decisive conclusions can be drawn from the research
linking sociodemographic and disease-related predictors
with BF. Conflicting findings may be due to differences in
the method (interview vs. questionnaire), domains of BF
assessment, and the population studied. If BF domains are
differentially related to predictors, study results may be
obscured when total scores, which combine or average BF
across domains, are used. Finally, studies of mixed cancer
types may combine men and women in the same samples,
potentially obscuring results if BF factors are expressed
differently by gender or disease type.
The purpose of this study was to refine the BFS
instrument and address some basic questions regarding BF
measurement with this scale: (1) Is the BFS best concep-
tualized as a unidimensional or multidimensional
instrument? (2) Can the factor structure of the BFS be
generalized across men and women with different types of
cancer? (3) Are demographic and disease-related variables
(e.g., age, marital status, ethnicity, and type of cancer
treatment) differentially related to BFS dimensions? We
examined measurement models of the BFS in women with
breast cancer and men with localized prostate cancer using
confirmatory factor analysis (CFA). We hypothesized that
multiple-factor models would provide a better fit for the
data in all samples and used multiple group CFA to
establish factorial invariance across the samples. Whereas
the means of the latent factors were expected to differ
between groups, factor loadings were not. Hybrid models,
including demographic (i.e., age, ethnicity, SES, and
marital status) and disease-related variables (i.e., type of
treatment), allowed us to determine if correlates differed by
BFS domain.
Method
Participants
Data for the study came from two larger psychosocial
intervention studies [31, 32]. We recruited participants
from Miami-Dade and Broward counties (Florida) through
direct recruitment and referrals from physicians, hospital
clinics, service agencies, tumor registries, community
health centers, conferences, and community events;
advertisements in the local press; and previous participant
referral. Participants were required to be free of cognitive
impairment and major psychopathology or substance
dependence. As immune variables were outcomes of
773
interest in the parent studies, we excluded participants with
a history of chronic illness associated with permanent
changes in the immune system or those who were pre-
scribed medications with immunomodulatory effects.
Complete recruitment and participation information has
been reported elsewhere [31, 32].
Breast cancer sample
Eligible participants included women between the ages of
18 and 70 with a primary breast cancer diagnosis within the
previous 24 months who were at least 3 months postadju-
vant treatment (excluding tamoxifen and aromatase
inhibitors). We excluded participants with metastatic breast
cancer (stage IV) or a previous diagnosis of cancer.
Prostate cancer sample
Men aged 45 years or older who had undergone radical
prostatectomy or radiation therapy for stage I or II prostate
cancer in the past 18 months were eligible. We excluded
men reporting a previous diagnosis of nonskin cancer or
current adjuvant treatment for prostate cancer.
Procedure
All participants provided informed consent prior to partic-
ipation in the study, and the university Institutional Review
Board approved all study procedures. Qualified participants
completed psychosocial instruments via interview and self-
report formats and a medical evaluation. Participants
received monetary compensation for their involvement. At
the completion of the baseline appointment, participants
were randomized to either a 10-week cognitive–behavioral
stress management intervention or a 1-day stress manage-
ment condition. The study used data from a subset of
patients who had completed the baseline assessment at the
time of analyses before recruitment was completed.
Measures
Benefit finding
We used the 29-item version of the BFS to measure per-
ception of growth from the experience of cancer. The
measure assesses six domains of BF—Acceptance, Family
Relations, Personal Growth, World View, Social Relations,
and Health Behaviors—using a 5-point Likert-type scale
(1 = not at all to 5 = extremely). Alpha reliability was
high (0.91–0.96) in samples of women with breast cancer
and men with prostate cancer for full and reduced versions
of the measure, and previous researchers treated the mea-
sure as unidimensional [18–20, 31, 33].
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774 Qual Life Res (2008) 17:771–781

Disease-related and sociodemographic variables Preliminary data screening

Surgical (radical prostatectomy vs. radiation treatment for
the prostate cancer sample; mastectomy vs. lumpectomy
for the breast cancer sample) and adjuvant treatment
(chemotherapy, radiation, and hormonal therapy) were
investigated as possible correlates. Age, education, income,
marital status, and ethnicity were assessed via self-report.
Results
Descriptive data
Sociodemographic and disease-related sample characteris-
tics are shown in Table 1. Of the men with prostate cancer,
48.9% had a radical prostatectomy and 51.1% had radiation
treatment. The majority of the women were diagnosed with
stage I (40.8%) or stage II (43.7%) breast cancer, with
40.5% receiving mastectomy and 59.5% receiving lump-
ectomy. Of the women with breast cancer, 69.6% received
chemotherapy and 76.8% radiation treatment.
Six participants did not complete the BFS questionnaire
during the initial assessment, and 15 participants were
missing items 26–29 due to the addition of these items after
assessments had begun. Prior to modeling, we examined
descriptive statistics including the mean, standard devia-
tion, skewness, and kurtosis for each BFS item in both
samples (see Table 2). No items violated assumptions of
univariate normality (skewness [ 2 or kurtosis [ 4).
Confirmatory factor analysis of the BFS
Analytic approach
We tested multiple factor models of the BFS in both
samples separately, made modifications to optimize fit, and
then compared multiple- and single-factor models using the
chi-square difference test. A significant change in chi-
square would indicate that the multiple-factor model is a
superior fit for the data compared with the single-factor
model. Group CFA analyses directly compared the breast

Table 1 Sociodemographic
Prostate CA Breast CA Test of association
and disease-related
(n = 186) (n = 115)
characteristics of the samples
Age [years (SD)] 65.05 (7.78) 49.71 (7.84) F = 271.93, P \ .001
Time since diagnosis 15.81 (7.68) 15.75 (5.07) F = 0.00, P [ .05
[months (SD)]
Income (%) v2 (4) = 11.99, P \ .05
\$20,000 18.3 5.3
$21,000–40,000 25.3 37.9
$41,000–60,000 19.3 16.8
$61,000–80,000 8.1 6.3
[$80,000 29.0 33.7
Ethnicity (%) v2 (2) = 10.25, P \ .05a
Non-Hispanic White 58.1 64.6
Hispanic 18.3 23.6
African American/Black 23.1 8.2
Caribbean
Other (American Indian, Asian, 0.5 3.6
or Multiethnic)
Education (%) v2 (3) = 4.52, P [ .05
\Grade 12 9.7 4.6
HS graduate or GED 20.4 15.4
Some college 25.3 31.8
SD standard deviation, HS high C4 Year college degree 44.6 48.2
school, GED General
Marital status (%) v2 (3) = 6.92, P [ .05
Educational Development
a Married or equivalent 75.8 64.6
This chi-square value reflects
the comparison for the first three Widowed 3.2 1.8
ethnic groups only due to the Divorced or separated 15.6 21.8
very small numbers in the other Never married 5.4 11.8
category

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Qual Life Res (2008) 17:771–781 775

Table 2 BFS item means (Having cancer…)

Item Mean (SD) Mean (SD) Skewness Kurtosis
Prostate Breast CA
CA

(1) Has led me to be more accepting of things 3.12 (1.23) 3.51 (1.11) -.34 -.95
(2) Has taught me to adjust to things I cannot change 3.46 (1.17) 3.53 (1.11) -.61 -.44
(3) Has helped me take things as they come 3.56 (1.09) 3.57 (1.08) -.72 -.15
(4) Has brought my family closer together 3.24 (1.33) 3.10 (1.23) -.26 -1.04
(5) Has made me more sensitive to family issues 3.26 (1.35) 3.45 (1.08) -.49 -.78
(6) Has made me more grateful for each day 3.71 (1.26) 4.35 (.97) -1.06 .16
(7) Has taught me that everyone has a purpose in life 3.25 (1.40) 3.32 (1.46) -.38 -1.20
(8) Has shown me that all people need to be loved 3.35 (1.41) 3.60 (1.45) -.54 -1.04
(9) Has confirmed my faith in God 3.24 (1.58) 3.62 (1.50) -.46 -1.32
(10) Has made me realize the importance of planning for my family’s future 3.61 (1.35) 3.57 (1.30) -.70 -.65
(11) Has made me more aware and concerned for the future of all human beings 3.21 (1.35) 3.21 (1.31) -.25 -1.07
(12) Has taught me to control my temper 2.52 (1.37) 2.47 (1.32) .39 -1.12
(13) Has taught me to be patient 2.82 (1.35) 2.93 (1.31) .02 -1.26
(14) Has made me a more responsible person 2.89 (1.40) 2.45 (1.33) .17 -1.30
(15) Has given my life better organization 2.75 (1.41) 2.26 (1.31) .30 -1.25
(16) Has made me more productive 2.39 (1.39) 2.15 (1.27) .54 -1.05
(17) Has led me to deal better with stress and problems 2.91 (1.35) 2.71 (1.31) .13 -1.22
(18) Has helped me to budget time better 2.64 (1.37) 2.32 (1.28) .36 -1.20
(19) Has led me to have more friends 2.05 (1.24) 2.07 (1.17) .89 -.32
(20) Has led me to meet people who have become some of my best friends 1.94 (1.24) 1.97 (1.25) 1.08 -.07
(21) Has renewed my interest in participating in different activities 2.33 (1.28) 2.43 (1.30) .47 -1.02
(22) Has contributed to my overall emotional and spiritual growth 2.88 (1.45) 3.36 (1.30) -.07 -1.33
(23) Has helped me become aware of the love & support available from other people 3.42 (1.21) 3.78 (1.17) -.50 -.75
(24) Has helped me realize who my real friends are 3.06 (1.41) 3.74 (1.34) -.44 -1.15
(25) Has helped me become more focused on priorities, with a deeper sense of purpose in life 3.30 (1.27) 3.75 (1.25) -.55 -.74
(26) Has helped me become a stronger person, more able to cope effectively with future life 3.32 (1.25) 3.66 (1.20) -.54 -.62
challenges.
(27) Has led me to eat a healthier diet 2.93 (1.45) 3.07 (1.25) -.10 -1.26
(28) Has led me to exercise more regularly 2.68 (1.37) 2.64 (1.25) .18 -1.20
(29) Has led me to live a healthier lifestyle 3.06 (1.30) 3.16 (1.18) -.20 -.99
SD standard deviation

and prostate cancer groups. By specifying parameters to be
equal between groups, we examined measurement invari-
ance and equivalence of factor means. Formal testing of
measurement invariance typically involves examining
factor loadings and item intercepts. However, invariance of
all these parameters is not a precondition for comparison of
latent factor means under conditions of partial measure-
ment invariance [34]. The approach of initially fitting the
model separately in the individual groups is recommended
by Thompson and Green [35], as fitting the model initially
in the combined sample might mask structural differences
between the groups.
We used Mplus statistical software (version 3.01) for all
analyses and the chi-square goodness-of-fit statistic,
Comparative Fit Index (CFI), the Root Mean Square Error
of Approximation (RMSEA), and the Standardized Root
Mean Squared Residual (SRMR) to evaluate the statistical
fit of the model to the data. Generally, a nonsignificant chi-
square, CFI greater than 0.95, a RMSEA less than 0.06, and
a SRMR less than 0.09 are considered to indicate good
fit [36]. We used full information maximum likelihood
(FIML) to estimate all models. This approach allowed us to
utilize all available data and provided unbiased parameter
estimates when missingness could be predicted from other
variables in the model.
Multiple-factor models
We grouped items using content analysis guided by theory
and previously identified BF dimensions. Six factors were
identified: Acceptance, Family Relations, Personal Growth,
World View, Social Relations, and Health Behaviors. We

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776 Qual Life Res (2008) 17:771–781

removed one item a priori whose content was excessively Table 3 Comparisons of goodness-of-fit indicators of nested single-
general (item 2: has contributed to my overall emotional factor and multiple-factor models of the benefit-finding scale
and spiritual growth). After examining this initial model, Model df v2 CFI RMSEA SRMR
we identified six items for which modification indices
Prostate cancer
suggested multiple factor loadings (items 6, 10, 19, 21, 25,
26). We examined models allowing these items to load on Single factor 207 1019.70* .76 .15 .08
more than one factor, confirmed that they did in fact have 6 Factor 192 333.23* .96 .06 .04
two or more factor loadings greater than 0.4, and subse- D v2 15 686.48*
quently removed them from the model. Following the Breast cancer
addition of two correlated errors that were suggested by the Single factor 206 570.44* .70 .13 .10
modification indices and were between items with very 6 Factor 191 263.79* .94 .06 .06
similar content (taught me to be patient/taught me to D v2 15 306.65*
control my temper & made me more responsible/given my A significant change in chi-square indicates worse model fit in the
life better organization), the multiple-factor model fit the single-factor models
prostate cancer data reasonably well [v2(192) = 333.226, CFI Confirmatory Fit Index, RMSEA Root Mean Square Error of
P B 0.0001; CFI = 0.96; RMSEA = 0.06; SRMR = Approximation, SRMR Standardized Root Mean Squared Residual.
* P \ 0.001
0.04]. Although the chi-square was significant, other fit
indices had acceptable values. With minor modifications
(see Fig. 1), the six factor model also fit the breast cancer significantly better than did the single factor-model in both
data reasonably well [v2(191) = 263.789, P \ 0.0001; samples (see Table 3).
CFI = 0.94; RMSEA = 0.06; SRMR = 0.06]. Many of
the correlated errors in both samples were between items Group analyses
that were adjacent on the scale, and the addition of these
parameters did not substantially change the factor loadings. Group CFA models assessed whether BF could be measured
the same way in women with breast cancer and men with
Comparing multiple-factor and single-factor models prostate cancer. A model specifying invariance of factor
loadings and item intercepts, but allowing the error vari-
A single-factor model of BF that specified all items to load ances and factor means, variances, and intercorrelations to
on a single general factor of BF was a poor fit in both vary, fit the data relatively well [v2(416) = 705.303,
sample (CFIs \0.77 and RMSEAs [0.11). A direct com- P \ 0.0001; CFI = 0.94; RMSEA = 0.069; SRMR =
parison between models was done by specifying factor 0.065]. Improvement in fit was achieved with the addition
intercorrelations to be one, implying a single-factor model. of three group-specific correlated errors [v2(413) =
This approach allowed us to directly test the difference in 660.035, P \ 0.0001; CFI = 0.95; RMSEA = 0.064;
model fit between multiple- and single-factor models using SRMR = 0.064]. These were the same correlated errors of
the chi-square difference test for nested models. As small magnitude that were necessary to fit the data in the
hypothesized, the multiple-factor model fit the data cancer samples separately. Unstandardized parameter

Family Personal Health

Acceptance Relations Growth Social Relations World View Behaviors

1.00 0.89 1.00 1.04 1.00 1.32 1.00 1.00

0.96 1.22 0.93

1 2 3 4 5 20 23 24 27 28 29
1.00 1.07 1.03 0.97
1.00 1.02 1.13 1.15 1.12 1.00 1.08
7 8 9 11
12 13 14 15 16 17 18

PCa= .27
BCa= .60 BCa= .30 BCa=.23 PCa=.18
PCa= .29 PCa= .11

Fig. 1 Unstandardized parameter estimates for a multiple-group Comparative Fit Index = 0.95; root mean squared error of approx-
confirmatory factor analysis (CFA) model comparing breast cancer imation = 0.064; standardized root mean squared residual = 0.064;
and prostate cancer. All parameters are statistically significant BCa breast cancer parameter, PCa prostate cancer parameter
(P \ .05). Model-fit statistics: v2 (413) = 660.035, P \ .0001;

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Qual Life Res (2008) 17:771–781
estimates for the cancer group model are shown in Fig. 1.
Latent-factor intercorrelations ranged from 0.44 to 0.88.
We examined differences in the latent-factor means to
determine whether men and women with cancer report
different levels of BF. The group analysis provides a test of
the difference between the means of the latent factors, as
one group is specified to have a factor mean equal to zero,
and the difference between the group means is estimated
and tested in the second group. Men with prostate cancer
reported greater Personal Growth BF (mean differ-
ence = 0.27, P \ 0.05) and women with breast cancer
reported greater Social Relations BF factor (mean differ-
ence = 0.32, P \ 0.05).1 The factor means were not
significantly different for the other factors.
Demographic and disease-related predictors of benefit
finding
Analytic plan
We used the multifactor measurement models of BF,
within structural equation models, to examine sociodemo-
graphic and disease-related correlates of BF. As few
studies have examined predictors of specific BF domains,
these exploratory analyses were designed to provide
guidance to future studies utilizing a multidimensional BF
approach. Significant collinearity was observed among
predictors (e.g., age, marital status, and ethnicity were all
significantly related to SES). Thus, we used the breast and
prostate cancer group model to examine each sociodemo-
graphic correlate of the BFS latent factors in a separate
model. Cancer treatment variables were examined sepa-
rately in the breast and prostate cancer samples, as there
were differences in the types of treatments received.
Unstandardized parameter estimates, which can be inter-
preted as the mean difference in BFS factor scores for
dummy coded variables, are summarized in Table 4.
Age, marital status, and socioeconomic status
Age was unrelated to all BFS factors in both samples.
Married or partnered breast and prostate cancer survivors
reported significantly higher levels of Family BF compared
with those who were not, and married women with breast
cancer also reported higher levels of World View BF. A
CFA model of SES, with income and education as indi-
cators, was examined in a combined model with the
measurement model of BF. The SES latent variable was
unrelated to any BFS factor in women with breast cancer
but was significantly negatively related to all BFS factors
1
The estimates of the means were identical for the models with and
without the group specific correlated errors.
777
in men with prostate cancer (standardized parameter esti-
mates ranging from -0.29 to -0.50, all P \ 0.05). Further
analyses indicated that SES was differentially related to
BFS factors in men with prostate cancer, as the paths could
not be constrained to be equal without harming model fit [D
v2(5) = 13.88, P \ 0.05]. SES was most strongly related
to World View, Personal Growth, Family Relations, and
Health Behaviors BF and less strongly related to Social
Relationships and Acceptance BF in men with prostate
cancer.
Ethnicity
The six latent factors of BF were regressed on two dummy
variables that coded for ethnicity [African American/Black
Caribbean (AA/BC) & Latino/Latina], with Non-Hispanic
Whites treated as the reference group. Latina women
reported greater Family Relations and World View BF. AA/
BC women reported greater Personal Growth and World
View BF. These results should be interpreted with caution
because of the relatively small number of ethnic minority
women in the breast cancer group. Latino and AA/BC men
with prostate cancer scored higher on all six factors of BF
when compared with Non-Hispanic White men.
Cancer treatment variables
We tested the relationship between cancer treatment vari-
ables and BF separately in breast and prostate cancer
because of differences in types of treatment received.
Treatment for prostate cancer (coded as radical prostatec-
tomy or radiation) was unrelated to any of the BF factors.
Neither surgery type (lumpectomy vs. mastectomy) nor
radiation treatment (received vs. not) was significantly
related to any factor of BF in women with breast cancer.
Women receiving chemotherapy treatment (compared with
those who did not) reported significantly greater Family
Relations, Personal Growth, and World View BF.
Comparison with total score approach
To determine whether conclusions regarding sociodemo-
graphic and treatment-related correlates of BF would differ
if we were to use the total score approach for the BFS, as
suggested by a unidimensional model, we examined the
same variables as predictors of the BFS total score. BFS
total score did not differ significantly between the men with
prostate cancer and the women with breast cancer. Con-
sistent with multidimensional model findings, age was
unrelated to BFS total score in both samples. BFS total
scores were greater for Latino/Latina and AA/BC women
with breast cancer and men with prostate cancer (mean
differences ranging from 12.6 to 28.1 points, all P \ 0.05).
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778 Qual Life Res (2008) 17:771–781

Table 4 Unstandardized
Acceptance Family Personal Social World Health
parameter estimates for Benefit
relations growth relations view behaviors
Finding Scale (BFS) factor
correlate analyses Age
Breast -.01 .00 -.02 .00 -.00 -.02
Prostate -.01 .00 .00 .00 .01 .00
Socioeconomic status
Breast -.01 .08 .11 -.04 -.12 .07
Prostate -.20* -.22* -.22* -.13* -.30* -.21*
Married/partnered
Breast .31 .62* -.04 .19 .44* .21
Prostate -.17 .87* -.04 .28** .29 -.06
African American/Black Caribbean
Breast .73** .45 .94* .38 1.51* .50
Prostate .40* .65* .95* .58* 1.05* 1.14*
Latino/Latina
Breast .08 .49* .22 .33** .87* .24
Prostate .60* .98* .99* .58* 1.11* 1.01*
PC Treatment -.04 -.03 .04 -.14 .00 .15
BC Surgery -.04 .04 -.14 .02 -.03 -.42
BC Radiation (y/n) -.01 -.25 -.15 -.11 .00 -.21
PC prostate cancer, BC breast
BC Chemotherapy .26 .49* .52* .15 .73* .30
cancer
(y/n)
* P \ 0.05, ** P \ 0.10

BFS total score was significantly related to SES in men
with prostate cancer (standardized parameter estimate = -
0.44, P \ 0.001) but not women with breast cancer. Mar-
ried/partnered persons did not differ from unmarried
persons in BFS total score in either the prostate cancer or
breast cancer groups. Women who received chemotherapy
reported greater BFS total scores (mean differ-
ence = 15.77, P \ 0.05) compared with those who did not,
but there were no significant differences by type of surgery
or receipt of radiation treatment. There were no significant
differences by type of treatment for prostate cancer. Thus,
analyzing the BFS using a total score approach would have
masked differences between the breast cancer and prostate
cancer groups and between married and unmarried persons
and overgeneralized findings regarding race/ethnicity and
chemotherapy treatment in women with breast cancer. In
addition, the differences in the strength of association
between SES and BF domains would have been obscured
in men with prostate cancer, although the direction was
consistent across factors.
Discussion
Study results support treating benefit finding, as measured
by the Benefit Finding Scale, as a multidimensional con-
struct. Confirmatory factor analysis of the BFS in men with
prostate cancer and women with breast cancer established
the presence of 6 latent factors of BF: Acceptance, Family
Relations, Personal Growth, World View, Social Relations,
and Health Behaviors. There is substantial overlap between
the factors identified in this study and the factors identified
using exploratory factor analysis on a shorter version of the
measure with cancer caregivers [24]. In both the caregiving
study and the cancer samples used in the current study, a
multidimensional model of BF fit the data significantly
better then a unidimensional model. Multiple group anal-
yses revealed that the factor loadings and item intercepts
were invariant across samples. These results suggest that
while samples may vary in the level of BF reported, the
BFS has a similar multidimensional structure across the
observed cancer patient groups.
Group differences in benefit finding
Women with breast cancer reported higher levels of Social
Relations BF and men with prostate cancer reported greater
Personal Growth BF. This is best thought of as a group
comparison rather than a simple gender comparison, as the
two groups differed on disease, age, and other sociode-
mographic characteristics. Perhaps men with prostate
cancer perceive their illness and treatment as more of a
personal challenge and/or struggle more with the crisis-
related task of preserving a satisfactory self-image and
consequently perceive greater growth in the Personal
Growth domain. Women with breast cancer may

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Qual Life Res (2008) 17:771–781
experience greater social disruption, utilize support from
friends and family as a primary coping strategy, and/or
have greater success with the crisis-related task of sus-
taining relationships with important others, stimulating
greater perceived growth in social relationships. Utilizing a
total score approach would have obscured these differ-
ences, In general, sociodemographic variables (SES,
marital status, and ethnicity) were more strongly associated
with BF in men compared with women. Psychosocial or
dispositional variables, such as coping, social support,
disclosure, and social constraint, may be more important
predictors of BF in women, especially given greater reports
of positive growth in social relationships.
Correlates of benefit finding
Married or partnered persons with cancer reported greater
Family Relations BF and World View BF, possibly due to a
greater number of intimate supportive relationships. Again,
these differences would not have been observed if BFS
total scores were used. Ethnic minority women reported
higher levels of Family Relations BF, World View BF, and
Personal Growth BF; and ethnic minority men reported
higher levels of all dimensions of BF. These dimensions
may be particularly sensitive to ethnic differences in family
structure, cultural values, use of coping strategies such as
acceptance, and spirituality. Lower SES was significantly,
but differentially, related to greater BF factor scores for
men with prostate cancer but not for women with breast
cancer. Low SES men may find the experience of being
diagnosed with cancer to be more stressful or threatening
because of difficulties accessing health care, limited health
knowledge, and financial concerns. This greater perception
of threat may translate to greater perception of benefits [6,
30]. Low SES individuals may also experience more
traumatic or stressful life events and therefore may have
more practice in searching for and/or finding benefits from
negative experiences [20]. More research is needed to
understand how gender or disease type may interact with
socioeconomic resources to influence BF and to confirm
that the observed SES associations are not due to income,
education, and/or ethnic differences between the groups or
limited power to detect associations in the breast cancer
sample. Future studies using a multidimensional approach
are necessary to further elucidate the relationships among
BF factors and correlates and ensure that differences
observed in this study are not sample specific.
The differential relationships between dimensions of BF
and predictive variables lends further support to treating
BF as a multidimensional construct and may provide one
explanation for the disparate findings in the research lit-
erature linking predictors such as age, gender, ethnicity,
and SES with BF. Commonly used total-score approaches
779
to measuring this construct may obscure significant rela-
tionships by combining BF dimensions that are
differentially related to predictors and possibly outcomes.
Future work should examine different domains of BF in
relationship to the specific crisis-related disruptions and
developmental tasks that individuals with medical illnesses
experience. This type of research has the potential to
advance conceptual models of BF by linking the life dis-
ruption and/or the completion of adaptive tasks with
specific domains of BF.
Implications for BFS scoring
The superior fit of multifactor models in both samples
studied here suggests that the total composite score
approach to this measure should be replaced by factor
scores using a 22-item version of the scale. It is recom-
mended that factors be calculated by summing or taking the
mean of the items, which assumes equal factor weights, as
opposed to using weighted factors scores, which are unli-
kely to generalize across samples [37].
Limitations and directions for future research
Several limitations of this study should be noted. First, the
BFS was not designed specifically to assess all dimensions
of BF in a comprehensive way. Whereas the six factors
identified are consistent with previous qualitative and
quantitative research, it is possible that there are other
dimensions of BF not assessed by this scale (e.g., an
expanded conceptualization of changes in spirituality,
religiosity, or altruism). Future research should focus on
identifying common and specific dimensions of BF across
populations (including trauma victims and medical
patients), as well as developing more refined instruments.
The factor structure should be examined for invariance
across samples of individuals who have faced a variety of
stressful and/or traumatic life events. This study provides a
template for the evaluation of multifactor models of future
BF scales across samples of medical patients.
This study examines men and women with different
types of cancer, thus the effect of gender cannot be dis-
tinguished from the effect of disease type. This may also be
a concern for studies of mixed cancer patients, as samples
are likely to include a large proportion of individuals with
common gender-specific cancers. Conclusive data regard-
ing the impact of gender of BF would be best generated
from studies examining gender-neutral cancers, such as
colorectal or lung cancers. In this study, BF was assessed
using a self-report measure. Some researchers have inves-
tigated ways of obtaining more ‘‘objective’’ reports of BF,
either through collaborative reports by family member or
friends or behavioral outcomes (e.g., [5]). However,
123
780
changes in internal states such as appreciation for life or
loved ones or confidence in one’s abilities may not be able
to be confirmed in a satisfactory way. In addition, we
examined a limited number of sociodemographic correlates
of BF cross-sectionally in this study, leaving the majority
of the variance in all dimensions of BF unexplained. Future
studies should examine the relationship between coping
strategies (particularly positive reframing), social support,
dispositional optimism, and personality variables and dif-
ferent domains of BF. In addition, this study examined BF
at only one point in the disease trajectory (approximately
15 months postdiagnosis). Future studies should examine
the trajectories of BF domains prospectively to understand
how BF develops in relation to disease processes.
Finally, this study does not address the relationship of
BF with psychosocial adjustment. Whereas many studies
have linked the identification of benefits following medical
illness with positive psychological and medical outcomes
(e.g., [7], [15], [38]), some studies have found no or neg-
ative relationships (e.g., [9], [20], [30], [39]). Importantly,
very few of these studies have examined multiple dimen-
sions of BF. Future research should examine the
relationships between BF domains and psychosocial and
medical outcomes over time. It is possible that certain
dimensions of BF will be more strongly related to positive
psychological adaptation than others or that dimensions of
BF will relate to psychosocial outcomes in opposite ways.
Differential relationships between BF dimensions and
measures of well-being have been observed in both medi-
cal patient [23] and cancer caregiver samples [24].
Replication of this pattern of results in cancer patients
would confirm the utility of a multidimensional model of
BF and provide one explanation for discrepancies in the
research literature.
Clinical implications
From a clinical vantage point, the notion that BF is best
conceptualized as multidimensional should encourage cli-
nicians to view patient reports of BF as such. That is,
clinicians should not expect patients to report high levels of
BF on every dimension and should take into account that
only certain dimensions of BF are likely to change in a
given patient. Should future research reveal that BFS
subscales are differentially related to psychosocial out-
comes, interventions will need to take this into account.
Although no interventions have been designed to enhance
BF per se, such studies are being conceptualized by
researchers in the field. Interventions should be tailored to
target those aspects of BF most likely to result in
improvements in psychological and physical well-being.
This study compared multidimensional and unidimen-
sional models of the BFS using multiple group confirmatory
123
Qual Life Res (2008) 17:771–781
factor analysis in men with prostate cancer and women with
breast cancer. Multidimensional models were superior to
unidimensional models in both samples. These results
suggest that researchers may want to examine domain-
specific models of personal growth in cancer patients when
using the BFS. Future work is needed to more clearly
identify different dimensions of BF and to understand how
different dimensions of BF relate to both quality of life and
medical outcomes over time.
Acknowledgements Kathryn Weaver is now a fellow in the Cancer
Prevention Fellowship Program, Office of Preventive Oncology,
National Cancer Institute, National Institutes of Health, Bethesda,
MD, USA. This research was supported by grants NIMH
5T32MH018917 (N. Schneiderman, PI), NCI 1P50CA84944 (Antoni,
PI), and NCI 5R03CA113096 (Lechner, PI).
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