Development and Validation of a Quality of Life Scale for Women with Pelvic Venous Disorder: A Mixed Methods Study

Development and Validation of a Quality of Life Scale for Women with Pelvic Venous Disorder: A Mixed Methods 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 Development and Validation of a Quality of Life Scale for Women with Pelvic Venous Disorder: A Mixed Methods Study Qin Yang, Yuting Lai, Yuming Zhao, Yan Huang, Jing Li, Wenzhe Zhang, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8190948/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Pelvic venous disorder (PeVD) predominantly affects women, causing chronic pelvic pain, dyspareunia, and lower extremity varicose veins that severely impair quality of life (QoL). Owing to the lack of QoL assessment tools tailored to the impact of PeVD on female patients, diagnosis and management remain challenging. We developed a PeVD-specific QoL scale (PeVD-QoL) for women, providing a scientific basis to optimize diagnostic, therapeutic, and nursing strategies. Methods Using a mixed-methods design (literature review, qualitative interviews, Delphi expert consultations, and clinical testing), we developed and refined the scale. The preliminary 48-item version was validated in 527 Chinese women with PeVD to assess its validity (content, construct, convergent, and discriminant) and reliability (Cronbach’s α and test-retest reliability), thereby verifying its scientific rigor and reliability. Results The PeVD-QoL demonstrated a content validity index of 0.995. Exploratory factor analysis revealed that the 40 items of the PeVD-QoL loaded on six factors, accounting for 73.23% of the total variance; confirmatory factor analysis supported its six-factor structure with acceptable model fits. Each dimension exhibited acceptable convergent and discriminant validity (AVE = 0.38–0.93, CR = 0.82–0.98). The scale showed high internal consistency (Cronbach’s α = 0.96), with Cronbach’s α coefficients for each dimension ranging from 0.86 to 0.98. The test-retest reliability across dimensions after two weeks ranged from 0.82 to 0.90. Conclusions We developed and validated a novel scale for assessing QoL in PeVD women. This tool can comprehensively capture the effects of PeVD on women's health status, facilitating optimized diagnosis, treatment, and nursing strategies to improvetheir quality of life. Multicenter studies with larger, more diverse cohorts are needed to confirm the generalizability of the tool and establish minimal clinically important differences. Pelvic venous disorder Health-related quality of life Scale Development Validation Figures Figure 1 Background Pelvic venous disorder (PeVD) is a clinical condition characterized by pelvic venous insufficiency, manifesting as chronic, non-cyclical pelvic pain or pressure. It is exacerbated by prolonged standing and is frequently accompanied by dysmenorrhea, dyspareunia, and varicosities of the perineum or lower extremities[1]. Reports indicate that chronic pelvic pain (CPP), defined as persistent intermittent pelvic pain lasting over six months, affects up to 26% of women[2]. CPP accounts for about 40% of gynecological outpatient consultations and 40% of diagnostic laparoscopies in gynecological practice[2]. In addition to its long-term physical impact, CPP severely impairs women’s emotional health, social functioning, and overall quality of life (QoL), making it one of the most debilitating yet under-addressed gynecological complaints. CPP also exerts a significant financial burden on the healthcare system: the cost of CPP was conservatively estimated to exceed $5.8 billion in U.S. healthcare expenditures in 2020[2,3]. In nearly 40% of women with CPP, the underlying cause remains undiagnosed, complicating definitive diagnosis and effective treatment selection[2,4]. This diagnostic challenge is particularly pronounced in PeVD, which is frequently overshadowed by other pelvic pathologies owing to overlapping symptoms and the absence of specific biomarkers. As a result, many women—potentially suffering from PeVD—are subjected to prolonged medical evaluations, unnecessary diagnostic tests, and, in some cases, inappropriate surgical interventions (e.g., hysterectomy) that may not align with their clinical needs[2,4]. Previous studies reported that PeVD may underlie about 30% of CPP cases[5,6]. The pathological characteristics of PeVD are pelvic varicose veins and venous dysfunction, accompanied by venous stasis and/or reflux[7]. Multiple pregnancies, abnormal pelvic venous anatomy, abnormal estrogen levels, and prolonged weight-bearing or standing are risk factors for PeVD[2]. The relationship between pelvic venous lesions and patient-perceived symptoms is very complex, as similar symptoms may be caused by different etiologies (e.g., CPP can be caused by ovarian vein reflux, left common iliac vein compression, or left renal vein compression), and the same etiology may present with different symptoms (e.g., ovarian vein reflux may be associated with CPP, dyspareunia, heavy menstrual bleeding, and menstrual pain)[8]. Therefore, the diagnosis of PeVD often involves multidisciplinary differential methods, including gynecology, neurology, orthopedics, gastroenterology, vascular surgery, psychiatry, etc., and requires a combination of pelvic and transvaginal ultrasound, pelvic venography with intravascular ultrasound, magnetic resonance imaging, or CT angiography with enhanced scanning for a definitive diagnosis[7]. Many women with PeVD spend much of their time seeking help from doctors in different disciplines, but delayed diagnosis and even misdiagnosis are common[9]. The combination of persistent physical discomfort, unresolved psychological distress, and the exhaustive process of navigating a complex diagnostic system severely decreases the holistic QoL for women with PeVD[10]. Unlike acute conditions, the chronic nature of PeVD leads to sustained impairments in daily functioning, social participation, and self-esteem, creating a vicious cycle of pain, frustration, and declining well-being[10]. Currently available treatment methods for PeVD include physical therapy, pharmacotherapy, surgical treatment, and endovascular treatment[6]. With the development of medical technology, endovascular treatment has become the preferred method for treating PeVD[7]. Although advances in treatment technology have significantly improved the anatomical abnormalities and hemodynamics of PeVD women, these improvements do not always align with the degree of symptom relief perceived by women[11]. This inconsistency may stem from multiple factors, such as insufficient sensitivity of diagnostic methods, individual differences among women, variations in surgical details, and inconsistent standards for evaluating the effectiveness of treatments[11]. Consequently, relying solely on imaging-based improvements as the endpoint for PeVD treatment is limited; patient-centered outcomes—particularly symptom improvement—should be the primary indicator of treatment effectiveness [10]. QoL is a key outcome measure for evaluating symptom improvement in women with PeVD[10]. Attention to QoL issues has several advantageous consequences for patient care[12]. First, a focus on QoL involves women in their medical care because patient input is required to make these assessments. Second, an assessment of QoL obligates the clinician to address issues important to women beyond objective laboratory data. This process redirects clinicians' and nurses' focus to the patient. Third, attention to QoL encourages patient-clinician communication, enabling women to work together to maximize their holistic health perceptions. However, assessing the QoL of women with PeVD is complex and requires standardized, validated instruments to measure the effect of the disease on physical, psychological, and social areas. Professional tools for assessing the quality of life of individuals with PeVD rely mainly on generic instruments[13-18], such as the Short Form 36 health survey (SF-36), the Aberdeen Varicose Vein Questionnaire (AVVQ), the Chronic Venous Insufficiency Quality of Life Questionnaire (CIVIQ), the European Quality of Life 5D (EQ-5D), and the visual analog scale (VAS). However, these tools fail to cover the unique disease dimensions of PeVD, including specific manifestations such as positional pain, sexual dysfunction, and vulvar varicose veins. These limitations render generic instruments inadequate for quantifying the true burden of PeVD on women’s lives, highlighting the urgent need for a disease-specific QoL assessment tool. Therefore, in this study, we developed an assessment scale for evaluating the QoL of women with PeVD. This scale may provide a foundation for healthcare professionals to develop comprehensive clinical treatment and care plans for women with PeVD. Methods Study design and setting We adopted a mixed-methods design that combined quantitative and qualitative approaches. The research team consisted of seven members, including a head nurse with a master’s degree in vascular surgery, a Master of Nursing, three vascular surgery nurses, a vascular surgery department director and PeVD expert, and a medical practitioner in the field of vascular surgery. The study followed the standard scale development process[19], which comprises three distinct stages: scale construction, reliability, validity testing, and test-retest reliability assessment. During the scale construction phase, qualitative interviews were conducted, and items on the scale were developed based on the results of these interviews, the Delphi method, and a literature review. The scale underwent clinical testing during the reliability and validity testing phase. Finally, test-retest reliability was conducted to gather more data on the performance of the scale. Development of the scale Literature review Using keywords such as “pelvic vein insufficiency”, “pelvic venous syndrome*”, “pelvic venous disorder*”, "pelvic congestion syndrome*", "iliac vein compression", "pelvic varicose veins", "quality of life", and "QoL", we searched Chinese and English databases, including CNKI, VIP, Wanfang, CBM, Web of Science, PubMed, the Cochrane Library, Embase, and CINAHL. The search period ranged from the establishment of the databases to May 31, 2024. The included articles covered various research methods, including scale development, intervention trials, and systematic reviews, all focused on the QoL of women with PeVD. Under the guidance of the QoL model[20], the research team extracted, analyzed, and summarized content related to the QoL of women with PeVD from the literature, forming a scale item pool comprising five dimensions and 47 items. Qualitative interviews To gain a deeper understanding of the constituent elements and influencing factors of QoL in women with PeVD, we conducted qualitative research. Using purposive sampling, we selected women with PeVD from a tertiary cardiovascular hospital in southeast China for semi-structured interviews conducted from June to October 2024. The interviews were conducted by a researcher (Y.L.) who had considerable experience in qualitative research. The sample size was determined based on the criterion of information saturation. The relevant information was organized within 24 h after the interview, and the contents of the interview were transcribed and formed into a text. The interview data were analyzed using Graneheim & Lundman's content analysis method[21]. The research team supplemented, modified, and improved the scale item pool based on the results of the interviews, forming an expert consultation version of the scale. Delphi expert consultation Following the principles of a reasonable knowledge structure and complementary expertise, we invited Chinese experts in the field of PeVD to participate in an online Delphi expert consultation. The criteria for including the experts were as follows: (1) had engaged in or studied PeVD treatment, nursing, scientific research, or other related fields for more than five years; (2) held a bachelor's degree and had an intermediate professional title or above; (3) were familiar with the content of PeVD nursing or had experience in developing relevant scales; and (4) were willing to participate in two rounds of Delphi consultation. The experts who did not respond within two weeks of receiving the e-mail were considered non-participants in that round. The expert consultation questionnaire included scale items for consultation and basic information about the experts, which was sent to each expert via WeChat or e-mail. The experts scored each item based on its importance, familiarity, and judgment criteria. Items were removed if they had an average score below 3.50, a full score rate under 20%, or a coefficient of variation greater than 0.25. The research team revised the scale dimensions and items based on expert feedback. The final initial scale consisted of five dimensions and 48 items. Scale scoring method Each item on the scale was scored using a five-point Likert-type scoring method, with responses ranging from 1 (“very inconsistent”) to 5 (“very consistent”) based on the level of agreement with each statement. Among them, items 1–44 were positively scored, and items 45–48 were negatively scored. Dimension scores were calculated by summing the item scores within each domain, and the total scale score was obtained by summing all dimension scores. A lower total score indicates better QoL among women with PeVD. Prediction test Before the formal survey, we conducted a pilot study with 10 women diagnosed with PeVD to evaluate the clinical version of the scale. The average completion time for the survey was 5.64 ±2.33 min. We asked women for their opinions and suggestions on the clarity and relevance of the scale and adjusted the scale's layout accordingly. Based on their feedback, a formal test version of the QoL scale was developed for PeVD women (PeVD-QoL), comprising 48 items across five dimensions. Women who participated in the prediction test were not included in the formal study. Reliability and validity test of the scale Participants and survey method Women with PeVD who received care at Xiamen Cardiovascular Hospital of Xiamen University, Zhongshan Hospital of Xiamen University, and the Third Affiliated Hospital of Zhengzhou University in China from January 2022 to February 2025 were selected for the psychometric validation of the scale. The inclusion criteria for participants were as follows: ① clinically diagnosed with PeVD; ② ≥18 years old; ③ conscious, with adequate communication ability; and ④ provided informed consent and voluntary participation in this study. The exclusion criteria were as follows: severe psychiatric disorders, cognitive impairment, or other serious physical illnesses. The sample size was determined by multiplying the number of scale items by 5 to 10. With 48 items on the scale and an anticipated 10% invalid response rate, at least 264 participants were needed. Since confirmatory factor analysis (CFA) requires a sample size exceeding 200, at least 464 participants were needed for the formal survey. A team of trained researchers distributed the electronic questionnaires to participants via Wenjuanxing, and participants were instructed to complete them on the day of the invitation. Incomplete or overdue responses were excluded from the analysis. A total of 540 women were invited, and 527 valid responses were ultimately included in the analysis. All participants were asked to return the completed retest questionnaire within 2 weeks of the first response. Finally, 30 participants completed the retest; the results were used to assess test-retest reliability. Data collection tools The research tools used in this study consisted of two parts. The first part was a general information questionnaire, designed by researchers, to collect data on gender, age, education level, place of residence, marital status, number of children, affected pelvic veins, and history of pelvic vein surgery. The second part was the validated version of the PeVD-QoL. Data analysis The data were analyzed using SPSS 26.0 and Amos 24.0. Categorical variables are presented as counts and percentages, whereas normally distributed continuous variables are presented as the means ± standard deviations. All the results were considered statistically significant at p < 0.05. The engagement, authority, and consensus of experts are represented by the effective recovery rate of questionnaires, the expert authority coefficient, and Kendall's coefficient of concordance. Item analysis examines the discrimination and differentiation of scale items using the critical ratio, correlation coefficient analysis, and internal consistency coefficients[22]. ① Critical ratio: All samples were sorted in descending order based on the total score of the scale. The top 27% of the total score was selected as the high group, and the bottom 27% was selected as the low group. An independent-samples t-test was conducted to compare the average score differences between the two groups for each item, and items with a critical ratio <3.00 or no statistically significant difference were deleted[19]. ② Item-total correlation analysis: Items with a Pearson correlation coefficient < 0.40 between the individual item score and the total score or without a statistically significant correlation were also excluded[23]. ③ Internal consistency coefficients: If the Cronbach's α coefficient of the total scale increases after a certain item is deleted, then that item should be removed[19]. To evaluate the relevance of each item in the scale to its corresponding content, experts participating in the second round of expert consultation were invited. A four-level scoring method was adopted, with 1 point indicating "not relevant", 2 points indicating "weakly relevant", 3 points indicating "relevant", and 4 points indicating "highly relevant". When the scale-level content validity index (S-CVI) is ≥0.780 and the item-level content validity index (I-CVI) is ≥0.800, the content validity is good[24]. Exploratory factor analysis (EFA) is used to analyze structural validity. First, the Kaiser-Meyer-Olkin (KMO) test (KMO> 0.60) and Bartlett's test of sphericity ( P < 0.05) were used to determine whether the data were suitable for EFA[19]. Then, principal component analysis and varimax orthogonal rotation were adopted. According to the principle of a cumulative variance contribution rate > 60% and an eigenvalue > 1, items with several entries under common factors ≥ 3 and factor loading ≥ 0.50 are retained[24]. When the same item has a load value > 0.40 on two or more common factors simultaneously, the item is deleted and factor analysis is repeated after each deletion[24]. Confirmatory factor analysis (CFA) adopts the maximum likelihood method (chi-square to degrees of freedom ratio (χ 2 /df), root mean square error of approximation (RMSEA), comparative fit index (CFI), incremental fit index (IFI), normed fit index (NFI), and Tucker-Lewis index (TLI)) to verify the structure of the scale. Convergent validity is evaluated using average variance extracted (AVE) and composite reliability (CR). Discriminant validity is tested by comparing the square root of the AVE of each factor with the correlation coefficient between that factor and other factors. Suppose the square root of the AVE for all factors is greater than the absolute value of the correlation coefficient between that factor and other factors. In that case, the scale can be considered to have good discriminant validity[24]. Reliability analysis was completed by Cronbach's α coefficient and test-retest reliability (intraclass correlation coefficient). When the Cronbach's α coefficient was ≥0.8 and the test-retest reliability was >0.75, the scale's internal reliability was considered good[19]. Ethical considerations This study was approved by the Medical Ethics Committee of Xiamen Cardiovascular Hospital Xiamen University (No. (Y)KY2024-004–01). The study was conducted in accordance with the Declaration of Helsinkiand relevant ethical guidelines for human research. Before participation, the women were informed of the purpose and methods of the study by the researchers, and all participants signed informed consent forms. Results Qualitative interview After conducting in-depth interviews with 23 women diagnosed with PeVD, no new themes emerged during the later stages of data collection. Following collective analysis and discussion, the research team determined that thematic saturation had been reached, and no additional interviews were conducted. By analyzing the interview data, we extracted four main themes, "Multidimensional Symptom Disturbance", "Cognitive Dissonance Regarding the Disease in the Context of Diagnostic and Therapeutic Dilemmas", "Resilience in the Face of Frustration", and "Life Reconstruction Under Disease Adaptation", along with 11 subthemes. Based on the interview results, a scale for expert consultation was developed, comprising five dimensions and 50 items. Expert enquiry A total of 22 experts from nine cities in China, including Xiamen, Zhangzhou, Fuzhou, Shanghai, Guangzhou, Changsha, and Zhengzhou, were invited to participate in two rounds of consultation. The age of the experts ranged from 32 to 57 years (43.86 ±6.64 years), and their professional experience ranged from 6 to 34 years (21.19 ±8.82 years). Among them, five (22.72%) had a doctoral degree, six (27.27%) had a master's degree, and 11 (50%) had a bachelor's degree. One expert (4.55%) was a university teacher, 13 (59.09%) were head nurses or clinical nurses, and eight (36.36%) were medical staff. Moreover, 18 experts (81.82%) held senior positions, and four (18.18%) held intermediate positions. One expert (4.54%) was involved in nursing research, five (22.73%) specialized in the rehabilitation of obstetrics and gynecology, and 16 (72.73%) specialized in the diagnosis, treatment, and nursing of vascular surgery. The recovery rates of the second-round questionnaires were 100% and 95.45%, respectively, indicating that the experts were more enthusiastic about responding. In the first round of consultation, the expert authority coefficient (Cr) was 0.886, and Kendall’s coefficient of concordance (W) was 0.265 (χ 2 = 272.59, p < 0.001). Based on the feedback of the experts, the revised scale consisted of five dimensions and 48 items. In the second round of consultation, the expert authority coefficient was 0.889, and Kendall’s coefficient of concordance was 0.291 (χ 2 = 267.49, p < 0.001). The final version of the scale, after item refinement, included five dimensions and 48 items. Characteristics of the participants In this study, questionnaires were distributed to 540 women. However, five participants submitted the same answers to all the questions without explanation; moreover, the answers of four women were incomplete, and those of four women were contradictory. Therefore, these participants were excluded. The final analysis included 527 PeVD women (Table 1), with an average age of 55.95 ±12.66 years. Table 1. Characteristics of the participants (n = 527) Variable Value n(%) Age, y ≤30 9(1.70) 30–40 64(12.14) 41–50 97(18.41) 51–60 163(30.93) ＞60 194(36.81) Educational level Junior high school and below 398(75.52) Senior secondary education 62(11.77) Higher education 67(12.71) Residence Urban area 283(53.70) Rural area 244(46.30) Marital status Married 501(95.07) Unmarried 15(2.85) Divorced 11(2.08) Number of pregnancies None 15(2.85) Once 113(21.44) Twice 230(43.64) Three times or more 169(32.07) Lesion vein 1 Inferior vena cava 28(5.31) Renal vein 3(0.57) Common iliac vein 103(19.54) Internal and external iliac veins 289(54.84) Gonadal vein 191(36.24) Unclear 85(16.13) History of pelvic vein surgery Yes 371(70.40) No 156(29.60) 1 Some women have two or more diseased veins at the same time. Item analysis According to the critical ratio method, the critical ratios of all 48 items were greater than 3, ranging from 5.73 to 25.69 ( p < 0.05), and all the items were retained. The results of the correlation coefficient method revealed that the item correlation coefficients ranged from 0.33 to 0.81 ( p < 0.001), and three items had correlation coefficients below 0.40 with the total score (items 4, 7, and 10). No items were deleted from the scale because of a significant increase in Cronbach’s α coefficient after removal. As a result, three items were removed, resulting in a final item pool of 45 items. Content validity The content validity was evaluated by 21 experts who completed two rounds of expert consultation. The S-CVI was 0.995, and the I-CVI was 0.905–1. Construct validity A total of 263 participants were randomly selected for EFA. The results of the first round were as follows: KMO of 0.91 and χ 2 of 13360.93 ( p < 0.001) for Bartlett's test. By conducting principal component analysis with maximum varimax (orthogonal) rotation, we found that eight common factors had eigenvalues exceeding 1. However, based on the scree plot, the curve stabilized after the sixth factor, leading to the extraction of six factors (Figure 1). These factors had eigenvalues ranging from 3.52 to 8.12, with a cumulative variance contribution of 69.60%. Items 23, 25, 26, 36, and 44 were removed because their factor loadings were less than 0.5. The results of the second round of EFA revealed that KMO was 0.91 and that χ 2 was 12235.69 ( p < 0.001) for Bartlett's test; the eigenvalues ranged from 3.39 to 7.40, and the cumulative variance contribution rate was 73.23%. The item loadings became stable. The scale structure closely aligned with the initially conceived dimensions, with sleep-related items independently clustering into a new factor in the EFA. Based on the content of the item measurements, we named the five common factors extracted as physiological function (nine items), symptom distress (seven items), sleep status (four items), psychological burden (nine items), social support (seven items), and life satisfaction (four items) (Table 2). Table 2 Factor loadings from exploratory factor analysis (n = 263) Item Factor loadings Physiological function Symptom distress Sleep status Psychological burden Social support Life satisfaction C1 Lower abdominal pain (non-menstrual) and/or discomfort such as aching and a sensation of heaviness 0.56 0.17 0.10 0.14 0.21 0.02 C2 Lower back/sacral tailbone/groin pain and/or discomfort, such as aching 0.63 0.26 0.18 0.20 0.09 0.18 C3 Persistent pain during and/or after intercourse and/or discomfort such as dryness, aching, or burning 0.60 0.03 -0.01 0.08 0.28 0.18 C5 Irregular menstrual cycles (irregular timing and duration of bleeding, excessive or insufficient bleeding) 0.67 0.10 0.35 0.02 0.22 0.10 C6 Premenstrual syndrome and/or dysmenorrhea, worsening pre-menstrually 0.57 0.04 0.15 0.22 0.04 -0.01 C8 Frequent urination, urgency, painful urination, urinary leakage, incontinence, sensation of incomplete bladder emptying, hematuria, etc. 0.61 0.20 0.07 0.20 -0.01 -0.03 C9 Anal discomfort (tenesmus)/worsening pain during bowel movements 0.66 0.07 0.08 0.25 0.04 0.06 C11 Varicose veins in the lower limbs, leg/hip pain, or other discomfort (e.g., heaviness, fatigue, soreness, burning, dryness, itching, cramps, swelling, hardening, numbness, etc.) 0.74 0.11 0.32 0.10 0.24 0.08 C12 Vulvar varicose veins, pain in the vulva (labia, vagina, urethra, perineum/scrotum, penis, or anus) (non-menstrual in women) or other discomfort (aching, heaviness, numbness, tenderness, sensitivity, sensation of heaviness, etc.) 0.68 0.14 0.01 0.31 0.01 0.01 C13 Inability to climb stairs/slopes 0.16 0.82 0.18 0.16 0.17 0.01 C14 Inability to squat/bend over 0.20 0.80 0.13 0.16 0.21 0.02 C15 Inability to walk at the desired speed 0.10 0.80 0.13 0.22 0.14 0.06 C16 Inability to stand/sit for long periods 0.25 0.79 0.05 0.13 0.17 0.09 C17 Difficulty changing positions (e.g., rising from a seated position to walk) -0.02 0.85 0.07 0.21 -0.01 0.07 C18 Easily fatigued during daily activities 0.14 0.69 0.15 0.40 0.14 0.07 C24 Decreased desire for sexual activity/aversion to sexual activity 0.27 0.52 -0.02 0.08 0.31 0.29 C19 Difficulty falling asleep 0.29 0.20 0.79 0.39 0.12 0.05 C20 Sleep interruptions, easily waking, etc. 0.27 0.16 0.78 0.44 0.15 0.11 C21 Reduced sleep duration 0.25 0.18 0.82 0.42 0.13 0.06 C22 Reduced sleep quality 0.26 0.18 0.81 0.41 0.13 0.08 C27 Feeling anxious, depressed, or irritable 0.36 0.19 0.10 0.72 0.22 0.20 C28 Worrying about the illness/feeling panicked or embarrassed in certain situations 0.27 0.25 0.22 0.70 0.30 0.16 C29 Difficulty relaxing 0.28 0.16 0.15 0.79 0.28 0.09 C30 Feeling ashamed to discuss one's illness 0.14 0.20 0.20 0.67 0.14 0.07 C31 Feeling down and losing interest in activities 0.22 0.20 0.12 0.84 0.21 0.12 C32 Feeling that one's body is holding them back 0.24 0.20 0.22 0.85 0.16 0.02 C33 Feeling afraid 0.27 0.18 0.19 0.85 0.15 0.04 C34 Feeling like a burden to one's family 0.15 0.20 0.24 0.78 0.15 0.00 C35 Difficulty concentrating, often feeling drowsy 0.13 0.18 0.25 0.84 0.19 0.06 C37 Doing household chores (cooking, laundry, dishwashing, cleaning, etc.) 0.37 0.44 -0.06 0.28 0.50 0.16 C38 Caring for the elderly or children 0.39 0.40 -0.05 0.26 0.55 0.12 C39 Engaging in physical exercise 0.33 0.44 0.09 0.25 0.53 0.19 C40 Relationship with family not as close as before 0.11 0.20 0.08 0.34 0.70 -0.04 C41 Friends/colleagues not understanding one's illness 0.12 0.21 0.16 0.26 0.76 -0.04 C42 Healthcare providers not offering desired assistance during treatment 0.31 0.17 0.05 0.28 0.65 -0.06 C43 Employers not making appropriate arrangements for medical needs 0.04 0.06 0.17 0.12 0.76 -0.09 C45 Overall, I consider my physical health to be very good 0.07 0.09 -0.02 0.05 0.00 0.95 C46 Overall, I consider my mental health to be very good 0.07 0.09 0.09 0.12 -0.04 0.95 C47 Overall, I consider my performance in daily social activities and roles (including family, work, and community activities) to be very good 0.10 0.09 0.06 0.10 -0.01 0.96 C48 Overall, I consider my current quality of life to be very good 0.083 0.073 0.08 0.08 -0.007 0.96 Confirmatory factor analysis (CFA) was conducted on the remaining 264 participants. The results of CFA revealed the following: χ 2 /df of 3.21, RMSEA of 0.09, CFI of 0.87, IFI of 0.87, NFI of 0.82, and TLI of 0.86. The fit indices of the model after correction are shown in Table 3. The CR of each factor ranged from 0.82 to 0.98, and the AVE ranged from 0.38 to 0.93, indicating that the scale had acceptable convergent validity. The Pearson correlation coefficient between factors ranged from 0.24 to 0.72 ( p < 0.05), and the square root of the AVE of each factor was greater than the maximum correlation coefficient with other factors, indicating good discriminant validity (Table 4). Table 3. Fit indices and normal values of CFA Indices Good fit Acceptable Result χ 2 /df <2 <5 2.51 RMSEA <0.05 0.95 >0.90 0.91 IFI >0.90 / 0.91 NFI >0.95 >0.80 0.86 TLI >0.95 >0.90 0.91 Table 4. Aggregate validity and discriminant validity of PeVD-QoL (n = 264) Dimensions CR AVE Square root of AVE Correlation coefficient Physiological function Symptom distress Sleep status Psychological burden Social support Life satisfaction Physiological function 0.82 0.38 0.61 1.00 Symptom distress 0.93 0.67 0.82 0.51 * 1.00 Sleep status 0.98 0.91 0.95 0.46 * 0.44 * 1.00 Psychological burden 0.97 0.76 0.87 0.59 * 0.64 * 0.43 * 1.00 Social support 0.88 0.53 0.73 0.57 * 0.71 * 0.42 * 0.74 * 1.00 Life satisfaction 0.98 0.93 0.96 0.33 * 0.32 * 0.28 * 0.25 * 0.24 * 1.00 注: * p ＜0.05. Reliability Cronbach ’s α coefficient of the scale was 0.96. In total, 30 women were randomly selected for retesting after a two-week interval, and the test-retest reliability was 0.92 (Table 5). Table 5. Reliability of each dimension of the PeVD-QoL Reliability Physiological function Symptom distress Sleep status Psychological burden Social support Life satisfaction Cronbach’s α 0.86 0.93 0.98 0.97 0.88 0.98 Test-retest reliability 0.83 0.83 0.86 0.82 0.90 0.85 Discussion PeVD, a chronic progressive disease, is characterized primarily by physical functional impairment due to long-term venous insufficiency, recurrent pain symptoms, and psychosocial dysfunction, which significantly affect the QoL of women[25]. QoL assessment in women with PeVD relies primarily on generic instruments, which fail to capture the disease-specific effects of PeVD on health status, potentially leading to biased or incomplete evaluations[26]. Therefore, based on the theoretical framework of QoL, we developed the PeVD-QoL using a stepwise scale development process[19]. First, a systematic literature review was conducted to identify core concepts closely related to QoL in pregnant women with PeVD, which served as the basis for an initial item pool. Subsequently, semi-structured interviews were conducted with PeVD women to validate and supplement the item content from their perspective, ensuring the comprehensiveness and clinical utility of the scale. Finally, the Delphi expert consultation method was used to screen and refine the items. We invited 22 experts from diverse fields, including obstetrics and gynecology, vascular surgery, and nursing research, to participate in the consultation. The authority coefficients for the two rounds of expert consultation were both >0.85[27], indicating that the expert group had deep theoretical knowledge and rich clinical experience in the field of PeVD and could provide professional evaluation of the scale's content from a multidisciplinary perspective. The Kendall coefficients of concordance for the two rounds of consultation were 0.265 and 0.291 ( p < 0.001), respectively, reflecting good consistency among expert opinions[28]. This development process involves theoretical guidance, patient input, and expert consensus, thereby supporting the scientific validity of the scale[29]. Validity was used to determine the extent to which the scale measures the parameters it is intended to measure[30]. In terms of content validity, the S-CVI and the I-CVI exceeded 0.80[24], indicating that the items on the scale comprehensively capture the disease-specific manifestations of QoL in women with PeVD. We used EFA and CFA to examine structural validity. The EFA results indicated that the six-factor structure of the PeVD-QoL explained 73.23% of the total variance. A higher variance ratio suggested a more robust factor structure of the scale. A factor loading of 40% or more accounts for the total variance and is considered valid, indicating that the scale has a strong factor structure and can comprehensively assess various dimensions of QoL in women[31]. In the CFA, the model was adjusted by establishing correlations among the residual terms[32]. After the adjustment, the model fit indices met the expected standards, and the overall scale structure was acceptable[31]. Convergent validity is used to assess whether different items within the same dimension are consistent with the latent trait of that dimension[32]. The AVE values for the six dimensions of the PVQoL ranged from 0.38 to 0.93, and all the CR values were greater than 0.8. When the AVE of each dimension exceeds 0.36 and the CR is greater than 0.6, the convergent validity of the scale is acceptable, suggesting that the items within each dimension align with the conceptual meaning of that dimension[33]. Discriminant validity is used to reflect whether there is adequate differentiation between the latent traits of different dimensions[32]. In this study, the correlation coefficients among the six dimensions were all lower than the square root of the AVE, indicating that the degree of internal relationships within each dimension was greater than the degree of relationships between dimensions[24]. This finding suggests that the scale has good discriminant validity and that the connotations of each dimension are unique and mutually independent[24]. Reliability, a key metric in evaluating measurement instruments, reflects the consistency, dependability, and stability of assessment outcomes[34]. In this study, the Cronbach’s α coefficients for the total scale and its subscales ranged from 0.814 to 0.982, all exceeding the threshold of 0.8[34], indicating good internal consistency of the PeVD-QoL. The test-retest reliability coefficients for the total scale and subscales ranged from 0.837 to 0.906 (i.e., >0.75), demonstrating satisfactory temporal stability of the scale[35]. These results suggest that the PeVD-QoL is highly reliable and has robust stability. QoL involves multidimensional evaluations[20], such as physical, psychological, and social functioning, and helps understand the effects of PeVD on overall health and the lives of women, providing a basis for formulating effective treatment and nursing strategies[26]. The PeVD-QoL systematically captures the disease-specific effect of PeVD on the health status of women within the QoL framework[20], addressing the limitations of existing generic scales regarding their applicability to specific diseases[26]. Physiological status serves as the cornerstone of QoL, and its impairment can trigger a cascade of abnormalities in physical, psychological, and social functioning[36]. By evaluating physiological functional status, the PeVD-QoL provides medical staff with quantifiable data to monitor disease progression while helping women recognize the connection between somatic symptoms and their condition, thereby enhancing self-management awareness. Symptom distress acts as a core driver influencing QoL, with its severity directly affecting the overall health perceptions of women[37]. PeVD is characterized by clinical features such as symptom diversity (e.g., CPP, urogenital symptoms, and sexual dysfunction) and symptom overlap (e.g., concurrent dyspareunia and dysuria), which often leads to ambiguous symptom recognition by women and medical staff[7,8]. Through its structured symptom distress domain, the PeVD-QoL systematically analyzes the differential effects of PeVD-specific symptoms on physical function, psychological adaptation, and social participation, providing an assessment tool to quantify subjective symptom burden. Psychological resilience acts as a crucial buffer against the deterioration of QoL[38]. Sleep problems are common accompanying symptoms in women with PeVD and are not only closely related to the pain and discomfort caused by the disease but also directly affect the emotional state and daytime function of women[9]. Previous QoL-related scales often categorized sleep assessment under the "psychological" dimensions or did not include relevant assessments[26]. The results of the EFA suggest that treating sleep status as an independent dimension of the PeVD-QoL can help capture this important factor affecting the QoL of women. The psychological burden experienced by PeVD women arises not only from the physiological damage caused by the disease but also from factors such as symptom unpredictability, social stigma, and long-term treatment pressures[39,40]. The psychological burden domain of the PeVD-QoL quantifies the severity of PeVD-induced psychological distress by assessing anxiety, depression, and stigma-related responses, serving as a screening tool for medical staff to identify populations at high risk of developing anxiety and depression. Social support represents a key protective factor for QoL, with its adequacy directly determining women's capacity to adapt to the challenges posed by diseases[41]. PeVD management requires not only biomedical interventions at the individual level but also coordinated social support systems[42]. The social support domain of the PeVD-QoL assesses environmental factors, including family relationships, healthcare accessibility, and financial burden, and reveals the systemic effects of the disease on women's social functioning. By quantifying gaps in social support, the PeVD-QoL guides medical staff in optimizing interdisciplinary collaboration and facilitates the development of PeVD-specific support systems. The ultimate evaluation of QoL must return to the subjective health perception of women—an integrative health state shaped by the synergistic effects of physiological, psychological, and social factors[43]. The life satisfaction domain of the PeVD-QoL transforms the four preceding domain-specific indicators (physical function, symptom burden, sleep status, psychological distress, and social support) into actionable composite outcome measures through patient-reported global health assessments. This reflects the comprehensive effect of PeVD on QoL and provides direction for clinical decision-making and the evaluation of intervention outcomes. Limitations This study had two limitations. First, participants were recruited primarily from three hospitals in Xiamen and Zhengzhou, China; therefore, the geographical coverage was limited, which may affect the scale's applicability across populations from different regions. Additionally, most of the participants were older, with relatively insufficient representation of younger women, which may influence the applicability of the scale across different age groups. Future studies can further validate the scale across broader geographical areas and more diverse age ranges to increase its generalizability. Conclusion We developed and validated a scale to assess the QoL of women with PeVD. This scale was developed following a standardized procedure, encompassing a literature review, qualitative interviews, expert consultations, expert validation, and patient validation. The PeVD-QoL comprises six dimensions and 40 items, comprehensively capturing the disease-specific effect of PeVD on the health status of women. This scale has excellent reliability and validity and thus can be used as a standardized tool for monitoring QoL and supporting the clinical management of pregnant women with PeVD. It also enables medical staff to identify disease-specific symptom burdens and psychosocial needs in PeVD women, thereby facilitating the development of personalized care plans. Abbreviations Pelvic venous disorder: PeVD; Chronic pelvic pain: CPP; Quality of life: QoL; Short-form 36 health survey: SF-36; Aberdeen varicose vein questionnaire: AVVQ; Chronic venous insufficiency quality of life questionnaire: CIVIQ; European quality of life 5D: EQ-5D; Visual analog scale: VAS; Quality of life scale for Pelvic venous disorder women: PeVD-QoL; Scale-level content validity index: S-CVI; Item-level content validity index: I-CVI; Empirical factor analysis: EFA; Keiser-Meyer-Olkin: KMO; Confirmatory factor analysis: CFA; Chi-square to degrees of freedom ratio: χ2/df; Root mean square error of approximation: RMSEA; Comparative fit index: CFI; Incremental fit index: IFI; Normed fit index: NFI; Tucker-Lewis index: TLI; Average variance extracted: AVE; Composite reliability: CR. Declarations Data availability The data that support the findings of this study are available from the corresponding author upon reasonable request. 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Quality of Life, Anxiety and Depression in Women Treated with Hysteroscopic Endometrial Resection or Ablation for Heavy Menstrual Bleeding: Systematic Review and Meta-Analysis of Randomized Controlled Trials. Medicina (Kaunas). 2022;58(11). doi:10.3390/medicina58111664. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 04 Jan, 2026 Reviewers agreed at journal 25 Dec, 2025 Reviewers invited by journal 25 Dec, 2025 Editor invited by journal 29 Nov, 2025 Editor assigned by journal 27 Nov, 2025 Submission checks completed at journal 27 Nov, 2025 First submitted to journal 24 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":67240,"visible":true,"origin":"","legend":"\u003cp\u003eScree plot factor structure\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8190948/v1/f2cd2378ff5265d3e02b6075.png"},{"id":99788188,"identity":"ef5a4ed3-52b5-4c60-8f37-4575a38267a4","added_by":"auto","created_at":"2026-01-08 12:45:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1131558,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8190948/v1/14d1b3eb-d3b9-4b2f-98be-6ba540f27e6c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development and Validation of a Quality of Life Scale for Women with Pelvic Venous Disorder: A Mixed Methods Study","fulltext":[{"header":"Background","content":"\u003cp\u003ePelvic venous disorder (PeVD) is a clinical condition characterized by pelvic venous insufficiency, manifesting as chronic, non-cyclical pelvic pain or pressure. It is exacerbated by prolonged standing and is frequently accompanied by dysmenorrhea, dyspareunia, and varicosities of the perineum or lower extremities[1]. Reports indicate that chronic pelvic pain (CPP), defined as persistent intermittent pelvic pain lasting over six months, affects up to 26% of women[2]. CPP accounts for about 40% of gynecological outpatient consultations and 40% of diagnostic laparoscopies in gynecological practice[2]. In addition to its long-term physical impact, CPP severely impairs women\u0026rsquo;s emotional health, social functioning, and overall quality of life (QoL), making it one of the most debilitating yet under-addressed gynecological complaints. CPP also exerts a significant financial burden on the healthcare system: the cost of CPP was conservatively estimated to exceed $5.8 billion in U.S. healthcare expenditures in 2020[2,3].\u003c/p\u003e\n\u003cp\u003eIn nearly 40% of women with CPP, the underlying cause remains undiagnosed, complicating definitive diagnosis and effective treatment selection[2,4]. This diagnostic challenge is particularly pronounced in PeVD, which is frequently overshadowed by other pelvic pathologies owing to overlapping symptoms and the absence of specific biomarkers. As a result, many women\u0026mdash;potentially suffering from PeVD\u0026mdash;are subjected to prolonged medical evaluations, unnecessary diagnostic tests, and, in some cases, inappropriate surgical interventions (e.g., hysterectomy) that may not align with their clinical needs[2,4]. Previous studies reported that PeVD may underlie about 30% of CPP cases[5,6].\u003c/p\u003e\n\u003cp\u003eThe pathological characteristics of PeVD are pelvic varicose veins and venous dysfunction, accompanied by venous stasis and/or reflux[7]. Multiple pregnancies, abnormal pelvic venous anatomy, abnormal estrogen levels, and prolonged weight-bearing or standing are risk factors for PeVD[2]. The relationship between pelvic venous lesions and patient-perceived symptoms is very complex, as similar symptoms may be caused by different etiologies (e.g., CPP can be caused by ovarian vein reflux, left common iliac vein compression, or left renal vein compression), and the same etiology may present with different symptoms (e.g., ovarian vein reflux may be associated with CPP, dyspareunia, heavy menstrual bleeding, and menstrual pain)[8]. Therefore, the diagnosis of PeVD often involves multidisciplinary differential methods, including gynecology, neurology, orthopedics, gastroenterology, vascular surgery, psychiatry, etc., and requires a combination of pelvic and transvaginal ultrasound, pelvic venography with intravascular ultrasound, magnetic resonance imaging, or CT angiography with enhanced scanning for a definitive diagnosis[7]. Many women with PeVD spend\u0026nbsp;much\u0026nbsp;of\u0026nbsp;their\u0026nbsp;time seeking help from doctors in different disciplines, but delayed diagnosis and even misdiagnosis are common[9].\u003c/p\u003e\n\u003cp\u003eThe combination of persistent physical discomfort, unresolved psychological distress, and the exhaustive process of navigating a complex diagnostic system severely decreases the holistic QoL for women with PeVD[10]. Unlike acute conditions, the chronic nature of PeVD leads to sustained impairments in daily functioning, social participation, and self-esteem, creating a vicious cycle of pain, frustration, and declining well-being[10]. Currently available treatment methods for PeVD include physical therapy, pharmacotherapy, surgical treatment, and endovascular treatment[6]. With the development of medical technology, endovascular treatment has become the preferred method\u0026nbsp;for\u0026nbsp;treating PeVD[7]. Although advances in treatment technology have significantly improved the anatomical abnormalities and hemodynamics of PeVD women, these improvements do not always align with the degree of symptom relief perceived by women[11]. This inconsistency may stem from multiple factors, such as insufficient sensitivity of diagnostic methods, individual differences among women, variations in surgical details, and inconsistent standards for evaluating the effectiveness of treatments[11]. Consequently, relying solely on imaging-based improvements as the endpoint for PeVD treatment is limited; patient-centered outcomes\u0026mdash;particularly symptom improvement\u0026mdash;should be the primary indicator of treatment effectiveness\u0026nbsp;[10].\u003c/p\u003e\n\u003cp\u003eQoL is a key outcome measure for evaluating symptom improvement in women with PeVD[10]. Attention to QoL issues has several advantageous consequences for patient care[12]. First, a focus on QoL involves women in their medical care because patient input is required to make these assessments. Second, an assessment of QoL obligates the clinician to address issues important to women beyond objective laboratory data. This process redirects clinicians\u0026apos; and nurses\u0026apos; focus to the patient. Third, attention to QoL encourages patient-clinician communication, enabling women to work together to maximize their holistic health perceptions. However, assessing the QoL of women with PeVD is complex and requires standardized, validated instruments to measure the effect of the disease on physical, psychological, and social areas. Professional tools for assessing the quality of life of individuals with PeVD rely mainly on generic instruments[13-18], such as the Short Form 36 health survey (SF-36), the Aberdeen Varicose Vein Questionnaire (AVVQ), the Chronic Venous Insufficiency Quality of Life Questionnaire (CIVIQ), the European Quality of Life 5D (EQ-5D), and the visual analog scale (VAS). However, these tools fail to cover the unique disease dimensions of PeVD, including specific manifestations such as positional pain, sexual dysfunction, and vulvar varicose veins. These limitations render generic instruments inadequate for quantifying the true burden of PeVD on women\u0026rsquo;s lives, highlighting the urgent need for a disease-specific QoL assessment tool. Therefore, in this study, we developed an assessment scale for evaluating the QoL of women with PeVD. This scale may provide a foundation for healthcare professionals to develop comprehensive clinical treatment and care plans for women with PeVD.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design and setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe adopted a mixed-methods design that combined quantitative and qualitative approaches. The research team consisted of seven members, including a head nurse with a master\u0026rsquo;s degree in vascular surgery, a Master of Nursing, three vascular surgery nurses, a vascular surgery department director and PeVD expert, and a medical practitioner in the field of vascular surgery. The study followed the standard scale development process[19], which\u0026nbsp;comprises\u0026nbsp;three distinct stages: scale construction, reliability, validity testing, and\u0026nbsp;test-retest\u0026nbsp;reliability assessment. During the scale construction phase, qualitative interviews were conducted, and items on the scale were developed based on\u0026nbsp;the\u0026nbsp;results of these interviews, the Delphi method, and a literature review. The scale underwent clinical testing during the reliability and validity testing phase. Finally, test-retest reliability was conducted to gather more data on the performance of the scale.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDevelopment of the scale\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLiterature review\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing keywords such as \u0026ldquo;pelvic vein insufficiency\u0026rdquo;, \u0026ldquo;pelvic venous syndrome*\u0026rdquo;, \u0026ldquo;pelvic venous disorder*\u0026rdquo;, \u0026quot;pelvic congestion syndrome*\u0026quot;, \u0026quot;iliac vein compression\u0026quot;, \u0026quot;pelvic varicose veins\u0026quot;, \u0026quot;quality of life\u0026quot;, and \u0026quot;QoL\u0026quot;, we searched Chinese and English databases, including CNKI, VIP, Wanfang, CBM, Web of Science, PubMed, the Cochrane Library, Embase, and CINAHL. The search period ranged from the establishment of the databases to May 31, 2024. The included articles covered various research methods, including scale development, intervention trials, and systematic reviews, all focused on the QoL of women with PeVD. Under the guidance of the QoL model[20], the research team extracted, analyzed, and summarized content related to the QoL of women with PeVD from the literature, forming a scale item pool comprising five dimensions and 47 items.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative interviews\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo gain a deeper understanding of the constituent elements and influencing factors of QoL in women with PeVD, we conducted qualitative research. Using purposive sampling, we selected women with PeVD from a tertiary cardiovascular hospital in southeast China for semi-structured interviews conducted from June to October 2024. The interviews were conducted by a researcher (Y.L.) who had considerable experience in qualitative research. The sample size was determined based on the criterion of information saturation. The relevant information was organized within 24 h after the interview, and the contents of the interview were transcribed and formed into a text. The interview data were analyzed using Graneheim \u0026amp; Lundman\u0026apos;s content analysis method[21]. The research team supplemented, modified, and improved the scale item pool based on the results of the interviews, forming an expert consultation version of the scale.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDelphi expert consultation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing the principles of a reasonable knowledge structure and complementary expertise, we invited Chinese experts in the field of PeVD to participate in an online Delphi expert consultation. The criteria for including the experts were as follows: (1) had engaged in or studied PeVD treatment, nursing, scientific research, or other related fields for more than five years; (2) held a bachelor\u0026apos;s degree and had an intermediate professional title or above; (3) were familiar with the content of PeVD nursing or had experience in developing relevant scales; and (4) were willing to participate in two rounds of Delphi consultation. The experts who did not respond within two weeks of receiving the e-mail were considered non-participants in that round. The expert consultation questionnaire included scale items for consultation and basic information about the experts, which was sent to each expert via WeChat or e-mail. The experts scored each item based on its importance, familiarity, and judgment criteria. Items were removed if they had an average score below 3.50, a full score rate under 20%, or a coefficient of variation greater than 0.25. The research team revised the scale dimensions and items based on expert feedback. The final initial scale consisted of five dimensions and 48 items.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eScale scoring method\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEach item on the scale was scored using a five-point Likert-type scoring method, with responses ranging from 1 (\u0026ldquo;very inconsistent\u0026rdquo;) to 5 (\u0026ldquo;very consistent\u0026rdquo;) based on the level of agreement with each statement. Among them, items 1\u0026ndash;44 were positively scored, and items 45\u0026ndash;48 were negatively scored. Dimension scores were calculated by summing the item scores within each domain, and the total scale score was obtained by summing all dimension scores. A lower total score indicates better QoL among women with PeVD.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrediction test\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBefore the formal survey, we conducted a pilot study with 10 women diagnosed with PeVD to evaluate the clinical version of the scale. The average completion time for the survey was 5.64\u0026nbsp;\u0026plusmn;2.33 min. We asked women for their opinions and suggestions on the clarity and relevance of the scale and adjusted the scale\u0026apos;s layout accordingly. Based on their feedback, a formal test version of the QoL scale was developed for PeVD women (PeVD-QoL), comprising 48 items across five dimensions. Women who participated in the prediction test were not included in the formal study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReliability and validity test of the scale\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants and survey method\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWomen with PeVD who received care at Xiamen Cardiovascular Hospital of Xiamen University, Zhongshan Hospital of Xiamen University, and the Third Affiliated Hospital of Zhengzhou University in China from January 2022 to February 2025 were selected for the psychometric validation of the scale. The inclusion criteria for participants were as follows: ① clinically diagnosed with PeVD; ② \u0026ge;18 years old; ③ conscious, with adequate communication ability; and ④ provided informed consent and voluntary participation in this study. The exclusion criteria were as follows: severe psychiatric disorders, cognitive impairment, or other serious physical illnesses. The sample size was determined by multiplying the number of scale items by 5 to 10. With 48 items on the scale and an anticipated 10% invalid response rate, at least 264 participants were needed. Since confirmatory factor analysis (CFA) requires a sample size exceeding 200, at least 464 participants were needed for the formal survey.\u003c/p\u003e\n\u003cp\u003eA team of trained researchers distributed the electronic questionnaires to participants via Wenjuanxing, and participants were instructed to complete them on the day of the invitation. Incomplete or overdue responses were excluded from the analysis. A total of 540 women were invited, and 527 valid responses were ultimately included in the analysis. All participants were asked to return the completed retest questionnaire within 2 weeks of the first response. Finally, 30 participants completed the retest; the results were used to assess test-retest reliability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection tools\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research tools used in this study consisted of two parts. The first part was a general information questionnaire, designed by researchers, to collect data on gender, age, education level, place of residence, marital status, number of children, affected pelvic veins, and history of pelvic vein surgery. The second part was the validated version of the PeVD-QoL.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data were analyzed using SPSS 26.0 and Amos 24.0. Categorical variables are presented as counts and percentages, whereas normally distributed continuous variables are presented as the means \u0026plusmn; standard deviations. All the results were considered statistically significant at \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05. The engagement, authority, and consensus of experts are represented by the effective recovery rate of questionnaires, the expert authority coefficient, and Kendall\u0026apos;s coefficient of concordance.\u003c/p\u003e\n\u003cp\u003eItem analysis examines the discrimination and differentiation of scale items using the critical ratio, correlation coefficient analysis, and internal consistency coefficients[22]. ① Critical ratio: All samples were sorted in descending order based on the total score of the scale. The top 27% of the total score was selected as the high group, and the bottom 27% was selected as the low group. An independent-samples t-test was conducted to compare the average score differences between the two groups for each item, and items with a critical ratio \u0026lt;3.00 or no statistically significant difference were deleted[19]. ② Item-total correlation analysis: Items with a Pearson correlation coefficient \u0026lt; 0.40 between the individual item score and the total score or without a statistically significant correlation were also excluded[23]. ③ Internal consistency coefficients: If the Cronbach\u0026apos;s \u0026alpha; coefficient of the total scale increases after a certain item is deleted, then that item should be removed[19].\u003c/p\u003e\n\u003cp\u003eTo evaluate the relevance of each item in the scale to its corresponding content, experts participating in the second round of expert consultation were invited. A four-level scoring method was adopted, with 1 point indicating \u0026quot;not relevant\u0026quot;, 2 points indicating \u0026quot;weakly relevant\u0026quot;, 3 points indicating \u0026quot;relevant\u0026quot;, and 4 points indicating \u0026quot;highly relevant\u0026quot;. When the scale-level content validity index (S-CVI) is \u0026ge;0.780 and the item-level content validity index (I-CVI) is \u0026ge;0.800, the content validity is good[24].\u003c/p\u003e\n\u003cp\u003eExploratory factor analysis (EFA) is used to analyze structural validity. First, the Kaiser-Meyer-Olkin (KMO) test (KMO\u0026gt; 0.60) and Bartlett\u0026apos;s test of sphericity (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05) were used to determine whether the data were suitable for EFA[19]. Then, principal component analysis and varimax orthogonal rotation were adopted. According to the principle of a cumulative variance contribution rate \u0026gt; 60% and an eigenvalue \u0026gt; 1, items with several entries under common factors \u0026ge; 3 and factor loading \u0026ge; 0.50 are retained[24]. When the same item has a load value \u0026gt; 0.40 on two or more common factors simultaneously, the item is deleted and factor analysis is repeated after each deletion[24].\u003c/p\u003e\n\u003cp\u003eConfirmatory factor analysis (CFA) adopts the maximum likelihood method (chi-square to degrees of freedom ratio (\u0026chi;\u003csup\u003e2\u003c/sup\u003e/df), root mean square error of approximation (RMSEA), comparative fit index (CFI), incremental fit index (IFI), normed fit index (NFI), and Tucker-Lewis index (TLI)) to verify the structure of the scale. Convergent validity is evaluated using average variance extracted (AVE) and composite reliability (CR). Discriminant validity is tested by comparing the square root of the AVE of each factor with the correlation coefficient between that factor and other factors. Suppose the square root of the AVE for all factors is greater than the absolute value of the correlation coefficient between that factor and other factors. In that case, the scale can be considered to have good discriminant validity[24]. Reliability analysis was completed by Cronbach\u0026apos;s \u0026alpha; coefficient and test-retest reliability (intraclass correlation coefficient). When the Cronbach\u0026apos;s \u0026alpha; coefficient was \u0026ge;0.8 and the test-retest reliability was \u0026gt;0.75, the scale\u0026apos;s internal reliability was considered good[19].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Medical Ethics Committee of Xiamen Cardiovascular Hospital Xiamen University (No. (Y)KY2024-004\u0026ndash;01). The study was conducted in accordance with the Declaration of Helsinkiand relevant ethical guidelines for human research. Before participation, the women were informed of the purpose and methods of the study by the researchers, and all participants signed informed consent forms.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eQualitative interview\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter conducting in-depth interviews with 23 women diagnosed with PeVD, no new themes emerged during the later stages of data collection. Following collective analysis and discussion, the research team determined that thematic saturation had been reached, and no additional interviews were conducted. By analyzing the interview data, we extracted four main themes, \u0026quot;Multidimensional Symptom Disturbance\u0026quot;, \u0026quot;Cognitive Dissonance Regarding the Disease in the Context of Diagnostic and Therapeutic Dilemmas\u0026quot;, \u0026quot;Resilience in the Face of Frustration\u0026quot;, and \u0026quot;Life Reconstruction Under Disease Adaptation\u0026quot;, along with 11 subthemes. Based on the interview results, a scale for expert consultation was developed, comprising five dimensions and 50 items.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExpert enquiry\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 22 experts from nine cities in China, including Xiamen, Zhangzhou, Fuzhou, Shanghai, Guangzhou, Changsha, and Zhengzhou, were invited to participate in two rounds of consultation. The age of the experts ranged from 32 to 57 years (43.86 \u0026plusmn;6.64 years), and their professional experience ranged from 6 to 34 years (21.19 \u0026plusmn;8.82 years). Among them, five (22.72%) had a doctoral degree, six (27.27%) had a master\u0026apos;s degree, and 11 (50%) had a bachelor\u0026apos;s degree. One expert (4.55%) was a university teacher, 13 (59.09%) were head nurses or clinical nurses, and eight (36.36%) were medical staff. Moreover, 18 experts (81.82%) held senior positions, and four (18.18%) held intermediate positions. One expert (4.54%) was involved in nursing research, five (22.73%) specialized in the rehabilitation of obstetrics and gynecology, and 16 (72.73%) specialized in the diagnosis, treatment, and nursing of vascular surgery. The recovery rates of the second-round questionnaires were 100% and 95.45%, respectively, indicating that the experts were more enthusiastic about responding. In the first round of consultation, the expert authority coefficient (Cr) was 0.886, and Kendall\u0026rsquo;s coefficient of concordance (W) was 0.265 (\u0026chi;\u003csup\u003e2\u003c/sup\u003e = 272.59, p \u0026lt; 0.001). Based on the feedback of the experts, the revised scale consisted of five dimensions and 48 items. In the second round of consultation, the expert authority coefficient was 0.889, and Kendall\u0026rsquo;s coefficient of concordance was 0.291 (\u0026chi;\u003csup\u003e2\u003c/sup\u003e = 267.49, p \u0026lt; 0.001). The final version of the scale, after item refinement, included five dimensions and 48 items.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCharacteristics of the participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, questionnaires were distributed to 540 women. However, five participants submitted the same answers to all the questions without explanation; moreover, the answers of four women were incomplete, and those of four women were contradictory. Therefore, these participants were excluded. The final analysis included 527 PeVD women (Table 1), with an average age of 55.95\u0026nbsp;\u0026plusmn;12.66 years.\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"449\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 449px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Characteristics of the participants (n = 527)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue n(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eAge, y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003e\u0026le;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e9(1.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003e30\u0026ndash;40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e64(12.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003e41\u0026ndash;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e97(18.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003e51\u0026ndash;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e163(30.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003e＞60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e194(36.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eEducational level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eJunior high school and below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e398(75.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eSenior secondary education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e62(11.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eHigher education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e67(12.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eResidence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eUrban area\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e283(53.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eRural area\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e244(46.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eMarital status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e501(95.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eUnmarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e15(2.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e11(2.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eNumber of pregnancies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e15(2.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eOnce\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e113(21.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eTwice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e230(43.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eThree times or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e169(32.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eLesion vein\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eInferior vena cava\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e28(5.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eRenal vein\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e3(0.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eCommon iliac vein\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e103(19.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eInternal and external iliac veins\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e289(54.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eGonadal vein\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e191(36.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eUnclear\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e85(16.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eHistory of pelvic vein surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e371(70.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 280px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e156(29.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 449px;\"\u003e\n \u003cp\u003e\u003csup\u003e1\u003c/sup\u003eSome women have two or more diseased veins at the same time.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eItem analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the critical ratio method, the critical ratios of all 48 items were greater than 3, ranging from 5.73 to 25.69 (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05), and all the items were retained. The results of the correlation coefficient method revealed that the item correlation coefficients ranged from 0.33 to 0.81 (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), and three items had correlation coefficients below 0.40 with the total score (items 4, 7, and 10). No items were deleted from the scale because of a significant increase in Cronbach\u0026rsquo;s \u0026alpha; coefficient after removal. As a result, three items were removed, resulting in a final item pool of 45 items.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContent validity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe content validity was evaluated by 21 experts who completed two rounds of expert consultation. The S-CVI was 0.995, and the I-CVI was 0.905\u0026ndash;1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConstruct validity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 263 participants were randomly selected for EFA. The results of the first round were as follows: KMO of 0.91 and \u003cem\u003e\u0026chi;\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e\u003c/em\u003eof\u003cem\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/em\u003e13360.93 (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt; 0.001) for Bartlett\u0026apos;s test. By conducting principal component analysis with maximum varimax (orthogonal) rotation, we found that eight common factors had eigenvalues exceeding 1. However, based on the scree plot, the curve stabilized after the sixth factor, leading to the extraction of six factors (Figure 1). These factors had eigenvalues ranging from 3.52 to 8.12, with a cumulative variance contribution of 69.60%. Items 23, 25, 26, 36, and 44 were removed because their factor loadings were less than 0.5. The results of the second round of EFA revealed that KMO was 0.91 and that \u003cem\u003e\u0026chi;\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e\u003c/em\u003ewas 12235.69 (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt; 0.001) for Bartlett\u0026apos;s test; the eigenvalues ranged from 3.39 to 7.40, and the cumulative variance contribution rate was 73.23%. The item loadings became stable. The scale structure closely aligned with the initially conceived dimensions, with sleep-related items independently clustering into a new factor in the EFA. Based on the content of the item measurements, we named the five common factors extracted as physiological function (nine items), symptom distress (seven items), sleep status (four items), psychological burden (nine items), social support (seven items), and life satisfaction (four items) (Table 2).\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"700\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 700px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003eFactor loadings from exploratory factor analysis (n\u0026nbsp;=\u0026nbsp;263)\u0026emsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItem\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"6\" style=\"width: 429px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFactor loadings\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003ePhysiological function\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eSymptom distress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003eSleep status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003ePsychological burden\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eSocial support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eLife satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC1 Lower abdominal pain (non-menstrual) and/or discomfort such as aching and a sensation of heaviness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.56\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC2 Lower back/sacral tailbone/groin pain and/or discomfort, such as aching\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.63\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC3 Persistent pain during and/or after intercourse and/or discomfort such as dryness, aching, or burning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.60\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e-0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC5 Irregular menstrual cycles (irregular timing and duration of bleeding, excessive or insufficient bleeding)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.67\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC6 Premenstrual syndrome and/or dysmenorrhea, worsening pre-menstrually\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.57\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e-0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC8 Frequent urination, urgency, painful urination, urinary leakage, incontinence, sensation of incomplete bladder emptying, hematuria, etc.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.61\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e-0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e-0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC9 Anal discomfort (tenesmus)/worsening pain during bowel movements\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.66\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC11 Varicose veins in the lower limbs, leg/hip pain, or other discomfort (e.g., heaviness, fatigue, soreness, burning, dryness, itching, cramps, swelling, hardening, numbness, etc.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.74\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC12 Vulvar varicose veins, pain in the vulva (labia, vagina, urethra, perineum/scrotum, penis, or anus) (non-menstrual in women) or other discomfort (aching, heaviness, numbness, tenderness, sensitivity, sensation of heaviness, etc.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.68\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC13 Inability to climb stairs/slopes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.82\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC14 Inability to squat/bend over\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.80\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC15 Inability to walk at the desired speed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.80\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC16 Inability to stand/sit for long periods\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.79\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC17 Difficulty changing positions (e.g., rising from a seated position to walk)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e-0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.85\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e-0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC18 Easily fatigued during daily activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.69\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC24 Decreased desire for sexual activity/aversion to sexual activity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.52\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e-0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC19 Difficulty falling asleep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.79\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC20 Sleep interruptions, easily waking, etc.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.78\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC21 Reduced sleep duration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.82\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC22 Reduced sleep quality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.81\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC27 Feeling anxious, depressed, or irritable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.72\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC28 Worrying about the illness/feeling panicked or embarrassed in certain situations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.70\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC29 Difficulty relaxing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.79\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC30 Feeling ashamed to discuss one\u0026apos;s illness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.67\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC31 Feeling down and losing interest in activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.84\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC32 Feeling that one\u0026apos;s body is holding them back\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.85\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC33 Feeling afraid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.85\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC34 Feeling like a burden to one\u0026apos;s family\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.78\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC35 Difficulty concentrating, often feeling drowsy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.84\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC37 Doing household chores (cooking, laundry, dishwashing, cleaning, etc.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e-0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.50\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC38 Caring for the elderly or children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e-0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.55\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC39 Engaging in physical exercise\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.53\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC40 Relationship with family not as close as before\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.70\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e-0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC41 Friends/colleagues not understanding one\u0026apos;s illness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.76\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e-0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC42 Healthcare providers not offering desired assistance during treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.65\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e-0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC43 Employers not making appropriate arrangements for medical needs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.76\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e-0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC45 Overall, I consider my physical health to be very good\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e-0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.95\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC46 Overall, I consider my mental health to be very good\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e-0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.95\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eC47 Overall, I consider my performance in daily social activities and roles (including family, work, and community activities) to be very good\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e-0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.96\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 270px;\"\u003e\n \u003cp\u003eC48 Overall, I consider my current quality of life to be very good\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.083\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.073\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e-0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.96\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eConfirmatory factor analysis (CFA) was conducted on the remaining 264 participants. The results of CFA revealed the following: \u0026chi;\u003csup\u003e2\u003c/sup\u003e/df of\u0026nbsp;3.21, RMSEA\u0026nbsp;of\u0026nbsp;0.09, CFI of 0.87, IFI\u0026nbsp;of\u0026nbsp;0.87, NFI\u0026nbsp;of\u0026nbsp;0.82, and TLI\u0026nbsp;of\u0026nbsp;0.86. The fit indices of the model after correction are shown in Table 3. The CR of each factor ranged from 0.82 to 0.98, and the AVE ranged from 0.38 to 0.93, indicating that the scale had acceptable convergent validity. The Pearson correlation coefficient between factors ranged from 0.24 to 0.72 (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt; 0.05), and the square root of the AVE of each factor was greater than the maximum correlation coefficient with other factors, indicating good discriminant validity (Table 4).\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"427\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 427px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Fit indices and normal values of CFA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndices\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGood fit\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAcceptable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResult\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e/df\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026lt;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026lt;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e2.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003eRMSEA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026lt;0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003eCFI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026gt;0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026gt;0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003eIFI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026gt;0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003eNFI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026gt;0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026gt;0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003eTLI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026gt;0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026gt;0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"717\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 4.\u003c/strong\u003e Aggregate validity and discriminant validity of PeVD-QoL (n = 264)\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDimensions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAVE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSquare root of AVE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" valign=\"bottom\" style=\"width: 375px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCorrelation coefficient\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003ePhysiological function\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003eSymptom distress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003eSleep status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003ePsychological burden\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003eSocial\u003c/p\u003e\n \u003cp\u003esupport\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eLife satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003ePhysiological function\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eSymptom distress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.51\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eSleep status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.46\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e0.44\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003ePsychological burden\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.59\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e0.64\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.43\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eSocial support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.57\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e0.71\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.42\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e0.74\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eLife satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e0.33\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e0.32\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.28\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e0.25\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.24\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\" valign=\"bottom\" style=\"width: 717px;\"\u003e\n \u003cp\u003e注:\u003csup\u003e*\u003c/sup\u003e\u003cem\u003ep\u003c/em\u003e＜0.05.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eReliability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCronbach\u003c/strong\u003e\u0026rsquo;s \u0026alpha; coefficient of the scale was 0.96. In total, 30 women were randomly selected for retesting after a two-week interval, and the test-retest reliability was 0.92 (Table 5).\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"684\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 489px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 5.\u0026nbsp;\u003c/strong\u003eReliability of each dimension of the PeVD-QoL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReliability\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePhysiological function\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSymptom distress\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSleep status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePsychological burden\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocial support\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLife satisfaction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003eCronbach\u0026rsquo;s \u0026alpha;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003eTest-retest reliability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003ePeVD, a chronic progressive disease, is characterized primarily by physical functional impairment due to long-term venous insufficiency, recurrent pain symptoms, and psychosocial dysfunction, which significantly affect the QoL of women[25]. QoL assessment in women with PeVD relies primarily on generic instruments, which fail to capture the disease-specific effects of PeVD on health status, potentially leading to biased or incomplete evaluations[26]. Therefore, based on the theoretical framework of QoL, we developed the PeVD-QoL using a stepwise scale development process[19]. First, a systematic literature review was conducted to identify core concepts closely related to QoL in pregnant women with PeVD, which served as the basis for an initial item pool. Subsequently, semi-structured interviews were conducted with PeVD women to validate and supplement the item content from their perspective, ensuring the comprehensiveness and clinical utility of the scale. Finally, the Delphi expert consultation method was used to screen and refine the items. We invited 22 experts from diverse fields, including obstetrics and gynecology, vascular surgery, and nursing research, to participate in the consultation. The authority coefficients for the two rounds of expert consultation were both \u0026gt;0.85[27], indicating that the expert group had deep theoretical knowledge and rich clinical experience in the field of PeVD and could provide professional evaluation of the scale\u0026apos;s content from a multidisciplinary perspective. The Kendall coefficients of concordance for the two rounds of consultation were 0.265 and 0.291 (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt; 0.001), respectively, reflecting good consistency among expert opinions[28]. This development process involves theoretical guidance, patient input, and expert consensus, thereby supporting the scientific validity of the scale[29].\u003c/p\u003e\n\u003cp\u003eValidity was used to determine the extent to which the scale measures the parameters it is intended to measure[30]. In terms of content validity, the S-CVI and the I-CVI exceeded 0.80[24], indicating that the items on the scale comprehensively capture the disease-specific manifestations of QoL in women with PeVD. We used EFA and CFA to examine structural validity. The EFA results indicated that the six-factor structure of the PeVD-QoL explained 73.23% of the total variance. A higher variance ratio suggested a more robust factor structure of the scale. A factor loading of 40% or more accounts for the total variance and is considered valid, indicating that the scale has a strong factor structure and can comprehensively assess various dimensions of QoL in women[31]. In the CFA, the model was adjusted by establishing correlations among the residual terms[32]. After the adjustment, the model fit indices met the expected standards, and the overall scale structure was acceptable[31]. Convergent validity is used to assess whether different items within the same dimension are consistent with the latent trait of that dimension[32]. The AVE values for the six dimensions of the PVQoL ranged from 0.38 to 0.93, and all the CR values were greater than 0.8. When the AVE of each dimension exceeds 0.36 and the CR is greater than 0.6, the convergent validity of the scale is acceptable, suggesting that the items within each dimension align with the conceptual meaning of that dimension[33]. Discriminant validity is used to reflect whether there is adequate differentiation between the latent traits of different dimensions[32]. In this study, the correlation coefficients among the six dimensions were all lower than the square root of the AVE, indicating that the degree of internal relationships within each dimension was greater than the degree of relationships between dimensions[24]. This finding suggests that the scale has good discriminant validity and that the connotations of each dimension are unique and mutually independent[24].\u003c/p\u003e\n\u003cp\u003eReliability, a key metric in evaluating measurement instruments, reflects the consistency, dependability, and stability of assessment outcomes[34]. In this study, the Cronbach\u0026rsquo;s \u0026alpha; coefficients for the total scale and its subscales ranged from 0.814 to 0.982, all exceeding the threshold of 0.8[34], indicating good internal consistency of the PeVD-QoL. The test-retest reliability coefficients for the total scale and subscales ranged from 0.837 to 0.906 (i.e., \u0026gt;0.75), demonstrating satisfactory temporal stability of the scale[35]. These results suggest that the PeVD-QoL\u0026nbsp;is highly reliable and has\u0026nbsp;robust stability.\u003c/p\u003e\n\u003cp\u003eQoL involves multidimensional evaluations[20], such as physical, psychological, and social functioning, and helps understand the effects of PeVD on overall health and the lives of women, providing a basis for formulating effective treatment and nursing strategies[26]. The PeVD-QoL systematically captures the disease-specific effect of PeVD on the health status of women within the QoL framework[20], addressing the limitations of existing generic scales regarding their applicability to specific diseases[26]. Physiological status serves as the cornerstone of QoL, and its impairment can trigger a cascade of abnormalities in physical, psychological, and social functioning[36]. By evaluating physiological functional status, the PeVD-QoL provides medical staff with quantifiable data to monitor disease progression while helping women recognize the connection between somatic symptoms and their condition, thereby enhancing self-management awareness. Symptom distress acts as a core driver influencing QoL, with its severity directly affecting the overall health perceptions of women[37]. PeVD is characterized by clinical features such as symptom diversity (e.g., CPP, urogenital symptoms, and sexual dysfunction) and symptom overlap (e.g., concurrent dyspareunia and dysuria), which often leads to ambiguous symptom recognition by women and medical\u0026nbsp;staff[7,8]. Through its structured symptom distress domain,\u0026nbsp;the PeVD-QoL\u0026nbsp;systematically analyzes the differential effects of PeVD-specific symptoms on physical function, psychological adaptation, and social participation, providing an assessment tool to quantify subjective symptom burden. Psychological resilience acts as a crucial buffer against the deterioration of QoL[38]. Sleep problems are common accompanying symptoms in women with PeVD\u0026nbsp;and\u0026nbsp;are not only closely related to\u0026nbsp;the\u0026nbsp;pain and discomfort caused by the disease but also directly affect the emotional state and daytime function of women[9]. Previous QoL-related scales often categorized sleep assessment under the \u0026quot;psychological\u0026quot; dimensions or did not include relevant assessments[26]. The results of the EFA suggest that treating sleep status as an independent dimension of\u0026nbsp;the PeVD-QoL\u0026nbsp;can help capture this important factor affecting the QoL of women. The psychological burden experienced by PeVD women arises not only from the physiological damage caused by the disease but also from factors such as symptom unpredictability, social stigma, and long-term treatment pressures[39,40]. The psychological burden domain of\u0026nbsp;the PeVD-QoL\u0026nbsp;quantifies the severity of PeVD-induced psychological distress by assessing anxiety, depression, and stigma-related responses, serving as a screening tool for medical\u0026nbsp;staff\u0026nbsp;to identify populations at high risk of developing anxiety and depression. Social support represents a key protective factor for QoL, with its adequacy directly determining women\u0026apos;s capacity to adapt to the challenges posed by diseases[41]. PeVD management requires not only biomedical interventions at the individual level but also coordinated social support systems[42]. The social support domain of\u0026nbsp;the PeVD-QoL\u0026nbsp;assesses environmental factors, including family relationships, healthcare accessibility, and financial burden, and reveals the systemic effects of the disease on women\u0026apos;s social functioning. By quantifying gaps in social support,\u0026nbsp;the\u0026nbsp;PeVD-QoL guides medical\u0026nbsp;staff\u0026nbsp;in optimizing interdisciplinary collaboration and facilitates the development of PeVD-specific support systems. The ultimate evaluation of QoL must return to the subjective health perception of women\u0026mdash;an integrative health state shaped by the synergistic effects of physiological, psychological, and social factors[43]. The life satisfaction domain of\u0026nbsp;the PeVD-QoL\u0026nbsp;transforms the four preceding domain-specific indicators (physical function, symptom burden, sleep status, psychological distress, and social support) into actionable composite outcome measures through patient-reported global health assessments. This reflects the comprehensive effect of PeVD on QoL and provides direction for clinical decision-making and\u0026nbsp;the\u0026nbsp;evaluation of intervention outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study had two limitations. First, participants were recruited primarily from three hospitals in Xiamen and Zhengzhou, China; therefore, the geographical coverage was limited, which may affect the scale\u0026apos;s applicability across populations from different regions. Additionally, most of the participants were older, with relatively insufficient representation of younger women, which may influence the applicability of the scale across different age groups. Future studies can further validate the scale across broader geographical areas and more diverse age ranges to increase its generalizability.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe developed and validated a scale to assess the QoL of women with PeVD. This scale was developed following a standardized procedure, encompassing a literature review, qualitative interviews, expert consultations, expert validation, and patient validation. The PeVD-QoL comprises six dimensions and 40 items, comprehensively capturing the disease-specific effect of PeVD on the health status of women. This scale has excellent reliability and validity and thus can be used as a standardized tool for monitoring QoL and supporting the clinical management of pregnant women with PeVD. It also enables medical staff to identify disease-specific symptom burdens and psychosocial needs in PeVD women, thereby facilitating the development of personalized care plans.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePelvic venous disorder: PeVD; Chronic pelvic pain: CPP; Quality of life: QoL; Short-form 36 health survey: SF-36; Aberdeen varicose vein questionnaire: AVVQ; Chronic venous insufficiency quality of life questionnaire: CIVIQ; European quality of life 5D: EQ-5D; Visual analog scale: VAS; Quality of life scale for Pelvic venous disorder women: PeVD-QoL; Scale-level content validity index: S-CVI; Item-level content validity index: I-CVI; Empirical factor analysis: EFA; Keiser-Meyer-Olkin: KMO; Confirmatory factor analysis: CFA; Chi-square to degrees of freedom ratio: \u0026chi;2/df; Root mean square error of approximation: RMSEA; Comparative fit index: CFI; Incremental fit index: IFI; Normed fit index: NFI; Tucker-Lewis index: TLI; Average variance extracted: AVE; Composite reliability: CR.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ed\u003c/strong\u003e\u003cstrong\u003eeclaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by grants from the Fujian Provincial Clinical Key Specialty Construction Project (Min Wei Yi Zheng Han [2022] No. 884) and Xiamen Municipal Clinical Key Specialty Construction Project (Xia Wei Ke Jiao [2021] No. 215). The funders had no role in study design, data collection, or manuscript preparation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFord RW, Winokur RS. Pelvic Venous Disorders (PeVD). Semin Intervent Radiol. 2022;39(5):483-9. doi:10.1055/s-0042-1757938.\u003c/li\u003e\n\u003cli\u003eLamvu G, Carrillo J, Ouyang C, Rapkin A. Chronic Pelvic Pain in Women: A Review. JAMA. 2021;325(23):2381-91. doi:10.1001/jama.2021.2631.\u003c/li\u003e\n\u003cli\u003eMathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege JF. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. OBSTET GYNECOL. 1996;87(3):321-7. doi:10.1016/0029-7844(95)00458-0.\u003c/li\u003e\n\u003cli\u003eHoward FM. The role of laparoscopy in chronic pelvic pain: promise and pitfalls. 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Medicina (Kaunas). 2022;58(11). doi:10.3390/medicina58111664.\u003c/li\u003e\n\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-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pelvic venous disorder, Health-related quality of life, Scale, Development, Validation","lastPublishedDoi":"10.21203/rs.3.rs-8190948/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8190948/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePelvic venous disorder (PeVD) predominantly affects women, causing chronic pelvic pain, dyspareunia, and lower extremity varicose veins that severely impair quality of life (QoL). Owing to the lack of QoL assessment tools tailored to the impact of PeVD on female patients, diagnosis and management remain challenging. We developed a PeVD-specific QoL scale (PeVD-QoL) for women, providing a scientific basis to optimize diagnostic, therapeutic, and nursing strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing a mixed-methods design (literature review, qualitative interviews, Delphi expert consultations, and clinical testing), we developed and refined the scale. The preliminary 48-item version was validated in 527 Chinese women with PeVD to assess its validity (content, construct, convergent, and discriminant) and reliability (Cronbach’s α and test-retest reliability), thereby verifying its scientific rigor and reliability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe PeVD-QoL demonstrated a content validity index of 0.995. Exploratory factor analysis revealed that the 40 items of the PeVD-QoL loaded on six factors, accounting for 73.23% of the total variance; confirmatory factor analysis supported its six-factor structure with acceptable model fits. Each dimension exhibited acceptable convergent and discriminant validity (AVE = 0.38–0.93, CR = 0.82–0.98). The scale showed high internal consistency (Cronbach’s α = 0.96), with Cronbach’s α coefficients for each dimension ranging from 0.86 to 0.98. The test-retest reliability across dimensions after two weeks ranged from 0.82 to 0.90.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe developed and validated a novel scale for assessing QoL in PeVD women. This tool can comprehensively capture the effects of PeVD on women's health status, facilitating optimized diagnosis, treatment, and nursing strategies to improvetheir quality of life. Multicenter studies with larger, more diverse cohorts are needed to confirm the generalizability of the tool and establish minimal clinically important differences.\u003c/p\u003e","manuscriptTitle":"Development and Validation of a Quality of Life Scale for Women with Pelvic Venous Disorder: A Mixed Methods Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-31 01:16:22","doi":"10.21203/rs.3.rs-8190948/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-01-05T03:09:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"167397838159682354204884073359578329829","date":"2025-12-25T15:50:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-25T15:09:59+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-29T16:50:30+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-27T06:40:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-27T06:36:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2025-11-24T08:21:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1896d6ac-74d5-4a29-a5c6-6be48bb9baeb","owner":[],"postedDate":"December 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-31T01:16:22+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-31 01:16:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8190948","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8190948","identity":"rs-8190948","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}