Assessing the psychometric properties and validating the Portuguese version of the INSPIRE measure of staff support for personal recovery in Portugal.

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Manuela Silva, Deborah Oyine Aluh, Ana Lourenço, Beatriz Resende, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5555928/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Jul, 2025 Read the published version in BMC Psychiatry → Version 1 posted 6 You are reading this latest preprint version Abstract Background : The importance of mental health services that support a recovery-oriented approach is increasingly recognized, and measures that evaluate this practice and promote change over time are needed. The INSPIRE measure is a 27-item questionnaire designed to assess service users’ perceptions of the support received from health professionals in their personal recovery. This study aimed to validate the Portuguese version of INSPIRE and assess its psychometric properties as a measure of staff support for personal recovery. Methods : The questionnaire survey was conducted from October 2023 to February 2024. Service users completed the Portuguese version of INSPIRE, the Client Satisfaction Questionnaire (CSQ-8), and a demographic and clinical questionnaire. Internal consistency was assessed using Cronbach’s alpha and McDonald's model-based Omega. Test-retest reliability was assessed through the intraclass correlation coefficient (ICC) and weighted kappa. Convergent validity was examined by assessing correlation with CSQ-8. Factor validity was evaluated using exploratory factor analysis (EFA), with confirmatory factor analysis (CFA) performed to test the fit of factor structures derived from the EFA. Results : The study included 165 participants from seven psychosocial rehabilitation units which primarily target persons with a severe mental illness. For test–retest evaluation, 52 participants completed the questionnaire a second time. Internal consistency was satisfactory across all subscales and dimensions of the Support subscale, except for the Identity domain, which had marginally acceptable values. INSPIRE demonstrated significant positive correlations with CSQ-8 scores, supporting its convergent validity. EFA identified five factors for the Support scale and one factor for the Relationship scale, explaining 62% and 59% of the cumulative variance, respectively. CFA confirmed a good model fit for the Relationship scale and all Support subscales, except for the Identity and Empowerment subscales. Conclusions : The Portuguese version of INSPIRE showed strong internal consistency, as well as convergent and factor validity. This validated instrument can be applied in research and clinical settings to assess staff support for personal recovery and promote recovery-oriented mental health practices. mental health recovery support measurement reliability validity INSPIRE BACKGROUND Globally, there is growing recognition of the need to provide mental health services that emphasize a recovery-oriented approach ( 1 – 4 ). Personal recovery is described as a deeply individual and unique process, defined as "a way of living a satisfying, hopeful, and contributing life despite the limitations caused by illness" ( 5 ). Although each person’s experience of recovery is unique, common themes include the significance of hope, taking personal responsibility, receiving support from others, engaging in meaningful activities, and developing a positive sense of identity ( 6 ). To capture this, a conceptual framework has identified five key processes in personal recovery: Connectedness, Hope, Identity, Meaning, and Empowerment (the CHIME Framework) ( 7 ). The lived experiences and perspectives of individuals with mental health challenges are central to fostering a recovery-oriented culture ( 8 ). Recovery, as a concept, was developed by and for individuals with mental health issues to describe their own journeys and affirm their identity beyond the limitations of their diagnoses ( 8 ). Personal recovery differs from clinical recovery, which is based on the medical model and focuses on the "remission of illness" as the goal of recovery ( 9 ). Recovery-oriented mental health practices and service delivery represent an approach that emphasizes personal recovery in mental health care. Insights from global best practices have outlined four key domains in supporting recovery: supporting personally defined recovery, working relationships, organisational commitment and promoting citizenship ( 10 ). This approach integrates the principles of self-determination and personalised care, emphasises hope, social inclusion, community participation, personal goal setting and self-management ( 11 ), and is guided by a set of underpinning values different from those that have traditionally informed mental health services ( 12 ). A mental health service system that is guided by the rehabilitation and recovery perspective has a more complete understanding of the total impact of severe mental illness, with an emphasis on treating the consequences of the illness rather than just the illness per se, and on meeting the multiple residential, vocational, educational, and social needs and wants ( 5 ). Current guidelines advocate for the adoption of recovery-oriented approaches by mental health teams and services for several reasons: research indicates they lead to improved outcomes ( 13 ), longitudinal studies have provided evidence that recovery is achievable ( 14 ), and they align with the lived experiences of individuals with mental health problems, reflecting what has supported their recovery journeys ( 15 , 16 ). Despite this, the practical implementation and integration of recovery principles into everyday practice remain limited ( 17 ). Various tools have been developed to evaluate the recovery orientation of mental health services, including the Attitudes towards Recovery Questionnaire (ARQ) ( 18 ), INSPIRE ( 19 ), the Mental Health Recovery Measure (MHRM) ( 20 , 21 ), the Provider Expectations for Recovery Scale (PERS) ( 22 ), the Recovery Attitudes Questionnaire (RAQ) ( 23 ), the Recovery Knowledge Inventory (RKI) ( 24 ), the Recovery Promoting Relationships Scale (RPRS) ( 25 ), the Recovery-Oriented Services Assessment (ROSA) ( 26 ), and RECOLLECT ( 27 ). However, there is currently no single, universally accepted measure that meets all criteria: psychometric validity and reliability, sensitivity to change, ease of use, and compatibility with both the conceptual frameworks of personal recovery and recovery-oriented services or systems. This lack of a standardized tool presents an ongoing challenge. Among these, INSPIRE stands out as the only measurement tool that aligns closely with the CHIME framework, is validated, reliable, and capable of assessing the recovery orientation of services from the perspective of the service user ( 28 , 29 ). The full version of INSPIRE measure is a 27-item questionnaire designed to assess service users’ experiences of support from health professionals in their personal recovery ( 19 ). It consists of two subscales: a 20-item Support subscale and a 7-item Relationship subscale. The Support subscale assesses the CHIME recovery processes, covering five domains: Connectedness (items S1–S4), Hope (items S5–S8), Identity (items S9–S12), Meaning and Purpose (items S13–S16), and Empowerment (items S17–S20). Each item is initially rated as being important for recovery (yes/no). For the items rated as important (i.e., yes), the level of support received from a mental health worker is rated on a 5-point Likert scale, ranging from “not at all” to “very much”. The Relationship subscale evaluates the working relationship between service users and providers, with items rated on a 5-point Likert scale from “strongly disagree” to “strongly agree.” Scores are calculated for each subscale, ranging from 0 (lowest support for recovery) to 100 (highest support for recovery). Scores below 72% in the Support subscale suggest the support may not be perceived as helpful, while scores below 78% in the Relationship subscale indicate that the quality of the relationship is perceived as insufficient and could be improved. Standardized recovery measures play a critical role in advancing research in this area and developing recovery-oriented system. Validation involves testing instruments across diverse settings to determine their accuracy, dependability and consistency in measuring what it purports to measure ( 30 ). In Portugal, we are now living a momentum of transformation and reform in mental health care, with the development of community mental health teams and recovery-oriented interventions and services. The validation of the full version of INSPIRE could inform clinical interventions, evaluation strategies, service development, and workforce planning. Additionally, using INSPIRE across different teams and over time could promote cross-team learning, guide policy decisions, and track progress in service improvement. The INSPIRE tool has been validated among community mental health service users in Japan ( 31 ) and in Sweden ( 32 ), demonstrating its reliability and validity. The present study aims to assess the internal consistency, test-retest reliability, and convergent and factor validity of the Portuguese version of INSPIRE for users of mental health services in Portugal. METHODS Study setting This study was conducted in psychosocial rehabilitation units, including four community rehabilitation centers and three day-hospitals within public psychiatric departments, all situated in the Lisbon Metropolitan Area. These units primarily serve individuals diagnosed with severe mental illness. These services were chosen because they were already involved in a broader ongoing study. The survey was conducted from October 2023 to February 2024. The authors took the questionnaires to the psychosocial rehabilitation units and information was provided to the staff to describe the INSPIRE measure and the study of evaluation of its psychometric properties and to explain the process of distributing and completing the questionnaire. Staff were instructed to distribute the questionnaire to all patients attending the services during the study period, explaining the purpose of the study, but refraining from helping to fill out the questionnaire. Staff also cooperated in the re-test to verify the test-retest reliability. Study participants All patients who were receiving services in the included psychosocial rehabilitation units were asked to participate. Service users should meet the following inclusion criteria: (1) use of community psychosocial rehabilitation centers and day hospitals, (2) age 18 years or older, (3) having a severe mental illness, (4) being able to give informed consent to participate in the study. After giving written informed consent, participants completed the questionnaire themselves. Participation was voluntary. Measures Client satisfaction questionnaire Service user satisfaction was measured using the 8-item Client Satisfaction Questionnaire (CSQ-8). Each item is rated on a 4-point Likert scale, ranging from "poor" to "excellent." The total score can range from 8 to 32, with higher scores reflecting higher levels of satisfaction (33). Demographic and clinical variables Demographic and clinical variables included age, gender, marital status, educational level, employment status, monthly income and psychiatric diagnosis. Procedure After obtaining permission from the authors to translate and use INSPIRE, a bilingual native speaker with clinical experience translated the 27-item full English version into Portuguese. This translation was then reviewed by a team of expert native speakers. Following this, an independent translator performed a back-translation of the Portuguese version into English, which was subsequently verified for accuracy by a team of experts. The instrument was then pilot tested with 5 patients from one of the community psychosocial rehabilitation centers involved in the study to identify any issues or misunderstandings with the terminology. No adjustments were needed at this stage. The study instrument was given to the participants at the initial time point (T0), and the same instrument was administered again two weeks later (T1). Participants completed the sociodemographic questionnaire at T0, and the 8-item Client Satisfaction Questionnaire (CSQ-8) was also recorded at T0. The study received approval from the Ethical Committee of the Nova Medical School (nº 121/2023/CEFCM). Written informed consent was obtained from all participants. Statistical Analysis The data processing and statistical analyses for the study were conducted using R software (Version 4.1.3) along with the dplyr (Version 1.1.0) and Psych (Version 2.2.3) packages. Descriptive statistics were initially performed to determine the number of valid responses for further analysis. Only responses with at least one completed item were included. Reliability was assessed by estimating internal consistency for the support subscale as a whole and for each of its five domains, as well as for the relationship subscale, using Cronbach’s alpha (35) and McDonald’s model-based Omega (ω) (36). A Cronbach’s alpha of 0.70 or higher was considered acceptable. Test-retest reliability was evaluated in a subsample of respondents who completed the survey a second time two weeks later. Weighted Kappa (for nominal data) and intraclass correlation coefficients (ICC; for ordinal data) were calculated for each item to assess the agreement between the first and second assessments (37). Kappa and ICC values were interpreted as follows: below 0.20 was poor agreement, 0.21–0.40 was fair, 0.41–0.60 was moderate, 0.61–0.80 was good, and 0.81–1.00 was very good agreement (37). Convergent validity for the support and relationship subscales was evaluated by correlating them with the CSQ-8 using Pearson's product-moment correlation. As there are no established criteria for convergent validity coefficients, values greater than 0.30 were considered satisfactory, reflecting a medium effect size according to Cohen (38). For further analysis, factor validity was assessed for each of the two INSPIRE subscales using responses from participants who answered "yes" to all items in the support subscale (20 items) and the relationship subscale (7 items). The appropriateness of the data for exploratory factor analysis (EFA) was first tested using the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy and Bartlett’s test of sphericity, with a p-value less than 0.05 considered significant for each subscale. EFA for each subscale was conducted using oblimin rotation, and factor loadings greater than 0.3 were considered for interpretation. Confirmatory factor analysis (CFA) was then performed to assess how well the data fit the factor structure derived from the EFA. Based on theoretical assumptions, five underlying factors were hypothesized. Due to issues with matrix invertibility when Empowerment and Relationship were included, CFA was conducted separately for each latent variable. The chi-square fit index was used to evaluate the fit between the hypothesized model and the data, (39) and the model fit was assessed using multiple indices: the ratio of χ2 to df (≤ 2), the Comparative Fit Index (CFI > 0.95), the Tucker-Lewis Index (TLI), and the Root Mean Square Error of Approximation (RMSEA < 0.07). (40,41). Two-tailed p-values below 0.05 were considered statistically significant. RESULTS Sociodemographic characteristics of the study sample A total of 165 questionnaires were collected with varying level of completion while 52 questionnaires were collected at the second assessment. A majority of the study sample were male (60.4%, n = 93), single (83.7%, n=128) and had schizophrenia and other related diagnosis (60.7%, n = 91). The mean age of the study sample was 47.197±12.329. Table 1: Sociodemographic characteristics of the study sample Variable Frequency Percentage a Gender (n=154) Male 93 60.4 Female 61 39.6 Marital status (n=153) Single 128 83.7 Married 13 8.5 Divorced 10 6.5 Widowed 2 1.3 Education (n=153) Primary 19 12.4 Basic 46 30.1 Secondary 59 38.6 University 29 19.0 Profession (n=152) Low employed 12 7.9 Unemployed 46 30.3 Retired 50 32.9 Student 9 5.9 Domestic 1 0.7 Without activity 34 22.4 Monthly income (Euros) (n= 135) 2000 3 2.2 Diagnosis (n= 150) Schizophrenia & other related diagnosis 91 60.7 Depression 26 17.3 Bipolar disorder 15 10.0 Other b 18 12.0 a: valid percentages are presented discounting missing variables. b: other include personality disorders, obsessive-compulsive disorder, and intellectual disability Reliability of the Portuguese-INSPIRE The measures of internal consistency were found to be satisfactory while the test-retest reliability did not show good consistency between the two measurements as ICC values less than 0.5 are indicative of poor reliability. (Table 2) Table 2: Reliability parameters of the Portuguese-INSPIRE Internal consistency Test-retest reliability Subscales McDonald's ω Cronbach's α ICC p-value Support 0.93 0.93 0.023 0.33 Relationship 0.90 0.91 -0.011 0.65 Domains Connectedness 0.82 0.82 0.037 0.20 Hope 0.84 0.84 0.041 0.19 Identity 0.72 0.69 0.045 0.18 Meaning & Purpose 0.77 0.78 0.018 0.29 Empowerment 0.80 0.79 0.028 0.24 Convergent Validity The correlation between the support subscale and the CSQ-8 score is positive and moderate (r=0.47, p-value < 0.001) and correlation between the Relationship subscale and the CSQ-8 is also positive and moderate (r=0.47, p-value < 0.001) demonstrating good convergent validity. Exploratory factor analysis To evaluate the factor validity of the INSPIRE support subscale, 150 responses in which all 20 items in the subscale were answered "yes" were analysed, revealing five factors based on a loading cutoff criterion of 0.3. Similarly, for the relationship subscale, 155 responses where all 7 items were answered were used. The KMO score for the support subscale was 0.89, and Bartlett's test of sphericity was significant (χ2 = 1892, df = 190, p < 0.001), indicating that factor analysis was appropriate. For the relationship subscale, the KMO score was 0.91, and Bartlett’s test of sphericity was also significant (χ2 = 612, df = 21, p < 0.001), confirming the suitability of factor analysis. The first factor MR1 represents the “Hope” domain (S5 to S8). The third factor (MR3) is clearly representing the “Connectedness” domain (S1 to S4). Some items from “Meaning and purpose” (S13 to S16) and others from “Empowerment” (S17 to S20) are together in the MR4 factor, meaning that these two domains are not clearly distinct (Table 3). The factor structure obtained had a cumulative explained variance of 62% (MR1 = 19%; MR2 = 15%; MR3 = 13%; MR4 = 10%; MR 5 = 5%). Table 3: Standardized factor loadings for the support subscale MR1 MR4 MR3 MR2 MR5 S1 0.85 S2 0.492 S3 0.628 S4 0.588 S5 0.818 S6 0.604 S7 0.388 0.336 S8 0.916 S9 0.344 S10 0.492 0.461 S11 0.922 S12 0.739 S13 0.352 S14 0.35 0.381 S15 0.312 0.403 S16 0.405 0.422 S17 0.652 0.302 S18 0.815 S19 0.314 S20 0.393 0.417 In the Factor Analysis dealing with Relationship items (n=1 factor to extract), the factor loadings were large (>0.70 in all cases) defining one Relationship factor (Table 4). The one-factor structure had a cumulative explained variance of 59%. Table 4: Standardized factor loadings for the Relationship subscale MR1 h2 u2 R1 0.82 0.68 0.32 R2 0.78 0.61 0.39 R3 0.72 0.52 0.48 R4 0.75 0.57 0.43 R5 0.78 0.61 0.39 R6 0.80 0.63 0.37 R7 0.71 0.50 0.50 Confirmatory Factor Analysis The R output could not compute the entire model because the main matrix was not invertible when Empowerment and Relationship domain were included. Excluding these domains yielded a model where the Chi-square had significant p-value (< 0.001), rejecting the null hypothesis that this model fits our data. So, a Confirmatory Factor Analysis was conducted for each latent variable. Since the p-value of the Chi-square test is non-significant (p= 0.156) for Item 1-4 of the support scale, we can retain the null hypothesis that “Connectedness” is well represented by the 4 first questions of the questionnaire. For the “Hope” domain, the p-value (0.44) of the Chi-square test indicates that Hope is well represented by the questions S5 to S8. Considering the “Identity” domain S9 to S12, the low p-value (<0.001) of the Chi-square test reveals that there is a mismatch between that factor and the data. For the Relationship feature, the p-value of the Chi-square test was non-significant (p = 0.284) when the scaled data was considered, meaning that Relationship subscale is well represented by the items R1 to R7 (Table 5). Table 5: Fit indices for latent variables tested. Latent variable χ2 Df p-value CFI TLI RMSEA Connectedness (S1-S4) 3.714 6 0.156 0.975 0.926 0.076 Hope (S5-S8) 1.145 2 0.564 1.000 1.016 0 Identity (S9-S12) 21.296 2 < 0.001 0.746 0.238 0.254 Meaning & Purpose (S13-S16) 1.841 2 0.398 1 1.006 0 Empowerment (S17-S20) 35.456 2 <0.001 0.830 0.491 0.334 Relationship (R1-R7) 16.492 14 0.284 0.991 0.986 0.034 χ2 = Chi-Square statistic; df = degrees of freedom; CFI = Comparative Fit Index; TLI = Tucker Lewis Index; RMSEA = Root Mean Square Error of Approximation DISCUSSION This study examined the psychometric properties of the Portuguese version of INSPIRE among users of psychosocial rehabilitation units, which primarily serve persons with a clinical diagnosis of severe mental illness. The findings indicate that INSPIRE demonstrates satisfactory internal consistency; however, the test-retest reliability did not exhibit strong consistency. Participants were recruited from various psychosocial rehabilitation units, including community rehabilitation centers, day hospitals, and multiple clinical teams, providing a broad spectrum of service experiences and clinical backgrounds. The sample reflected demographic diversity in age, gender, socioeconomic status, and urban or rural residence, which may enhance the generalizability of the findings. Portugal’s linguistic uniformity, with no significant regional dialects, supports the assumption that the questionnaire would be consistently interpreted and representative of the national population. Additionally, the Lisbon metropolitan area attracts individuals from across the country, further strengthening sample representativeness. Given the national guidelines for mental health service organization, participants’ experiences are likely to reflect the broader national context. Reliability refers to the consistency of results when a testing procedure is repeated ( 42 ). There are various types of scale reliability: ( 1 ) the equivalence of items in a test (internal consistency) or of assessments made by different observers using the same instrument (interrater reliability) and ( 2 ) the stability of measurements taken at different times from the same individuals (test–retest reliability) ( 43 ). Internal consistency evaluates how well all items in a scale measure the same construct ( 43 ). It is recommended that new instruments achieve a minimum Cronbach's alpha of 0.70, while established instruments should meet a threshold of 0.80 ( 19 , 31 , 32 , 44 ). In this study, both Cronbach's alpha and McDonald's omega indicated satisfactory internal consistency for the subscales and for the dimensions within the support subscale, except for the Identity domain, which showed marginally acceptable values. Like previous studies ( 19 , 31 , 32 ), the alpha coefficient for the total score of the support subscale was notably high (0,93), suggesting potential redundancy, with some items possibly addressing the same concepts in slightly different ways ( 44 ). Future research with other Portuguese samples could explore whether reducing the number of items improves the instrument's efficiency. Test–retest reliability, which assesses the stability of measurements over time, is determined by administering the test at two different points in time to the same individuals and analysing the correlation or strength of association between the scores ( 43 ). The timing of the second administration is critical: the interval should be long enough to avoid carryover effects from the initial assessment but short enough to prevent changes in health status or learning from altering responses ( 43 ). The changing nature over time of the construct being measured is the second main factor which may influence the evaluation of test-retest reliability ( 45 ). ICC (Intraclass Correlation Coefficient) is a reliability measure that assesses both the correlation and agreement between measurements, and values less than 0.5, between 0.5 and 0.75, between 0.75 and 0.9, and greater than 0.90 are indicative of poor, moderate, good, and excellent reliability, respectively ( 46 ). In this study, the test-retest reliability showed inconsistent results. This result may be attributed to variations in the timing of the second assessment, which may have varied somewhat between the different psychosocial rehabilitation units. It may also reflect changes in participants’ functioning, mood or willingness to collaborate. Validity assesses the extent to which an instrument measures what it is intended to measure ( 43 ). Validity is not an inherent characteristic of the instrument itself but depends on its use in a particular context ( 42 ). When an instrument is used in a new context, its validity must be evaluated ( 42 ). In this study, correlations between INSPIRE subscales and the CSQ-8 were positive and moderate (Pearson’s correlation: 0.47), supporting INSPIRE’s validity as a measure of staff support for personal recovery. Factor analysis explores relationships among survey items to determine whether subsets of items are more closely related to one another than to others, thereby analysing dimensionality among the items ( 42 ). The exploratory factor analysis in this study identified five factors, but there was cross-loading of items in the Meaning and Purpose and Empowerment domains, suggesting that these items may measure overlapping concepts. This could indicate that Meaning and Purpose are not entirely distinct from Empowerment within the context of recovery. In fact, within the CHIME framework of mental health recovery, Meaning and Purpose and Empowerment are closely intertwined rather than entirely distinct concepts. Both components center around the individual’s agency and sense of self in the recovery journey. Meaning and Purpose involves having direction, goals, and a sense that life holds value, while Empowerment is about gaining confidence, autonomy, and control over one’s life. However, discovering meaning in one’s experiences, roles, or future aspirations often leads to a sense of empowerment. Conversely, feeling empowered can motivate someone to pursue or reclaim purpose in life. Rather than existing in isolation, these elements reinforce one another. Recognizing this interconnection is vital for person-centered recovery approaches, as it allows for more integrated and holistic support strategies. Confirmatory factor analysis of each latent variable revealed good model fit for most domains, although the Identity and Empowerment domains showed some inconsistencies. Certain items, such as “Feeling I can deal with stigma” (S9), may reflect concepts (stigma, in this case) that are more research-oriented and less familiar in everyday use. Additionally, items like “Having my spiritual belief respected” (S11) and “Having my ethnic/cultural/racial identity respected” (S12), also within the Identity domain, may reflect cultural and ethnic differences between the British population, where the INSPIRE instrument was originally developed, and the population that participated in the validation of the instrument in Portugal, with less ethnic diversity. These variations might also stem from the heterogeneity of the studied sample or non-independent observations ( 47 ). For the Relationship subscale, factor loadings of 0.70 or higher confirmed the one-factor structure consistent with the structure of the original INSPIRE ( 19 ). The Confirmatory factor analysis also indicated good model fit with satisfactory fit indices. Strengths and Limitations This study makes a valuable contribution by validating a measure to assess staff support for personal recovery within the Portuguese context. Participants were a convenience sample of service users from various psychosocial rehabilitation units in the Lisbon metropolitan area. Nevertheless, some methodological limitations should be noted. First, the selection of participants from specific geographic areas and service types may restrict the generalizability of the findings. However, the sample reflects clinical and demographic diversity in age, gender, socioeconomic status, urban/rural residence, and service background. Moreover, Portugal’s relative linguistic and organizational homogeneity supports broader applicability. Second, the test-retest reliability revealed limited consistency. Future research should adopt a more rigorous approach to timing between assessments to better evaluate this dimension. Third, convergent validity was assessed using the Portuguese version of the Client Satisfaction Questionnaire, even though this tool has not been previously validated. Fourth, the rarity of service users evaluating psychiatric service quality, service providers, and recovery processes adds complexity to the study design and interpretation. Finally, the questionnaires were distributed by the staff under evaluation. Although anonymity and confidentiality were assured, this distribution method may have introduced bias. CONCLUSIONS This study confirmed the internal consistency, as well as the convergent and factor validity, of the Portuguese version of INSPIRE among users of psychosocial rehabilitation units in Portugal. The findings support INSPIRE as a reliable tool for assessing staff support for personal recovery. By facilitating structured conversations between users and staff, INSPIRE can promote person-centered care and help identify individual support priorities. It also offers a valuable means of evaluating personal recovery experiences, comparing practices against national and international standards, and monitoring progress over time — contributing to the advancement of a recovery-oriented mental health system. Furthermore, INSPIRE may play a key role in developing training programs for mental health professionals and guiding future research on how services can better support personal recovery in Portuguese-speaking countries. Abbreviations ARQ: Attitudes towards Recovery Questionnaire; CFA: Confirmatory factor analysis; CFI: Comparative Fit Index; CHIME: Connectedness, Hope, Identity, Meaning and Empowerment; CSQ-8: Client Satisfaction Questionnaire; EFA: Exploratory factor analysis; ICC: Intraclass Correlation Coefficients; KMO: Kaiser-Meyer-Olkin; MHRM: Mental Health Recovery Measure; PERS: Provider Expectations for Recovery Scale; RAQ: Recovery Attitudes Questionnaire; RKI: Recovery Knowledge Inventory; RMSEA: Root Mean Square Error of Approximation; RPRS: Recovery Promoting Relationships Scale; ROSA: Recovery-Oriented Services Assessment; TLI: Tucker Lewis Index. Declarations Clinical trial number Not applicable Ethics approval and consent to participate The study was approved by the Ethical Committee of the Nova Medical School (nº 121/2023/CEFCM) and has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Written informed consent was obtained from all individual participants included in the study. Participation was voluntary. Consent for publication Not applicable Availability of data and materials The datasets generated and analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study integrated the research project “Effectiveness of the Critical Time Intervention-Peer Support (CTI-PS) model for persons with serious mental illness discharged from inpatient psychiatric treatment facilities in Portugal”, funded by FLAD – Luso-American Development Foundation. Authors' contributions MS conceptualised the study design, contributed to data analysis and interpretation, and drafted the manuscript. DOA made substantial contributions to the study design, data analysis and interpretation, and substantively reviewed the manuscript. MJH, JG and GC contributed to the study design and reviewed the manuscript. All authors read and approved the submitted version of the manuscript. Acknowledgements The authors are grateful to the participants for taking part in the study, and would like to acknowledge the assistance of the staff in the psychosocial rehabilitation units: Dr. Catarina Klut (Unidade Local de Saúde de Loures-Odivelas), Nurse Ana Paula Alves, Dr. Paula Godinho, Dr. Patrícia Baronet and Dr. Marta Croca (Unidade Local de Saúde Santa Maria), Dr. Paula Duarte and Dr. Marta Moreira (Unidade Local de Saúde de Lisboa Ocidental), Dr. Beatriz Carapeta (GAC – Grupo de Ação Comunitária), Dr. Sofia Couto (GIRA – Grupo de Intervenção e Reabilitação Activa), Dr. Catarina Malcata and Dr. Sílvia Almeida (ARIA – Associação de Reabilitação e Integração Ajuda) and Dr. Susana Guimarães (Recomeço - Associação para a Reabilitação e Integração Social Amadora/Sintra). References World Health Organization. Guidance on community mental health services: promoting person-centred and rights-based approaches. . Geneva: World Health Organization; 2021. World Health Organization. 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A structured review of psychiatric rehabilitation for individuals living with severe mental illness within three regions of the Asia-Pacific: Implications for practice and policy. Vol. 11, Asia-Pacific Psychiatry. Wiley-Blackwell; 2019. National Institute for Health and Care Excellence. Rehabilitation for adults with complex psychosis NICE guideline. 2020 [cited 2024 Jun 5]; Available from: www.nice.org.uk/guidance/ng181 Harding CMBG ATSJBA. The Vermont longitudinal study of persons with severe mental illness, II: Long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia. American Journal of Psychiatry. 1987 Jun;144(6):727–35. Ridgway P. ReStorying psychiatric disability: Learning from first person recovery narratives. Psychiatr Rehabil J. 2001;24(4):335–43. Deegan PE. Recovery: The lived experience of rehabilitation. Psychiatr Rehabil J. 1988;11:11–9. Slade M, Bird V, Clarke E, Le Boutillier C, McCrone P, Macpherson R, et al. Supporting recovery in patients with psychosis through care by community-based adult mental health teams (REFOCUS): a multisite, cluster, randomised, controlled trial. Lancet Psychiatry. 2015 Jun;2(6):503–14. Mak WWS, Chan RCH, Yau SSW. Development and validation of Attitudes towards Recovery Questionnaire across Chinese people in recovery, their family carers, and service providers in Hong Kong. Psychiatry Res. 2018 Sep;267:48–55. Williams J, Leamy M, Bird V, Le Boutillier C, Norton S, Pesola F, et al. Development and evaluation of the INSPIRE measure of staff support for personal recovery. Soc Psychiatry Psychiatr Epidemiol. 2015 May 20;50(5):777–86. Bullock W& YS. The mental health recovery measure (MHRM). In Toronto: 111th Annual Meeting of the American Psychological Association.; 2003. Oliveira-Maia AJ, Mendonça C, Pessoa MJ, Camacho M, Gago J. The mental health recovery measure can be used to assess aspects of both customer-based and service-based recovery in the context of severe mental illness. Front Psychol [Internet]. 2016 Nov 3 [cited 2024 Aug 24];7(NOV):210927. Available from: www.frontiersin.org Salyers MP, Brennan M, Kean J. Provider Expectations for Recovery Scale: Refining a measure of provider attitudes. Psychiatr Rehabil J. 2013 Sep;36(3):153–9. Borkin JR SJELKKWHWKYN. Recovery Attitudes Questionnaire: Development and evaluation. . Psychiatr Rehabil J . 2000;24(2):95–102. Bedregal LE OMDL. The Recovery Knowledge Inventory: Assessment of Mental Health Staff Knowledge and Attitudes aboutRecovery. . Psychiatr Rehabil J . 2006;30(2):96–103. Russinova Z, Rogers ES, Cook KF, Ellison ML, Lyass A. Conceptualization and measurement of mental health providers’ recovery-promoting competence: The Recovery Promoting Relationships Scale (RPRS). Psychiatr Rehabil J. 2013;36(1):7–14. Lodge AC, Kuhn W, Earley J, Stevens Manser S. Initial development of the recovery-oriented services assessment: A collaboration with peer-provider consultants. Psychiatr Rehabil J. 2018 Jun;41(2):92–102. Toney R, Knight J, Hamill K, Taylor A, Henderson C, Crowther A, et al. Development and Evaluation of a Recovery College Fidelity Measure. The Canadian Journal of Psychiatry. 2019 Jun 30;64(6):405–14. Penas P IIMMUJ. How is evaluated mental health recovery? Actas Esp Psiquiatr. 2019;47(1):23–32. Leamy M, Foye U, Hirrich A, Bjørgen D, Silver J, Simpson A, et al. A systematic review of measures of the personal recovery orientation of mental health services and staff. Vol. 17, International Journal of Mental Health Systems. BioMed Central Ltd; 2023. Sherina Mohd Sidik. Validation studies. In: Taylor & Francis Group, editor. How To Do Primary Care Research. 1st Edition. 2018. Kotake R, Kanehara A, Miyamoto Y, Kumakura Y, Sawada U, Takano A, et al. Reliability and validity of the Japanese version of the INSPIRE measure of staff support for personal recovery in community mental health service users in Japan. BMC Psychiatry. 2020 Feb 7;20(1). Schön UK, Svedberg P, Rosenberg D. Evaluating the INSPIRE measure of staff support for personal recovery in a Swedish psychiatric context. Nord J Psychiatry. 2015 May 1;69(4):275–81. Larsen DL, Attkisson CC, Hargreaves WA, Nguyen TD. Assessment of client/patient satisfaction: Development of a general scale. Eval Program Plann. 1979 Jan;2(3):197–207. R Core Team. R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. 2018. Cronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrika [Internet]. 1951 Sep [cited 2024 Apr 22];16(3):297–334. Available from: https://link.springer.com/article/10.1007/BF02310555 Gadermann AM, Guhn M, Zumbo BD. Estimating ordinal reliability for likert-type and ordinal item response data: A conceptual, empirical, and practical guide. Practical Assessment, Research and Evaluation. 2012;17(3):1–13. Altman DG. Practical Statistics for Medical Research. Practical Statistics for Medical Research [Internet]. 1990 Nov 22 [cited 2024 Apr 22]; Available from: https://www.taylorfrancis.com/books/mono/10.1201/9780429258589/practical-statistics-medical-research-douglas-altman Cohen J. Statistical Power Analysis for the Behavioral Sciences. Statistical Power Analysis for the Behavioral Sciences [Internet]. 2013 May 13 [cited 2023 Jul 15]; Available from: https://www.taylorfrancis.com/books/mono/10.4324/9780203771587/statistical-power-analysis-behavioral-sciences-jacob-cohen Jöreskog KG. A general approach to confirmatory maximum likelihood factor analysis. Psychometrika [Internet]. 1969 Jun [cited 2024 Apr 26];34(2):183–202. Available from: https://link.springer.com/article/10.1007/BF02289343 Schreiber JB. Core reporting practices in structural equation modeling. Res Social Adm Pharm [Internet]. 2008 Jun [cited 2024 Apr 22];4(2):83–97. Available from: https://pubmed.ncbi.nlm.nih.gov/18555963/ Hooper D, Coughlan J, Mullen MR. Structural Equation Modelling: Guidelines for Determining Model Fit. Electronic Journal of Business Research Methods [Internet]. 2008 Sep 1 [cited 2024 Apr 22];6(1):pp53‑60-pp53‑60. Available from: https://academic-publishing.org/index.php/ejbrm/article/view/1224 Knekta E, Runyon C, Eddy S. One size doesn’t fit all: Using factor analysis to gather validity evidence when using surveys in your research. CBE Life Sci Educ. 2019 Mar 1;18(1). Kimberlin CL, Winterstein AG. Validity and reliability of measurement instruments used in research. Vol. 65, American Journal of Health-System Pharmacy. American Society of Health-Systems Pharmacy; 2008. p. 2276–84. Fleiss JL, Cohen J. The Equivalence of Weighted Kappa and the Intraclass Correlation Coefficient as Measures of Reliability. Educ Psychol Meas. 1973 Oct 2;33(3):613–9. Shou Y, Sellbom M, Chen HF. Fundamentals of Measurement in Clinical Psychology. In: Comprehensive Clinical Psychology. Elsevier; 2022. p. 13–35. Koo TK, Li MY. A Guideline of Selecting and Reporting Intraclass Correlation Coefficients for Reliability Research. J Chiropr Med. 2016 Jun 1;15(2):155–63. Fouladi RT. Performance of Modified Test Statistics in Covariance and Correlation Structure Analysis Under Conditions of Multivariate Nonnormality. Struct Equ Modeling. 2000 Jul;7(3):356–410. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 01 Jul, 2025 Read the published version in BMC Psychiatry → Version 1 posted Editorial decision: Accepted 30 May, 2025 Reviews received at journal 19 May, 2025 Reviewers agreed at journal 21 Apr, 2025 Reviewers invited by journal 15 Apr, 2025 Submission checks completed at journal 12 Apr, 2025 First submitted to journal 11 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5555928","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":443343716,"identity":"526fa5b8-5d4f-47ad-a8a8-6c623550bf3f","order_by":0,"name":"Manuela Silva","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYNCCAiBmZm5gYKiAMQgCA5BKRqDKMzAGUVoYgCoZ26AMfEC3/ewxiQ8Gdgzy7YxtEj/n1UbztwO1/KjYhlOL2Zm8NMkZBskMBocZ2yR7tx3PnXGYsYGx58xt3FoO5JhJ8xgwMxgwMzYb8G47ltsA1MLM2IZHy/k3ZtJ/DOoZ5JsZmw3/zjmWO5+glhtAW4CuYmA4zNj4mLehJncDYS1vjC17DI7zGIC0yBw7kLsRqOUgXr+czzG88aOiWk6+//CBg29q6nLnnT988MGPCtxaYIAHSh8GkwcIqkcCdaQoHgWjYBSMghECAMdmV89z+8i+AAAAAElFTkSuQmCC","orcid":"","institution":"Lisbon Institute of Global Mental Health","correspondingAuthor":true,"prefix":"","firstName":"Manuela","middleName":"","lastName":"Silva","suffix":""},{"id":443343717,"identity":"7a2741a2-3d99-4320-855b-181e2eb25e70","order_by":1,"name":"Deborah Oyine Aluh","email":"","orcid":"","institution":"Lisbon Institute of Global Mental Health","correspondingAuthor":false,"prefix":"","firstName":"Deborah","middleName":"Oyine","lastName":"Aluh","suffix":""},{"id":443343718,"identity":"971c75cd-ee70-49f9-b5d3-717de645019b","order_by":2,"name":"Ana Lourenço","email":"","orcid":"","institution":"Department of Psychiatry and Mental Health, Unidade Local de Saúde Santa Maria","correspondingAuthor":false,"prefix":"","firstName":"Ana","middleName":"","lastName":"Lourenço","suffix":""},{"id":443343719,"identity":"77657fe4-22e5-4434-816a-33df1eddbf5e","order_by":3,"name":"Beatriz Resende","email":"","orcid":"","institution":"Department of Psychiatry and Mental Health, Unidade Local de Saúde de Loures-Odivelas","correspondingAuthor":false,"prefix":"","firstName":"Beatriz","middleName":"","lastName":"Resende","suffix":""},{"id":443343720,"identity":"42cc728d-f5cc-42c6-9d6a-78e396df6452","order_by":4,"name":"Francisco Agostinho","email":"","orcid":"","institution":"Department of Psychiatry and Mental Health, Unidade Local de Saúde de Loures-Odivelas","correspondingAuthor":false,"prefix":"","firstName":"Francisco","middleName":"","lastName":"Agostinho","suffix":""},{"id":443343721,"identity":"1fda249f-6f4c-4e28-a826-e7f68eba91cd","order_by":5,"name":"João Bessa Rodrigues","email":"","orcid":"","institution":"Department of Psychiatry and Mental Health, Unidade Local de Saúde de Lisboa Ocidental","correspondingAuthor":false,"prefix":"","firstName":"João","middleName":"Bessa","lastName":"Rodrigues","suffix":""},{"id":443343722,"identity":"7965e2c2-3767-4f07-85fd-4df74a9cd869","order_by":6,"name":"João Pedro Azenha","email":"","orcid":"","institution":"Department of Psychiatry and Mental Health, Unidade Local de Saúde de Lisboa Ocidental","correspondingAuthor":false,"prefix":"","firstName":"João","middleName":"Pedro","lastName":"Azenha","suffix":""},{"id":443343723,"identity":"0c098c48-0f86-469b-b0ec-93aa45f7d447","order_by":7,"name":"João Revez Lopes","email":"","orcid":"","institution":"Department of Psychiatry and Mental Health, Unidade Local de Saúde Santa Maria","correspondingAuthor":false,"prefix":"","firstName":"João","middleName":"Revez","lastName":"Lopes","suffix":""},{"id":443343724,"identity":"434ef742-4b3e-45a8-a215-ddeede0136d0","order_by":8,"name":"Marta Ribeiro","email":"","orcid":"","institution":"Department of Psychiatry and Mental Health, Unidade Local de Saúde Santa Maria","correspondingAuthor":false,"prefix":"","firstName":"Marta","middleName":"","lastName":"Ribeiro","suffix":""},{"id":443343725,"identity":"dab5a943-ddd0-4505-abb2-83cfdb6d4795","order_by":9,"name":"Maria João Heitor","email":"","orcid":"","institution":"Centro de Investigação Interdisciplinar em Saúde (CIIS), Faculdade de Medicina, Universidade Católica Portuguesa","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"João","lastName":"Heitor","suffix":""},{"id":443343726,"identity":"02ade409-9378-45e3-929e-ab2125498cf2","order_by":10,"name":"Joaquim Gago","email":"","orcid":"","institution":"NOVA Medical School, Nova University of Lisbon","correspondingAuthor":false,"prefix":"","firstName":"Joaquim","middleName":"","lastName":"Gago","suffix":""},{"id":443343727,"identity":"1ad095d2-e3b8-4cc8-b2a7-38587a01fdc5","order_by":11,"name":"Graça Cardoso","email":"","orcid":"","institution":"Lisbon Institute of Global Mental Health","correspondingAuthor":false,"prefix":"","firstName":"Graça","middleName":"","lastName":"Cardoso","suffix":""}],"badges":[],"createdAt":"2024-11-30 19:53:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5555928/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5555928/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12888-025-07060-3","type":"published","date":"2025-07-01T15:58:43+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":86179441,"identity":"56f5766a-6a38-4347-bf20-462dff098473","added_by":"auto","created_at":"2025-07-07 16:17:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":876644,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5555928/v1/dd7317f6-caa5-4b9b-ab30-3d920021fed9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessing the psychometric properties and validating the Portuguese version of the INSPIRE measure of staff support for personal recovery in Portugal.","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eGlobally, there is growing recognition of the need to provide mental health services that emphasize a recovery-oriented approach (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Personal recovery is described as a deeply individual and unique process, defined as \"a way of living a satisfying, hopeful, and contributing life despite the limitations caused by illness\" (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Although each person\u0026rsquo;s experience of recovery is unique, common themes include the significance of hope, taking personal responsibility, receiving support from others, engaging in meaningful activities, and developing a positive sense of identity (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). To capture this, a conceptual framework has identified five key processes in personal recovery: Connectedness, Hope, Identity, Meaning, and Empowerment (the CHIME Framework) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The lived experiences and perspectives of individuals with mental health challenges are central to fostering a recovery-oriented culture (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Recovery, as a concept, was developed by and for individuals with mental health issues to describe their own journeys and affirm their identity beyond the limitations of their diagnoses (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Personal recovery differs from clinical recovery, which is based on the medical model and focuses on the \"remission of illness\" as the goal of recovery (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRecovery-oriented mental health practices and service delivery represent an approach that emphasizes personal recovery in mental health care. Insights from global best practices have outlined four key domains in supporting recovery: supporting personally defined recovery, working relationships, organisational commitment and promoting citizenship (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). This approach integrates the principles of self-determination and personalised care, emphasises hope, social inclusion, community participation, personal goal setting and self-management (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), and is guided by a set of underpinning values different from those that have traditionally informed mental health services (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). A mental health service system that is guided by the rehabilitation and recovery perspective has a more complete understanding of the total impact of severe mental illness, with an emphasis on treating the consequences of the illness rather than just the illness per se, and on meeting the multiple residential, vocational, educational, and social needs and wants (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Current guidelines advocate for the adoption of recovery-oriented approaches by mental health teams and services for several reasons: research indicates they lead to improved outcomes (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), longitudinal studies have provided evidence that recovery is achievable (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), and they align with the lived experiences of individuals with mental health problems, reflecting what has supported their recovery journeys (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Despite this, the practical implementation and integration of recovery principles into everyday practice remain limited (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eVarious tools have been developed to evaluate the recovery orientation of mental health services, including the Attitudes towards Recovery Questionnaire (ARQ) (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), INSPIRE (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), the Mental Health Recovery Measure (MHRM) (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), the Provider Expectations for Recovery Scale (PERS) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), the Recovery Attitudes Questionnaire (RAQ) (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), the Recovery Knowledge Inventory (RKI) (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), the Recovery Promoting Relationships Scale (RPRS) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), the Recovery-Oriented Services Assessment (ROSA) (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), and RECOLLECT (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). However, there is currently no single, universally accepted measure that meets all criteria: psychometric validity and reliability, sensitivity to change, ease of use, and compatibility with both the conceptual frameworks of personal recovery and recovery-oriented services or systems. This lack of a standardized tool presents an ongoing challenge. Among these, INSPIRE stands out as the only measurement tool that aligns closely with the CHIME framework, is validated, reliable, and capable of assessing the recovery orientation of services from the perspective of the service user (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe full version of INSPIRE measure is a 27-item questionnaire designed to assess service users\u0026rsquo; experiences of support from health professionals in their personal recovery (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). It consists of two subscales: a 20-item Support subscale and a 7-item Relationship subscale. The Support subscale assesses the CHIME recovery processes, covering five domains: Connectedness (items S1\u0026ndash;S4), Hope (items S5\u0026ndash;S8), Identity (items S9\u0026ndash;S12), Meaning and Purpose (items S13\u0026ndash;S16), and Empowerment (items S17\u0026ndash;S20). Each item is initially rated as being important for recovery (yes/no). For the items rated as important (i.e., yes), the level of support received from a mental health worker is rated on a 5-point Likert scale, ranging from \u0026ldquo;not at all\u0026rdquo; to \u0026ldquo;very much\u0026rdquo;. The Relationship subscale evaluates the working relationship between service users and providers, with items rated on a 5-point Likert scale from \u0026ldquo;strongly disagree\u0026rdquo; to \u0026ldquo;strongly agree.\u0026rdquo; Scores are calculated for each subscale, ranging from 0 (lowest support for recovery) to 100 (highest support for recovery). Scores below 72% in the Support subscale suggest the support may not be perceived as helpful, while scores below 78% in the Relationship subscale indicate that the quality of the relationship is perceived as insufficient and could be improved.\u003c/p\u003e \u003cp\u003eStandardized recovery measures play a critical role in advancing research in this area and developing recovery-oriented system. Validation involves testing instruments across diverse settings to determine their accuracy, dependability and consistency in measuring what it purports to measure (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). In Portugal, we are now living a momentum of transformation and reform in mental health care, with the development of community mental health teams and recovery-oriented interventions and services. The validation of the full version of INSPIRE could inform clinical interventions, evaluation strategies, service development, and workforce planning. Additionally, using INSPIRE across different teams and over time could promote cross-team learning, guide policy decisions, and track progress in service improvement.\u003c/p\u003e \u003cp\u003eThe INSPIRE tool has been validated among community mental health service users in Japan (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) and in Sweden (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), demonstrating its reliability and validity. The present study aims to assess the internal consistency, test-retest reliability, and convergent and factor validity of the Portuguese version of INSPIRE for users of mental health services in Portugal.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in psychosocial rehabilitation units, including four community rehabilitation centers and three day-hospitals within public psychiatric departments, all situated in the Lisbon Metropolitan Area. These units primarily serve individuals diagnosed with severe mental illness. These services were chosen because they were already involved in a broader ongoing study. The survey was conducted from October 2023 to February 2024.\u003c/p\u003e\n\u003cp\u003eThe authors took the questionnaires to the\u0026nbsp;psychosocial rehabilitation units and information was provided to the staff to describe the INSPIRE measure and the study of evaluation of its psychometric properties and to explain the process of distributing and completing the questionnaire. Staff were instructed to distribute the questionnaire to all patients attending the services during the study period, explaining the purpose of the study, but refraining from helping to fill out the questionnaire. Staff also cooperated in the re-test to verify the test-retest reliability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients who were receiving services in the included psychosocial rehabilitation units were asked to participate.\u003c/p\u003e\n\u003cp\u003eService users should meet the following inclusion criteria: (1) use of community\u0026nbsp;psychosocial rehabilitation centers and day hospitals, (2) age 18 years or older, (3) having a severe mental illness, (4) being able to give informed consent to participate in the study. After giving written informed consent, participants completed the questionnaire themselves. Participation was voluntary.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClient satisfaction questionnaire\u003c/p\u003e\n\u003cp\u003eService user satisfaction was measured using the 8-item Client Satisfaction Questionnaire (CSQ-8). Each item is rated on a 4-point Likert scale, ranging from \u0026quot;poor\u0026quot; to \u0026quot;excellent.\u0026quot; The total score can range from 8 to 32, with higher scores reflecting higher levels of satisfaction\u0026nbsp;(33).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographic and clinical variables\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDemographic and clinical variables included\u0026nbsp;age, gender, marital status, educational level, employment status, monthly income and psychiatric diagnosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter obtaining permission from the authors to translate and use INSPIRE, a bilingual native speaker with clinical experience translated the 27-item full English version into Portuguese. This translation was then reviewed by a team of expert native speakers. Following this, an independent translator performed a back-translation of the Portuguese version into English, which was subsequently verified for accuracy by a team of experts. The instrument was then pilot tested with 5 patients from one of the community psychosocial rehabilitation centers involved in the study to identify any issues or misunderstandings with the terminology. No adjustments were needed at this stage.\u003c/p\u003e\n\u003cp\u003eThe study instrument was given to the participants at the initial time point (T0), and the same instrument was administered again two weeks later (T1). Participants completed the sociodemographic questionnaire at T0, and the 8-item Client Satisfaction Questionnaire (CSQ-8) was also recorded at T0.\u003c/p\u003e\n\u003cp\u003eThe study received approval from the Ethical Committee of the Nova Medical School (n\u0026ordm; 121/2023/CEFCM). Written informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data processing and statistical analyses for the study were conducted using R software (Version 4.1.3) along with the dplyr (Version 1.1.0) and Psych (Version 2.2.3) packages. Descriptive statistics were initially performed to determine the number of valid responses for further analysis. Only responses with at least one completed item were included.\u003c/p\u003e\n\u003cp\u003eReliability was assessed by estimating internal consistency for the support subscale as a whole and for each of its five domains, as well as for the relationship subscale, using Cronbach\u0026rsquo;s alpha (35) and McDonald\u0026rsquo;s model-based Omega (\u0026omega;) (36). A Cronbach\u0026rsquo;s alpha of 0.70 or higher was considered acceptable.\u003c/p\u003e\n\u003cp\u003eTest-retest reliability was evaluated in a subsample of respondents who completed the survey a second time two weeks later. Weighted Kappa (for nominal data) and intraclass correlation coefficients (ICC; for ordinal data) were calculated for each item to assess the agreement between the first and second assessments (37). Kappa and ICC values were interpreted as follows: below 0.20 was poor agreement, 0.21\u0026ndash;0.40 was fair, 0.41\u0026ndash;0.60 was moderate, 0.61\u0026ndash;0.80 was good, and 0.81\u0026ndash;1.00 was very good agreement (37).\u003c/p\u003e\n\u003cp\u003eConvergent validity for the support and relationship subscales was evaluated by correlating them with the CSQ-8 using Pearson\u0026apos;s product-moment correlation. As there are no established criteria for convergent validity coefficients, values greater than 0.30 were considered satisfactory, reflecting a medium effect size according to Cohen (38).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor further analysis, factor validity was assessed for each of the two INSPIRE subscales using responses from participants who answered \u0026quot;yes\u0026quot; to all items in the support subscale (20 items) and the relationship subscale (7 items). The appropriateness of the data for exploratory factor analysis (EFA) was first tested using the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy and Bartlett\u0026rsquo;s test of sphericity, with a p-value less than 0.05 considered significant for each subscale. EFA for each subscale was conducted using oblimin rotation, and factor loadings greater than 0.3 were considered for interpretation. Confirmatory factor analysis (CFA) was then performed to assess how well the data fit the factor structure derived from the EFA. Based on theoretical assumptions, five underlying factors were hypothesized. Due to issues with matrix invertibility when Empowerment and Relationship were included, CFA was conducted separately for each latent variable. The chi-square fit index was used to evaluate the fit between the hypothesized model and the data, (39) and the model fit was assessed using multiple indices: the ratio of \u0026chi;2 to df (\u0026le; 2), the Comparative Fit Index (CFI \u0026gt; 0.95), the Tucker-Lewis Index (TLI), and the Root Mean Square Error of Approximation (RMSEA \u0026lt; 0.07). \u0026nbsp;(40,41). Two-tailed p-values below 0.05 were considered statistically significant.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eSociodemographic characteristics of the study sample\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 165 questionnaires were collected with varying level of completion while 52 questionnaires were collected at the second assessment. A majority of the study sample were male (60.4%, n = 93), single (83.7%, n=128) and had schizophrenia and other related diagnosis (60.7%, n = 91). The mean age of the study sample was 47.197\u0026plusmn;12.329.\u003c/p\u003e\n\u003cp\u003eTable 1: Sociodemographic characteristics of the study sample\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003ePercentage\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eGender (n=154)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e60.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e39.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eMarital status (n=153)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e83.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e8.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eWidowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eEducation (n=153)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e12.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eBasic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e30.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e38.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eUniversity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e19.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eProfession (n=152)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eLow employed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e30.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eRetired\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e32.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eStudent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eDomestic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eWithout activity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e22.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eMonthly income (Euros) (n= 135)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u0026lt;150\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e151-500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e48.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e501-1000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e23.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e1001-2000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u0026gt;2000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eDiagnosis (n= 150)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eSchizophrenia \u0026amp; other related diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e60.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e17.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eBipolar disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eOther \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e12.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003ea: valid percentages are presented discounting missing variables. b: other include personality disorders, obsessive-compulsive disorder, and intellectual disability\u0026nbsp;\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReliability of the Portuguese-INSPIRE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe measures of internal consistency were found to be satisfactory while the test-retest reliability did not show good consistency between the two measurements as ICC values less than 0.5 are indicative of poor reliability. (Table 2)\u003c/p\u003e\n\u003cp\u003eTable 2: Reliability parameters of the Portuguese-INSPIRE\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eInternal consistency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eTest-retest reliability\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003eSubscales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eMcDonald\u0026apos;s \u0026omega;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eCronbach\u0026apos;s \u0026alpha;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eICC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003eSupport\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003eRelationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e-0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003eDomains\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003eConnectedness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.037\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003eHope\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003eIdentity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.045\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003eMeaning \u0026amp; Purpose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003eEmpowerment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.028\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eConvergent Validity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe correlation between the support subscale and the CSQ-8 score is positive and moderate (r=0.47, p-value \u0026lt; 0.001) and correlation between the Relationship subscale and the CSQ-8 is also positive and moderate (r=0.47, p-value \u0026lt; 0.001) demonstrating good convergent validity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExploratory factor analysis\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo evaluate the factor validity of the INSPIRE support subscale, 150 responses in which all 20 items in the subscale were answered \u0026quot;yes\u0026quot; were analysed, revealing five factors based on a loading cutoff criterion of 0.3. Similarly, for the relationship subscale, 155 responses where all 7 items were answered were used. The KMO score for the support subscale was 0.89, and Bartlett\u0026apos;s test of sphericity was significant (\u0026chi;2 = 1892, df = 190, p \u0026lt; 0.001), indicating that factor analysis was appropriate. For the relationship subscale, the KMO score was 0.91, and Bartlett\u0026rsquo;s test of sphericity was also significant (\u0026chi;2 = 612, df = 21, p \u0026lt; 0.001), confirming the suitability of factor analysis.\u003c/p\u003e\n\u003cp\u003eThe first factor MR1 represents the \u0026ldquo;Hope\u0026rdquo; domain (S5 to S8). The third factor (MR3) is clearly representing the \u0026ldquo;Connectedness\u0026rdquo; domain (S1 to S4). Some items from \u0026ldquo;Meaning and purpose\u0026rdquo; (S13 to S16) and others from \u0026ldquo;Empowerment\u0026rdquo; (S17 to S20) are together in the MR4 factor, meaning that these two domains are not clearly distinct (Table 3). The factor structure obtained had a cumulative explained variance of 62% (MR1 = 19%; MR2 = 15%; MR3 = 13%; MR4 = 10%; MR 5 = 5%).\u003c/p\u003e\n\u003cp\u003eTable 3: Standardized factor loadings for the support subscale\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"408\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003eMR1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003eMR4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003eMR3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003eMR2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003eMR5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eS1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eS2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.492\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eS3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.628\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eS4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.588\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eS5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.818\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eS6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.604\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eS7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.388\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.336\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eS8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.916\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eS9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.344\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eS10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.492\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.461\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eS11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.922\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eS12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.739\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eS13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.352\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eS14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.381\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eS15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.312\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.403\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eS16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.405\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.422\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eS17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.652\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.302\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eS18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.815\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eS19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.314\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eS20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.393\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.417\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eIn the Factor Analysis dealing with Relationship items (n=1 factor to extract), the factor loadings were large (\u0026gt;0.70 in all cases) defining one Relationship factor (Table 4). The one-factor structure had a cumulative explained variance of 59%.\u003c/p\u003e\n\u003cp\u003eTable 4: Standardized factor loadings for the Relationship subscale\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003eMR1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003eh2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003eu2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003eR1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u0026nbsp;0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u0026nbsp;0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003e0.32 \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003eR2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u0026nbsp;0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u0026nbsp;0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003eR3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u0026nbsp;0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u0026nbsp;0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003e0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003eR4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u0026nbsp;0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u0026nbsp;0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003e0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003eR5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003eR6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003eR7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25px;\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eConfirmatory Factor Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe R output could not compute the entire model because the main matrix was not invertible when Empowerment and Relationship domain were included. Excluding these domains yielded a model where the Chi-square had significant p-value (\u0026lt; 0.001), rejecting the null hypothesis that this model fits our data. So, a Confirmatory Factor Analysis was conducted for each latent variable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSince the p-value of the Chi-square test is non-significant (p= 0.156) for Item 1-4 of the support scale, we can retain the null hypothesis that \u0026ldquo;Connectedness\u0026rdquo; is well represented by the 4 first questions of the questionnaire. \u0026nbsp;For the \u0026ldquo;Hope\u0026rdquo; domain, the p-value (0.44) of the Chi-square test indicates that Hope is well represented by the questions S5 to S8. Considering the \u0026ldquo;Identity\u0026rdquo; domain S9 to S12, the low p-value (\u0026lt;0.001) of the Chi-square test reveals that there is a mismatch between that factor and the data. For the Relationship feature, the p-value of the Chi-square test was non-significant (p = 0.284) when the scaled data was considered, meaning that Relationship subscale is well represented by the items R1 to R7 (Table 5).\u003c/p\u003e\n\u003cp\u003eTable 5: Fit indices for latent variables tested.\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"630\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003eLatent variable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026chi;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003eDf\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003eCFI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003eTLI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003eRMSEA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003eConnectedness\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(S1-S4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e3.714\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.156\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.975\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.926\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.076\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003eHope (S5-S8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e1.145\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.564\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e1.016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003eIdentity (S9-S12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e21.296\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.746\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.238\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.254\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003eMeaning \u0026amp; Purpose (S13-S16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e1.841\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.398\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e1\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e1.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003eEmpowerment\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(S17-S20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e35.456\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.830\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.491\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.334\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003eRelationship (R1-R7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e16.492\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.284\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.991\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.986\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.034\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026chi;2 = Chi-Square statistic; df = degrees of freedom; CFI = Comparative Fit Index; TLI = Tucker Lewis Index; RMSEA = Root Mean Square Error of Approximation\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study examined the psychometric properties of the Portuguese version of INSPIRE among users of psychosocial rehabilitation units, which primarily serve persons with a clinical diagnosis of severe mental illness. The findings indicate that INSPIRE demonstrates satisfactory internal consistency; however, the test-retest reliability did not exhibit strong consistency.\u003c/p\u003e \u003cp\u003eParticipants were recruited from various psychosocial rehabilitation units, including community rehabilitation centers, day hospitals, and multiple clinical teams, providing a broad spectrum of service experiences and clinical backgrounds. The sample reflected demographic diversity in age, gender, socioeconomic status, and urban or rural residence, which may enhance the generalizability of the findings. Portugal\u0026rsquo;s linguistic uniformity, with no significant regional dialects, supports the assumption that the questionnaire would be consistently interpreted and representative of the national population. Additionally, the Lisbon metropolitan area attracts individuals from across the country, further strengthening sample representativeness. Given the national guidelines for mental health service organization, participants\u0026rsquo; experiences are likely to reflect the broader national context.\u003c/p\u003e \u003cp\u003eReliability refers to the consistency of results when a testing procedure is repeated (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). There are various types of scale reliability: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) the equivalence of items in a test (internal consistency) or of assessments made by different observers using the same instrument (interrater reliability) and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) the stability of measurements taken at different times from the same individuals (test\u0026ndash;retest reliability) (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eInternal consistency evaluates how well all items in a scale measure the same construct (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). It is recommended that new instruments achieve a minimum Cronbach's alpha of 0.70, while established instruments should meet a threshold of 0.80 (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). In this study, both Cronbach's alpha and McDonald's omega indicated satisfactory internal consistency for the subscales and for the dimensions within the support subscale, except for the Identity domain, which showed marginally acceptable values. Like previous studies (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), the alpha coefficient for the total score of the support subscale was notably high (0,93), suggesting potential redundancy, with some items possibly addressing the same concepts in slightly different ways (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Future research with other Portuguese samples could explore whether reducing the number of items improves the instrument's efficiency.\u003c/p\u003e \u003cp\u003eTest\u0026ndash;retest reliability, which assesses the stability of measurements over time, is determined by administering the test at two different points in time to the same individuals and analysing the correlation or strength of association between the scores (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). The timing of the second administration is critical: the interval should be long enough to avoid carryover effects from the initial assessment but short enough to prevent changes in health status or learning from altering responses (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). The changing nature over time of the construct being measured is the second main factor which may influence the evaluation of test-retest reliability (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). ICC (Intraclass Correlation Coefficient) is a reliability measure that assesses both the correlation and agreement between measurements, and values less than 0.5, between 0.5 and 0.75, between 0.75 and 0.9, and greater than 0.90 are indicative of poor, moderate, good, and excellent reliability, respectively (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). In this study, the test-retest reliability showed inconsistent results. This result may be attributed to variations in the timing of the second assessment, which may have varied somewhat between the different psychosocial rehabilitation units. It may also reflect changes in participants\u0026rsquo; functioning, mood or willingness to collaborate.\u003c/p\u003e \u003cp\u003eValidity assesses the extent to which an instrument measures what it is intended to measure (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Validity is not an inherent characteristic of the instrument itself but depends on its use in a particular context (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). When an instrument is used in a new context, its validity must be evaluated (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). In this study, correlations between INSPIRE subscales and the CSQ-8 were positive and moderate (Pearson\u0026rsquo;s correlation: 0.47), supporting INSPIRE\u0026rsquo;s validity as a measure of staff support for personal recovery.\u003c/p\u003e \u003cp\u003eFactor analysis explores relationships among survey items to determine whether subsets of items are more closely related to one another than to others, thereby analysing dimensionality among the items (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). The exploratory factor analysis in this study identified five factors, but there was cross-loading of items in the Meaning and Purpose and Empowerment domains, suggesting that these items may measure overlapping concepts. This could indicate that Meaning and Purpose are not entirely distinct from Empowerment within the context of recovery. In fact, within the CHIME framework of mental health recovery, Meaning and Purpose and Empowerment are closely intertwined rather than entirely distinct concepts. Both components center around the individual\u0026rsquo;s agency and sense of self in the recovery journey. Meaning and Purpose involves having direction, goals, and a sense that life holds value, while Empowerment is about gaining confidence, autonomy, and control over one\u0026rsquo;s life. However, discovering meaning in one\u0026rsquo;s experiences, roles, or future aspirations often leads to a sense of empowerment. Conversely, feeling empowered can motivate someone to pursue or reclaim purpose in life. Rather than existing in isolation, these elements reinforce one another. Recognizing this interconnection is vital for person-centered recovery approaches, as it allows for more integrated and holistic support strategies. Confirmatory factor analysis of each latent variable revealed good model fit for most domains, although the Identity and Empowerment domains showed some inconsistencies. Certain items, such as \u0026ldquo;Feeling I can deal with stigma\u0026rdquo; (S9), may reflect concepts (stigma, in this case) that are more research-oriented and less familiar in everyday use. Additionally, items like \u0026ldquo;Having my spiritual belief respected\u0026rdquo; (S11) and \u0026ldquo;Having my ethnic/cultural/racial identity respected\u0026rdquo; (S12), also within the Identity domain, may reflect cultural and ethnic differences between the British population, where the INSPIRE instrument was originally developed, and the population that participated in the validation of the instrument in Portugal, with less ethnic diversity. These variations might also stem from the heterogeneity of the studied sample or non-independent observations (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor the Relationship subscale, factor loadings of 0.70 or higher confirmed the one-factor structure consistent with the structure of the original INSPIRE (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The Confirmatory factor analysis also indicated good model fit with satisfactory fit indices.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThis study makes a valuable contribution by validating a measure to assess staff support for personal recovery within the Portuguese context. Participants were a convenience sample of service users from various psychosocial rehabilitation units in the Lisbon metropolitan area. Nevertheless, some methodological limitations should be noted. First, the selection of participants from specific geographic areas and service types may restrict the generalizability of the findings. However, the sample reflects clinical and demographic diversity in age, gender, socioeconomic status, urban/rural residence, and service background. Moreover, Portugal\u0026rsquo;s relative linguistic and organizational homogeneity supports broader applicability. Second, the test-retest reliability revealed limited consistency. Future research should adopt a more rigorous approach to timing between assessments to better evaluate this dimension. Third, convergent validity was assessed using the Portuguese version of the Client Satisfaction Questionnaire, even though this tool has not been previously validated. Fourth, the rarity of service users evaluating psychiatric service quality, service providers, and recovery processes adds complexity to the study design and interpretation. Finally, the questionnaires were distributed by the staff under evaluation. Although anonymity and confidentiality were assured, this distribution method may have introduced bias.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThis study confirmed the internal consistency, as well as the convergent and factor validity, of the Portuguese version of INSPIRE among users of psychosocial rehabilitation units in Portugal. The findings support INSPIRE as a reliable tool for assessing staff support for personal recovery. By facilitating structured conversations between users and staff, INSPIRE can promote person-centered care and help identify individual support priorities. It also offers a valuable means of evaluating personal recovery experiences, comparing practices against national and international standards, and monitoring progress over time \u0026mdash; contributing to the advancement of a recovery-oriented mental health system. Furthermore, INSPIRE may play a key role in developing training programs for mental health professionals and guiding future research on how services can better support personal recovery in Portuguese-speaking countries.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eARQ: Attitudes towards Recovery Questionnaire; CFA: Confirmatory factor analysis; CFI: Comparative Fit Index; CHIME: Connectedness, Hope, Identity, Meaning and Empowerment; CSQ-8: Client Satisfaction Questionnaire; EFA: Exploratory factor analysis; ICC: Intraclass Correlation Coefficients; KMO: Kaiser-Meyer-Olkin; MHRM: Mental Health Recovery Measure; PERS: Provider Expectations for Recovery Scale; RAQ: Recovery Attitudes Questionnaire; RKI: Recovery Knowledge Inventory; RMSEA: Root Mean Square Error of Approximation; RPRS: Recovery Promoting Relationships Scale; ROSA: Recovery-Oriented Services Assessment; TLI: Tucker Lewis Index.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethical Committee of the Nova Medical School (n\u0026ordm; 121/2023/CEFCM)\u0026nbsp;and has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.\u0026nbsp;Written informed consent was obtained from all individual participants included in the study. Participation was voluntary.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study integrated the research project \u0026ldquo;Effectiveness of the Critical Time Intervention-Peer Support (CTI-PS) model for persons with serious mental illness discharged from inpatient psychiatric treatment facilities in Portugal\u0026rdquo;, funded by FLAD \u0026ndash; Luso-American Development Foundation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMS conceptualised the study design, contributed to data analysis and interpretation, and drafted the manuscript. DOA made substantial contributions to the study design, data analysis and interpretation, and substantively reviewed the manuscript. MJH, JG and GC contributed to the study design and reviewed the manuscript. All authors read and approved the submitted version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are grateful to the participants for taking part in the study, and would like to acknowledge the assistance of the staff in the psychosocial rehabilitation units: Dr. Catarina Klut (Unidade Local de Sa\u0026uacute;de de Loures-Odivelas), Nurse Ana Paula Alves, Dr. Paula Godinho, Dr. Patr\u0026iacute;cia Baronet and Dr. Marta Croca (Unidade Local de Sa\u0026uacute;de Santa Maria), Dr. Paula Duarte and Dr. Marta Moreira (Unidade Local de Sa\u0026uacute;de de Lisboa Ocidental), Dr. Beatriz Carapeta (GAC \u0026ndash; Grupo de A\u0026ccedil;\u0026atilde;o Comunit\u0026aacute;ria), Dr. Sofia Couto (GIRA \u0026ndash; Grupo de Interven\u0026ccedil;\u0026atilde;o e Reabilita\u0026ccedil;\u0026atilde;o Activa), Dr. \u0026nbsp;Catarina Malcata and Dr. S\u0026iacute;lvia Almeida (ARIA \u0026ndash; Associa\u0026ccedil;\u0026atilde;o de Reabilita\u0026ccedil;\u0026atilde;o e Integra\u0026ccedil;\u0026atilde;o Ajuda) and Dr. Susana Guimar\u0026atilde;es (Recome\u0026ccedil;o - Associa\u0026ccedil;\u0026atilde;o para a Reabilita\u0026ccedil;\u0026atilde;o e Integra\u0026ccedil;\u0026atilde;o Social Amadora/Sintra).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. Guidance on community mental health services: promoting person-centred and rights-based approaches. . Geneva: World Health Organization; 2021. \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. World mental health report: transforming mental health for all. . Geneva: World Health Organization; 2022. \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Comprehensive mental health action plan 2013\u0026ndash;2030. . Geneva: World Health Organization; 2021. \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Legal capacity and the right to decide. WHO QualityRights Core training: mental health and social services. Course guide [Internet]. 2019. Available from: http://apps.who.int/bookorders.\u003c/li\u003e\n\u003cli\u003eAnthony WA. Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosoc Rehabil J. 1993 Apr;16(4):11\u0026ndash;23. \u003c/li\u003e\n\u003cli\u003eWilliams J, Leamy M, Bird V, Harding C, Larsen J, Boutillier C, et al. Measures of the recovery orientation of mental health services: systematic review. Soc Psychiatry Psychiatr Epidemiol. 2012 Nov 10;47(11):1827\u0026ndash;35. \u003c/li\u003e\n\u003cli\u003eLeamy M, Bird V, Boutillier C Le, Williams J, Slade M. Conceptual framework for personal recovery in mental health: systematic review and narrative synthesis. British Journal of Psychiatry. 2011 Dec 2;199(6):445\u0026ndash;52. \u003c/li\u003e\n\u003cli\u003eGovernment Department of Health A. A national framework for recovery-oriented mental health services: guide for practitioners and providers. 2013; \u003c/li\u003e\n\u003cli\u003eMacpherson R, Pesola F, Leamy M, Bird V, Le Boutillier C, Williams J, et al. The relationship between clinical and recovery dimensions of outcome in mental health. Vol. 175, Schizophrenia Research. Elsevier B.V.; 2016. p. 142\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eLe Boutillier C, Leamy M, Bird VJ, Davidson L, Williams J, Slade M. What Does Recovery Mean in Practice? A Qualitative Analysis of International Recovery-Oriented Practice Guidance. Psychiatric Services. 2011 Dec;62(12):1470\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eLeamy M, Foye U, Hirrich A, Bj\u0026oslash;rgen D, Silver J, Simpson A, et al. A systematic review of measures of the personal recovery orientation of mental health services and staff. Int J Ment Health Syst. 2023 Oct 17;17(1):33. \u003c/li\u003e\n\u003cli\u003eHill H, Killaspy H, Ramachandran P, Ng RMK, Bulman N, Harvey C. A structured review of psychiatric rehabilitation for individuals living with severe mental illness within three regions of the Asia-Pacific: Implications for practice and policy. Vol. 11, Asia-Pacific Psychiatry. Wiley-Blackwell; 2019. \u003c/li\u003e\n\u003cli\u003eNational Institute for Health and Care Excellence. Rehabilitation for adults with complex psychosis NICE guideline. 2020 [cited 2024 Jun 5]; Available from: www.nice.org.uk/guidance/ng181\u003c/li\u003e\n\u003cli\u003eHarding CMBG ATSJBA. The Vermont longitudinal study of persons with severe mental illness, II: Long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia. American Journal of Psychiatry. 1987 Jun;144(6):727\u0026ndash;35. \u003c/li\u003e\n\u003cli\u003eRidgway P. ReStorying psychiatric disability: Learning from first person recovery narratives. Psychiatr Rehabil J. 2001;24(4):335\u0026ndash;43. \u003c/li\u003e\n\u003cli\u003eDeegan PE. Recovery: The lived experience of rehabilitation. Psychiatr Rehabil J. 1988;11:11\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eSlade M, Bird V, Clarke E, Le Boutillier C, McCrone P, Macpherson R, et al. Supporting recovery in patients with psychosis through care by community-based adult mental health teams (REFOCUS): a multisite, cluster, randomised, controlled trial. Lancet Psychiatry. 2015 Jun;2(6):503\u0026ndash;14. \u003c/li\u003e\n\u003cli\u003eMak WWS, Chan RCH, Yau SSW. Development and validation of Attitudes towards Recovery Questionnaire across Chinese people in recovery, their family carers, and service providers in Hong Kong. Psychiatry Res. 2018 Sep;267:48\u0026ndash;55. \u003c/li\u003e\n\u003cli\u003eWilliams J, Leamy M, Bird V, Le Boutillier C, Norton S, Pesola F, et al. Development and evaluation of the INSPIRE measure of staff support for personal recovery. Soc Psychiatry Psychiatr Epidemiol. 2015 May 20;50(5):777\u0026ndash;86. \u003c/li\u003e\n\u003cli\u003eBullock W\u0026amp; YS. The mental health recovery measure (MHRM). In Toronto: 111th Annual Meeting of the American Psychological Association.; 2003. \u003c/li\u003e\n\u003cli\u003eOliveira-Maia AJ, Mendon\u0026ccedil;a C, Pessoa MJ, Camacho M, Gago J. The mental health recovery measure can be used to assess aspects of both customer-based and service-based recovery in the context of severe mental illness. Front Psychol [Internet]. 2016 Nov 3 [cited 2024 Aug 24];7(NOV):210927. Available from: www.frontiersin.org\u003c/li\u003e\n\u003cli\u003eSalyers MP, Brennan M, Kean J. Provider Expectations for Recovery Scale: Refining a measure of provider attitudes. Psychiatr Rehabil J. 2013 Sep;36(3):153\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eBorkin JR SJELKKWHWKYN. Recovery Attitudes Questionnaire: Development and evaluation. . Psychiatr Rehabil J . 2000;24(2):95\u0026ndash;102. \u003c/li\u003e\n\u003cli\u003eBedregal LE OMDL. The Recovery Knowledge Inventory: Assessment of Mental Health Staff Knowledge and Attitudes aboutRecovery. . Psychiatr Rehabil J . 2006;30(2):96\u0026ndash;103. \u003c/li\u003e\n\u003cli\u003eRussinova Z, Rogers ES, Cook KF, Ellison ML, Lyass A. Conceptualization and measurement of mental health providers\u0026rsquo; recovery-promoting competence: The Recovery Promoting Relationships Scale (RPRS). Psychiatr Rehabil J. 2013;36(1):7\u0026ndash;14. \u003c/li\u003e\n\u003cli\u003eLodge AC, Kuhn W, Earley J, Stevens Manser S. Initial development of the recovery-oriented services assessment: A collaboration with peer-provider consultants. Psychiatr Rehabil J. 2018 Jun;41(2):92\u0026ndash;102. \u003c/li\u003e\n\u003cli\u003eToney R, Knight J, Hamill K, Taylor A, Henderson C, Crowther A, et al. Development and Evaluation of a Recovery College Fidelity Measure. The Canadian Journal of Psychiatry. 2019 Jun 30;64(6):405\u0026ndash;14. \u003c/li\u003e\n\u003cli\u003ePenas P IIMMUJ. How is evaluated mental health recovery? Actas Esp Psiquiatr. 2019;47(1):23\u0026ndash;32. \u003c/li\u003e\n\u003cli\u003eLeamy M, Foye U, Hirrich A, Bj\u0026oslash;rgen D, Silver J, Simpson A, et al. A systematic review of measures of the personal recovery orientation of mental health services and staff. Vol. 17, International Journal of Mental Health Systems. BioMed Central Ltd; 2023. \u003c/li\u003e\n\u003cli\u003eSherina Mohd Sidik. Validation studies. In: Taylor \u0026amp; Francis Group, editor. How To Do Primary Care Research. 1st Edition. 2018. \u003c/li\u003e\n\u003cli\u003eKotake R, Kanehara A, Miyamoto Y, Kumakura Y, Sawada U, Takano A, et al. Reliability and validity of the Japanese version of the INSPIRE measure of staff support for personal recovery in community mental health service users in Japan. BMC Psychiatry. 2020 Feb 7;20(1). \u003c/li\u003e\n\u003cli\u003eSch\u0026ouml;n UK, Svedberg P, Rosenberg D. Evaluating the INSPIRE measure of staff support for personal recovery in a Swedish psychiatric context. Nord J Psychiatry. 2015 May 1;69(4):275\u0026ndash;81. \u003c/li\u003e\n\u003cli\u003eLarsen DL, Attkisson CC, Hargreaves WA, Nguyen TD. Assessment of client/patient satisfaction: Development of a general scale. Eval Program Plann. 1979 Jan;2(3):197\u0026ndash;207. \u003c/li\u003e\n\u003cli\u003eR Core Team. R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. 2018. \u003c/li\u003e\n\u003cli\u003eCronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrika [Internet]. 1951 Sep [cited 2024 Apr 22];16(3):297\u0026ndash;334. Available from: https://link.springer.com/article/10.1007/BF02310555\u003c/li\u003e\n\u003cli\u003eGadermann AM, Guhn M, Zumbo BD. Estimating ordinal reliability for likert-type and ordinal item response data: A conceptual, empirical, and practical guide. Practical Assessment, Research and Evaluation. 2012;17(3):1\u0026ndash;13. \u003c/li\u003e\n\u003cli\u003eAltman DG. Practical Statistics for Medical Research. Practical Statistics for Medical Research [Internet]. 1990 Nov 22 [cited 2024 Apr 22]; Available from: https://www.taylorfrancis.com/books/mono/10.1201/9780429258589/practical-statistics-medical-research-douglas-altman\u003c/li\u003e\n\u003cli\u003eCohen J. Statistical Power Analysis for the Behavioral Sciences. Statistical Power Analysis for the Behavioral Sciences [Internet]. 2013 May 13 [cited 2023 Jul 15]; Available from: https://www.taylorfrancis.com/books/mono/10.4324/9780203771587/statistical-power-analysis-behavioral-sciences-jacob-cohen\u003c/li\u003e\n\u003cli\u003eJ\u0026ouml;reskog KG. A general approach to confirmatory maximum likelihood factor analysis. Psychometrika [Internet]. 1969 Jun [cited 2024 Apr 26];34(2):183\u0026ndash;202. Available from: https://link.springer.com/article/10.1007/BF02289343\u003c/li\u003e\n\u003cli\u003eSchreiber JB. Core reporting practices in structural equation modeling. Res Social Adm Pharm [Internet]. 2008 Jun [cited 2024 Apr 22];4(2):83\u0026ndash;97. Available from: https://pubmed.ncbi.nlm.nih.gov/18555963/\u003c/li\u003e\n\u003cli\u003eHooper D, Coughlan J, Mullen MR. Structural Equation Modelling: Guidelines for Determining Model Fit. Electronic Journal of Business Research Methods [Internet]. 2008 Sep 1 [cited 2024 Apr 22];6(1):pp53‑60-pp53‑60. Available from: https://academic-publishing.org/index.php/ejbrm/article/view/1224\u003c/li\u003e\n\u003cli\u003eKnekta E, Runyon C, Eddy S. One size doesn\u0026rsquo;t fit all: Using factor analysis to gather validity evidence when using surveys in your research. CBE Life Sci Educ. 2019 Mar 1;18(1). \u003c/li\u003e\n\u003cli\u003eKimberlin CL, Winterstein AG. Validity and reliability of measurement instruments used in research. Vol. 65, American Journal of Health-System Pharmacy. American Society of Health-Systems Pharmacy; 2008. p. 2276\u0026ndash;84. \u003c/li\u003e\n\u003cli\u003eFleiss JL, Cohen J. The Equivalence of Weighted Kappa and the Intraclass Correlation Coefficient as Measures of Reliability. Educ Psychol Meas. 1973 Oct 2;33(3):613\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eShou Y, Sellbom M, Chen HF. Fundamentals of Measurement in Clinical Psychology. In: Comprehensive Clinical Psychology. Elsevier; 2022. p. 13\u0026ndash;35. \u003c/li\u003e\n\u003cli\u003eKoo TK, Li MY. A Guideline of Selecting and Reporting Intraclass Correlation Coefficients for Reliability Research. J Chiropr Med. 2016 Jun 1;15(2):155\u0026ndash;63. \u003c/li\u003e\n\u003cli\u003eFouladi RT. Performance of Modified Test Statistics in Covariance and Correlation Structure Analysis Under Conditions of Multivariate Nonnormality. Struct Equ Modeling. 2000 Jul;7(3):356\u0026ndash;410. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"mental health, recovery, support, measurement, reliability, validity, INSPIRE","lastPublishedDoi":"10.21203/rs.3.rs-5555928/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5555928/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: The importance of mental health services that support a recovery-oriented approach is increasingly recognized, and measures that evaluate this practice and promote change over time are needed. The INSPIRE measure is a 27-item questionnaire designed to assess service users’ perceptions of the support received from health professionals in their personal recovery. This study aimed to validate the Portuguese version of INSPIRE and assess its psychometric properties as a measure of staff support for personal recovery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: The questionnaire survey was conducted from October 2023 to February 2024. Service users completed the Portuguese version of INSPIRE, the Client Satisfaction Questionnaire (CSQ-8), and a demographic and clinical questionnaire. Internal consistency was assessed using Cronbach’s alpha and McDonald's model-based Omega. Test-retest reliability was assessed through the intraclass correlation coefficient (ICC) and weighted kappa. Convergent validity was examined by assessing correlation with CSQ-8. Factor validity was evaluated using exploratory factor analysis (EFA), with confirmatory factor analysis (CFA) performed to test the fit of factor structures derived from the EFA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The study included 165 participants from seven psychosocial rehabilitation units which primarily target persons with a severe mental illness. For test–retest evaluation, 52 participants completed the questionnaire a second time. Internal consistency was satisfactory across all subscales and dimensions of the Support subscale, except for the Identity domain, which had marginally acceptable values. INSPIRE demonstrated significant positive correlations with CSQ-8 scores, supporting its convergent validity. EFA identified five factors for the Support scale and one factor for the Relationship scale, explaining 62% and 59% of the cumulative variance, respectively. CFA confirmed a good model fit for the Relationship scale and all Support subscales, except for the Identity and Empowerment subscales.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: The Portuguese version of INSPIRE showed strong internal consistency, as well as convergent and factor validity. This validated instrument can be applied in research and clinical settings to assess staff support for personal recovery and promote recovery-oriented mental health practices.\u003c/p\u003e","manuscriptTitle":"Assessing the psychometric properties and validating the Portuguese version of the INSPIRE measure of staff support for personal recovery in Portugal.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-16 10:30:39","doi":"10.21203/rs.3.rs-5555928/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2025-05-30T09:13:36+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-19T10:56:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9004484095819073775088347296331157803","date":"2025-04-21T16:33:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-15T14:24:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-12T13:17:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2025-04-11T18:58:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dfe16452-6329-4f50-88d9-b6c4e3bc27a5","owner":[],"postedDate":"April 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-07T16:08:21+00:00","versionOfRecord":{"articleIdentity":"rs-5555928","link":"https://doi.org/10.1186/s12888-025-07060-3","journal":{"identity":"bmc-psychiatry","isVorOnly":false,"title":"BMC Psychiatry"},"publishedOn":"2025-07-01 15:58:43","publishedOnDateReadable":"July 1st, 2025"},"versionCreatedAt":"2025-04-16 10:30:39","video":"","vorDoi":"10.1186/s12888-025-07060-3","vorDoiUrl":"https://doi.org/10.1186/s12888-025-07060-3","workflowStages":[]},"version":"v1","identity":"rs-5555928","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5555928","identity":"rs-5555928","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}