Construction of a quality evaluation index system for assessing a breast cancer self-management intervention on the basis of a three-dimensional quality evaluation model: A Delphi study

Construction of a quality evaluation index system for assessing a breast cancer self-management intervention on the basis of a three-dimensional quality evaluation model: A Delphi study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Construction of a quality evaluation index system for assessing a breast cancer self-management intervention on the basis of a three-dimensional quality evaluation model: A Delphi study Lingling Xue, Beibei Wu, Xifeng Xiao, Jing Yu, Xiaoli Zhang, Yongbing Liu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6715202/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Objective: To construct a system to evaluate the quality of an index for breast cancer (BC) self-management interventions and to provide a tool for assessing the quality of these interventions to promote their effective implementation. Methods The three-dimensional quality evaluation model was used as the theoretical framework in this study, which included a literature survey and semistructured interviews with health professionals. The Delphi method and the analytic hierarchy process (AHP) were used to screen for indicators, determine their weights, and establish a quality evaluation indicator system for self-management interventions in BC patients. Results: The effective response rates of the two questionnaires were 95.83% and 95.65%, the authority coefficients of the experts in the two rounds of consultation were 0.874 and 0.912, and the Kendall harmony coefficients of the overall indicators were 0.143 and 0.237. The final system for evaluating the quality index system for self-management interventions for BC patients included 3 primary indicators, 15 secondary indicators, and 42 tertiary indicators. Conclusions: The quality evaluation indicator system has high reliability and scientific value and therefore provides a tool for evaluating the quality of self-management interventions in BC patients. After further validation, these findings could be used to evaluate the quality of these interventions in clinical practice. three-dimensional quality evaluation model breast cancer Delphi self-management intervention evaluation index system Background According to global cancer statistics in 2020, the incidence of breast cancer (BC) has surpassed that of lung cancer, and BC has become the malignant tumor with the highest incidence rate in the world. BC accounts for 11.7% of new cases of malignant tumors [ 1 ] and is recognized as one of the most important public health problems and the most common tumor type in women [ 2 ] . Data from 2022 revealed that although the global total incidence rate of BC has decreased to second place in women, it still far exceeds that of other cancers and is the main factor that threatens a woman's life and health [ 3 ] . There are many risk factors for BC, such as the postponement of childbearing, a reduction in childbearing times, eating habits, and other unhealthy behavioral factors, all of which influence changes in epidemic trends of BC worldwide. This is especially relevant for countries undergoing social and economic transformation, in which the increasing trend in the incidence of BC is more significant [ 4 ] . BC patients still face various problems in the long-term survival process, such as treatment side effects, postoperative complications, and emotional problems, all of which may seriously affect their physiological, psychological, and social health [ 5 ] , thereby lowering their health-related quality of life (HRQOL) [ 6 ] . However, healthcare resources have not improved accordingly, resulting in the supportive care needs of BC patients remaining unmet [ 7 ] . When external support is insufficient, the ability to self-manage is particularly important. Studies have shown that BC patients are not able to manage themselves well at home [ 8 – 10 ] , such as their management of symptoms, including pain, depression, and fatigue. Therefore, during the process of BC, the ability of a patient to self-manage has an extremely important role. Previous research has indicated that the level of health knowledge of BC patients directly affects their quality of life, with a significant correlation between their level of health knowledge and their ability to self-manage. Accordingly, improving the ability of patients to self-manage effectively improves their quality of life [ 11 ] . Self-management interventions are those that help patients master disease management skills and improve their quality of life through education, support, and strategies for behavioural change. Studies have reported that effective self-management interventions significantly improve the psychological state, physical functioning, and social resilience of BC patients [ 12 ] . Various interventions appear to affect the self-management ability of BC patients [ 13 – 14 ] . However, the index system for evaluating the effects of BC self-management interventions is not perfect in China or abroad, as it lacks systematization and scientificity and does not fully reflect the effect of the intervention. The structure-process-outcome (SPO) model was proposed by Donabedian and has been widely used in the field of medical quality evaluation [ 15 ] . The model comprehensively evaluates the effectiveness of medical interventions in three dimensions: structure (medical resources and facilities), process (medical service delivery process), and outcome (patient health outcomes). In recent years, self-management interventions based on the SPO model have achieved remarkable results in the management of chronic diseases [ 16 ] , although their application in the field of BC is still in the exploratory stage. There is no systematic tool for reviewing the quality of BC self-management interventions in China or other countries; therefore, it is not possible to comprehensively measure the overall quality of these interventions. The current study used the SPO model as a theoretical framework to construct an index system to evaluate the quality of BC self-management interventions, with the aim of providing a scientific and practical tool for evaluating BC self-management interventions. Methods Establishment of the research team The research team consisted of 8 members, including 1 head of the nursing department, 2 ward nursing supervisors, 2 oncology nurses, and 3 graduate students specializing in BC care. The experts trained on the implementation methods and application processes. The main tasks of the research team members included determining the inclusion and exclusion criteria for the experts who would be consulted; preliminary drafting of a quality evaluation system for BC self-management interventions via a literature survey and analysis; and the formulation, distribution, collection, and analysis of expert consultation questionnaires and data processing and analysis. Literature survey and analysis The research references were included in the study in a snowball manner via a computer literature search of CNKI, the Wanfang database, the VIP Chinese Science and Technology Journal database, Web of Science, PubMed, and Embase. The search was carried out according to the "6S" evidence resource pyramid model, which searches from top to bottom in turn, with the retrieval time set from the establishment of the database to October 2024. The search terms used included "breast cancer", "breast tumor", "breast neoplasms", "self-management", "intervention", "effect", "questionnaire", "scale", and "assessment". The inclusion criteria for the literature were as follows: studies related to BC self-management intervention, including clinical decision-making, evidence summary, systematic review, expert consensus, and guidelines. The exclusion criteria for the literature were as follows: evidence quality evaluation of Grade C, literature that has been published repeatedly, and literature in languages other than Chinese and English. The quality level of the included literature was evaluated on the basis of the evidence preclassification and evidence recommendation level system developed by the JBI Center for Evidence-Based Health Care. The evaluation of the evidence was carried out independently by two researchers, and after completion, cross-checking was performed. If there was a disagreement, the evaluation was decided upon by a third researcher. We used the three-dimensional quality evaluation model as the theoretical basis to understand the current development status of the evaluation of BC self-management interventions in China and other countries, which involved combining the Exercise of Self-Care Agency (ESCA) scale evaluation indicators for each dimension [ 17 ] with the literature analysis results and the actual clinical situation, with a preliminary compilation of the evaluation index system for the BC self-management intervention that included 3 first-level indicators, 16 second-level indicators, and 59 third-level indicators. Semistructured interviews Using purposive sampling, interviews were conducted on the basis of the criterion of information saturation, with 3 oncology nurses, 3 BC care experts, and 6 BC patients selected for the semistructured interviews.We must clarify that all participants have signed the informed consent form.The outline of the semistructured interviews with oncology nurses and BC care experts included questions such as the following: What contents are included in BC self-management interventions? What situations do you think could lead to patient disconnection during the intervention process to improve BC patients' self-management? What situations enhance patient compliance, and which aspects can be used to evaluate the effectiveness of BC self-management intervention programs? What indicators need to be deleted or added to the existing evaluation tools? The outline for the semistructured interviews for BC patients included the following questions: What concerns do you have during the entire comprehensive treatment process for BC? What help do you most hope that medical staff or other caregivers will provide in changing your self-management? What factors do you think affect your self-management situation? What methods do you think can improve your level of self-management? A thematic analysis was used to analyse and summarize the content of the collected text into relevant themes [ 18 ] . This analysis summarized the interview data into themes related to the evaluation of the quality of the BC self-management interventions, which included human resources, environment and equipment, norms and processes, nursing staff training, health education, professional team guidance, physical health, mental health, behavioral change, social function, economic burden, incidence of complications, long-term effects, satisfaction, intervention compliance, and knowledge level. Ultimately, after repeated discussions and modifications based on the results of the semistructured interviews, the research team deleted 12 third-level indicators and drafted a BC case management evaluation indicator system that included 3 first-level indicators, 16 second-level indicators, and 47 third-level indicators. Compilation of the expert inquiry questionnaire A preliminary survey was conducted with two oncology nurses and four BC patients to discuss and modify the structural system, item language, and order of the questionnaire, ultimately forming the formal inquiry form. The inquiry form consisted of the following four parts: (1) a letter to experts introducing the purpose and significance of the study, along with instructions for completion; (2) general information about the experts; (3) content of the questionnaire; and (4) the experts' familiarity with the questionnaire and the basis for their judgments. The content of the questionnaire included 3 primary indicators, 16 secondary indicators, and 47 tertiary indicators. A five-point Likert scale was used to determine the importance of the indicators, with the experts asked to fill in the corresponding opinion column below each indicator with their suggested modifications. Invitation for expert consultation Using purposive sampling, 22 experts, including breast specialists, nursing administrators, oncology nurses, and clinical breast care experts, were selected from hospitals providing specialized nursing care for BC. The inclusion criteria were as follows: (1) nursing and clinical experts with more than 10 years of work experience in the field of breast cancer; (2) bachelor's degree or higher; (3) intermediate or higher professional title; (4) familiarity with specialized BC work; and (5) understanding of the study and willingness to participate in the inquiry. The study was approved by the Ethics Committee of Yangzhou Maternal and Child Health Hospital [(2024) Ethical Approval No. (044)]. Distribution inquiry questionnaire From October to December 2024, a Delphi survey was conducted via email or WeChat. After the first round of expert questionnaires were collected, the following indicator selection criteria were followed: (1) mean importance score > 3.5 points and (2) coefficient of variation < 0.25. After screening, the indicators were modified and adjusted on the basis of the opinions of the experts [ 19 ], and in the second round of the survey, the opinions of the experts and the final revisions were fed back to the experts. After two rounds of surveys, the expert opinions generally converged, and the Delphi survey was concluded. Statistical methods SPSS 22.0 software was used for data entry and analyses. Count data are expressed as frequencies and percentages (%), and measurement data are expressed as the means ± standard deviations ( ). The effective response rate of the questionnaire indicated the level of expert engagement, with a rate higher than 70% indicating a high level of expert enthusiasm. Expert authority was represented by the authority coefficient (Cr), which was determined mainly by the expert's judgment basis (Ca) and familiarity (Cs), with the indicator Cr calculated as (Ca + Cs)/2 and a value of ≥ 0.7, suggesting a high level of expert authority [ 20 ] . The coordination coefficient of expert opinions was represented by the coefficient of variation and Kendall's coefficient. A P value < 0.05 was considered statistically significant. The analytic hierarchy process (AHP) was used to determine the weights of the indicators at various levels on the basis of the mean importance scores of the indicators from the second round of expert correspondence. These findings were then used to establish the Satty scale for hierarchical analysis, ranking, and consistency testing and to determine the weight coefficients of evaluation indicators at various levels. Results Inquiry to experts on general information The study conducted two rounds of expert correspondence, and 22 experts ultimately completed the correspondence. These experts came from eight tertiary first-class hospitals and two key medical colleges in cities, Nanjing, Suzhou, Shanghai, Nantong, and Yangzhou. The general information of the experts in the study is summarized in Table 1 . Table 1 Basic information of experts(N = 22) Variables Frequency (N = 22) Percentage (%) Gender Male 3 13.64 Female 19 86.36 Age (year) 50 7 31.82 Degree Bachelor 7 31.82 Master 9 40.91 Doctor and above 6 27.27 Job title Intermediate title 6 27.27 Vice-senior title 9 40.91 Senior title 7 31.82 Working years 10 ~ 20 9 40.91 21 ~ 30 7 31.82 > 30 6 27.27 Mainly engaged in the field Clinical care 14 63.63 Nursing management 3 13.64 Nursing education 3 13.64 Clinical Medicine 2 9.09 Expert engagement level Two rounds of expert correspondence surveys were conducted. In the first round, 24 questionnaires were distributed, with 23 returned, yielding an effective response rate of 95.83%. Sixteen experts provided suggestions, indicating a high level of enthusiasm for participating in the development of the indicator system. In the second round, 23 questionnaires were distributed, and 22 were returned, for an effective response rate of 95.65%. The percentage of experts offering opinions was 31.82%, suggesting a relatively high level of expert recognition for the indicators in this round. Expert authority coefficient The basis for the experts' judgment of the indicators was divided into four dimensions: practical experience, theoretical analysis, reference to domestic and international literature, and intuitive feelings. Each dimension was further divided into different levels of significance: large, medium, and small. The scoring for each dimension was as follows: practical experience (0.5, 0.4, 0.3), theoretical analysis (0.3, 0.2, 0.1), reference to domestic and international literature (0.1, 0.1, 0.1), and intuitive feelings (0.1, 0.1, 0.1). The familiarity of the experts with the indicators was categorized into five levels: very familiar (0.9), fairly familiar (0.7), moderately familiar (0.5), not very familiar (0.3), and unfamiliar (0.1) [ 21 ] . The basis for the judgment (Ca) in the two rounds of Delphi consultation by the experts was 0.943 and 0.959, the familiarity (Cs) was 0.804 and 0.864, and the authority coefficient (Cr) was 0.874 and 0.912. This finding indicated that the Delphi consultation experts selected for this study had a high level of authority, with the results of the consultation also having a high degree of credibility. Concentration and coordination of expert opinions The degree of concentration of expert opinions was represented mainly by the mean value of the importance of the indicators. The mean value of the importance scores of the experts in the first round of the study was 4.27 ~ 5.00, with CV values ranging from 0.000 to 0.236, whereas the overall Kendall harmony coefficient of the indicators was 0.143 ( P < 0.001). The mean value of the importance scores of the experts in the second round of inquiry was 0.417 ~ 0.491, with CV values ranging from 0.083 to 0.151, all less than 0.25, and the overall Kendall harmony coefficient of the indicators was 0.237 ( P < 0.001). This finding indicated that the expert scores tended to be consistent and statistically significant. Table 2 A quality evaluation index system for assessing a breast cancer self-management intervention First-level indicator Weights Second-level indicator Weights Combined weights Third-level indicator Weights Combined weights Importance value Coefficient of variation A.Structural quality 0.333 A1.Human resource elements 0.246 0.082 A1.1 Bed-to-nurse ratio 0.334 0.027 4.55 ± 0.59 0.13 A1.2 Building a professional team (building a multidisciplinary team, including dietitians, counselors, rehabilitation therapists, breast doctors, nurses) 0.328 0.027 4.45 ± 0.62 0.14 A1.3 Duration of intervention per case 0.338 0.028 4.59 ± 0.59 0.13 A2.Environmental and equipment management 0.254 0.085 A2.1 Breast cancer self-management promotion (including graphics, videos, etc.) 0.339 0.029 4.59 ± 0.58 0.13 A2.2 The environment of the intervention implementation process meets the requirements 0.326 0.028 4.41 ± 0.59 0.13 A2.3 The equipment required for the implementation of the intervention is complete 0.335 0.028 4.17 ± 0.63 0.15 A3.Standardize systems and processes 0.249 0.083 A3.1 Breast cancer self-management intervention system and process 0.512 0.042 4.64 ± 0.49 0.11 A3.2 Relevant care routines are revised in a timely manner according to the guidelines 0.488 0.040 4.25 ± 0.58 0.14 A4.Nursing staff training 0.251 0.084 A4.1 Duration of training on breast cancer self-management intervention for caregivers 0.334 0.028 4.36 ± 0.58 0.13 A4.2 Standardized training assessment pass rate 0.355 0.030 4.54 ± 0.56 0.12 A4.3 Proportion of relevant courses or further studies 0.311 0.026 4.54 ± 0.51 0.11 B.Process quality 0.337 B1.Health education 0.498 0.168 B1.1 Advocacy for breast cancer self-management 0.253 0.042 4.51 ± 0.59 0.13 B1.2 The intervention team had regular telephone follow-up 0.253 0.042 4.54 ± 0.56 0.12 B1.3 Brochures and log books are provided 0.203 0.034 4.64 ± 0.58 0.13 B1.4Diversification of forms of education 0.291 0.049 4.52 ± 0.59 0.13 B2.Guidance from a professional team 0.502 0.169 B2.1Timely intervention rate of professional team 0.246 0.042 4.63 ± 0.49 0.12 B2.2 Duration and frequency of counselling by psychological counselors 0.254 0.043 4.63 ± 0.58 0.13 B2.3 Duration and frequency of guidance by rehabilitation therapists 0.251 0.042 4.55 ± 0.59 0.13 B2.4 Duration and frequency of professional medical guidance 0.249 0.042 4.59 ± 0.54 0.12 C.Outcome quality 0.330 C1.Physiological health 0.112 0.037 C1.1 Symptom control: improvement in pain, fatigue, lymphedema, etc. 0.249 0.009 4.68 ± 0.57 0.12 C1.2 Treatment adherence 0.221 0.008 4.59 ± 0.59 0.13 C1.3 Recovery of physical function 0.252 0.009 4.59 ± 0.55 0.13 C1.4 Complication rate 0.279 0.010 4.54 ± 0.56 0.12 C2.Mental health 0.111 0.037 C2.1 Anxiety and depression levels 0.498 0.018 4.64 ± 0.66 0.14 C2.2 Self-efficacy 0.502 0.018 4.64 ± 0.49 0.11 C3.Behavior changes 0.101 0.033 C3.1 Health behaviors 0.357 0.012 4.59 ± 0.50 0.11 C3.2 Self-monitoring 0.421 0.014 4.68 ± 0.57 0.12 C3.3 Access to and Use of Information 0.222 0.007 4.68 ± 0.48 0.10 C4.Social function 0.092 0.030 C4.1 Utilization of social support 0.333 0.010 4.55 ± 0.59 0.13 C4.2 Work & Social Skills 0.412 0.012 4.68 ± 0.47 0.10 C4.3 Family relationships 0.255 0.007 4.46 ± 0.59 0.13 C5.Financial burden 0.115 0.038 C5.1 Medical expenses 0.491 0.018 4.64 ± 0.58 0.13 C5.2 Percentage of medical expenses 0.509 0.019 4.59 ± 0.54 0.12 C6.Long-term effects 0.076 0.025 C6.1 Recurrence rate 0.302 0.008 4.65 ± 0.49 0.11 C6.2 Survival rate 0.307 0.008 4.59 ± 0.59 0.13 C6.3 Chronic disease management 0.391 0.010 4.55 ± 0.56 0.12 C7.Satisfaction 0.105 0.035 C7.1 Satisfaction with the intervention 0.489 0.017 4.73 ± 0.36 0.08 C7.2 Satisfaction with health care services 0.511 0.018 4.64 ± 0.53 0.11 C8.Intervention adherence 0.109 0.036 C8.1 Intervention engagement 0.497 0.018 4.59 ± 0.59 0.13 C8.2 Intervention completion rate 0.503 0.018 4.59 ± 0.53 0.12 C9.Level of knowledge 0.179 0.059 C9.1 Disease knowledge mastery 0.508 0.030 4.41 ± 0.59 0.13 C9.2 Self-management skills 0.492 0.029 4.91 ± 0.44 0.09 Expert consultation results In the first round of expert correspondence, 16 experts (69.57%) provided opinions. On the basis of the indicator selection criteria, in conjunction with expert opinions and group discussions, the team members made the following revisions to the indicator system. The secondary indicator "complication incidence rate" was modified to a tertiary indicator and adjusted to the content of the secondary indicators. "Physical Health", "Nutritionist Qualification", "Psychological Counselor Qualification", and "Rehabilitation Counselor Qualification" were merged with "Medical Staff Qualification" into "Building a Professional Team"; "Pain Improvement", "Cancer-related Fatigue Improvement", and "Lymphedema Improvement" were combined with "Symptom Control". After the second round of expert correspondence, seven experts (31.82%) provided opinions. After discussion, the members of the research group agreed to make the following modifications. The "Nurse-to-Patient Ratio" was modified to "Bed-to-Nurse Ratio", "Professional Team Timely Assistance" to "Professional Team Intervention Timeliness Rate", and "Intervention Measures Utilization" to "Intervention Completion Rate". The final indicator system was formed, which included three primary indicators, 15 secondary indicators, and 42 tertiary indicators. The final indicators at all levels and their weights are shown in Table 2 , with all the consistency ratios (CRs) being less than 0.1. Discussion This study, on the basis of a large volume of research, established various indicators for evaluating the quality of interventions for BC self-management using Donabedian's "SPO" three-dimensional quality structure model as the framework. This model is a three-level theory of quality evaluation proposed by Donabedian, an American expert on quality management [ 15 ] , and has been used to develop indicators for evaluating nursing quality and system construction [ 22 ] . The model has been widely used in areas such as nursing management, nursing education, and clinical nursing research [ 23 – 24 ] . Methods such as Delphi expert consultation have also been used to supplement and modify these indicators, thereby enhancing their scientific validity. The experts consulted in this study came from eight tertiary first-class hospitals and two key medical colleges, covering fields such as clinical nursing, nursing management, nursing education, and clinical medicine, which are representative to some extent. In the end, 22 experts completed two rounds of consultation. The expert authority coefficients for the two rounds of questionnaires in the study were 0.874 and 0.912, both greater than 0.7, which confirms a high level of academic authority among the experts. The effective response rates of the two rounds of expert consultation questionnaires were 95.83% and 95.65%, whereas the proportion of experts who proposed opinions in the first round was 69.57%, indicating a high level of recognition among these experts for the indicators used in the study. The coefficients of variation for the two rounds of expert consultation were 0.000 ~ 0.236 and 0.083 ~ 0.151, whereas the Kendall coefficients were 0.143 and 0.237, with statistically significant differences ( P < 0.001), indicating good consistency and coordination among the expert opinions. In addition, a consistency test of the weights of indicators at all levels was conducted via the AHP, with the CR of each indicator being less than 0.1, indicating a reasonable distribution of weights for the indicators. Therefore, the quality evaluation index system for BC self-management intervention constructed in this study has a high degree of scientificity and reliability. First-level indicators The primary indicators in the quality evaluation index system for BC self-management interventions in this study include structural, process, and outcome indicators. By combining the Delphi method and the AHP, the scores of the experts consulted were quantified and judged, with clarification of the weight of each indicator and control of the mutual influence between the dimensions of the indicators [ 25 ] . The weights of the primary indicators were 0.333, 0.337, and 0.330, indicating that the weights were equally important. The results of this study are inconsistent with those of Shi Tang et al. [ 26 ] , where the process and outcome indicators of a whole-course nursing quality evaluation system for liver transplantation in children had greater weights. Quality control focuses on the process and outcome quality, whereas in the quality control of BC self-management interventions, structural indicators are the foundation for ensuring the quality of these interventions. Process indicators promote the standardization of BC self-management interventions and provide a guide to improve the quality of these interventions, whereas outcome indicators provide feedback on the effectiveness of the interventions and offer reference opinions for continuous quality improvement. Therefore, to increase the quality of BC self-management interventions, strict control over structural, process, and outcome indicators is needed. Second-level indicators In this study, of the 15 secondary indicators, health education and professional team guidance had weights of 0.168 and 0.169, respectively. Given the intensive and long-term treatment required for BC patients, as well as their need for self-management, timely and effective interventions are crucial for improving their overall self-management. Some scholars [ 27 ] have investigated the effects of a self-management lymphedema education program (SMLEP) on lymphedema and confirmed that it is an effective method for self-management of long-term lymphedema. Health education can effectively improve the self-management levels of patients, which is consistent with the findings of the current study. However, some studies have shown that certain groups are less willing to engage in health promotion during the disease process and require professional guidance to improve the overall health behaviors and self-management abilities of patients [ 28 ] . During the intervention process, guidance from a professional team is therefore important, a need that is also consistent with the results of the current study. Health education and professional team guidance are therefore key components of quality evaluation for self-management interventions. Third-level indicators "Diversification of educational forms" had the highest weight among the third-level indicators, at 0.049. In addition, the weight for "Duration and frequency of psychological counselor guidance" was 0.043, whereas the weights for "BC self-management intervention system and process," "Advocacy for BC self-management," "Regular telephone follow-ups by the intervention team," "Timeliness of professional team involvement," "Duration and frequency of rehabilitation therapist guidance," and "Duration and frequency of professional medical guidance" were all 0.042. Some researchers have noted that promoting self-management and implementing health programs can improve patient outcomes. Furthermore, providing ongoing interventions and management is crucial for supporting patients with BC during and after treatment [ 29 ] . Moreover, the quality of BC self-management interventions directly affects the quality of life of patients. Through various educational methods, such as writing diaries, video education, and game participation, the psychological state of BC patients can be improved effectively, thereby promoting recovery [ 30 ] . This finding indicates that the diversification of educational forms can encourage patients to actively participate in self-management. The BC self-management professional team also plays a significant role in BC self-management by conducting accurate and dynamic assessments and monitoring patient conditions, providing personalized health guidance, and following standardized BC self-management intervention processes and systems to ensure the effective implementation of these interventions. Taken together, these results indicate that diverse educational forms, comprehensive systems and processes, and professional intervention teams are prerequisites for ensuring the quality of self-management interventions. Therefore, these factors are included as key focus areas in quality evaluation systems of BC self-management. Conclusion This study uses the "SPO" three-dimensional quality structure model as its theoretical framework and performs a literature analysis, semistructured interviews, the Delphi method, and the AHP to ultimately develop a quality evaluation index system for BC self-management interventions. This system includes three primary indicators, 15 secondary indicators, and 42 tertiary indicators to provide a scientific and reliable standard for evaluating the quality of BC self-management interventions. The system was also highly important for standardizing these interventions. The next steps involve applying the constructed index system in clinical settings to further refine the quality evaluation index system for BC self-management interventions and to set target values for each indicator in accordance with the characteristics of BC. Declarations This study was performed in accordance with the Declaration of Helsinki, and the study protocol was approved by the Ethics Committee of Yangzhou Maternal and Child Health Hospital(2024-044). The manuscript does not contain data from any individual person.The datasets used and analysed during the current study are available from the corresponding author on reasonable request.None of the authors have any conflicts of interest to declare, and all authors are involved in research program design, data collection and thesis writing.The authors would like to express their gratitude to EditSprings ( https://www.editsprings.cn)fo r the expert linguistic services provided. Funding Declarations This research was supported by Yangzhou Municipal Health Commission under grant number 2024064.There is no conflict of interest between funders and authors. Author Contribution L.X.: Conceptualization,Data curation,Formal analysis,Writing - original draft. X.X.: Data curation, Funding acquisition,Writing- original draft preparation. J.Y.: Visualization, Investigation. X.Z.: Supervision.Y.L.: Writing- Reviewing and Editing.B.W.:Project administration,Writing- Reviewing and Editing. References Sung H, Ferlay J, Siegel RL et al. Global cancer statistics 2020:GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries[J]. CA Cancer J Clin, 2021,71(3):209–249.doi: 10.3322/caac.21660. Epub2021 Feb 4. PMID: 33538338. Trapani D, Ginsburg O, Fadelu T, et al. Global challenges and policy solutions in breast cancer control. Cancer Treat Rev. 2022;104:102339. 10.1016/j.ctrv.2022.102339 . Epub 2022 Jan 19. PMID: 35074727. Bray F, Laversanne M, Sung H et al. Global cancer statistics 2022:GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries[J]. CA Cancer J Clin 2024,74(3):229–63.doi:10.3322/caac.21834.Epub2024 Apr 4. PMID: 38572751. Wilkinson L, Gathani T. Understanding breast cancer as a global health concern [J]. Br J Radiol. 2022;95(1130):20211033. 10.1259/bjr.20211033 . Epub 2021 Dec 14. PMID: 34905391; PMCID: PMC8822551. De Vrieze T, Nevelsteen I, Thomis S, et al. What are the economic burden and costs associated with the treatment of breast cancer-related lymphoedema? A systematic review. Support Care Cancer. 2020;28(2):439–49. 10.1007/s00520-019-05101-8 . Epub 2019 Oct 28. PMID: 31656987. Ho PJ, Gernaat SAM, Hartman M, et al. Health-related quality of life in Asian patients with breast cancer: a systematic review. BMJ Open. 2018;8(4):e020512. 10.1136/bmjopen-2017-020512 . PMID: 29678980; PMCID: PMC5914715. Gálvez-Hernández CL, Boyes A, Ortega-Mondragón A et al. Unmet Needs Among Breast Cancer Patients in a Developing Country and Supportive Care Needs Survey Validation. Rev Invest Clin. 2021;73(4):245–250. doi: 10.24875/RIC.21000068. Epub ahead of print. PMID: 33956785. Fan L, Strasser-Weippl K, Li JJ, St Louis J, Finkelstein DM, Yu KD, Chen WQ, Shao ZM, Goss PE. Breast cancer in China. Lancet Oncol. 2014;15(7):e279-89. 10.1016/S1470-2045(13)70567-9 . PMID: 24872111. Fu X, Lu Q, Pang D, Shen A, Shih YA, Wei X. Experiences of breast cancer survivors with lymphedema self-management: a systematic review of qualitative studies. J Cancer Surviv. 2023;17(3):619–33. 10.1007/s11764-022-01225-9 . Epub 2022 Jun 30. PMID: 35773611. Shen A, Wu P, Qiang W, Fu X, Zhu F, Pang L, Wang F, Lu Q. Factors associated with lymphedema self-management behaviours among breast cancer survivors: A cross-sectional study. J Clin Nurs. 2023;32(19–20):7330–45. 10.1111/jocn.16833 . Epub 2023 Jul 25. PMID: 37491890. Ahmadzadeh I, Abdekhoda M, Bejani M. Improving Self-Care Management in Patients with Breast Cancer through Health Literacy Promotion. Ethiop J Health Sci. 2021;31(1):85–90. 10.4314/ejhs.v31i1.10 . PMID: 34158755; PMCID: PMC8188109. Dibble KE, Rosenberg SM, Snow C, Kirkner GJ, Tayob N, Contreras M, Roma ND, DeGraffinreid CR, Nolan TS, Hershman DL, Naughton M, Partridge AH, Young. Empowered & strong (YES): a study protocol paper for a randomized controlled trial of an mHealth symptom monitoring and self-management intervention for adolescent and young adult (AYA) breast cancer survivors. BMC Public Health. 2025;25(1):126. 10.1186/s12889-025-21288-4 . PMID: 39799291; PMCID: PMC11724548. Shi N, Wong AKC, Wong FKY, Sha L. Mobile Health Application-Based Interventions to Improve Self-management of Chemotherapy-Related Symptoms Among People with Breast Cancer Who Are Undergoing Chemotherapy: A Systematic Review. Oncologist. 2023;28(4):e175–82. 10.1093/oncolo/oyac267 . PMID: 36801955; PMCID: PMC10078896. Shi N, Zhang N, Wong FKY, Zhu W, Lai X, Jin Y, Gu C, Nie L, Dong X, Wong AKC. Perceptions of utilizing a symptom self-management app for breast cancer patients receiving outpatient chemotherapy. Eur J Oncol Nurs. 2024;71:102624. Epub 2024 May 28. PMID: 38878691. Donabedian A. The quality of care. How can it be assessed? JAMA. 1988 Sep 23–30;260(12):1743-8. 10.1001/jama.260.12.1743 . PMID: 3045356. Kang L, Wang MH, Wu SJ. Construction of nursing-sensitive quality indicator system for cardiac rehabilitation of patients undergoing percutaneous coronary intervention based on structure-process-outcome model. BMC Nurs. 2023;22(1):457. 10.1186/s12912-023-01618-w . PMID: 38049804; PMCID: PMC10696800. Wong CL, Ip WY, Shiu TY. Translation and validation of the Chinese-Cantonese version of the Exercise of Self-Care Agency Scale. Int J Nurs Stud. 2012;49(9):1122–37. 10.1016/j.ijnurstu.2012.04.004 . Epub 2012 May 8. PMID: 22572019. Beng TS, Xin CA, Ying YK, Khuen LP, Yee A, Zainuddin SI, Chin LE, Loong LC. Hope in Palliative Care: A Thematic Analysis. J Palliat Care. 2022;37(2):177–82. Epub 2020 Aug 14. PMID: 32791956. Wan F, Yang L, Zhou N, He Y. Construction of learning objectives and content for newly graduated nurses in tertiary teaching hospitals: A Delphi study. Nurse Educ Today. 2023;121:105716. 10.1016/j.nedt.2023.105716 . Epub 2023 Jan 13. PMID: 36657320. Jiang N, Liu WB, Zong Y, Yu L, Cheng S. Construction of an index system of core competence assessment for sleep medicine nurse specialists in China: a Delphi study. BMC Nurs. 2024;23(1):689. 10.1186/s12912-024-02349-2 . PMID: 39334099; PMCID: PMC11438144. Liu W, Hu M, Chen W. Identifying the Service Capability of Long-Term Care Facilities in China: An e-Delphi Study. Front Public Health. 2022;10:884514. 10.3389/fpubh.2022.884514 . PMID: 35844860; PMCID: PMC9277176. Opele JK, Adepoju KO. Validation of the Donabedian Model of Health Service Quality in Selected States in Nigeria. Niger J Clin Pract. 2024;27(2):167–173. 10.4103/njcp.njcp_220_22 . Epub 2024 Feb 26. PMID: 38409143. White KM, Dulko D, DiPietro B. The Effect of Burnout on Quality of Care Using Donabedian's Framework. Nurs Clin North Am. 2022;57(1):115–130. doi: 10.1016/j.cnur.2021.11.008. PMID: 35236602. Wei L, Zhang X, Li H, Wang Y, Lu M, Chai Q. Construction of internet Plus Wound Care Service Quality Evaluation System Based on Donabedian and SERVQUAL Models-A Delphi-Analytic Hierarchy Process Study. Nurs Health Sci. 2025;27(1):e70051. 10.1111/nhs.70051 . PMID: 39894036. Lu J, Sun X, Zhang Y. Establishment and analysis of quality index system for pediatric tumor nursing. Technol Health Care. 2024;32(6):4343–4351. 10.3233/THC-240252 . PMID: 39058465. Tang S, Huang MZ, Lu YF, Liu W, Wang BB, Wang Y. [A Whole-Course Nursing Quality Evaluation System for Liver Transplantation in Children Based on Donabedian Theory]. Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2024;46(1):55–61. Chinese. 10.3881/j.issn.1000-503X.15888 . PMID: 38433632. Cansız G, Arıkan Dönmez A, Kapucu S, Borman P. The effect of a self-management lymphedema education program on lymphedema, lymphedema-related symptoms, patient compliance, daily living activities and patient activation in patients with breast cancer-related lymphedema: A quasiexperimental study. Eur J Oncol Nurs. 2022;56:102081. Epub 2021 Dec 1. PMID: 34875398. Hsia HH, Tien Y, Lin YC, Huang HP. Factors Influencing Health Promotion Lifestyle in Female Breast Cancer Survivors: The Role of Health Behavior Self-Efficacy and Associated Factors. Semin Oncol Nurs. 2024;40(2):151622. 10.1016/j.soncn.2024.151622 . Epub 2024 Mar 24. PMID: 38522967. An HJ, Kang SJ, Choi GE. Technology-based self-management interventions for women with breast cancer: a systematic review. Korean J Women Health Nurs. 2023;29(3):160–78. 10.4069/kjwhn.2023.09.07 . Epub 2023 Sep 26. PMID: 37813660; PMCID: PMC10565530. Sansom-Daly UM, Wakefield CE, Ellis SJ, McGill BC, Donoghoe MW, Butow P, Bryant RA, Sawyer SM, Patterson P, Anazodo A, Plaster M, Thompson K, Holland L, Osborn M, Maguire F, O'Dwyer C, De Abreu Lourenco R, Cohn RJ. The Recapture Life Working Party. Online, Group-Based Psychological Support for Adolescent and Young Adult Cancer Survivors: Results from the Recapture Life Randomized Trial. Cancers (Basel). 2021;13(10):2460. 10.3390/cancers13102460 . PMID: 34070134; PMCID: PMC8158368. Additional Declarations No competing interests reported. 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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-6715202","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":476232317,"identity":"c1017ceb-a8ec-4733-9746-fa722e95f8bb","order_by":0,"name":"Lingling Xue","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzElEQVRIiWNgGAWjYBACfoaD7T8keGzq+dkbiNQi2Xi4QcJCJi1BsucAkVoMmo83SFTYHEowuJFArBa2gw0GN3IO5DHcfLzxBkONTTRBLeY8BxsSZ5y5U8w4O63YguFYWm4DIS2WMw42HJbsecbYLJ1jJsHYcJiwFoP7Dxub//47zNgmeYZYLQcONjNI8BxO7JHgIVKLZMPBNqCWNGMgLrZIIMYv/AzHnwG12MjZHz+88caHGhvCWlAcKZFAinKIFlJ1jIJRMApGwcgAAJVqReZokX36AAAAAElFTkSuQmCC","orcid":"","institution":"Yangzhou Maternal and Child Health Hospital, Yangzhou University","correspondingAuthor":true,"prefix":"","firstName":"Lingling","middleName":"","lastName":"Xue","suffix":""},{"id":476232318,"identity":"086dbe86-d312-4232-a02f-5e9eda745e93","order_by":1,"name":"Beibei Wu","email":"","orcid":"","institution":"Yangzhou Maternal and Child Health Hospital, Yangzhou University","correspondingAuthor":false,"prefix":"","firstName":"Beibei","middleName":"","lastName":"Wu","suffix":""},{"id":476232319,"identity":"3401579c-4e48-4e15-a953-95482010c8a7","order_by":2,"name":"Xifeng Xiao","email":"","orcid":"","institution":"Yangzhou Maternal and Child Health Hospital, Yangzhou University","correspondingAuthor":false,"prefix":"","firstName":"Xifeng","middleName":"","lastName":"Xiao","suffix":""},{"id":476232321,"identity":"702b64b7-4ab4-4019-a70b-992203268370","order_by":3,"name":"Jing Yu","email":"","orcid":"","institution":"Jiangsu Cancer Hospital, The affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Institute of Cancer Research/Jiangsu Red Cross Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Jing","middleName":"","lastName":"Yu","suffix":""},{"id":476232325,"identity":"c8006b88-1f35-43f6-9a8c-1fdfdad9ad4b","order_by":4,"name":"Xiaoli Zhang","email":"","orcid":"","institution":"Yangzhou Maternal and Child Health Hospital, Yangzhou University","correspondingAuthor":false,"prefix":"","firstName":"Xiaoli","middleName":"","lastName":"Zhang","suffix":""},{"id":476232327,"identity":"abeb1ca1-381a-4722-9cb0-9f5eb298fe75","order_by":5,"name":"Yongbing Liu","email":"","orcid":"","institution":"Yangzhou University","correspondingAuthor":false,"prefix":"","firstName":"Yongbing","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2025-05-21 09:53:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6715202/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6715202/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85466387,"identity":"905d5ea6-c437-488b-af0e-9e242b89abc3","added_by":"auto","created_at":"2025-06-26 08:30:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1099930,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6715202/v1/486d086f-5c38-4df7-b7f5-004f912d281a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Construction of a quality evaluation index system for assessing a breast cancer self-management intervention on the basis of a three-dimensional quality evaluation model: A Delphi study","fulltext":[{"header":"Background","content":"\u003cp\u003eAccording to global cancer statistics in 2020, the incidence of breast cancer (BC) has surpassed that of lung cancer, and BC has become the malignant tumor with the highest incidence rate in the world. BC accounts for 11.7% of new cases of malignant tumors \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e and is recognized as one of the most important public health problems and the most common tumor type in women \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Data from 2022 revealed that although the global total incidence rate of BC has decreased to second place in women, it still far exceeds that of other cancers and is the main factor that threatens a woman's life and health \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. There are many risk factors for BC, such as the postponement of childbearing, a reduction in childbearing times, eating habits, and other unhealthy behavioral factors, all of which influence changes in epidemic trends of BC worldwide. This is especially relevant for countries undergoing social and economic transformation, in which the increasing trend in the incidence of BC is more significant \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eBC patients still face various problems in the long-term survival process, such as treatment side effects, postoperative complications, and emotional problems, all of which may seriously affect their physiological, psychological, and social health \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e, thereby lowering their health-related quality of life (HRQOL) \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. However, healthcare resources have not improved accordingly, resulting in the supportive care needs of BC patients remaining unmet \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. When external support is insufficient, the ability to self-manage is particularly important. Studies have shown that BC patients are not able to manage themselves well at home \u003csup\u003e[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e, such as their management of symptoms, including pain, depression, and fatigue. Therefore, during the process of BC, the ability of a patient to self-manage has an extremely important role.\u003c/p\u003e \u003cp\u003ePrevious research has indicated that the level of health knowledge of BC patients directly affects their quality of life, with a significant correlation between their level of health knowledge and their ability to self-manage. Accordingly, improving the ability of patients to self-manage effectively improves their quality of life \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSelf-management interventions are those that help patients master disease management skills and improve their quality of life through education, support, and strategies for behavioural change. Studies have reported that effective self-management interventions significantly improve the psychological state, physical functioning, and social resilience of BC patients \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eVarious interventions appear to affect the self-management ability of BC patients \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. However, the index system for evaluating the effects of BC self-management interventions is not perfect in China or abroad, as it lacks systematization and scientificity and does not fully reflect the effect of the intervention.\u003c/p\u003e \u003cp\u003eThe structure-process-outcome (SPO) model was proposed by Donabedian and has been widely used in the field of medical quality evaluation \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. The model comprehensively evaluates the effectiveness of medical interventions in three dimensions: structure (medical resources and facilities), process (medical service delivery process), and outcome (patient health outcomes). In recent years, self-management interventions based on the SPO model have achieved remarkable results in the management of chronic diseases \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e, although their application in the field of BC is still in the exploratory stage.\u003c/p\u003e \u003cp\u003eThere is no systematic tool for reviewing the quality of BC self-management interventions in China or other countries; therefore, it is not possible to comprehensively measure the overall quality of these interventions. The current study used the SPO model as a theoretical framework to construct an index system to evaluate the quality of BC self-management interventions, with the aim of providing a scientific and practical tool for evaluating BC self-management interventions.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEstablishment of the research team\u003c/h2\u003e \u003cp\u003eThe research team consisted of 8 members, including 1 head of the nursing department, 2 ward nursing supervisors, 2 oncology nurses, and 3 graduate students specializing in BC care. The experts trained on the implementation methods and application processes. The main tasks of the research team members included determining the inclusion and exclusion criteria for the experts who would be consulted; preliminary drafting of a quality evaluation system for BC self-management interventions via a literature survey and analysis; and the formulation, distribution, collection, and analysis of expert consultation questionnaires and data processing and analysis.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eLiterature survey and analysis\u003c/h3\u003e\n\u003cp\u003eThe research references were included in the study in a snowball manner via a computer literature search of CNKI, the Wanfang database, the VIP Chinese Science and Technology Journal database, Web of Science, PubMed, and Embase. The search was carried out according to the \"6S\" evidence resource pyramid model, which searches from top to bottom in turn, with the retrieval time set from the establishment of the database to October 2024. The search terms used included \"breast cancer\", \"breast tumor\", \"breast neoplasms\", \"self-management\", \"intervention\", \"effect\", \"questionnaire\", \"scale\", and \"assessment\". The inclusion criteria for the literature were as follows: studies related to BC self-management intervention, including clinical decision-making, evidence summary, systematic review, expert consensus, and guidelines. The exclusion criteria for the literature were as follows: evidence quality evaluation of Grade C, literature that has been published repeatedly, and literature in languages other than Chinese and English. The quality level of the included literature was evaluated on the basis of the evidence preclassification and evidence recommendation level system developed by the JBI Center for Evidence-Based Health Care. The evaluation of the evidence was carried out independently by two researchers, and after completion, cross-checking was performed. If there was a disagreement, the evaluation was decided upon by a third researcher. We used the three-dimensional quality evaluation model as the theoretical basis to understand the current development status of the evaluation of BC self-management interventions in China and other countries, which involved combining the Exercise of Self-Care Agency (ESCA) scale evaluation indicators for each dimension \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e with the literature analysis results and the actual clinical situation, with a preliminary compilation of the evaluation index system for the BC self-management intervention that included 3 first-level indicators, 16 second-level indicators, and 59 third-level indicators.\u003c/p\u003e\n\u003ch3\u003eSemistructured interviews\u003c/h3\u003e\n\u003cp\u003eUsing purposive sampling, interviews were conducted on the basis of the criterion of information saturation, with 3 oncology nurses, 3 BC care experts, and 6 BC patients selected for the semistructured interviews.We must clarify that all participants have signed the informed consent form.The outline of the semistructured interviews with oncology nurses and BC care experts included questions such as the following: What contents are included in BC self-management interventions? What situations do you think could lead to patient disconnection during the intervention process to improve BC patients' self-management? What situations enhance patient compliance, and which aspects can be used to evaluate the effectiveness of BC self-management intervention programs? What indicators need to be deleted or added to the existing evaluation tools? The outline for the semistructured interviews for BC patients included the following questions: What concerns do you have during the entire comprehensive treatment process for BC? What help do you most hope that medical staff or other caregivers will provide in changing your self-management? What factors do you think affect your self-management situation? What methods do you think can improve your level of self-management? A thematic analysis was used to analyse and summarize the content of the collected text into relevant themes \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. This analysis summarized the interview data into themes related to the evaluation of the quality of the BC self-management interventions, which included human resources, environment and equipment, norms and processes, nursing staff training, health education, professional team guidance, physical health, mental health, behavioral change, social function, economic burden, incidence of complications, long-term effects, satisfaction, intervention compliance, and knowledge level. Ultimately, after repeated discussions and modifications based on the results of the semistructured interviews, the research team deleted 12 third-level indicators and drafted a BC case management evaluation indicator system that included 3 first-level indicators, 16 second-level indicators, and 47 third-level indicators.\u003c/p\u003e\n\u003ch3\u003eCompilation of the expert inquiry questionnaire\u003c/h3\u003e\n\u003cp\u003eA preliminary survey was conducted with two oncology nurses and four BC patients to discuss and modify the structural system, item language, and order of the questionnaire, ultimately forming the formal inquiry form. The inquiry form consisted of the following four parts: (1) a letter to experts introducing the purpose and significance of the study, along with instructions for completion; (2) general information about the experts; (3) content of the questionnaire; and (4) the experts' familiarity with the questionnaire and the basis for their judgments. The content of the questionnaire included 3 primary indicators, 16 secondary indicators, and 47 tertiary indicators. A five-point Likert scale was used to determine the importance of the indicators, with the experts asked to fill in the corresponding opinion column below each indicator with their suggested modifications.\u003c/p\u003e\n\u003ch3\u003eInvitation for expert consultation\u003c/h3\u003e\n\u003cp\u003eUsing purposive sampling, 22 experts, including breast specialists, nursing administrators, oncology nurses, and clinical breast care experts, were selected from hospitals providing specialized nursing care for BC. The inclusion criteria were as follows: (1) nursing and clinical experts with more than 10 years of work experience in the field of breast cancer; (2) bachelor's degree or higher; (3) intermediate or higher professional title; (4) familiarity with specialized BC work; and (5) understanding of the study and willingness to participate in the inquiry. The study was approved by the Ethics Committee of Yangzhou Maternal and Child Health Hospital [(2024) Ethical Approval No. (044)].\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDistribution inquiry questionnaire\u003c/h2\u003e \u003cp\u003eFrom October to December 2024, a Delphi survey was conducted via email or WeChat. After the first round of expert questionnaires were collected, the following indicator selection criteria were followed: (1) mean importance score\u0026thinsp;\u0026gt;\u0026thinsp;3.5 points and (2) coefficient of variation\u0026thinsp;\u0026lt;\u0026thinsp;0.25. After screening, the indicators were modified and adjusted on the basis of the opinions of the experts \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e],\u003c/sup\u003e and in the second round of the survey, the opinions of the experts and the final revisions were fed back to the experts. After two rounds of surveys, the expert opinions generally converged, and the Delphi survey was concluded.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStatistical methods\u003c/h3\u003e\n\u003cp\u003eSPSS 22.0 software was used for data entry and analyses. Count data are expressed as frequencies and percentages (%), and measurement data are expressed as the means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations (\u003cspan class=\"InlineEquation\"\u003e\u003c/span\u003e). The effective response rate of the questionnaire indicated the level of expert engagement, with a rate higher than 70% indicating a high level of expert enthusiasm. Expert authority was represented by the authority coefficient (Cr), which was determined mainly by the expert's judgment basis (Ca) and familiarity (Cs), with the indicator Cr calculated as (Ca\u0026thinsp;+\u0026thinsp;Cs)/2 and a value of \u0026ge;\u0026thinsp;0.7, suggesting a high level of expert authority \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. The coordination coefficient of expert opinions was represented by the coefficient of variation and Kendall's coefficient. A \u003cem\u003eP\u003c/em\u003e value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. The analytic hierarchy process (AHP) was used to determine the weights of the indicators at various levels on the basis of the mean importance scores of the indicators from the second round of expert correspondence. These findings were then used to establish the Satty scale for hierarchical analysis, ranking, and consistency testing and to determine the weight coefficients of evaluation indicators at various levels.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eInquiry to experts on general information\u003c/h2\u003e \u003cp\u003eThe study conducted two rounds of expert correspondence, and 22 experts ultimately completed the correspondence. These experts came from eight tertiary first-class hospitals and two key medical colleges in cities, Nanjing, Suzhou, Shanghai, Nantong, and Yangzhou. The general information of the experts in the study is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e Basic information of experts(N\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (N\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e86.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u0026thinsp;~\u0026thinsp;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDegree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaster\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoctor and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJob title\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntermediate title\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVice-senior title\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSenior title\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorking years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u0026thinsp;~\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u0026thinsp;~\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMainly engaged in the field\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNursing management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNursing education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eExpert engagement level\u003c/h2\u003e \u003cp\u003eTwo rounds of expert correspondence surveys were conducted. In the first round, 24 questionnaires were distributed, with 23 returned, yielding an effective response rate of 95.83%. Sixteen experts provided suggestions, indicating a high level of enthusiasm for participating in the development of the indicator system. In the second round, 23 questionnaires were distributed, and 22 were returned, for an effective response rate of 95.65%. The percentage of experts offering opinions was 31.82%, suggesting a relatively high level of expert recognition for the indicators in this round.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eExpert authority coefficient\u003c/h2\u003e \u003cp\u003eThe basis for the experts' judgment of the indicators was divided into four dimensions: practical experience, theoretical analysis, reference to domestic and international literature, and intuitive feelings. Each dimension was further divided into different levels of significance: large, medium, and small. The scoring for each dimension was as follows: practical experience (0.5, 0.4, 0.3), theoretical analysis (0.3, 0.2, 0.1), reference to domestic and international literature (0.1, 0.1, 0.1), and intuitive feelings (0.1, 0.1, 0.1). The familiarity of the experts with the indicators was categorized into five levels: very familiar (0.9), fairly familiar (0.7), moderately familiar (0.5), not very familiar (0.3), and unfamiliar (0.1) \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. The basis for the judgment (Ca) in the two rounds of Delphi consultation by the experts was 0.943 and 0.959, the familiarity (Cs) was 0.804 and 0.864, and the authority coefficient (Cr) was 0.874 and 0.912. This finding indicated that the Delphi consultation experts selected for this study had a high level of authority, with the results of the consultation also having a high degree of credibility.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eConcentration and coordination of expert opinions\u003c/h2\u003e \u003cp\u003eThe degree of concentration of expert opinions was represented mainly by the mean value of the importance of the indicators. The mean value of the importance scores of the experts in the first round of the study was 4.27\u0026thinsp;~\u0026thinsp;5.00, with CV values ranging from 0.000 to 0.236, whereas the overall Kendall harmony coefficient of the indicators was 0.143 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The mean value of the importance scores of the experts in the second round of inquiry was 0.417\u0026thinsp;~\u0026thinsp;0.491, with CV values ranging from 0.083 to 0.151, all less than 0.25, and the overall Kendall harmony coefficient of the indicators was 0.237 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This finding indicated that the expert scores tended to be consistent and statistically significant.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e A quality evaluation index system for assessing a breast cancer self-management intervention\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst-level indicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWeights\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSecond-level indicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWeights\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCombined weights\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThird-level indicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWeights\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCombined weights\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eImportance value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCoefficient of variation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA.Structural quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.333\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eA1.Human resource elements\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.246\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.082\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eA1.1 Bed-to-nurse ratio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.334\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.55\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eA1.2 Building a professional team (building a multidisciplinary team, including dietitians, counselors, rehabilitation therapists, breast doctors, nurses)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.328\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.45\u0026thinsp;\u0026plusmn;\u0026thinsp;0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eA1.3 Duration of intervention per case\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.338\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.028\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eA2.Environmental and equipment management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.254\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.085\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eA2.1 Breast cancer self-management promotion (including graphics, videos, etc.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.339\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eA2.2 The environment of the intervention implementation process meets the requirements\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.326\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.028\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eA2.3 The equipment required for the implementation of the intervention is complete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.335\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.028\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eA3.Standardize systems and processes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.249\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.083\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eA3.1 Breast cancer self-management intervention system and process\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.512\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eA3.2 Relevant care routines are revised in a timely manner according to the guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.488\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.040\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eA4.Nursing staff training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.251\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.084\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eA4.1 Duration of training on breast cancer self-management intervention for caregivers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.334\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.028\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.36\u0026thinsp;\u0026plusmn;\u0026thinsp;0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eA4.2 Standardized training assessment pass rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.355\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.030\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.54\u0026thinsp;\u0026plusmn;\u0026thinsp;0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eA4.3 Proportion of relevant courses or further studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.311\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.54\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB.Process quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.337\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eB1.Health education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.498\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eB1.1 Advocacy for breast cancer self-management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.51\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eB1.2 The intervention team had regular telephone follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.54\u0026thinsp;\u0026plusmn;\u0026thinsp;0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eB1.3 Brochures and log books are provided\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.034\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eB1.4Diversification of forms of education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.291\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.049\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.52\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eB2.Guidance from a professional team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.502\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eB2.1Timely intervention rate of professional team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.246\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.63\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eB2.2 Duration and frequency of counselling by psychological counselors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.254\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.043\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.63\u0026thinsp;\u0026plusmn;\u0026thinsp;0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eB2.3 Duration and frequency of guidance by rehabilitation therapists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.251\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.55\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eB2.4 Duration and frequency of professional medical guidance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.249\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC.Outcome quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.330\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eC1.Physiological health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC1.1 Symptom control: improvement in pain, fatigue, lymphedema, etc.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.249\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.68\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC1.2 Treatment adherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.221\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC1.3 Recovery of physical function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.252\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC1.4 Complication rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.279\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.54\u0026thinsp;\u0026plusmn;\u0026thinsp;0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eC2.Mental health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC2.1 Anxiety and depression levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.498\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC2.2 Self-efficacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.502\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eC3.Behavior changes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.033\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC3.1 Health behaviors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.357\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC3.2 Self-monitoring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.421\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.68\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC3.3 Access to and Use of Information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.222\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.68\u0026thinsp;\u0026plusmn;\u0026thinsp;0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eC4.Social function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.092\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.030\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC4.1 Utilization of social support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.333\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.55\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC4.2 Work \u0026amp; Social Skills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.412\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.68\u0026thinsp;\u0026plusmn;\u0026thinsp;0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC4.3 Family relationships\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.255\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.46\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eC5.Financial burden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC5.1 Medical expenses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.491\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC5.2 Percentage of medical expenses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.509\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eC6.Long-term effects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.076\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC6.1 Recurrence rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.302\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.65\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC6.2 Survival rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.307\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC6.3 Chronic disease management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.391\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.55\u0026thinsp;\u0026plusmn;\u0026thinsp;0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eC7.Satisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC7.1 Satisfaction with the intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.489\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC7.2 Satisfaction with health care services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.511\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eC8.Intervention adherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC8.1 Intervention engagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.497\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC8.2 Intervention completion rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.503\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eC9.Level of knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.179\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC9.1 Disease knowledge mastery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.508\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.030\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC9.2 Self-management skills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.492\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c9\"\u003e \u003cp\u003e4.91\u0026thinsp;\u0026plusmn;\u0026thinsp;0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eExpert consultation results\u003c/h2\u003e \u003cp\u003eIn the first round of expert correspondence, 16 experts (69.57%) provided opinions. On the basis of the indicator selection criteria, in conjunction with expert opinions and group discussions, the team members made the following revisions to the indicator system. The secondary indicator \"complication incidence rate\" was modified to a tertiary indicator and adjusted to the content of the secondary indicators. \"Physical Health\", \"Nutritionist Qualification\", \"Psychological Counselor Qualification\", and \"Rehabilitation Counselor Qualification\" were merged with \"Medical Staff Qualification\" into \"Building a Professional Team\"; \"Pain Improvement\", \"Cancer-related Fatigue Improvement\", and \"Lymphedema Improvement\" were combined with \"Symptom Control\". After the second round of expert correspondence, seven experts (31.82%) provided opinions. After discussion, the members of the research group agreed to make the following modifications. The \"Nurse-to-Patient Ratio\" was modified to \"Bed-to-Nurse Ratio\", \"Professional Team Timely Assistance\" to \"Professional Team Intervention Timeliness Rate\", and \"Intervention Measures Utilization\" to \"Intervention Completion Rate\". The final indicator system was formed, which included three primary indicators, 15 secondary indicators, and 42 tertiary indicators. The final indicators at all levels and their weights are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, with all the consistency ratios (CRs) being less than 0.1.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study, on the basis of a large volume of research, established various indicators for evaluating the quality of interventions for BC self-management using Donabedian's \"SPO\" three-dimensional quality structure model as the framework. This model is a three-level theory of quality evaluation proposed by Donabedian, an American expert on quality management \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e, and has been used to develop indicators for evaluating nursing quality and system construction \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. The model has been widely used in areas such as nursing management, nursing education, and clinical nursing research \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. Methods such as Delphi expert consultation have also been used to supplement and modify these indicators, thereby enhancing their scientific validity.\u003c/p\u003e \u003cp\u003eThe experts consulted in this study came from eight tertiary first-class hospitals and two key medical colleges, covering fields such as clinical nursing, nursing management, nursing education, and clinical medicine, which are representative to some extent. In the end, 22 experts completed two rounds of consultation. The expert authority coefficients for the two rounds of questionnaires in the study were 0.874 and 0.912, both greater than 0.7, which confirms a high level of academic authority among the experts. The effective response rates of the two rounds of expert consultation questionnaires were 95.83% and 95.65%, whereas the proportion of experts who proposed opinions in the first round was 69.57%, indicating a high level of recognition among these experts for the indicators used in the study. The coefficients of variation for the two rounds of expert consultation were 0.000\u0026thinsp;~\u0026thinsp;0.236 and 0.083\u0026thinsp;~\u0026thinsp;0.151, whereas the Kendall coefficients were 0.143 and 0.237, with statistically significant differences (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating good consistency and coordination among the expert opinions. In addition, a consistency test of the weights of indicators at all levels was conducted via the AHP, with the CR of each indicator being less than 0.1, indicating a reasonable distribution of weights for the indicators. Therefore, the quality evaluation index system for BC self-management intervention constructed in this study has a high degree of scientificity and reliability.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eFirst-level indicators\u003c/h2\u003e \u003cp\u003eThe primary indicators in the quality evaluation index system for BC self-management interventions in this study include structural, process, and outcome indicators. By combining the Delphi method and the AHP, the scores of the experts consulted were quantified and judged, with clarification of the weight of each indicator and control of the mutual influence between the dimensions of the indicators \u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. The weights of the primary indicators were 0.333, 0.337, and 0.330, indicating that the weights were equally important. The results of this study are inconsistent with those of Shi Tang et al. \u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e, where the process and outcome indicators of a whole-course nursing quality evaluation system for liver transplantation in children had greater weights. Quality control focuses on the process and outcome quality, whereas in the quality control of BC self-management interventions, structural indicators are the foundation for ensuring the quality of these interventions. Process indicators promote the standardization of BC self-management interventions and provide a guide to improve the quality of these interventions, whereas outcome indicators provide feedback on the effectiveness of the interventions and offer reference opinions for continuous quality improvement. Therefore, to increase the quality of BC self-management interventions, strict control over structural, process, and outcome indicators is needed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eSecond-level indicators\u003c/h2\u003e \u003cp\u003eIn this study, of the 15 secondary indicators, health education and professional team guidance had weights of 0.168 and 0.169, respectively. Given the intensive and long-term treatment required for BC patients, as well as their need for self-management, timely and effective interventions are crucial for improving their overall self-management. Some scholars \u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e have investigated the effects of a self-management lymphedema education program (SMLEP) on lymphedema and confirmed that it is an effective method for self-management of long-term lymphedema. Health education can effectively improve the self-management levels of patients, which is consistent with the findings of the current study. However, some studies have shown that certain groups are less willing to engage in health promotion during the disease process and require professional guidance to improve the overall health behaviors and self-management abilities of patients \u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e. During the intervention process, guidance from a professional team is therefore important, a need that is also consistent with the results of the current study. Health education and professional team guidance are therefore key components of quality evaluation for self-management interventions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eThird-level indicators\u003c/h2\u003e \u003cp\u003e\"Diversification of educational forms\" had the highest weight among the third-level indicators, at 0.049. In addition, the weight for \"Duration and frequency of psychological counselor guidance\" was 0.043, whereas the weights for \"BC self-management intervention system and process,\" \"Advocacy for BC self-management,\" \"Regular telephone follow-ups by the intervention team,\" \"Timeliness of professional team involvement,\" \"Duration and frequency of rehabilitation therapist guidance,\" and \"Duration and frequency of professional medical guidance\" were all 0.042. Some researchers have noted that promoting self-management and implementing health programs can improve patient outcomes. Furthermore, providing ongoing interventions and management is crucial for supporting patients with BC during and after treatment \u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e. Moreover, the quality of BC self-management interventions directly affects the quality of life of patients. Through various educational methods, such as writing diaries, video education, and game participation, the psychological state of BC patients can be improved effectively, thereby promoting recovery \u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. This finding indicates that the diversification of educational forms can encourage patients to actively participate in self-management. The BC self-management professional team also plays a significant role in BC self-management by conducting accurate and dynamic assessments and monitoring patient conditions, providing personalized health guidance, and following standardized BC self-management intervention processes and systems to ensure the effective implementation of these interventions. Taken together, these results indicate that diverse educational forms, comprehensive systems and processes, and professional intervention teams are prerequisites for ensuring the quality of self-management interventions. Therefore, these factors are included as key focus areas in quality evaluation systems of BC self-management.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study uses the \"SPO\" three-dimensional quality structure model as its theoretical framework and performs a literature analysis, semistructured interviews, the Delphi method, and the AHP to ultimately develop a quality evaluation index system for BC self-management interventions. This system includes three primary indicators, 15 secondary indicators, and 42 tertiary indicators to provide a scientific and reliable standard for evaluating the quality of BC self-management interventions. The system was also highly important for standardizing these interventions. The next steps involve applying the constructed index system in clinical settings to further refine the quality evaluation index system for BC self-management interventions and to set target values for each indicator in accordance with the characteristics of BC.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e This study was performed in accordance with the Declaration of Helsinki, and the study protocol was approved by the Ethics Committee of Yangzhou Maternal and Child Health Hospital(2024-044). The manuscript does not contain data from any individual person.The datasets used and analysed during the current study are available from the corresponding author on reasonable request.None of the authors have any conflicts of interest to declare, and all authors are involved in research program design, data collection and thesis writing.The authors would like to express their gratitude to EditSprings (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.editsprings.cn)fo\u003c/span\u003e\u003cspan address=\"https://www.editsprings.cn)fo\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003er the expert linguistic services provided.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDeclarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by Yangzhou Municipal Health Commission under grant number 2024064.There is no conflict of interest between funders and authors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eL.X.: Conceptualization,Data curation,Formal analysis,Writing - original draft. X.X.: Data curation, Funding acquisition,Writing- original draft preparation. J.Y.: Visualization, Investigation. X.Z.: Supervision.Y.L.: Writing- Reviewing and Editing.B.W.:Project administration,Writing- Reviewing and Editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSung H, Ferlay J, Siegel RL et al. Global cancer statistics 2020:GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries[J]. CA Cancer J Clin, 2021,71(3):209\u0026ndash;249.doi: 10.3322/caac.21660. Epub2021 Feb 4. PMID: 33538338.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrapani D, Ginsburg O, Fadelu T, et al. Global challenges and policy solutions in breast cancer control. Cancer Treat Rev. 2022;104:102339. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ctrv.2022.102339\u003c/span\u003e\u003cspan address=\"10.1016/j.ctrv.2022.102339\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2022 Jan 19. PMID: 35074727.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBray F, Laversanne M, Sung H et al. Global cancer statistics 2022:GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries[J]. CA Cancer J Clin 2024,74(3):229\u0026ndash;63.doi:10.3322/caac.21834.Epub2024 Apr 4. PMID: 38572751.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilkinson L, Gathani T. Understanding breast cancer as a global health concern [J]. Br J Radiol. 2022;95(1130):20211033. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1259/bjr.20211033\u003c/span\u003e\u003cspan address=\"10.1259/bjr.20211033\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2021 Dec 14. PMID: 34905391; PMCID: PMC8822551.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Vrieze T, Nevelsteen I, Thomis S, et al. What are the economic burden and costs associated with the treatment of breast cancer-related lymphoedema? A systematic review. Support Care Cancer. 2020;28(2):439\u0026ndash;49. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00520-019-05101-8\u003c/span\u003e\u003cspan address=\"10.1007/s00520-019-05101-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2019 Oct 28. PMID: 31656987.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHo PJ, Gernaat SAM, Hartman M, et al. Health-related quality of life in Asian patients with breast cancer: a systematic review. BMJ Open. 2018;8(4):e020512. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2017-020512\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2017-020512\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 29678980; PMCID: PMC5914715.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eG\u0026aacute;lvez-Hern\u0026aacute;ndez CL, Boyes A, Ortega-Mondrag\u0026oacute;n A et al. Unmet Needs Among Breast Cancer Patients in a Developing Country and Supportive Care Needs Survey Validation. Rev Invest Clin. 2021;73(4):245\u0026ndash;250. doi: 10.24875/RIC.21000068. Epub ahead of print. PMID: 33956785.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFan L, Strasser-Weippl K, Li JJ, St Louis J, Finkelstein DM, Yu KD, Chen WQ, Shao ZM, Goss PE. Breast cancer in China. Lancet Oncol. 2014;15(7):e279-89. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S1470-2045(13)70567-9\u003c/span\u003e\u003cspan address=\"10.1016/S1470-2045(13)70567-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 24872111.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFu X, Lu Q, Pang D, Shen A, Shih YA, Wei X. Experiences of breast cancer survivors with lymphedema self-management: a systematic review of qualitative studies. J Cancer Surviv. 2023;17(3):619\u0026ndash;33. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11764-022-01225-9\u003c/span\u003e\u003cspan address=\"10.1007/s11764-022-01225-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2022 Jun 30. PMID: 35773611.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShen A, Wu P, Qiang W, Fu X, Zhu F, Pang L, Wang F, Lu Q. Factors associated with lymphedema self-management behaviours among breast cancer survivors: A cross-sectional study. J Clin Nurs. 2023;32(19\u0026ndash;20):7330\u0026ndash;45. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/jocn.16833\u003c/span\u003e\u003cspan address=\"10.1111/jocn.16833\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2023 Jul 25. PMID: 37491890.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmadzadeh I, Abdekhoda M, Bejani M. Improving Self-Care Management in Patients with Breast Cancer through Health Literacy Promotion. Ethiop J Health Sci. 2021;31(1):85\u0026ndash;90. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4314/ejhs.v31i1.10\u003c/span\u003e\u003cspan address=\"10.4314/ejhs.v31i1.10\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 34158755; PMCID: PMC8188109.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDibble KE, Rosenberg SM, Snow C, Kirkner GJ, Tayob N, Contreras M, Roma ND, DeGraffinreid CR, Nolan TS, Hershman DL, Naughton M, Partridge AH, Young. Empowered \u0026amp; strong (YES): a study protocol paper for a randomized controlled trial of an mHealth symptom monitoring and self-management intervention for adolescent and young adult (AYA) breast cancer survivors. BMC Public Health. 2025;25(1):126. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12889-025-21288-4\u003c/span\u003e\u003cspan address=\"10.1186/s12889-025-21288-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 39799291; PMCID: PMC11724548.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShi N, Wong AKC, Wong FKY, Sha L. Mobile Health Application-Based Interventions to Improve Self-management of Chemotherapy-Related Symptoms Among People with Breast Cancer Who Are Undergoing Chemotherapy: A Systematic Review. Oncologist. 2023;28(4):e175\u0026ndash;82. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/oncolo/oyac267\u003c/span\u003e\u003cspan address=\"10.1093/oncolo/oyac267\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 36801955; PMCID: PMC10078896.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShi N, Zhang N, Wong FKY, Zhu W, Lai X, Jin Y, Gu C, Nie L, Dong X, Wong AKC. Perceptions of utilizing a symptom self-management app for breast cancer patients receiving outpatient chemotherapy. Eur J Oncol Nurs. 2024;71:102624. Epub 2024 May 28. PMID: 38878691.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDonabedian A. The quality of care. How can it be assessed? JAMA. 1988 Sep 23\u0026ndash;30;260(12):1743-8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jama.260.12.1743\u003c/span\u003e\u003cspan address=\"10.1001/jama.260.12.1743\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 3045356.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKang L, Wang MH, Wu SJ. Construction of nursing-sensitive quality indicator system for cardiac rehabilitation of patients undergoing percutaneous coronary intervention based on structure-process-outcome model. BMC Nurs. 2023;22(1):457. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12912-023-01618-w\u003c/span\u003e\u003cspan address=\"10.1186/s12912-023-01618-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 38049804; PMCID: PMC10696800.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWong CL, Ip WY, Shiu TY. Translation and validation of the Chinese-Cantonese version of the Exercise of Self-Care Agency Scale. Int J Nurs Stud. 2012;49(9):1122\u0026ndash;37. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijnurstu.2012.04.004\u003c/span\u003e\u003cspan address=\"10.1016/j.ijnurstu.2012.04.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2012 May 8. PMID: 22572019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeng TS, Xin CA, Ying YK, Khuen LP, Yee A, Zainuddin SI, Chin LE, Loong LC. Hope in Palliative Care: A Thematic Analysis. J Palliat Care. 2022;37(2):177\u0026ndash;82. Epub 2020 Aug 14. PMID: 32791956.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWan F, Yang L, Zhou N, He Y. Construction of learning objectives and content for newly graduated nurses in tertiary teaching hospitals: A Delphi study. Nurse Educ Today. 2023;121:105716. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.nedt.2023.105716\u003c/span\u003e\u003cspan address=\"10.1016/j.nedt.2023.105716\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2023 Jan 13. PMID: 36657320.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJiang N, Liu WB, Zong Y, Yu L, Cheng S. Construction of an index system of core competence assessment for sleep medicine nurse specialists in China: a Delphi study. BMC Nurs. 2024;23(1):689. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12912-024-02349-2\u003c/span\u003e\u003cspan address=\"10.1186/s12912-024-02349-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 39334099; PMCID: PMC11438144.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu W, Hu M, Chen W. Identifying the Service Capability of Long-Term Care Facilities in China: An e-Delphi Study. Front Public Health. 2022;10:884514. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpubh.2022.884514\u003c/span\u003e\u003cspan address=\"10.3389/fpubh.2022.884514\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 35844860; PMCID: PMC9277176.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOpele JK, Adepoju KO. Validation of the Donabedian Model of Health Service Quality in Selected States in Nigeria. Niger J Clin Pract. 2024;27(2):167\u0026ndash;173. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/njcp.njcp_220_22\u003c/span\u003e\u003cspan address=\"10.4103/njcp.njcp_220_22\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2024 Feb 26. PMID: 38409143.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhite KM, Dulko D, DiPietro B. The Effect of Burnout on Quality of Care Using Donabedian's Framework. Nurs Clin North Am. 2022;57(1):115\u0026ndash;130. doi: 10.1016/j.cnur.2021.11.008. PMID: 35236602.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWei L, Zhang X, Li H, Wang Y, Lu M, Chai Q. Construction of internet Plus Wound Care Service Quality Evaluation System Based on Donabedian and SERVQUAL Models-A Delphi-Analytic Hierarchy Process Study. Nurs Health Sci. 2025;27(1):e70051. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/nhs.70051\u003c/span\u003e\u003cspan address=\"10.1111/nhs.70051\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 39894036.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLu J, Sun X, Zhang Y. Establishment and analysis of quality index system for pediatric tumor nursing. Technol Health Care. 2024;32(6):4343\u0026ndash;4351. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3233/THC-240252\u003c/span\u003e\u003cspan address=\"10.3233/THC-240252\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 39058465.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTang S, Huang MZ, Lu YF, Liu W, Wang BB, Wang Y. [A Whole-Course Nursing Quality Evaluation System for Liver Transplantation in Children Based on Donabedian Theory]. Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2024;46(1):55\u0026ndash;61. Chinese. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3881/j.issn.1000-503X.15888\u003c/span\u003e\u003cspan address=\"10.3881/j.issn.1000-503X.15888\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 38433632.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCansız G, Arıkan D\u0026ouml;nmez A, Kapucu S, Borman P. The effect of a self-management lymphedema education program on lymphedema, lymphedema-related symptoms, patient compliance, daily living activities and patient activation in patients with breast cancer-related lymphedema: A quasiexperimental study. Eur J Oncol Nurs. 2022;56:102081. Epub 2021 Dec 1. PMID: 34875398.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHsia HH, Tien Y, Lin YC, Huang HP. Factors Influencing Health Promotion Lifestyle in Female Breast Cancer Survivors: The Role of Health Behavior Self-Efficacy and Associated Factors. Semin Oncol Nurs. 2024;40(2):151622. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.soncn.2024.151622\u003c/span\u003e\u003cspan address=\"10.1016/j.soncn.2024.151622\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2024 Mar 24. PMID: 38522967.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAn HJ, Kang SJ, Choi GE. Technology-based self-management interventions for women with breast cancer: a systematic review. Korean J Women Health Nurs. 2023;29(3):160\u0026ndash;78. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4069/kjwhn.2023.09.07\u003c/span\u003e\u003cspan address=\"10.4069/kjwhn.2023.09.07\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2023 Sep 26. PMID: 37813660; PMCID: PMC10565530.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSansom-Daly UM, Wakefield CE, Ellis SJ, McGill BC, Donoghoe MW, Butow P, Bryant RA, Sawyer SM, Patterson P, Anazodo A, Plaster M, Thompson K, Holland L, Osborn M, Maguire F, O'Dwyer C, De Abreu Lourenco R, Cohn RJ. The Recapture Life Working Party. Online, Group-Based Psychological Support for Adolescent and Young Adult Cancer Survivors: Results from the Recapture Life Randomized Trial. Cancers (Basel). 2021;13(10):2460. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/cancers13102460\u003c/span\u003e\u003cspan address=\"10.3390/cancers13102460\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 34070134; PMCID: PMC8158368.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"three-dimensional quality evaluation model, breast cancer, Delphi, self-management intervention, evaluation index system","lastPublishedDoi":"10.21203/rs.3.rs-6715202/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6715202/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e To construct a system to evaluate the quality of an index for breast cancer (BC) self-management interventions and to provide a tool for assessing the quality of these interventions to promote their effective implementation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e The three-dimensional quality evaluation model was used as the theoretical framework in this study, which included a literature survey and semistructured interviews with health professionals. The Delphi method and the analytic hierarchy process (AHP) were used to screen for indicators, determine their weights, and establish a quality evaluation indicator system for self-management interventions in BC patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The effective response rates of the two questionnaires were 95.83% and 95.65%, the authority coefficients of the experts in the two rounds of consultation were 0.874 and 0.912, and the Kendall harmony coefficients of the overall indicators were 0.143 and 0.237. The final system for evaluating the quality index system for self-management interventions for BC patients included 3 primary indicators, 15 secondary indicators, and 42 tertiary indicators.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The quality evaluation indicator system has high reliability and scientific value and therefore provides a tool for evaluating the quality of self-management interventions in BC patients. After further validation, these findings could be used to evaluate the quality of these interventions in clinical practice.\u003c/p\u003e","manuscriptTitle":"Construction of a quality evaluation index system for assessing a breast cancer self-management intervention on the basis of a three-dimensional quality evaluation model: A Delphi study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-26 08:14:03","doi":"10.21203/rs.3.rs-6715202/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-06T12:03:12+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-11T05:39:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-20T07:47:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"102809934812729928595828354394402773970","date":"2025-07-10T13:10:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"210089565721691822056870689246807543002","date":"2025-07-08T17:13:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-24T10:09:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-18T09:38:54+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-27T05:33:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-27T03:41:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-05-27T03:40:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1e8dd20f-a044-4035-8bcc-53c91a8e4490","owner":[],"postedDate":"June 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-12T11:53:28+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-26 08:14:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6715202","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6715202","identity":"rs-6715202","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}