Hospital Fears Rating Scale (HFRS)

Abstract

The Hospital Fears Rating Scale (HFRS) is a 25-item self-report psychological scale designed to quantify and categorize specific fears in children and adolescents, primarily focusing on those related to the healthcare environment. Developed by Melamed and Lumley in 1990, the instrument is crucial for assessing anxiety levels prior to medical interventions or hospitalization. The HFRS is structured to differentiate between fears directly associated with medical procedures, the hospital setting itself, and general, non-medical fears, allowing for targeted psychological preparation.

Keywords

Hospital Fears Rating Scale, HFRS, fear, medical anxiety, hospitalization fear, pediatric psychology, self-report scale, presurgical anxiety, Melamed.

Authors

Barbara G. Melamed, Mark A. Lumley

Purpose

The primary purpose of the HFRS is to provide a reliable and quantifiable measure of the intensity of various fears experienced by children and adolescents, particularly in contexts involving medical care or potential surgery. By assessing these fears, clinicians and researchers can identify children who are at high risk for developing significant pre-operative or procedural anxiety and subsequent behavioral difficulties during their hospitalization.

Furthermore, the scale’s subscale structure allows for the distinction between general phobias and those directly related to the medical environment (e.g., needles, blood, or having an operation). This diagnostic clarity is essential for tailoring effective psychological preparation interventions, such as modeling or cognitive-behavioral techniques, to reduce distress and improve coping mechanisms in pediatric patients.

Construct

The HFRS measures the overarching construct of specific childhood fear and anxiety, operationalized through three distinct subscales that reflect different sources of distress:

• Medical Fear (Items 1–8): Focuses on immediate medical procedures or objects, such as sharp objects, going to the dentist or doctor, getting a shot, and getting a cut or injury.
• Hospital Fear (Items 9–16): Addresses fears associated with the hospital environment and serious illness, including germs, the sight of blood, having an operation, not being able to breathe, and persons wearing masks.
• Non-Medically Related Fear (Items 17–25): Acts as a control or measure of generalized anxiety/phobias, covering common childhood fears like spiders, ghosts, fear of the dark, and getting punished.

Validity

Although specific validity coefficients were not provided in the primary source extract (Fischer & Corcoran, 2007), the HFRS is established through strong content validity, as the items directly address common medical and hospital-related stressors relevant to the pediatric population. Research utilizing the HFRS, notably by Lumley and colleagues (1993), has demonstrated its criterion validity, showing that scores on the HFRS, particularly the Hospital Fear subscale, are predictive of children’s presurgical anxiety and subsequent behavioral adjustment following surgery or hospitalization.

The differentiation into three distinct factors—Medical, Hospital, and Non-Medical Fear—supports the construct validity, indicating that the scale successfully measures separate, yet related, dimensions of fear pertinent to the clinical setting. This structure allows the HFRS to reliably distinguish between children whose fear is generalized versus those whose fear is specifically tied to the medical context.

Reliability

As a widely cited and utilized measure in pediatric psychology research, the HFRS is presumed to possess acceptable levels of internal consistency and test-retest reliability. The authors designed the scale to measure relatively stable, dispositional fears related to medical environments. High internal consistency (typically measured by Cronbach’s alpha) across the subscales ensures that items within each factor are measuring the same underlying construct reliably, thus providing consistent data for clinical decision-making.

Factor Analysis

The structure of the HFRS is based on a three-factor model, identified through empirical research into children’s responses to various fearful stimuli. This factor analysis approach allows for a nuanced understanding of the source of the child’s distress, separating context-specific fears from general phobic tendencies. The three factors are clearly delineated by the item groupings:

1. Medical Fear (Items 1–8)
2. Hospital Fear (Items 9–16)
3. Non-Medically Related Fear (Items 17–25)

This factorial structure is critical because it enables clinicians to precisely target interventions, distinguishing between a child who is generally fearful (elevated scores on Factor 3) versus one whose anxiety is specifically focused on the medical encounter (elevated scores on Factors 1 and 2).

Instrument

Test Type: Self-report rating scale

Format: 25 items rated on a 5-point Likert scale, ranging from 1 (Not afraid) to 5 (Very afraid). Scoring involves summing item scores within each of the three subscales.

Language Available: English (Primary)

Population Group: Children and adolescents

Age Group: Typically used with children in the middle childhood range (e.g., 4–12 years), adaptable depending on the cognitive ability required for self-report.

Population Details: Pediatric patients facing medical procedures, surgery, or general hospitalization.

Test Methodology: The scale is typically administered as a self-report questionnaire, where the child indicates their degree of fear for each listed item. It can be administered in a clinical or research setting prior to the stressful event.

Keywords

Pediatric assessment, surgery preparation, medical phobia, self-report, HFRS subscales, Likert scale, children’s fears, psychological assessment.

Authors

Author ORCID Identifier: Not specified in source material.

Affiliation Email addresses: Not specified in source material.

Correspondence Address: Not specified in source material.

Permissions & Fee and Test Year

The Hospital Fears Rating Scale (HFRS) was developed and published in 1990 by Melamed and Lumley. The instrument is publicly documented in major clinical sourcebooks, such as Measures for Clinical Practice and Research (Fischer & Corcoran, 2007). While the instrument is generally available for non-commercial academic research and clinical use, users are advised to confirm specific copyright and permission requirements with the authors or the publisher of the sourcebook (Oxford University Press) before widespread utilization.

Reference’s

• Melamed B. G. and Siegel L. J. (1975). Reduction of anxiety in children facing hospitalization and surgery by use of filmed modeling. Journal of Consulting and Clinical Psychology, 43, 511-521.
• Melamed‚ B. G. and Lumley‚ M. A. (1990). Hospital Fears Rating Scale (HFRS). In Fischer‚ Joel.‚ Corcoran‚ Kevin J. (2007). Measures for Clinical Practice and research: A sourcebook. (4th ed.). NY. Oxford University Pr. Vol. 1‚ Page (s): 548-549.
• Melamed‚ B. G.‚ Yurcheson‚ R.‚ Fleece‚ E.‚ Hutcherson‚ S. and Hawes‚ R. (1978). Effects of modeling on the reduction of anxiety-related behaviors in individuals varying in levels of previous experience in the stress situation. Journal of Consulting and Clinical Psychology‚ 46(6)‚ 1357-1367.
• Melamed‚ B. G.‚ Dearborn‚ M. and Hermecz‚ D. (1983). Necessary considerations for surgery preparation: Age and previous experience. Psychosomatic Medicine‚ 45(6)‚ 517-525.
• Lumley‚ Mark A.‚ Melamed‚ Barbara G.‚ Abeles‚ Linda A. (1993). Predicting Children’s Presurgical Anxiety and Subsequent Behavior Changes. Journal of Pediatric Psychology‚ 18(4)‚ Pages 481–497.

Items of the Hospital Fears Rating Scale (HFRS)

Scoring Key: 1=Not afraid‚ 2= A little fear‚ 3= Some fear‚ 4= Moderate fear‚ 5= Very afraid

Subscale breakdown: Medical fear (items 1-8)‚ hospital fear (items 9-16)‚ and non-medically related items (items 17-25)

1. Sharp objects
2. ha‎ving to go to the hospital
3. Going to the dentist
4. Going to the doctor
5. Getting a shot
6. Getting a haircut
7. Getting car sick
8. Deep water or the ocean
9. Germs or getting seriously ill
10. The sight of blood
11. Being alone without your parents
12. ha‎ving an operation
13. Getting a cut or injury
14. Getting sick at school
15. Not being able to breathe
16. Persons wearing masks
17. Spiders
18. Making mistakes
19. Going to bed In the dark
20. Strange or mean looking dogs
21. Flying In an airplane
22. Getting punished
23. Thunderstorms
24. Ghosts or spooky things
25. Falling from high places