REVIEW OF POSITIVE PSYCHOLOGY OUTCOME MEASURES FOR CHRONIC

Dement Geriatr Cogn Disord 2015;40:340–357 DOI: 10.1159/000439044 Accepted: July 27, 2015 Published online: September 25, 2015

© 2015 S. Karger AG, Basel 1420–8008/15/0406–0340$39.50/0 www.karger.com/dem

Review Article

Review of Positive Psychology Outcome Measures for Chronic Illness, Traumatic Brain Injury and Older Adults: Adaptability in Dementia? Charlotte R. Stoner a

Martin Orrell b

Aimee Spector a

a Department

of Clinical, Educational and Health Psychology, and b Division of Psychiatry, University College London, London, UK

Key Words Psychometric assessment · Dementia · Alzheimer · Resilience · Self-efficacy · Spirituality · Satisfaction · Resourcefulness · Autonomy · Coherence Abstract Background: Despite positive psychology being increasingly recognised as an important agent in well-being, there is a lack of standardised outcome measures for psychosocial dementia research. This review assessed positive psychology outcome measures using standardised criterion in populations that were identified as having shared characteristics. It aimed to identify robust measures that were suitable for potential adaption or use within a dementia population. Summary: The review identified 16 positive psychology outcome measures (and 8 further psychometric assessments of these) within the constructs of resilience, selfefficacy, religiousness/spirituality, life valuation, sense of coherence, autonomy, resourcefulness and a combined measure (CASP-19). Scale development studies were subject to a quality assessment, and most were found to be lacking information on reproducibility and responsiveness. Key Messages: A wide range of measures within the constructs of positive psychology was identified as having potential utility for psychosocial research within a dementia population. Examples included the CD-RISC, GSWB, SWLS, MPAQ, RSOA and CASP-19. It is recommended that such scales are further adapted or validated for people with dementia. Underreporting of appropriate psychometric analyses hampered this review, and it is recommended that future authors endeavour to report such analyses. © 2015 S. Karger AG, Basel

Charlotte R. Stoner Department of Clinical, Educational and Health Psychology University College London, 1–19 Torrington Place London WC1E 7HB (UK) E-Mail charlotte.stoner.14 @ ucl.ac.uk

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Dement Geriatr Cogn Disord 2015;40:340–357 DOI: 10.1159/000439044

© 2015 S. Karger AG, Basel www.karger.com/dem

Stoner et al.: Review of Positive Psychology Outcome Measures for Chronic Illness, Traumatic Brain Injury and Older Adults: Adaptability in Dementia?

Introduction

The psychology of dementia has generally been constructed in terms of progressive deficits, negative aspects of behaviour or mood and progressive dependency. Whilst a number of recent psychosocial intervention studies have aimed to promote quality of life, the outcomes utilised within these studies assess neuropsychiatric symptoms such as agitation and depression, thereby inferring well-being or quality of life by the reduction or absence of these behaviours [1]. Furthermore, the measurement of quality of life within dementia research is not without its challenges. Quality of life is a highly subjective concept and, therefore, there is debate as to whether proxy or observational measures of this concept truly reflect an individual’s appraisal of their own quality of life [2]. Positive psychology (PP) is recognised as an important contributing factor in terms of well-being. However, there is little research in relation to it within the dementia field, possibly due to the lack of suitable PP outcome scales. Whilst a consensus on more general measures to be used in dementia research has been reached, it has also highlighted the absence of PP outcome measures in the field [3]. In fact, there are no specifically tested or designed PP outcome measures for people with dementia. For the purpose of this review, PP was defined as the study of positive emotions that enable individuals, communities and organisation to thrive [4]. Whilst other models and definitions were considered [5], Seligman’s theory was chosen for the basis of this review due to its inclusive and influential nature. Since the reintroduction of PP as a meaningful branch of psychology [6], a number of studies have explored positive attributes for dementia caregivers including resilience and self-efficacy [7, 8], in both qualitative and quantitative settings. PP research focusing predominantly on the person with dementia has largely been of a qualitative nature, for example the use of spirituality in coping with a diagnosis of Alzheimer’s disease [9]. More recently, a meta-synthesis of living positively with dementia was undertaken, which highlighted retained capacities to utilise character strengths and actively seek enjoyment and pleasure and provides a strong rationale for the development of PP outcome measures within dementia research [10]. In order to consider the outcomes which may have potential utility for people with dementia, this review identified populations which may have shared characteristics. Chronic illness populations were selected due to the persistent, incurable nature, traumatic brain injury (TBI) populations for their shared symptoms including impairment of cognitive, physical and psychosocial functions, and older adults as they share similar issues in old age and this population has the highest prevalence of dementia [11]. The aims of this review were to: (1) assess the psychometric properties of PP outcome measures in use for chronic illness, TBI and older adults, and (2) appraise the potential applicability of measures of positive outcomes for people with dementia. Review

Method Design A systematic search and psychometric property appraisal of published PP outcome measures for people with chronic illness, TBI and for older adults was undertaken. Systematic principles were followed for searching, screening and appraising results [12]. Constructs denoting PP were sourced from current literature [13–15] to identify salient and pertinent constructs. Such constructs included resilience, hope, optimism, autonomy and spirituality.

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Search Strategy The following electronic databases were searched: PsycINFO, MEDLINE and PubMed. The search terms were: ‘measure’, ‘instrument’, ‘questionnaire’, ‘quiz’, ‘test’ and ‘scale’ combined with ‘goal’, ‘life satisfaction’, ‘self-efficacy’, ‘hope’, ‘resilience’, ‘cope’, ‘wisdom’, ‘growth’, ‘coherence’, ‘control’, ‘autonomy’, ‘pleasure’, ‘self-realisation’, ‘sense of agency’, ‘gratitude’, ‘happiness’, ‘optimism’, ‘transcendence’, ‘positive’, ‘dignity’, ‘social participation’, ‘social inclusion’, ‘self-concept’, ‘humour’, ‘creativity’, ‘flow’, ‘spirituality’, ‘love’, ‘compassion’, ‘benefit finding’, ‘community integration’, ‘opportunity’, ‘social adjustment’, ‘mindfulness’, ‘acceptance’ and ‘successful aging’. These search terms were then, again, combined with: ‘chronic illness’, ‘traumatic brain injury’ and ‘older adult’. Truncations of search terms were used where necessary. Search terms such as ‘quality of life’ and ‘well-being’ were not included as the review focused on concepts that contribute to these dimensions. In the first instance, studies were screened for the development of a PP outcome measure. Studies were also screened for independent assessments of psychometric properties of a PP outcome measure in either a chronic illness, TBI or an older adult population (hereafter referred to as ‘validation studies’). If a validation study was identified, a search for the original psychometric development study was performed, even if this date preceded 1998. Finally, a manual check of text and reference lists was conducted to identify additional measures. The inclusion criteria were: (1) outcome measures published in a peer-reviewed journal; (2) an outcome measure purporting to measure a specific construct, as identified in the search terms, within PP and developed or validated in chronic illness, TBI or older adult populations, and (3) published between 1998 and 2015 (1998 was the date when the term PP was re-introduced by Seligman). The exclusion criteria were: (1) papers published in a language other than English if a translation was not available, and (2) measures that focused on external or situational factors rather than an internal trait within PP. Data Extraction Identified abstracts were exported to EndNote, where they were screened against eligibility criteria. Full text articles were then sought for the studies included. In uncertain cases, of which there were 6, scales were given to A.S. to screen against the eligibility criteria and were discussed until a decision on its inclusion/exclusion was reached. The final list of measures included was also reviewed by A.S. Appraisal of Psychometric Properties Included measures were grouped within the construct they intended to measure, and a quality assessment was undertaken, utilising a published criterion that appraises the development process of outcome measures [16]. This criterion has been applied in other reviews [17] and provides a scoring system based on reported aspects of reliability and validity during measure development (table 1). This analysis was undertaken for measure development papers only by the primary author and corroborated by A.S. For each item within the criterion, positive scores were awarded when the study was adequately designed and appropriate statistics are reported. An intermediate score (?) was given if there were either methodological shortfalls including inadequate description of the design or analysis and sampling issues. A negative rating was awarded if, despite adequate study design and methods, the study produced results indicating poor psychometric properties. A zero was awarded if the authors failed to report the appropriate information. A positive score was awarded 2 points, an intermediate score 1 point and both negative ratings and zero ratings were awarded a score of zero. These scores were then added together to produce an overall quality score for the development process of the scale with a possible score range of 0–18.

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Table 1. Quality assessment scoring criteria

Property

Definition

Quality criteria

1

The extent to which the domain of interest is comprehensively sampled by the items in the questionnaire (the extent to which the measure represents all facets of the construct under question)

+ 2

2

Content validity

Internal consistency The extent to which items in a (sub)scale are inter-correlated, thus measuring the same construct

? 1 – 0 0 0 + 2 ? 1 – 0 0 0

A clear description of measurement aim, target population, concept(s) that are being measured, and the item selection and target population (investigators OR experts) were involved in item selection A clear description of the above-mentioned aspects in lacking OR only target population involved OR doubtful design or method No target population involvement No information found on target population involvement Factor analyses performed on adequate sample size (7* #items and ≥100) and Cronbach’s α(s) calculated per dimension and Cronbach’s α(s) between 0.70 and 0.95 No factor analysis OR doubtful design or method Cronbach’s α(s) <0.70 or >0.95 despite adequate design and method No information found on internal consistency

3

Criterion validity

The extent to which scores on a particular questionnaire relate to a gold standard

+ 2 ? 1 – 0 0 0

Convincing arguments that gold standard is ‘gold’ and correlation with gold standard ≥0.70 No convincing arguments that gold standard is ‘gold’ OR doubtful design or method Correlation with gold standard <0.70 despite adequate design and method No information found on criterion validity

4

Construct validity

The extent to which scores on a particular questionnaire relate to other measures in a manner that is consistent with theoretically derived hypotheses concerning the concepts that are being measured

+ 2 ? 1 – 0 0 0

Specific hypotheses were formulated AND at least 75% of the results are in accordance with these hypotheses Doubtful design or method (e.g. no hypotheses)

The extent to which the scores on repeated measures are close to each other (absolute measurement error)

+ 2 ? 1 – 0 0 0

SDC
5 5.1

Reproducibility Agreement

Less than 75% of hypotheses were confirmed despite adequate design and methods No information found on construct validity

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Table 1 (continued)

Property

Definition

Quality criteria

5.2

The extent to which patients can be distinguished from each other despite measurement errors (relative measurement error)

+ 2 2 ? 1 – 0 0 0

ICC or weighted κ ≥0.70

The ability of a questionnaire to detect clinically important changes over time

+ 2 ? 1 – 0 0 0

SDC or SDC 1.96 OR AUC ≥0.70 Doubtful design or method

+ 2 ? 1 – 0 0 0

≤15% of the respondents achieved the highest or lowest possible scores Doubtful design or method

+ 2 ? 1 0 0

Mean and SD scores presented of at least 4 relevant subgroups of patients and MIC defined Doubtful design or method OR less than 4 subgroups OR no MIC defined No information found on interpretation

6

7

8

Reliability

Responsiveness

Floor and ceiling effects

Interpretability

The number of respondents who achieved the lowest or highest possible score

The degree to which one can assign qualitative meaning to quantitative scores

Doubtful design or method ICC or weighted κ <0.70 despite adequate design and method No information found on reliability

SDC or SDC ≥MIC OR MIC equals or inside LOA OR RR ≤1.96 or AUC <0.70 despite adequate design and methods No information found on responsiveness

>15% of the respondents achieved the highest or lowest possible scores despite adequate design and methods No information found on interpretation

In order to calculate a total score + = 2; ? = 1; – = 0; 0 = 0 (scale of 0 – 18). SDC = Smallest detectable difference [this is the smallest within-person change, above measurement error; a positive rating is given when the SDC or the limits of agreement (LOA) are smaller than the MIC]; MIC = minimal important change (this is the smallest difference in score in the domain of interest which patients perceive as beneficial and would agree to, in the absence of side effects and excessive costs); SEM = standard error of measurement; AUC = area under the curve; RR = responsiveness ratio.

The appraisal of validation papers was undertaken to assess the degree of translatability to other populations and therefore guide selection of a measure that could be used for people with dementia. An analysis of reported psychometric properties including internal consistency (employing magnitude guidelines) [18] and convergent validity was undertaken. A measure was identified as potentially applicable to people with dementia if reported psychometric properties within a validation study were robust and consistent with the original scale. This would indicate the measure’s stability and utilisation across populations. Study characteristics such as including sample size and psychometric properties were synthesised to compare properties of a measure when used in a different population (table 2).

4-item, 5-point Likert Scale with responses ranging from ‘1 – does not describe you at all’ to ‘5 – describes you very well’

25-item scale, 7-point Likert Scale Responses ranging from ‘1 – disagree’ to ‘7 – agree’, with higher scores reflecting greater resilience

6-item, 5-point Likert Scale Three items negatively coded Responses ranging from ‘1 – strongly disagree’ to ‘5 – strongly agree’; also includes ‘3 – neutral’

RS [22]

BRS [23]

25-item scale, 5-point Likert Scale (0 – 4) with responses ranging from ‘0 – not true at all’ to ‘4 – nearly all the time’ Higher scores reflect greater resilience

Description

BRCS [21]

Resilience CD-RISC [20]

Construct and instrument

Table 2. Description of included measures

Internal consistency: α = 0.80 – 0.91 (good) Test-retest (ICC) = 0.62 – 0.69 from specific subset of participants within sample

Internal consistency: At pilot α = 0.89 (good) In subsequent studies correlations ranged from α = 0.67 (acceptable) to α = 0.84 (good) (p < 0.01)

Internal consistency: Cronbach’s α = 0.69 (acceptable) Test-retest: Correlation = 0.71 (5 – 6 weeks baseline) and 0.68 (3-month follow-up)

Internal consistency: Cronbach’s α = 0.89 (good) Test-retest: intra-class correlation coefficient of 0.87 (good)

Reliability

Criterion/convergent: Positively correlated with the resilience measures, social support, optimism and purpose in life (statistics of overall scales not included) Negatively correlated with behavioural disengagement, denial, and self-blame (statistics of overall scales not included) Predictive: Predicts expected outcomes for perceived stress, anxiety, depression, negative affect, positive affect and physical symptoms (p < 0.01)

Criterion: Positive correlation with Kobasa hardiness (r = 0.83, p < 0.0001) Convergent: SSS (r = 0.36, p < 0.0001) Negative correlation with PSS-10 (r = –0.76, p < 0.001), SVS (r = –0.32, p < 0.0001) and SDS (r = –0.62, p < 0.0001) Sensitivity to change: effect of time and interaction between time and response category (F = 17.36; d.f. 1, 46; p < 0.0001 and F = 12.87; d.f. 2, 47; p < 0.001, respectively) Indicates scores increased with overall clinical improvement Convergent: Expected correlations with measures of personal coping resources, pain coping behaviours and psychological wellbeing (overall scales not reported) Predictive: Significant predictor of post-intervention outcomes as measured by Outcomes Index (b = 2.35; p < 0.03) Sensitivity to change: significant linear effect across four assessment periods (F = 7.78; d.f. 1, 81; p < 0.01) and paired t tests showed increase in mean average score before and after intervention (t = 2.12; d.f. 89; p < 0.05) Convergent: Positive correlation with Life Satisfaction Index-A (r = 0.30), and Morale (PGCMS; r = 0.28) Negatively correlated with depression (r = –0.37) All significant to p < 0.001

Validity

Spanish translation of RS in chronic musculoskeletal pain sample [25] (n = 300) Internal consistency: α = 0.92 (excellent) Test-retest reliability: r = 0.90; p < 0.001 Scale stability: no significant difference over two time points (t299 = 95.297; p = 0.15) Construct: significantly correlated with pain scales e.g. Pain Catastrophizing Scale (–0.70), Spanish version of the Chronic Pain Acceptance Questionnaire (0.74)

Validation study in older adults (age range 55 – 75+) [24] Excellent internal consistency (α = 0.93) Convergent: Established (CES-D, GSES, PSMS and MOS-SSS: p < 0.001; handgrip strength: p < 0.050)

Translatability identified within review

DOI: 10.1159/000439044

American population (n = 354) including undergraduate students, cardiac rehabilitation and fibromyalgia patients

Developed in a qualitative study of 24 women using verbatim statements to generate items piloted with 39 undergraduate nursing students Psychometric properties explored in general population (n = 810)

American sample with rheumatoid arthritis (sample 1 n = 90; mean age 46, sample 2 n = 140; mean age 57.8)

American sample (n = 806; mean age 43.8) Random-digit dial general population (non-help-seeking), primary care recipients, psychiatric outpatients, GAD and PTSD

Sample population

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12-item, 5-point Likert Scale 2 subscales Responses range from ‘1 – strongly agree’ to ‘5 – strongly disagree’

16-item scale, 6-point Likert Scale Responses range from ‘1 – strongly disagree’ to ‘6 – strongly agree’

GSWS [29]

16-item/6-item, 6-point Likert Scale Usually self-administered Responses range from ‘1 – many times a day’ to ‘6 – never or almost never’ 16th item responses ‘not close at all’ to ‘as close as possible’ (4-point Likert)

5-point Likert Scale including a neutral midpoint

Description

SIWB [28]

Religiousness/ spirituality DSES [27]

Self-efficacy CRES [26]


Table 2 (continued)

Internal consistency: α = 0.76 Test-retest: significant relationship (r = 0.60; p < 0.01)

Internal consistency: α = 0.87 (good)

Internal consistency: item correlation in SWAN study range from 0.60 – 0.80 (acceptable) 2 items collinear: ‘finds strength in religion, spirituality’ and ‘finds comfort in religion, spirituality’ (α = 0.96) Cronbach alpha: α = 0.94 – 0.95 (excellent) Reliability coefficients (inter-rater): 0.64 – 0.78 (acceptable)

Internal consistency: subscales ranged from α = 0.69 (fair) to α = 0.91 (excellent) Authors noted that subscales 3 (perception of dependence) and 5 (accepting help) were of questionable practical used but were retained for potential future modification

Reliability

Convergent: Negatively correlated with depression (GDS; r = –0.32; p < 0.01)

Construct: SWAN study lower scores in African-American women, indicating greater degree of DSE (p < 0.01) Pattern repeated in GSS sample (6-item scale; p < 0.01) Non-religious people had significantly higher scores in GSS sample than Catholics and Protestants (p < 0.01) Convergent: SWAN study – frequency of DSE negatively correlated with psychosocial factors including anxiety, alcohol consumption, and positively correlated with optimism, social support and QoL (all significant to p < 0.01) Chicago study – More frequent DSE associated with positive affect (Pearson’s correlation 0.29; p < 0.01) Convergent: Positive correlations with self-report health status, functional QoL and physical functions (no statistics given) Negative correlation with fear for death and depression

Convergent: Moderate correlations with validation measures (0.3 – 0.4) and subscales at a low to moderate level Subscale 5 did not overlap other subscales to any marked extent Subscale 4 (performance related QoL) negatively correlated with depression (r = –0.47) Face validity/content validity: item difficulty and item location rating from four ‘experts’ Spearman’s rho used to correlate empirical item location and mean judged item location by subscale Correlations for subscales 4 (performance related QoL) and 5 (accepting help; p = 0.020) Expert rating of subscales 1 and 2 unrelated to empirical item locations

Validity

American adult outpatients at primary care clinics (chronic illness) [32] (n = 509; mean age 46.8) Internal consistency: α = 0.91 (excellent) Test retest: subsample (n = 93) tested again over telephone within 2 weeks 0.79 Factor analysis: 56% variance accounted for by 2-factor model Convergent: positive correlation with Spiritual Well-Being Scale (0.62) and general well-being (0.64) Negative correlation with depression (–0.42), all significant to p < 0.001

Translation and validation in French older adults (SF) [31]: (n = 338; mean age 77.87; women 62.6%; men 37.4%) Internal consistency: α = 0.92 (excellent) Mean item correlation α = 0.65 Test-retest: subsample of 40 participants after two weeks showed good temporal stability (r = 0.85) Convergent: positively correlated with SWLS (0.22; p < 0.01) and physical health (0.16; p < 0.05 and 0.15; p < 0.05)


DOI: 10.1159/000439044

Convenience sample of American communitydwelling older adults (n = 138; mean age 74.2)

Community dwelling older adults (n = 277; mean age 74)

Study of Women Across the Nation (SWAN) (n = 233; 100% women; mean age = 46.76) Patients with arthritic pain (n = 45) University of Chicago area (n = 122) GSS (1997 – 1998) used 6-item scale (n = 1,445; mean age 45.64)

American functionally disabled older adults (n = 177; mean age = 78.42)

Sample population


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19-item Subscales of positive VOL and negative VOL

22-item, 7-point Likert Scale 5 subscales: sense of purpose and ambition, zest and spirituality, body and health, aging in place and stability and social support

VLS [34]

AtA [35]

5-item scale, 7-point Likert Scale. Responses range from ‘1 – strongly disagree’ to ‘7 – strongly agree’ Includes a neutral midpoint ‘4 – neither agree nor disagree’

12-item, 5-point Likert Scale Responses range from ‘0 – not at all’ to ‘4 – very much’

FACIT-Sp [30]

Life valuation SWLS [33]

Description


Table 2 (continued)

Internal consistency α = 0.891 for whole scale and range of α = 0.862 – 0.927 for subscales (good to excellent)

Internal consistency: positive VOL α = 0.94 (excellent) and negative VOL α = 0.83 (good) Inter-item correlation r = 0.55 for positive VOL and r = 0.44 for negative VOL

Internal consistency: coefficient α = 0.87 Test-retest: sample 1 2-month retest coefficient = 0.87

Internal consistency: α = 0.87 (good)

Reliability

Indices of fit (AGFI): 0.929 (good) Convergent: Positive VOL correlated with scales of well-being, hardiness and mastery (range from 0.39 to 0.62) Negative VOL negatively correlated with scales of well-being and mastery (range from 0.47 to 0.67), all correlations were significant to p < 0.01 apart from autonomy, which was not significant Positive VOL negatively correlated with depression (CESDD; –0.37; p < 0.01) Construct: Exploratory factor analysis resulted in five-factor model fit explaining 75.6% variance Negative and week correlations with PANAS (r = –0.099, p < 0.001) Sense of coherence – QtLQ (r = –0.202, p < 0.001)

Factor loadings: Single factor accounting for 66% variance (sample 1) Convergent: Positively correlated with positive affect (PANAS) 0.50 and 0.51 for samples 1 and 2, respectively Negatively correlated with negative affect (PANAS) –0.37 and –0.32 for samples 1 and 2, respectively

Convergent: Positively correlated with QoL (FACT-G; 0.58; p < 0.001) Negatively correlated with depression (POMS subscale; –0.48; p = 0.0001) Content: Assessed in second sample (n = 131; European American 87%; cancer patients 65.7%) Moderately correlated with other religiousness scales (p < 0.005)

Validity

Validation in Turkish older adults [36] (n = 123) Internal consistency: α = 0.81 (good) Convergent: positively correlated with selfesteem (r = 0.20; p = 0.023), perceived current health status (r = 0.20; p = 0.027) and negatively correlated with depression (r = –0.39; p = 0.000) Spanish translation and analysis [37]: Analysis of factorial variance between adolescents (n = 133) and older adults (n = 133); acceptable one factor model for both adolescents and older adults found; sensitive to these age groups Portuguese translation and validation in older adults [38] (n = 1,003) Internal consistency: α = 0.92 (excellent) Convergent: positively correlated with perceived health (0.326; p < 0.01), generativity (0.202; p < 0.01)


DOI: 10.1159/000439044

Portuguese community-dwelling older adults (n = 1,291); mean age: 83.9 Participants were excluded if they scored 26 on an MMSE

American older adults sample 1: n = 602; mean age 77.34; sample 2: n = 462; mean age 76.89; sample 3: n = 138; mean age 80.64; sample 4: n = 850; mean age 75.65

American undergraduate students at University of Illinois (sample 1 n = 176, sample 2 n = 176)

American cancer patients (n = 1,617; median age 54.6; chronic illness)

Sample population


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British older adults (n = 286, age range 65 – 75)

Older adults (n = 451) mean age: 81 Average of 3 chronic health conditions per participant

Jewish population Details unavailable

Older adults with chronic physical illness (n = 412, mean age: 70.25)

Sample population

VOL = Valuation of life; DSE = daily spiritual experience; SF = short form.

19-item, 4-point Likert Scale Responses ranged from ‘0 – never’ to ‘3 – often’

28-item, 6-point Likert Scale Two subscales: personal resourcefulness and social resourcefulness

29-item or 13-item (SF), 7-point semantic differential scale

16-item, 5-point Likert Scale Three subscales

Description

Internal consistency: Control: α = 0.59 Self-realisation: α = 0.77 Pleasure: α = 0.74 Autonomy: α = 0.67 (all acceptable)

Internal consistency: personal resourcefulness subscale: α = 0.84 (good) Social resourcefulness: α = 0.80 (good) Overall: α = 0.85 (good)

Internal consistency: average of α = 0.91 for 29 item and α = 0.82 for 13 item (good)

Internal consistency: ICC: 0.61, 0.71, 0.80 for three subscales

Reliability

Convergent: Positive correlation with LSI-W (r = 0.63; p = 0.001) Factor analysis: All domains had strong factor loadings (0.72 – 0.88) on a latent factor

Confirmatory factor analysis: Higher order factor analysis: single second order factor explaining 93.27% variance

Face: Feedback from experts Unable to establish convergent validity as the scale was novel

Convergent: MPAQ – degree of autonomy positively correlated (Pearson) with Autonomy Visual Analogue Scale (0.71, p < 0.001, two tailed) and satisfaction with life (SWLS; 0.65, p < 0.001, two tailed) Negatively correlated with Impact on Participation and Autonomy Questionnaire (IPA) indoors (–0.54, p < 0.001, two tailed), family role (0.56, p < 0.001, two tailed), outdoor (0.68, p < 0.001, two tailed) and social relations (0.46, p < 0.001) two tailed

Validity

Used as a predictor of ‘QoL’, so unlikely to be identified within the context of this review

Validation study of the 13-item Sense of Coherence Scale in Dutch young adults with chronic illness [41] (n = 2,781): 14- to 18- and 19- to 25-yearolds scored lowest, whereas 14- to 18-year-olds with congenital heart disease and 26- to 30-year-olds scored highest irrespective of gender A CFA resulted in items 5 and 6 being dropped 3 subscales of meaningfulness, comprehensibility and manageability loaded onto a single second order factor, with factor loadings of 0.58, 0.93 and 1.00, respectively


DOI: 10.1159/000439044

Combined measures CASP-19 [19]

Resourcefulness RSOA [43]

Sense of coherence SOCS [40]

Autonomy MPAQ [39]


Table 2 (continued)


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Dement Geriatr Cogn Disord 2015;40:340–357 © 2015 S. Karger AG, Basel www.karger.com/dem

DOI: 10.1159/000439044


Potentially relevant studies identified for retrieval: 6,709

No scale development or validation and did not focus on construct of positive psychology: 6,568

Full articles retrieved: 139

Outcome measures identified: 109

No positive psychology trait: 64 Language other than English: 20 Not in peer-reviewed journal: 4

Validation papers identified: 32 Original scale did not meet inclusion criteria: 19

Measures identified from references: 2

Final outcome measures included: 16

Language other than English: 5 Final validation papers included: 8

No scale development: 6 Population unsuitable for review: 1

Fig. 1. Steps taken during the review.

Results

A total of 6,709 results were identified from the databases PsycINFO, MEDLINE and PubMed, of which 109 potential scale and 32 validation papers were identified. Figure 1 summarises the steps taken during the review when including or excluding potential scales. Of the 109 potential scales, only 16 met the criteria for inclusion within this review. The main reason for the exclusion was that scales did not measure a trait or characteristic indicative of PP (64 out of 109 were excluded on this basis). A breakdown of the inclusion and exclusion process is shown in figure 1. Of the 32 validation papers, 8 met the inclusion criteria. The majority of validation papers (19 out of 32) were excluded on the basis that the original scale did not meet the inclusion criteria (fig. 1). The appraisal of the scale development process is contained within table 3. Scores were relatively low, ranging from 2 to 9 out of a possible 18. Overall, the Control, Autonomy, SelfRealisation and Pleasure (CASP-19) [19] was awarded the highest score, demonstrating its comprehensive reliability and validity for older adults. Table 2 provides a description of the 15 included measures and validations in populations of interest. In one instance, a short form version of a scale was utilised, and both versions were included in the quality assessment.

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DOI: 10.1159/000439044


Table 3. Quality assessment for development of included scales Construct

Scale

Content validity

Internal consistency

Criterion validity

Construct validity

Reproducibility agreement

Reproducibility reliability

Responsive- Floor/ ness ceiling effect

Interpretability

Total

Self-efficacy CRES

+ 2

+ 2

? 1

+ 2

0 0

0 0

0 0

0 0

0 0

7

Resilience

? 1 – 0 + 2 ? 1

? 1 – 0 + 2 + 2

0 0 0 0 0 0 – 0

? 1 + 2 + 2 ? 1

0 0 0 0 0 0 0 0

? 1 – 0 0 0 ? 1

? 1 0 0 0 0 0 0

0 0 0 0 0 0 0 0

? 1 0 0 ? 1 + 1

7

? 1 ? 1 + 2 ? 1

+ 2 + 2 + 2 + 2

0 0 0 0 0 0 0 0

? 1 ? 1 + 2 + 2

0 0 0 0 0 0 0 0

0 0 0 0 ? 1 0 0

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

+ 2 0 0 0 0 + 2

6

– 0 – 0 ? 1

– 0 + 2 + 2

0 0 0 0 0 0

? 1 ? 1 ? 1

0 0 0 0 0 0

+ 2 0 0 0 0

0 0 0 0 0 0

0 0 0 0 + 2

0 0 + 2 0 0

3

CD-RISC BRCS RS BRS

Spirituality

DSES SIWB GSWS FACIT-Sp

Life valuation

SWLS VLS AtA

2 7 6

4 7 7

5 6

Autonomy

MPAQ

+ 2

– 0

0 0

+ 2

? 1

+ 2

– 0

0 0

? 1

8

Sense of coherence

SOCS-29 and 13

–/– 0/ 0

?/ ? 1/ 1

0 0

?/ ? 1/ 1

0/ 0 0/ 0

–/– 0/ 0

0/ 0 0/0

0/ 0 0/ 0

0/ 0 0/ 0

2/2

Resourcefulness

RSOA

? 1

+ 2

? 1

? 1

0 0

0 0

0 0

0 0

0 0

5

Combined

CASP-19

+ 2

+ 2

? 1

+ 2

0 0

0 0

0 0

+ 2

0 0

9

Resilience Four scales measuring resilience were identified: the Connor-Davidson Resilience Scale (CD-RISC) [20], the Brief Resilient Coping Scale (BRCS) [21], the Resilience Scale (RS) [22] and the Brief Resilience Scale (BRS) [23]. The CD-RISC, RS and BRS were awarded the highest scores for resilience measurement (7/18). In particular, the RS was rigorously developed with items being generated following an extensive literature review and in-depth interviews, with the target population contributing to its high score on the content validity criterion. Internal consistency using Cronbach’s α was reported in all 4 development studies. Scores ranged from acceptable to good, of which the BRS had the highest score. Test-retest reliability was reported for 3 of the 4 (CD-RISC, BRCS and BRS), and scores again ranged from acceptable to good, of which the CD-RISC had the highest score. Convergent validity was reported for all 4 scales with expected and significant results, of which the CD-RISC was the most thorough. Overall correlations between the BRCS and scales attempting to establish convergent validity were not established. However, expected and

351




significant correlations were reported for subscales. The BRS was found to be positively correlated with a number of scales and subscales including the CD-RISC. The RS was found to be positively correlated with life satisfaction and morale and negatively correlated with depression. Sensitivity to change was established for 2 scales (CD-RISC and BRCS), with the CD-RISC showing a significant effect of time and an interaction effect between the time and response categories, indicating an increase in score associated with overall clinical improvement. The BRCS demonstrated a significant linear effect across four assessment periods and an increase in the mean average score before and after intervention (table 2). Predictive validity was reported for 2 scales (BRCS and BRS). For the BRCS, the authors created an Outcomes Index, consisting of 6 standardised variables reflecting post-intervention scores. This outcomes index had an adequate α reliability score (α = 0.86) and was found to be a moderately significant predictor of post-intervention outcomes (p < 0.03). The BRS predicted outcomes for perceived stress, anxiety, depression, positive affect and physical symptoms. Two validation papers were identified within this review. The CD-RISC was validated in a Native American, older adults sample and was found to have excellent internal consistency (α = 0.93) [24]. Its convergent validity was also established by significant positive correlations with depression and scales of self-efficacy and mastery and negatively correlated with handgrip strength. The RS was translated and validated in a Spanish chronic musculoskeletal pain sample and was found to have adequate psychometric properties [25]. The authors also analysed the scales stability and found no significant differences across two time points. The RS was also found to be positively correlated with pain scales and negatively correlated pain catastrophising. Overall, the CD-RISC appears to be the most psychometrically robust measure, reflected in the quality assessment and validation stages. Although the RS scored equally as well as the CD-RISC, the latter was subject to an increased level of validity checks including sensitivity to change analyses and stringent validity checks and, therefore, the CD-RISC seems the most appropriate scale for further validation in a dementia population. Self-Efficacy The Care-Receiver Efficacy Scale (CRES) [26] was the only measure of self-efficacy to meet the inclusion criteria for this review. It was given a moderate 7/18 for the scale development, notably lacking information regarding reproducibility, responsiveness and interpretability. The CRES had an adequate reported internal consistency for most of its subscales; however, one of these came close to the minimum required score of α = 0.70. The authors conceded that this subscale was of questionable practical use but was retained for potential future analysis and modification. The authors reported expected negative correlations between depression and subscale 4 (performance-related quality of life) but, overall, subscale correlations with validation measures were only moderate, ranging from r = 0.3 to 0.4. No validation studies for the CRES were identified within this review. The CRES, although scoring moderately on the quality assessment, appears to be of questionable practical value and would benefit from further development and analysis. Religiousness/Spirituality The Daily Spiritual Experience Scale (DSES) [27], the Spirituality Index of Well-Being (SIWB) [28], the Geriatric Spiritual Well-Being Scale (GSWS) [29] and the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp) [30] were identified for inclusion within this review, of which the final 2 were given the highest rating during the quality assessment stage (7/18).

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Internal consistency was reported for all 4 scales and ranged from good to excellent, of which the DSES scored highest. However, 2 items were found to be collinear (α = 0.96) for this scale, as participants seemed unable to distinguish between finding comfort and finding strength at an item level. The authors conceded that if similar patterns were to be found in other populations, 1 of the items should be omitted. These items were nevertheless included within the final scale. Test-retest reliability was only reported for the GSWS with a significant relationship being found (p < 0.001). Convergent validity was reported for all scales with acceptable, expected correlations for each (table 2). Of particular note was the DSES, for which the authors reported positive correlations for a range of factors including optimism, social support and quality of life, and negative correlations with anxiety and alcohol consumption. Furthermore, the DSES was reported to have good construct validity. Validations in appropriate populations were identified for the DSES and the SIWB. The DSES has been translated and validated for French older adults and was found to have excellent internal consistency, test-retest reliability and convergent validity, highlighting its possible applicability for older adults with dementia [31]. The SIWB was validated in a chronic illness setting and was also found to have excellent internal consistency, test-retest reliability and convergent validity [32]. Overall, of the 4 scales identified, the GSWB and FACIT-Sp were more rigorously developed, as reflected in their higher scoring on the quality criteria (table 3). Also, the GSWB and the SIWB were developed for older adults, and the SIWB has been validated in a chronic illness population and therefore might be more applicable in a dementia setting. Life Valuation The Satisfaction with Life Scale (SWLS) [33], the Valuation of Life Scale (VLS) [34] and the Attitude towards Aging Scale (AtA) [35] were identified and grouped under the construct of ‘life valuation’. The AtA received the highest rating on the quality assessment in the development stage (6/18) illustrating the thoroughness of the reporting style for the AtA, which received a positive score for its reporting of floor/ceiling effects, a criterion that appears to be underreported in scale development. All reported good internal consistency and suitable convergent assessments (table 2). The VLS consists of 2 subscales (positive valuation and negative valuation) and appeared most thorough in the assessment of convergent validity. The authors noted a significant, positive relationship between well-being, hardiness and mastery and positive valuation of life, and a significant negative relationship between negative valuation of life and well-being, hardiness and mastery. Furthermore, a negative relationship was found between positive valuation of life and depression. In contrast, the AtA reported aspects of construct validity but only weak negative correlations with other scales as a questionable indicator of discriminant validity. Three validation studies were identified for the SWLS, consisting of a translation and validation in Turkish older adults [36], a translation and factor analysis in Spanish adolescents and older adults [37] and a Portuguese translation and validation for older adults [38]. Two of these studies reported good to excellent internal consistency for older adults, with appropriate sample sizes and expected significant relationships. The Spanish translation examined factorial variance between adolescents and older adults and concluded that the SWLS was indeed sensitive to both these age groups, with an acceptable one-factor model identified for both. No validation studies were identified for the VLS or AtA. Overall, it appears that the SWLS scale seems most appropriate for future use for people with dementia. Although its development was not as rigorous as the VLS, it has been the subject of at least 3 validation studies for older adults, illustrating its applicability to older

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adults cross-culturally. The AtA is a new scale, which would benefit from additional development with regard to convergent validity before adaption for people with dementia. Autonomy The Maastricht Personal Autonomy Questionnaire (MPAQ) [39] received a score of 8/18 for the quality assessment, illustrating adequate development, particularly with regard to establishing content validity. Acceptable internal consistency was reported using ICC for each of the 3 subscales, and a wide range of expected correlations were noted, thereby establishing its convergent validity (table 2). No validation studies were identified for the MPAQ, but this is unsurprising as the scale was published in 2014. Sense of Coherence The Sense of Coherence Scale (SOCS) [40] is a 29- or 13-item measure. Both the 29- and 13-item scale were given a low score of 2/18 for its development process, largely because information was not available for most of the criteria. For example, whilst it is noted that the scale was developed with a Jewish population, there was no indication of norms for this sample. Furthermore, content validity was difficult to establish as there was no record of target population involvement in the generation of items, and as there was no examination of convergent/divergent validity, construct validity for the scale was questionable. Internal consistency for both the 29- and 13-item versions of the scale was reported and found to be high. However, convergent validity was not examined as the scale was proposed as ‘novel’, and face validity was established from colleague feedback to the author. The 13-item SOCS was subject to a confirmatory factor analysis in a Dutch sample of young adults living with a chronic illness (n = 2,781) [41]. Results indicated that 2 items should be dropped to improve overall consistency and, furthermore, the 3 subscales loaded onto a single order factor model with factor loadings ranging from 0.58 to 1.00. Whilst the development of the scale was lacking in some basic areas, it has since been subject to extensive psychometric assessments. In a review of 124 studies [42], the SOCS was reported to have adequate internal consistency, to be relatively stable over time and predictive of health outcomes including risk of post-traumatic stress symptoms. As such, the SOCS is a well-established outcome measure that could be adopted within psychosocial dementia research. Resourcefulness The Resourcefulness Scale for Older Adults (RSOA) [43] is a 28-item scale developed in older adults, of which there was an average of three chronic health conditions per participant. It was awarded 5/18 on the development of the scale, and notably the authors conducted in-depth factor analyses and reported appropriate levels of internal consistency for subscales and overall scales. However, convergent validity was not established for this scale and, therefore, further development is needed before the possibility of adaptation for people with dementia. Combined Measures The CASP-19 is a 19-item scale developed in a sample of older adults with an age range of 65–75 years and had the greatest score at the quality assessment stage, achieving a score of 9/18. This illustrates its thorough psychometric development, including the use of experts, discussion groups with target populations and factor analyses. Internal consistency was reported for each of the 4 subscales and ranged from α = 0.59 to α = 0.77. Whilst this falls below the acceptable limit for Cronbach’s α, the authors compensated for this by undertaking a factor analysis which suggested evidence for a single, under-

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lying quality of life factor, with strong factor loadings occurring for each of the subscales (0.71–0.88) on a latent factor. The scale was also strongly positively correlated with the Life Satisfaction Index-W (p = 0.001). Whilst The CASP-19 is used as an indicator of quality of life, it was developed using a needs satisfaction model, strongly linked with Maslow’s work on human motivation [44] and assesses quality of life by the degree to which the requirements of the four domains it consists of are satisfied. However, as the CASP-19 is used as a quality of life indicator, validation studies were unlikely to be identified within this review. Nevertheless, the CASP-19 appears to be a psychometrically sound measure that could be used for people with dementia in future instances. Conclusion

Whilst the quality criteria used within this review have been applied to a review of resilience measures [17], this is, to our knowledge, the first review to use well-defined criteria to assess outcome measures in the broad field of PP. It is debateable as to why PP outcome measures have not been developed for or validated in dementia populations as there was no shortage of scales in populations identified as being similar within this review. This may be because of the prevailing medical model of diagnosing and treating dementia despite the emergence of more person-centred models [45], or it may be due to the continuing stigma surrounding the perception of dementia as a negative and debilitating condition, for which there is little to offer [46]. However, we identified a wide range of measures within the constructs of PP that could be further validated for people with dementia. These included the CD-RISC for resilience, the GSWB, FACIT-Sp and SIWB for spirituality, the SWLS and AtA for life valuation, the MPAQ for autonomy, the SOCS for sense of coherence, the RSOA for resourcefulness and the CASP-19 as a combined measure. However, for the constructs of self-efficacy, no suitable scales were identified. Although most scales identified scored moderately on a quality assessment, it is recommended that they are subject to further psychometric assessments, so that clinicians may better understand the potential role of positive traits within well-being for a dementia population. As the efficacy of non-pharmacological interventions within dementia has been established [47], positive outcomes may aid the facilitation of more appropriate psychosocial intervention studies that aim to enhance quality of life. Methodological Problems and Limitations Whilst an effort was made to include all-encompassing PP search terms, results often included outcome measures that were not indicative of PP, and the vast majority was subsequently excluded from the review on this basis. Furthermore, only one definition was used for the review. Whilst this definition was selected for its diverse nature, it is noted that there are variations as to what constitutes PP. Obtaining the original development paper of outcome measures was sometimes difficult and often accomplished through extensive searching of databases. For example, the SOCS proved difficult to obtain, and an additional review of the measure was included in the review to more comprehensively assess its psychometric properties [42]. It is important to acknowledge that 14 of the 16 scales were developed in American populations, the exceptions being the CASP-19, which was developed in a British sample and the AtA, developed in a Portuguese sample. As such, it is questionable as to whether these scales are culturally appropriate for other populations as definitions of positive constructs may differ between cultures. However, of the 14 scales developed in American samples, 6 were

355




translated into other languages and were validated appropriately, the most comprehensive of which was the SWLS, for which we identified three translations within the confines of this review. The quality criteria employed here may have been overly constraining, and their use was largely hindered by a lack of available information. For example, it was nearly impossible to award a score for the responsiveness or reproducibility section of the assessment as authors rarely reported this. This difficulty was also reported by authors using these criteria in previous reviews [17]. Future researchers may wish to include such information for the purpose of future reviews. However, the criteria employed here are amongst the few assessment criteria comprehensive enough to cover most aspects of measurement development. Future Research It has been argued that below a certain level of cognitive function, it is difficult for people with dementia to accurately appraise their quality of life [48], but nevertheless some people still appear able to give a view to their quality of life even with severe impairment. Similar issues complicate the related assessment of PP ratings with people with dementia, which are likely to require more challenging appraisals than quality of life. However, there are so few studies in PP and dementia that further evidence is needed before a more definitive statement can be made. This review highlights the need for authors to better report aspects of scale development and validation. For example, most of the scales identified failed to report a minimal important change (MIC) under the responsiveness criteria of the quality assessment. The exception to this was the MPAQ, although the authors conceded the MIC used during scale development was arbitrarily defined. Only one paper (CD-RISC) examined change in response during treatment for specific subgroups, but no MIC was identified. It is recommended that this should be a requirement of authors when developing scales, to determine a clinically meaningful change in score, as most of these scales are in use for clinical populations. Qualitative research alongside scale development may aid the identification of a clinically meaningful change or sensitivity to the effect of treatment. The populations that were selected for the purpose of this review were chosen with the view to assessing the most suitable and adaptable scales for people with dementia, and consequently future researchers may wish to expand their search to include other populations as well, where there would be a larger range of measures available. The CASP-19 and the AtA were the only measures for which the authors reported a floor and ceiling effect, identifying the range of the scale, skew and kurtosis of results. It is recommended that future authors endeavour to report these factors. Only one scale of self-efficacy was identified for inclusion. The CRSES scored moderately at the quality assessment stage, and no further validation studies were identified. Whilst there is a wealth of research measuring self-efficacy for caregivers of people with dementia [49], there appears to be a lack of research concerning self-efficacy for people with dementia. This may be due to an absence of specific measures, developed for this population. As such, it is recommended that a domain-specific scale of self-efficacy be developed and validated for people with dementia. Domain-specific measures of self-efficacy are often reported to have greater predictive ability and a greater capacity to inform theoretical models [50]. Also of note was the MPAQ, a very recent scale, which scored 8/18 at the quality assessment stage. This scale was developed with older adults who reported a chronic physical illness and, therefore, represents two populations identified as being suitably similar to dementia within this review. Future researchers may wish to refine this measure and validate it for people with dementia.

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As the CASP-19 received the highest score at the quality assessment stage and was developed specifically for older adults, it may be appropriate to assess the psychometric properties of this measure within a dementia population and adapt it, if necessary. Acknowledgements The authors would like to thank Dr. Emese Csipke who provided advice on methodology.

Disclosure Statement The authors declare no competing interests.

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REVIEW OF POSITIVE PSYCHOLOGY OUTCOME MEASURES FOR CHRONIC

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