Translation, Cross-Cultural Adaptation and Validation of the Chinese version of Supportive and Palliative Care Indicators tool (SPICT-CH) to Identify Cancer Patients with Palliative Care Needs 

Translation, Cross-Cultural Adaptation and Validation of the Chinese version of Supportive and Palliative Care Indicators tool (SPICT-CH) to Identify Cancer Patients with Palliative Care Needs | 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 Translation, Cross-Cultural Adaptation and Validation of the Chinese version of Supportive and Palliative Care Indicators tool (SPICT-CH) to Identify Cancer Patients with Palliative Care Needs Zhishan Xie, Siyuan Tang, Claire E Johnson, Lin Xiao, Chongmei Huang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3889285/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction People diagnosed with cancer are the most frequent users of palliative care. However, there are no specific standards for early identifying patients with palliative care needs in mainland China. The Supportive and Palliative Care Indicators tool (SPICT) can identify patients with cancer who are in need of palliative care across healthcare settings. Objective To translate, cross-cultural adapt and validate the SPICT in a Chinese healthcare context. Method We translated and culturally adapted the SPICT from English into Chinese, following both Beaton's and WHO's recommendations: 1) initial translation, 2) synthesis, 3) back translation, 4) expert committee review, and 5) pretest. The psychometric properties (e.g., content validity, internal consistency, and inter-rater reliability) were analyzed. Between January and August 2023, a convenience sample of 212 hospitalized cancer patients was assessed by two nurses within 24 hours to determine the inter-rater reliability and stability of the Chinese version of SPICT (SPICT-CH). Results All items were retained in response to expert review, resulting in a total of 36 items. The Scale-Content Validity Index/Ave (S-CVI/Ave) of the SPICT-CH was 0.98, demonstrating very strong content validity. The SPICT-CH exhibited good coherence (Cronbach’s alpha = 0.76) and reliability (Kappa = 0.71, 95% CI 0.71–0.72, p < 0.05). Conclusion The SPICT-CH has good content validity and acceptable reliability in assessing cancer patients within a Chinese hospital setting. This instrument can be effectively integrated into routine clinical practice to early identify patients who need palliative care in mainland China. Palliative care SPICT Chinese Screening instrument Introduction China had the highest number of new cancer cases (4.57 million) and deaths which 3 million in the world in 2020, representing 23.7% and 30% of the global population, respectively [ 1 , 2 ]. This has considerably increased the cancer burden in the country. Chinese patients with advanced cancer often experience increasing physical and psychological symptom severity and distress (e.g., pain and fear) during their final months of life [ 3 – 5 ]. Additionally, those patients have diverse needs and preferences regarding healthcare services, including physical, psychological, spiritual, and social support, towards the end of their lives. The disease trajectory and varied care needs imply the importance of introducing palliative care early in the treatment of cancer patients. Palliative care is aimed at ensuring that patients facing life-threatening illnesses have access to tailored symptom management and appropriate holistic care to meet their needs and preferences [ 6 ]. In the early stages of disease progression, palliative care can be integrated with curative treatments to address the patient’s physical, psychological, social, and spiritual needs [ 7 ]. Early integration of palliative care and curative treatments could alleviate psychological distress (e.g., depression and anxiety), enhance quality of life, reduce symptoms, and decrease healthcare costs for advanced cancer patients [ 8 – 10 ]. The initial step in providing timely support is to identify individuals who are likely to benefit from early palliative care, and this holds significant importance in meeting the needs of patients requiring palliative care. Our recent review determined several instruments that are used to identify patients who may benefit from palliative care [ 11 ]. The findings revealed that Supportive and Palliative Care Indicators Tool (SPICT) had better clinical performance than other screening instruments [Gold Standards Framework Prognostic Indicator Guidance (GSF-PIG), the Necesidades Paliativas [PalliativeNeeds] (NECPAL), the RADboud indicators for Palliative Care needs (RADPAC), the Taiwanese version Palliative Care Screening Tool, Rainone and AnticiPal]. The SPICT was developed by a team of researchers at the University of Edinburgh in collaboration with clinicians from various healthcare settings, including hospitals, clinics and community settings [ 12 ]. The SPICT is a simple and easy-to-understand one-page instrument which helps clinicians to quickly and early identify individuals with palliative care needs [ 13 ]. The SPICT consists of three sections: 1) seven general indicators of deterioration in health, such as unplanned emergency admissions to hospitals, 2) seven sets of disease-specific clinical indicators (e.g., cancer, cardiovascular disease), and 3) seven healthcare recommendations which guide the clinicians in discussing the future care plan with the patient and their families based on the six-step guide in the REDMAP framework. There are evident strengths for SPICT compared to other screening instruments. First, it does not include the Surprise Question, which to some extent reduces the possibility that the clinicians may omit patients who could benefit from early palliative care [ 14 ]. This is because the Surprise Question relies on clinicians’ intuition and experience to assess a patient's prognosis before making a decision on palliative care provision. Second, it also presumes a suitable timeframe for patients to access palliative care. Third, it includes recommendations for palliative care plans, promoting the clinicians to address the patient’s needs and preferences in a structured manner. It is widely applicable across various healthcare settings, including hospitals and primary care settings, and boasts extensive global use, having been translated into 15 languages with good reliability and validity. However, a Chinese version is currently unavailable. Therefore, this study aims to translate, cross-culturally adapt, and validate the Chinese version of SPICT (SPICT-CH) among cancer patients in Mainland China. Methods The study involved two phases: the translation and cross-cultural adaptation of the SPICT among cancer patients and the assessment of its psychological properties of the SPICT-CH. Translation progress and cross-cultural adaption The Chinese translation and adaption of the SPICT followed the Beaton method and the WHO’s recommendation, which included the following five steps [ 15 , 16 ]. Step 1: Initial translation The instrument was independently translated the original version into Chinese by two researchers whose mother tongue is Chinese (X.Z. and T.M.), both holding Master's degrees in nursing, resulting in documents I and II. The translation followed Guillemin's principle which emphasizes the preservation of cross-cultural equivalence between the original version and the target language version, and conformed to Chinese linguistic norms and expressions [ 17 ]. Step 2: Synthesis of the translation Two researchers (X.Z. and T.M.) and a translation coordinator (D.J.) convened a meeting to compare documents I and II, analyzed the variations in expressions in relation to the original instrument, and ultimately forming document III. Step 3: Back-translation To verify the content of the instrument with the original, two additional translators (X.J. and John) independently conducted back-translations of document III. Subsequently, the research team compared the translated documents with the original instrument, identified the differences, and made necessary modifications to ensure that the content of the Chinese translation is more than 90% consistent with the original. This resulted in the version IV of the SPICT-CH. X.J. is proficient in English as she has a Ph.D. degree in nursing from Hong Kong, and John is a professional English translator. Step 4: Expert committee review An expert committee of 18 palliative care specialists conducted two rounds of review of document IV to address any issues related to semantic, concept, idiomatic, and empirical equivalence. Each specialist was asked to complete an electronic questionnaire and provide feedback on the document IV. The questionnaire includes three parts: the importance of early identification of palliative care, the introduction of the Chinese version of SPICT, the purpose of the research and the content of the review. The revised document IV was sent back to the expert committee for further review. The expert committee was consisted of six palliative care researchers, four palliative care physicians, one oncology physicians, three oncology nurses and four palliative care nurses. Step 5: Pretest To assess the understanding of each item and the feasibility of the instruments, seven nurses independently evaluated three adult cancer patients, by using the revised SPICT-CH. Those nurses had more than five years of clinical experience in the field of oncology, and they were from four different oncology unit. After completing the evaluation, they were asked to rate the feasibility on a scale ranging from one to 10 points where one was “very unsuitable” and 10 was “very feasible”. Ease of understanding was from one (very difficult) to 10 (very easy). We then conducted brief interviews with them to determine whether there were any doubts or uncertainties the use of the SPICT-CH. Based on the completion of the instrument, on-site interviews and feedback, modifications were made, leading to the final version of the SPICT-CH. Validation of the Psychometric Properties An expert panel of five specialists was grouped to evaluate the content validity of the SPICT-CH. The experts rated each indicator for clarity, completeness, appropriateness, and relevance on a four-point Likert scale (1 = not relevant; 2 = quite relevant; 3 = relevant; 4 = highly relevant) and to provide advice where necessary [ 18 , 19 ]. The panel consisted of three oncology doctors and two palliative care specialists (one academic and one nurse). All of them had extensive experience in palliative care. Subsequently, to assess the reliability of the SPICT-CH, this study involved a convenience sample of 212 adult patients diagnosed with cancer from the oncology units of three hospitals. The patient’s nurse conducted assessments using the SPICT-CH. Assessments were repeated by another nurse within 24 hours. We used PASS to calculate the sample size was according to the guidelines proposed by Mohamad [ 20 ]. Selection of the Kappa coefficient was used to assess the level of inter-assessor agreement. We hypothesized that the Kappa coefficient 0.60, would be similar to the previous study [ 21 ]. In order to achieve a sample test power of 80% with a 95% confidence interval of 0.05, 144 patients were needed. We recruited additional 16 patients with consideration of a 10% attrition rate. Therefore, a minimum sample size of 160 paired assessments was required. Statistical analysis Socio-demographic data of the patients were analyzed using descriptive statistics. The following analytical methods were used to test the validity and reliability of SPICT-CH. The SPSS 26.0 software was used for all statistical analyses. Content validity We used Item-level CVI (I-CVI) and Scale-level CVI (S-CVI) to evaluate the content validity. Each Item-level CVI was adjusted for chance agreement using the multi-rater kappa statistic, following the criteria: fair = 0.40 to 0.59, good = 0.60 to 0.74, excellent > 0.74 [ 22 ]. The overall SPICT scale-level CVI (S-CVI) was calculated by using the average S-CVI (S-CVI Ave) and universal agreement Scale-level CVI (S-CVI/UA) recommended by Lynn [ 22 ]. The S-CVI/UA was calculated as a percentage of the total number of items rated by the expert panel as relevant/highly relevant (score of 3 or 4). The S-CVI Ave was the average of all items’ I-CVI. I-CVI > 0.78, S-CVI/UA > 0.80 and S-CVI Ave > 0.80 are the criteria for good content validity [ 23 ]. Reliability The Cronbach’s alpha was used to evaluate the internal consistency of the instrument. and is considered an acceptable criterion when it is above 0.70 [ 24 ]. The muti-rater Fleiss-Kappa statistic (Kappa) was employed to determine the significance of the degree of inter-rater agreement. The Fleiss-kappa statistic is the ratio of the number of times that the nurses agreed on the SPICT-CH to the number of times that the nurses could agree (correction of chance agreement). A Fleiss-Kappa value between 0.60 and 0.80 is considered good and moderate when between 0.40 and 0.60 [ 25 ]. Usefulness The usefulness was described as the feasibility of the instrument’s application and its acceptance by clinicians. The time to complete the instrument was reported as the average time. The perception of instrument’ use in clinical practice and the understanding of the instrument’s content were obtained through a brief interview with the nurses in the pre-test process. All interviews are recorded with the consent of the interviewees. After the interview, the data were transcribed word for word and translated into English within 24 hours. The research team confirmed the accuracy of the translation in the form of group discussion, and summarized into two themes: availability of the instrument and understanding of the content. Ethical Considerations This study was approved by the Nursing and Behavioral Medicine Research Ethics Review Committee of the Xiangya School of Nursing, Central South University in December 2022 (E2022209). We obtained permission from the developer of the original SPCIT for translation and cultural adaptation of the English into Chinese version. Results The translation and cultural adaptation All of 36 items were retained after adaptation. The format was adjusted as follows: initial items linked by the terms "or" and ";" were divided into two or more subentries. For example, the indicators of deterioration in health, originally written as "Progressive weight loss; remains underweight; low muscle mass" is present as three sub-entries in SPICT-CH. If any one of the subentries was considered positive, the item was deemed positive. The Chinese version of SPICT and the introduction of usage are attached in Appendix S1. The expert review committee identified several concepts that required modification to address the Chinese context. The following describes the points of consensus reached by the expert review committee. Semantic equivalence The translation of the item "depends on others for care due to increasing physical and/or mental health problems" was not carried out literally. The panel believed that "physical and mental health problem" and "physical or mental health problem” emphasize respectively "symptoms complexity" and "physical functioning and emotional function", which are two different dimensions. In addition, the experts reached a consensus to add "spiritual concerns" to the item because the presence or absence of spiritual concerns is an important element of palliative care. Consequently, the item was divided into two subentries: "Dependent on others for care due to increasing physical problems" and "Need for psychological or spiritual support due to increasing mental health or psychiatric problems, " aiming to enhance clarity for clinicians during use. Idiomatic equivalence The panel suggested adapting the term "limited reversibility" (可逆性有限) into "low probability of reversal" (逆转的可能性低). The panel’s recommendations led to adaptation of "life-limiting conditions"(限制生命的情况) into "terminal"(终末期). The panel adapted the term "specialist assessment"(专家评估) to " multidisciplinary team assessment" (多学科团队评估). Empirical equivalence The panel agreed to add the information of "oxygen partial pressure below 90mmhg" to the item "persistent hypoxia" to clarify the criteria for hypoxia. The experts concurred on the addition of "advance care planning" to the "future care plan" item to provide clarity regarding the form of future plans. Conceptual equivalence The panel reached a consensus that the term "optimal treatment" in the Chinese context did not make clear what treatment regimen is optimal. It was therefore redefined as "the intervention that produces the greatest value or maximizes utility for the patient". This clarification has been incorporated as a supplementary explanation of the item. The panel agreed that the literal translation of "liver transplant is not possible" posed a difficulty in comprehension in Chinese. Therefore, it was translated as "unable or unsuitable for a liver transplant" and "or liver transplant failed" to enhance clarity and understanding within the Chinese context. Subsequently, a pretest was conducted with seven nurses in the oncology units, resulting in a total of 25 completed assessments. The average time of completion was three minutes and 40 seconds. The instrument received an average score of 7.6 out of 10 for feasibility, while the ease of understanding scored an average of 8.3 out of 10. Two themes were identified from brief interview data. (1) Feasibility of application Oncology nurses perceived that integrating the SPICT-CH into their daily clinical practice was feasible and acceptable. Comments from nurses highlighted the instrument's brevity, stating that it did not add to their workload. They acknowledged its utility in identifying patients with palliative care needs, even for those nurses who are already attentive to patient care. "The SPICT-CH is short and does not add to my workload. " (Nurse 1) "This instrument could help me identify patients with palliative care needs in my daily work. " (Nurse 3) "Although I usually pay close attention to patients ’ care needs, using this instrument made it easy for me to identify their needs for palliative care. "(Nurse 6) (2) Easy-to-understand contents All nurses agreed that the content of SPICT-CH was clear and easily comprehensible. While most items were well-understood, there were specific challenges related to subjective/comparative terms such as the judgment of 'remains underweight or low muscle mass.' Nurses with prior exposure to palliative care found the instrument more user-friendly than nurses with minimal palliative care experience. "…Except for ‘remains underweight or low muscle mass,’ which is a little hard to judge, the rest of the content is pretty well understood. "(Nurse 5 and 7) "Nurse who have attended or studied palliative care are more proficient in using SPICT-CH compared to those who have not been exposed to palliative care. " (Nurses 3,4 and 5) "I think that clarity regarding the concept of palliative care is essential, as a lack of understanding may pose difficulties in using SPICT-CH. " (Nurse 2) Following discussions within the research team, no modifications were made to the contents of the instrument. The psychometric properties of SPICT-CH A total of 424 matched assessments were completed for 212 cancer patients from oncology units of three hospitals in Hunan Province. One of the hospitals is a cancer hospital and the other two are general hospitals. All assessments took place in inpatient units. As shown in table 1, ages of patients ranged from 20 to 81 years (mean = 56 years, SD = 11.09). The proportion of men and women was roughly equal. The three most prevalent cancers were lung cancer (32.5%), colorectal cancer (22.6%), and breast and gynecological malignancies (20.8%). Content validity Five palliative care experts participated in assessment of the content validity. Demographic characteristics of the experts is present in Appendix S2. As shown in table 2, the multi-rater kappa statistics after adjusting for opportunity agreement were > 0.74 for all items, indicating excellent agreement among assessors. The S-CVI/ Ave and S-CVI/UA was 0.98 and 0.92, which suggested high relevance and good comprehensiveness of the items. The experts did not recommend removal of any items, indicating good acceptability of the items. Reliability As shown in Table 3, the Cronbach's Alpha was 0.76, indicating that the SPICT-CH exhibits acceptable internal consistency. When examining reliability among inter-rater agreement between nurses, a kappa value of 0.71 (95% CI 0.71 - 0.72, p =0.000) demonstrated good agreement between assessing nurses. Discussion This is the first study to translate and validate a screening instrument in mainland China to support the early identification of individuals with a cancer diagnosis who would benefit from palliative care. In this study, we report the systematic methodological steps undertaken to translate the SPICT into Chinese and culturally adapt it to ensure relevance and validity in the Chinese context. An evaluation of the psychometric properties of SPICT-CH when used by clinicians among patients with cancer in a hospital setting showed that it has high levels of content validity, internal consistency and inter-rater reliability. We undertook a rigorous and scientific process of translation and cross-cultural adaptation in modifying the SPICT for use in China and we can be confident in its use to identify cancer patients who are suitable for palliative care in China. Since different religious beliefs and cultures will have an impact on the connotations expressed in the tool content, it is crucial to address linguistic diversity and cultural differences to minimize their impact on outcome measurements [ 26 ]. During the translation and cross-cultural adaptation phase, some clinically specialized vocabulary and terminology were discussed, particularly for indicators lacking defined criteria in the English version of the SPICT. Relevant criteria were added based on the healthcare context in mainland China, enabling a clearer description of the indicators and reducing cultural and linguistic differences in communication. Although some experts argued that certain indicators, such as “Depends on others for care due to increasing physical and/or mental health problems,” should add scores for self-care and psychological distress, we did not include any additional questions or items. This is because the SPICT-CH is an easy-to-use instrument that may support all types of clinicians in their daily work; adding too many questions would make it more complex and less efficient to use. Given the level of consistency among experts on the content during the adaptation phase of our study, we are confident the SPICT-CH has well-defined items and is consistent with the construct being measured. This result aligns with the findings reported in the Italian version of SPICT [ 27 ]. This study used two strategies of internal consistency and inter-rater reliability to assess the reliability of the SPICT-CH. Firstly, the instrument exhibited good internal consistency with a Cronbach’s Alpha of 0.76, indicating a good correlation between items. The internal consistency of SPICT-CH is slightly lower than that (Cronbach’s Alpha = 0.84) of the Chilean version of SPICT [ 28 ]. It may be due to differences in the aged composition of the participants. Our study included a broad aged range of the participants in our study, whereas the Chilean version of SPICT was exclusively tested on elderly patients. Our study found that SPICT-CH has an acceptable agreement between inter-rater reliability nurses, demonstrating a good stability of instrument. The inter-rater consistency (Kappa = 0.71) of SPICT-CH is higher than that (Kappa = 0.66) of the Thai version of SPICT [ 21 ]. It possibly due to the different composition of assessors in the studies. In our study, assessors were exclusively nurses, while the validation study of the Thai version of SPICT included both doctors and nurses. Inter-rater reliability is a measure of the degree of agreement between different assessors in rating the same patients, and the different composition of assessors can impact the instrument’s reliability [ 25 ]. In addition, previous studies have indicated that doctors are more accurate than nurses in identifying individuals with palliative care need. Therefore, differences in assessment perspectives between doctors and nurses may contribute to low consistency overall rater consistency. Overall, the SPICT-CH is a valuable instrument to identify patients in the inpatient setting and facilitate early initiation of palliative care. In mainland China, a validated screening instrument which can be used to systematically identify individuals with a cancer diagnosis who are in need of palliative care will be beneficial for enhancing access to palliative care services and facilitating the development of palliative care. The rise in the number of people who require palliative care in China due to changes in demographics and disease spectrum underscores the importance of this initiative [ 29 ]. While the Center to Advance Palliative Care (CAPC) recommends that palliative care should be provided in any settings based on patient needs, irrespective of the diagnosis and therapeutic goals [ 30 ], cancer patients constitute the largest group in need of palliative care in mainland China [ 31 ]. However, due to the influence of traditional Chinese culture and under-development of palliative care services as well as a medical specialty, most patients and their families lack sufficient knowledge about palliative care and have low motivation to engage in such care [ 32 ]. Furthermore, there are no clear referral criteria for palliative care to guide access in mainland China [ 33 ]. Therefore, to effectively meet the growing need for support for people suffering with advanced cancer, it is imperative to introduce resources and process early to identify individuals with palliative care needs and a pathway for referral. The SPICT-CH has the potential as a screening instrument for early identifying individuals with palliative care needs. This could help to provide evidence-based support for establishing referral criteria for palliative care and improve the accessibility to palliative care in mainland China. Future research should focus on the accuracy in identifying patients with any advanced non-communicable diseases, and how it can be embedded in routine clinical practice to improve palliative care coverage. In addition, current screening instruments are in the format of traditional paper-based. However, artificial intelligence applications such as ChatGPT and big data have developed rapidly, which can not only structure data, but also process unstructured data in the patient's medical record system, and even images and pictures. These methods have the potential to significantly improve the efficiency and accuracy of identification, while reducing the burden on clinicians. The usefulness of the instrument was also measured by its ease of use in routine clinical practice, including its acceptance, and feasibility of application [ 34 ]. In the pretest phase, we considered the amount of time needed to complete the assessment and the assessor's content comprehension. Our results indicated that the completion time of the instrument was acceptable, closely aligning with the time reported in previous studies [ 28 , 35 ]. Additionally, assessors stated that the instrument was easy to understand and complete. Therefore, it is suitable to use SPICT-CH in mainland China’s busy routine clinical practices without imposing excessive workload on clinicians. Study strengths and limitations Our major strength is that we used a rigorous cross-cultural approach in collaboration with multiple professionals form different disciplines to systematically adapt the SPICT for use in mainland China. This study has some limitations. Firstly, we did not perform criterion validity due to the absence of a similar instrument serving as a gold standard to identify people needing palliative care in mainland China. Secondly, only nurses were involved in the validation phase of SPICT-CH, we recommend caution when interpreting the validation results. Although nurses are the healthcare professionals who have the most contact with patients, many nurses expressed that patients are more likely to communicate with their doctors about their treatment plans and needs. Finally, the generalizability of the results is limited because we only recruited cancer patients in an inpatient setting for validation SPICT-CH. Conclusion The Chinese version of the SPICT has the potential to identify cancer patients with palliative care needs in a hospital setting. It has good content validity and acceptable internal consistency and inter-rater reliability. Therefore, the next step is to test the SPICT-CH in clinical daily practice, especially its accuracy in identifying the need for palliative care. Additionally, we recommend further studies to evaluate the effectiveness of SPICT-CH in diverse disease populations. Declarations Contributors Statement All authors have contributed to the study and have read and approved the submitted version of the manuscript. Zhishan Xie designed the study, contributed to data collection and analysis, and drafted the articles.Chongmei Huang, Siyuan Tang and Jinfeng Ding supervised the study design, contributed to the methods and critically revised the articles. Lin Xiao and Claire E Johnson critically revised the articles. Acknowledgements We would like to acknowledge Dr.Minghui Tan and Dr.Jinnan Xiao who were engaged in the translation of SPICT, and Qing Wang who were engaged in the data collection. We also are grateful to the expert committee members. Funding This research was supported by the Graduate Innovation Project of Central South University. (No.1053320221830) Ethics approval and consent to participate This study was approved by the Nursing and Behavioral Medicine Research Ethics Review Committee of the School of Nursing, Central South University (No. E2022209) on December 22, 2022. All participants gave written informed consent. Availability of data and materials The dataset used and analyzed during the current study can be obtained from the corresponding author upon a reasonable request. Competing interest The authors declare no conflicts of interest. References Sung, H., Ferlay, J., Siegel, R. L., Laversanne, M., Soerjomataram, I., Jemal, A., & Bray, F. (2021). Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA: a cancer journal for clinicians, 71(3), 209–249. https://doi.org/10.3322/caac.21660 Seventh National Census Bulletin (No. 5): (China) National Bureau of Statistics (NBS); [cited 2023 16 Nov]. 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American journal of mental deficiency, 86(2), 127–137. Fleiss, J. L., Levin, B., & Paik, M. C. (1981). The measurement of interrater agreement. Statistical methods for rates and proportions, 2(212–236), 22–23. Bujang, M. A., & Baharum, N. (2017). Guidelines of the minimum sample size requirements for Kappa agreement test. Epidemiology, biostatistics, and public health, 14(2). Sripaew, S., Fumaneeshoat, O., & Ingviya, T. (2021). Systematic adaptation of the Thai version of the supportive and palliative care indicators tool for low-income setting (SPICT-LIS). BMC palliative care, 20(1), 35. https://doi.org/10.1186/s12904-021-00729-y Lynn, M. R. (1986). Determination and quantification of content validity. Nursing research, 35(6), 382–386. Polit, D. F., Beck, C. T., & Owen, S. V. (2007). Is the CVI an acceptable indicator of content validity? Appraisal and recommendations. Research in nursing & health, 30(4), 459–467. https://doi.org/10.1002/nur.20199 Streiner D. L. (2003). Starting at the beginning: an introduction to coefficient alpha and internal consistency. Journal of personality assessment, 80(1), 99–103. https://doi.org/10.1207/S15327752JPA8001_18 McHugh M. L. (2012). Interrater reliability: the kappa statistic. Biochemia medica, 22(3), 276–282. Gill, P. S., & Jones, D. (2000). Cross-cultural adaptation of outcome measures. The European Journal of General Practice, 6(4), 120–121. Casale, G., Magnani, C., Fanelli, R., Surdo, L., Goletti, M., Boyd, K., D'Angelo, D., Mastroianni, C., & SPICT-IT™ study group (2020). Supportive and palliative care indicators tool (SPICT™): content validity, feasibility and pre-test of the Italian version. BMC palliative care, 19(1), 79. https://doi.org/10.1186/s12904-020-00584-3 Farfán-Zuñiga, X., & Zimmermann-Vildoso, M. (2022). Cultural adaptation and validation of the SPICT-ES™ instrument to identify palliative care needs in Chilean older adults. BMC palliative care, 21(1), 223. https://doi.org/10.1186/s12904-022-01111-2 Sleeman, K. E., De Brito, M., Etkind, S., Nkhoma, K., Guo, P., Higginson, I. J., … Harding, R. (2019). The escalating global burden of serious health-related suffering: projections to 2060 by world regions, age groups, and health conditions. The Lancet Global Health, 7(7), e883-e892. Center to Advance Palliative Care [cited 2023 16 Nov]. Available from: https://www.capc.org/about/patient-and-family-resources/ . Connor SR. Global atlas of palliative care at the end of life London, England2020 [cited 2023 12–31]. 2nd Edition:[Available from: https://www.thewhpca.org/resources/global-atlas-on-end-of-life-care . Stocklassa, S., Zhang, S., Mason, S., & Elsner, F. (2022). Cultural implications for disclosure of diagnosis and prognosis toward terminally ill cancer patients in China: A literature review. Palliative & supportive care, 20(2), 283–289. https://doi.org/10.1017/S1478951521000535 Yongy C, Xinjuan W, Xuying L, Qinqin C, Ting M. (2019) The development of hospice care under the background of building a healthy China. Chinese Nursing Management. 19(6):801–6. (in Chinese) Walsh, R. I., Mitchell, G., Francis, L., & van Driel, M. L. (2015). What Diagnostic Tools Exist for the Early Identification of Palliative Care Patients in General Practice? A systematic review. Journal of palliative care, 31(2), 118–123. https://doi.org/10.1177/082585971503100208 Fachado, A. A., Martínez, N. S., Roselló, M. M., Rial, J. J. V., Oliver, E. B., García, R. G., & García, J. M. F. (2018). Spanish adaptation and validation of the supportive & palliative care indicators tool - SPICT-ESTM. Revista de saude publica, 52, 3. https://doi.org/10.11606/s1518-8787.2018052000398 Tables Table 1 Characteristics of patients Variable N (%) Total patients 212(100%) Gender Male Female 117(55.2%) 95(44.8%) Age (years) ≤ 44 45-59 ≥ 60 32(15.1%) 96(45.3%) 84(39.6%) Educational level Primary Junior Secondary Secondary Higher 76(35.8%) 98(46.2%) 23(10.9%) 15(7.1%) Cancer type Lung Colorectal Breast and gynecological Nasopharyngeal Esophageal Gastric Liver Mixed Others 69(32.5%) 48(22.6%) 44(20.8%) 14(6.6%) 6(2.8%) 6(2.8%) 5(2.4%) 7(3.3%) 16(7.5%) Pathological classification I II III IV unknown 4(1.9%) 45(21.2%) 77(36.3%) 82(38.7%) 4(1.9%) Co-morbidities Yes No unknown 116(54.7%) 93(43.9%) 3(1.4%) Treatment Operation Chemoradiotherapy 38(17.9%) 174(82.1%) Re-admission within 30 days Yes No 77(36.3%) 135(63.7%) Table 2 Content validity of SPICT-CH on evaluation of the expert panel Item Expert rating Number of experts with a rating of 3 or 4 I-CVI Pc Kappa-adjusted I-CVI Evaluation Expert A Expert B Expert C Expert D Expert E 1-1 4 4 4 3 4 5 1.00 0.041 1.00 Excellent 1-2 4 4 3 3 4 5 1.00 0.041 1.00 Excellent 1-3 4 4 3 3 4 5 1.00 0.041 1.00 Excellent 1-4 4 4 3 4 4 5 1.00 0.041 1.00 Excellent 1-5 4 4 4 4 4 5 1.00 0.041 1.00 Excellent 1-6 4 4 3 3 4 5 1.00 0.041 1.00 Excellent 1-7 4 4 4 4 4 5 1.00 0.041 1.00 Excellent 2-1 4 4 3 4 4 5 1.00 0.041 1.00 Excellent 2-2 4 4 3 4 4 5 1.00 0.041 1.00 Excellent 2-3 4 4 3 2 4 4 0.80 0.156 0.76 Excellent 2-4 4 4 3 3 4 5 1.00 0.041 1.00 Excellent 2-5 4 4 3 3 4 5 1.00 0.041 1.00 Excellent 2-6 4 4 3 3 4 5 1.00 0.041 1.00 Excellent 2-7 4 4 3 4 4 5 1.00 0.041 1.00 Excellent 2-8 4 4 3 4 4 5 1.00 0.041 1.00 Excellent 2-9 4 4 3 4 4 5 1.00 0.041 1.00 Excellent 2-10 4 4 3 4 4 5 1.00 0.041 1.00 Excellent 2-11 4 4 3 4 4 5 1.00 0.041 1.00 Excellent 2-12 4 4 3 2 4 4 0.80 0.156 0.76 Excellent 2-13 4 4 3 4 4 5 1.00 0.041 1.00 Excellent (continue) Table 2 Content validity of SPICT-CH on evaluation of the expert panel (continue) Item Expert rating Number of experts with a rating of 3 or 4 I-CVI Pc Kappa-adjusted I-CVI Evaluation Expert A Expert B Expert C Expert D Expert E 2-14 4 4 3 2 4 4 0.80 0.041 1.00 Excellent 2-15 4 4 3 3 4 5 1.00 0.041 1.00 Excellent 2-16 4 4 3 4 4 5 1.00 0.041 1.00 Excellent 2-17 4 4 3 4 4 5 1.00 0.041 1.00 Excellent 2-18 4 4 3 3 4 5 1.00 0.041 1.00 Excellent 2-19 4 4 3 4 4 5 1.00 0.041 1.00 Excellent 2-20 4 4 3 4 4 5 1.00 0.041 1.00 Excellent 2-21 4 4 3 4 4 5 1.00 0.041 1.00 Excellent 2-22 4 4 3 4 4 5 1.00 0.041 1.00 Excellent 2-23 4 4 3 4 4 5 1.00 0.041 1.00 Excellent 3-1 4 4 4 3 4 5 1.00 0.041 1.00 Excellent 3-2 4 4 3 3 4 5 1.00 0.041 1.00 Excellent 3-3 4 4 3 4 4 5 1.00 0.041 1.00 Excellent 3-4 4 4 3 3 4 5 1.00 0.041 1.00 Excellent 3-5 4 4 3 3 4 5 1.00 0.041 1.00 Excellent 3-6 4 4 4 4 4 5 1.00 0.041 1.00 Excellent I-CVI, Item-level Content Validity Index; Table 3 Rater agreement for the SPICT-CH Fleiss-Kappa 95% Confidence Interval P Agreement Disagreement SPICT-CH 0.71 0.71-0.72 < 0.001 Positive 26.42% Negative 60.85% 12.74% Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3889285","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":268969215,"identity":"c6befbaf-dd01-42f8-abe9-599103f8e379","order_by":0,"name":"Zhishan Xie","email":"","orcid":"","institution":"Central South University","correspondingAuthor":false,"prefix":"","firstName":"Zhishan","middleName":"","lastName":"Xie","suffix":""},{"id":268969216,"identity":"82a5c9a9-232b-4d39-8c01-246e81eb5046","order_by":1,"name":"Siyuan Tang","email":"","orcid":"","institution":"Central South University","correspondingAuthor":false,"prefix":"","firstName":"Siyuan","middleName":"","lastName":"Tang","suffix":""},{"id":268969217,"identity":"1bea5327-ccd7-4d56-9ef7-44a991a14a1f","order_by":2,"name":"Claire E Johnson","email":"","orcid":"","institution":"University of Wollongong","correspondingAuthor":false,"prefix":"","firstName":"Claire","middleName":"E","lastName":"Johnson","suffix":""},{"id":268969218,"identity":"30d083a3-124b-4513-9b82-7da635156992","order_by":3,"name":"Lin Xiao","email":"","orcid":"","institution":"Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Lin","middleName":"","lastName":"Xiao","suffix":""},{"id":268969219,"identity":"de21a339-df76-4336-92d5-5d7d0fafd808","order_by":4,"name":"Chongmei Huang","email":"","orcid":"","institution":"Ningxia Medical University","correspondingAuthor":false,"prefix":"","firstName":"Chongmei","middleName":"","lastName":"Huang","suffix":""},{"id":268969220,"identity":"3160fe3d-6820-4073-9d9d-5e41a54bd7a1","order_by":5,"name":"Jinfeng Ding","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+UlEQVRIiWNgGAWjYBACxmYGhg9g1mEGGIvBgJAWxhkwLVAWAS0McIUHGBiYeYjRwtzOe7Dh445aBr7jvIdf29TUJTawN2+TYKi5g8dhfImNM88cZ5A8zJdmnXPscGIDz7EyCYZjz/Bo4TF/zNt2jMHgMI+ZcW7DgcQGiRwzCcaGw/i0GDb/hWmxbAA6TP4NEVoY22pAWowfMzYwA23hIaylsbftAI8k0BbGnmOHjdt40ootEo7h1mLYf8aw4WdbnRzf+TPGH37U1Mn2sx/eeONDDR4tDWDqMChG2CRATDYQkYBTAwODPISqAxHMH/AoHAWjYBSMghEMAF2HVBei5XLBAAAAAElFTkSuQmCC","orcid":"","institution":"Central South University","correspondingAuthor":true,"prefix":"","firstName":"Jinfeng","middleName":"","lastName":"Ding","suffix":""}],"badges":[],"createdAt":"2024-01-22 23:44:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3889285/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3889285/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51398262,"identity":"69af41ea-a0ad-41b0-b75d-b3a47290b3e7","added_by":"auto","created_at":"2024-02-20 21:00:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":369903,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3889285/v1/1431575a-0f09-4972-9cc4-5988a372d396.pdf"},{"id":50317917,"identity":"659a73fd-bd14-4bee-a798-420d743e1a16","added_by":"auto","created_at":"2024-01-29 16:28:14","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":24497,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixS12.docx","url":"https://assets-eu.researchsquare.com/files/rs-3889285/v1/e468bf19357a2561ac444034.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Translation, Cross-Cultural Adaptation and Validation of the Chinese version of Supportive and Palliative Care Indicators tool (SPICT-CH) to Identify Cancer Patients with Palliative Care Needs ","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChina had the highest number of new cancer cases (4.57\u0026nbsp;million) and deaths which 3\u0026nbsp;million in the world in 2020, representing 23.7% and 30% of the global population, respectively [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This has considerably increased the cancer burden in the country. Chinese patients with advanced cancer often experience increasing physical and psychological symptom severity and distress (e.g., pain and fear) during their final months of life [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Additionally, those patients have diverse needs and preferences regarding healthcare services, including physical, psychological, spiritual, and social support, towards the end of their lives. The disease trajectory and varied care needs imply the importance of introducing palliative care early in the treatment of cancer patients.\u003c/p\u003e \u003cp\u003ePalliative care is aimed at ensuring that patients facing life-threatening illnesses have access to tailored symptom management and appropriate holistic care to meet their needs and preferences [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In the early stages of disease progression, palliative care can be integrated with curative treatments to address the patient\u0026rsquo;s physical, psychological, social, and spiritual needs [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Early integration of palliative care and curative treatments could alleviate psychological distress (e.g., depression and anxiety), enhance quality of life, reduce symptoms, and decrease healthcare costs for advanced cancer patients [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The initial step in providing timely support is to identify individuals who are likely to benefit from early palliative care, and this holds significant importance in meeting the needs of patients requiring palliative care.\u003c/p\u003e \u003cp\u003eOur recent review determined several instruments that are used to identify patients who may benefit from palliative care [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The findings revealed that Supportive and Palliative Care Indicators Tool (SPICT) had better clinical performance than other screening instruments [Gold Standards Framework Prognostic Indicator Guidance (GSF-PIG), the Necesidades Paliativas [PalliativeNeeds] (NECPAL), the RADboud indicators for Palliative Care needs (RADPAC), the Taiwanese version Palliative Care Screening Tool, Rainone and AnticiPal]. The SPICT was developed by a team of researchers at the University of Edinburgh in collaboration with clinicians from various healthcare settings, including hospitals, clinics and community settings [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The SPICT is a simple and easy-to-understand one-page instrument which helps clinicians to quickly and early identify individuals with palliative care needs [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe SPICT consists of three sections: 1) seven general indicators of deterioration in health, such as unplanned emergency admissions to hospitals, 2) seven sets of disease-specific clinical indicators (e.g., cancer, cardiovascular disease), and 3) seven healthcare recommendations which guide the clinicians in discussing the future care plan with the patient and their families based on the six-step guide in the REDMAP framework. There are evident strengths for SPICT compared to other screening instruments. First, it does not include the Surprise Question, which to some extent reduces the possibility that the clinicians may omit patients who could benefit from early palliative care [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This is because the Surprise Question relies on clinicians\u0026rsquo; intuition and experience to assess a patient's prognosis before making a decision on palliative care provision. Second, it also presumes a suitable timeframe for patients to access palliative care. Third, it includes recommendations for palliative care plans, promoting the clinicians to address the patient\u0026rsquo;s needs and preferences in a structured manner. It is widely applicable across various healthcare settings, including hospitals and primary care settings, and boasts extensive global use, having been translated into 15 languages with good reliability and validity. However, a Chinese version is currently unavailable.\u003c/p\u003e \u003cp\u003eTherefore, this study aims to translate, cross-culturally adapt, and validate the Chinese version of SPICT (SPICT-CH) among cancer patients in Mainland China.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe study involved two phases: the translation and cross-cultural adaptation of the SPICT among cancer patients and the assessment of its psychological properties of the SPICT-CH.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eTranslation progress and cross-cultural adaption\u003c/h2\u003e \u003cp\u003eThe Chinese translation and adaption of the SPICT followed the Beaton method and the WHO\u0026rsquo;s recommendation, which included the following five steps [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eStep 1: Initial translation\u003c/h2\u003e \u003cp\u003eThe instrument was independently translated the original version into Chinese by two researchers whose mother tongue is Chinese (X.Z. and T.M.), both holding Master's degrees in nursing, resulting in documents I and II. The translation followed Guillemin's principle which emphasizes the preservation of cross-cultural equivalence between the original version and the target language version, and conformed to Chinese linguistic norms and expressions [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStep 2: Synthesis of the translation\u003c/h2\u003e \u003cp\u003eTwo researchers (X.Z. and T.M.) and a translation coordinator (D.J.) convened a meeting to compare documents I and II, analyzed the variations in expressions in relation to the original instrument, and ultimately forming document III.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStep 3: Back-translation\u003c/h2\u003e \u003cp\u003eTo verify the content of the instrument with the original, two additional translators (X.J. and John) independently conducted back-translations of document III. Subsequently, the research team compared the translated documents with the original instrument, identified the differences, and made necessary modifications to ensure that the content of the Chinese translation is more than 90% consistent with the original. This resulted in the version IV of the SPICT-CH. X.J. is proficient in English as she has a Ph.D. degree in nursing from Hong Kong, and John is a professional English translator.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStep 4: Expert committee review\u003c/h2\u003e \u003cp\u003eAn expert committee of 18 palliative care specialists conducted two rounds of review of document IV to address any issues related to semantic, concept, idiomatic, and empirical equivalence. Each specialist was asked to complete an electronic questionnaire and provide feedback on the document IV. The questionnaire includes three parts: the importance of early identification of palliative care, the introduction of the Chinese version of SPICT, the purpose of the research and the content of the review. The revised document IV was sent back to the expert committee for further review. The expert committee was consisted of six palliative care researchers, four palliative care physicians, one oncology physicians, three oncology nurses and four palliative care nurses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStep 5: Pretest\u003c/h2\u003e \u003cp\u003eTo assess the understanding of each item and the feasibility of the instruments, seven nurses independently evaluated three adult cancer patients, by using the revised SPICT-CH. Those nurses had more than five years of clinical experience in the field of oncology, and they were from four different oncology unit. After completing the evaluation, they were asked to rate the feasibility on a scale ranging from one to 10 points where one was \u0026ldquo;very unsuitable\u0026rdquo; and 10 was \u0026ldquo;very feasible\u0026rdquo;. Ease of understanding was from one (very difficult) to 10 (very easy). We then conducted brief interviews with them to determine whether there were any doubts or uncertainties the use of the SPICT-CH. Based on the completion of the instrument, on-site interviews and feedback, modifications were made, leading to the final version of the SPICT-CH.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eValidation of the Psychometric Properties\u003c/h2\u003e \u003cp\u003eAn expert panel of five specialists was grouped to evaluate the content validity of the SPICT-CH. The experts rated each indicator for clarity, completeness, appropriateness, and relevance on a four-point Likert scale (1\u0026thinsp;=\u0026thinsp;not relevant; 2\u0026thinsp;=\u0026thinsp;quite relevant; 3\u0026thinsp;=\u0026thinsp;relevant; 4\u0026thinsp;=\u0026thinsp;highly relevant) and to provide advice where necessary [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The panel consisted of three oncology doctors and two palliative care specialists (one academic and one nurse). All of them had extensive experience in palliative care.\u003c/p\u003e \u003cp\u003eSubsequently, to assess the reliability of the SPICT-CH, this study involved a convenience sample of 212 adult patients diagnosed with cancer from the oncology units of three hospitals. The patient\u0026rsquo;s nurse conducted assessments using the SPICT-CH. Assessments were repeated by another nurse within 24 hours. We used PASS to calculate the sample size was according to the guidelines proposed by Mohamad [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Selection of the Kappa coefficient was used to assess the level of inter-assessor agreement. We hypothesized that the Kappa coefficient 0.60, would be similar to the previous study [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In order to achieve a sample test power of 80% with a 95% confidence interval of 0.05, 144 patients were needed. We recruited additional 16 patients with consideration of a 10% attrition rate. Therefore, a minimum sample size of 160 paired assessments was required.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eSocio-demographic data of the patients were analyzed using descriptive statistics. The following analytical methods were used to test the validity and reliability of SPICT-CH. The SPSS 26.0 software was used for all statistical analyses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eContent validity\u003c/h2\u003e \u003cp\u003eWe used Item-level CVI (I-CVI) and Scale-level CVI (S-CVI) to evaluate the content validity. Each Item-level CVI was adjusted for chance agreement using the multi-rater kappa statistic, following the criteria: fair\u0026thinsp;=\u0026thinsp;0.40 to 0.59, good\u0026thinsp;=\u0026thinsp;0.60 to 0.74, excellent\u0026thinsp;\u0026gt;\u0026thinsp;0.74 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The overall SPICT scale-level CVI (S-CVI) was calculated by using the average S-CVI (S-CVI Ave) and universal agreement Scale-level CVI (S-CVI/UA) recommended by Lynn [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The S-CVI/UA was calculated as a percentage of the total number of items rated by the expert panel as relevant/highly relevant (score of 3 or 4). The S-CVI Ave was the average of all items\u0026rsquo; I-CVI. I-CVI\u0026thinsp;\u0026gt;\u0026thinsp;0.78, S-CVI/UA\u0026thinsp;\u0026gt;\u0026thinsp;0.80 and S-CVI Ave\u0026thinsp;\u0026gt;\u0026thinsp;0.80 are the criteria for good content validity [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eReliability\u003c/h2\u003e \u003cp\u003eThe Cronbach\u0026rsquo;s alpha was used to evaluate the internal consistency of the instrument. and is considered an acceptable criterion when it is above 0.70 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The muti-rater Fleiss-Kappa statistic (Kappa) was employed to determine the significance of the degree of inter-rater agreement. The Fleiss-kappa statistic is the ratio of the number of times that the nurses agreed on the SPICT-CH to the number of times that the nurses could agree (correction of chance agreement). A Fleiss-Kappa value between 0.60 and 0.80 is considered good and moderate when between 0.40 and 0.60 [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eUsefulness\u003c/h2\u003e \u003cp\u003eThe usefulness was described as the feasibility of the instrument\u0026rsquo;s application and its acceptance by clinicians. The time to complete the instrument was reported as the average time. The perception of instrument\u0026rsquo; use in clinical practice and the understanding of the instrument\u0026rsquo;s content were obtained through a brief interview with the nurses in the pre-test process. All interviews are recorded with the consent of the interviewees. After the interview, the data were transcribed word for word and translated into English within 24 hours. The research team confirmed the accuracy of the translation in the form of group discussion, and summarized into two themes: availability of the instrument and understanding of the content.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003e This study was approved by the Nursing and Behavioral Medicine Research Ethics Review Committee of the Xiangya School of Nursing, Central South University in December 2022 (E2022209). We obtained permission from the developer of the original SPCIT for translation and cultural adaptation of the English into Chinese version.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eThe translation and cultural adaptation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll of 36 items were retained after adaptation. The format was adjusted as follows: initial items linked by the terms \u0026quot;or\u0026quot; and \u0026quot;;\u0026quot; were divided into two or more subentries. For example, the indicators of deterioration in health, originally written as\u0026nbsp;\u0026quot;Progressive weight loss; remains underweight; low muscle mass\u0026quot;\u0026nbsp;is present as three sub-entries in SPICT-CH. If any one of the subentries was considered positive, the item was deemed positive. The Chinese version of SPICT and the introduction of usage are attached in Appendix S1. The expert review committee identified several concepts that required modification to address the Chinese context. The following describes the points of consensus reached by the expert review committee.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSemantic equivalence\u003c/em\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThe translation of the item \u0026quot;depends on others for care due to increasing physical and/or mental health problems\u0026quot; was not carried out literally. The panel believed that \u0026quot;physical and mental health problem\u0026quot; and \u0026quot;physical or mental health problem\u0026rdquo; emphasize respectively \u0026quot;symptoms complexity\u0026quot; and \u0026quot;physical functioning and emotional function\u0026quot;, which are two different dimensions. In addition, the experts reached a consensus to add \u0026quot;spiritual concerns\u0026quot; to the item because the presence or absence of spiritual concerns is an important element of palliative care. Consequently, the item was divided into two subentries: \u0026quot;Dependent on others for care due to increasing physical problems\u0026quot; and \u0026quot;Need for psychological or spiritual support due to increasing mental health or psychiatric problems, \u0026quot; aiming to enhance clarity for clinicians during use.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003eIdiomatic equivalence\u003c/em\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThe panel suggested adapting the term \u0026quot;limited reversibility\u0026quot; (可逆性有限) into \u0026quot;low probability of reversal\u0026quot; (逆转的可能性低).\u003c/li\u003e\n \u003cli\u003eThe panel\u0026rsquo;s recommendations led to adaptation of \u0026quot;life-limiting conditions\u0026quot;(限制生命的情况) into \u0026quot;terminal\u0026quot;(终末期).\u003c/li\u003e\n \u003cli\u003eThe panel adapted the term \u0026quot;specialist assessment\u0026quot;(专家评估) to \u0026quot; multidisciplinary team assessment\u0026quot; (多学科团队评估).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003eEmpirical equivalence \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThe panel agreed to add the information of \u0026quot;oxygen partial pressure below 90mmhg\u0026quot; to the item \u0026quot;persistent hypoxia\u0026quot; to clarify the criteria for hypoxia.\u003c/li\u003e\n \u003cli\u003eThe experts concurred on the addition of \u0026quot;advance care planning\u0026quot; to the \u0026quot;future care plan\u0026quot; item to provide clarity regarding the form of future plans.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003eConceptual equivalence\u003c/em\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThe panel reached a consensus that the term \u0026quot;optimal treatment\u0026quot; in the Chinese context did not make clear what treatment regimen is optimal. It was therefore redefined as \u0026quot;the intervention that produces the greatest value or maximizes utility for the patient\u0026quot;. This clarification has been incorporated as a supplementary explanation of the item.\u003c/li\u003e\n \u003cli\u003eThe panel agreed that the literal translation of \u0026quot;liver transplant is not possible\u0026quot; posed a difficulty in comprehension in Chinese. Therefore, it was translated as \u0026quot;unable or unsuitable for a liver transplant\u0026quot; and \u0026quot;or liver transplant failed\u0026quot; to enhance clarity and understanding within the Chinese context.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eSubsequently, a pretest was conducted with seven nurses in the oncology units, resulting in a total of 25 completed assessments. The average time of completion was three minutes and 40 seconds. The instrument received an average score of 7.6 out of 10 for feasibility, while the ease of understanding scored an average of 8.3 out of 10. Two themes were identified from brief interview data.\u003c/p\u003e\n\u003cp\u003e(1) Feasibility of application\u003c/p\u003e\n\u003cp\u003eOncology nurses perceived that integrating the SPICT-CH into their daily clinical practice was feasible and acceptable. Comments from nurses highlighted the instrument\u0026apos;s brevity, stating that it did not add to their workload. They acknowledged its utility in identifying patients with palliative care needs, even for those nurses who are already attentive to patient care.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The SPICT-CH is short and does not add to my workload. \u0026quot; (Nurse 1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;This instrument could help me identify patients with palliative care needs in my daily work. \u0026quot; (Nurse 3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Although I usually pay close attention to patients\u003c/em\u003e\u0026rsquo; \u003cem\u003ecare needs, using this instrument made it easy for me to identify their needs for palliative care.\u003c/em\u003e \u003cem\u003e\u0026quot;(Nurse 6)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e(2) Easy-to-understand contents\u003c/p\u003e\n\u003cp\u003eAll nurses agreed that the content of SPICT-CH was clear and easily comprehensible. While most items were well-understood, there were specific challenges related to subjective/comparative terms such as the judgment of \u0026apos;remains underweight or low muscle mass.\u0026apos; Nurses with prior exposure to palliative care found the instrument more user-friendly than nurses with minimal palliative care experience.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;\u0026hellip;Except for \u0026lsquo;remains underweight or low muscle mass,\u0026rsquo; which is a little hard to judge, the rest of the content is pretty well understood. \u0026quot;(Nurse 5 and 7)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Nurse who have attended or studied palliative care are more proficient in using SPICT-CH compared to those who have not been exposed to palliative care. \u0026quot; (Nurses 3,4 and 5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I think that clarity regarding the concept of palliative care is essential, as a lack of understanding may pose difficulties in using SPICT-CH. \u0026quot; (Nurse 2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFollowing discussions within the research team, no modifications were made to the contents of the instrument.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe psychometric properties of SPICT-CH\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 424 matched assessments were completed for 212 cancer patients from oncology units of three hospitals in Hunan Province. One of the hospitals is a cancer hospital and the other two are general hospitals. All assessments took place in inpatient units. As shown in table 1, ages of patients ranged from 20 to 81 years (mean = 56 years, SD = 11.09). The proportion of men and women was roughly equal. The three most prevalent cancers were lung cancer (32.5%), colorectal cancer (22.6%), and breast and gynecological malignancies (20.8%).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eContent validity\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFive palliative care experts participated in assessment of the content validity. Demographic characteristics of the experts is present in Appendix S2. As shown in table 2, the multi-rater kappa statistics after adjusting for opportunity agreement were \u0026gt; 0.74 for all items, indicating excellent agreement among assessors. The S-CVI/ Ave and S-CVI/UA was 0.98 and 0.92, which suggested high relevance and good comprehensiveness of the items. The experts did not recommend removal of any items, indicating good acceptability of the items.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eReliability\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in Table 3, the Cronbach\u0026apos;s Alpha was 0.76, indicating that the SPICT-CH exhibits acceptable internal consistency. When examining reliability among inter-rater agreement between nurses, a kappa value of 0.71 (95% CI 0.71 - 0.72, p =0.000) demonstrated good agreement between assessing nurses.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e This is the first study to translate and validate a screening instrument in mainland China to support the early identification of individuals with a cancer diagnosis who would benefit from palliative care. In this study, we report the systematic methodological steps undertaken to translate the SPICT into Chinese and culturally adapt it to ensure relevance and validity in the Chinese context. An evaluation of the psychometric properties of SPICT-CH when used by clinicians among patients with cancer in a hospital setting showed that it has high levels of content validity, internal consistency and inter-rater reliability.\u003c/p\u003e \u003cp\u003e We undertook a rigorous and scientific process of translation and cross-cultural adaptation in modifying the SPICT for use in China and we can be confident in its use to identify cancer patients who are suitable for palliative care in China. Since different religious beliefs and cultures will have an impact on the connotations expressed in the tool content, it is crucial to address linguistic diversity and cultural differences to minimize their impact on outcome measurements [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. During the translation and cross-cultural adaptation phase, some clinically specialized vocabulary and terminology were discussed, particularly for indicators lacking defined criteria in the English version of the SPICT. Relevant criteria were added based on the healthcare context in mainland China, enabling a clearer description of the indicators and reducing cultural and linguistic differences in communication. Although some experts argued that certain indicators, such as \u0026ldquo;Depends on others for care due to increasing physical and/or mental health problems,\u0026rdquo; should add scores for self-care and psychological distress, we did not include any additional questions or items. This is because the SPICT-CH is an easy-to-use instrument that may support all types of clinicians in their daily work; adding too many questions would make it more complex and less efficient to use. Given the level of consistency among experts on the content during the adaptation phase of our study, we are confident the SPICT-CH has well-defined items and is consistent with the construct being measured. This result aligns with the findings reported in the Italian version of SPICT [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study used two strategies of internal consistency and inter-rater reliability to assess the reliability of the SPICT-CH. Firstly, the instrument exhibited good internal consistency with a Cronbach\u0026rsquo;s Alpha of 0.76, indicating a good correlation between items. The internal consistency of SPICT-CH is slightly lower than that (Cronbach\u0026rsquo;s Alpha\u0026thinsp;=\u0026thinsp;0.84) of the Chilean version of SPICT [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. It may be due to differences in the aged composition of the participants. Our study included a broad aged range of the participants in our study, whereas the Chilean version of SPICT was exclusively tested on elderly patients. Our study found that SPICT-CH has an acceptable agreement between inter-rater reliability nurses, demonstrating a good stability of instrument. The inter-rater consistency (Kappa\u0026thinsp;=\u0026thinsp;0.71) of SPICT-CH is higher than that (Kappa\u0026thinsp;=\u0026thinsp;0.66) of the Thai version of SPICT [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. It possibly due to the different composition of assessors in the studies. In our study, assessors were exclusively nurses, while the validation study of the Thai version of SPICT included both doctors and nurses. Inter-rater reliability is a measure of the degree of agreement between different assessors in rating the same patients, and the different composition of assessors can impact the instrument\u0026rsquo;s reliability [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In addition, previous studies have indicated that doctors are more accurate than nurses in identifying individuals with palliative care need. Therefore, differences in assessment perspectives between doctors and nurses may contribute to low consistency overall rater consistency. Overall, the SPICT-CH is a valuable instrument to identify patients in the inpatient setting and facilitate early initiation of palliative care.\u003c/p\u003e \u003cp\u003eIn mainland China, a validated screening instrument which can be used to systematically identify individuals with a cancer diagnosis who are in need of palliative care will be beneficial for enhancing access to palliative care services and facilitating the development of palliative care. The rise in the number of people who require palliative care in China due to changes in demographics and disease spectrum underscores the importance of this initiative [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. While the Center to Advance Palliative Care (CAPC) recommends that palliative care should be provided in any settings based on patient needs, irrespective of the diagnosis and therapeutic goals [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], cancer patients constitute the largest group in need of palliative care in mainland China [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. However, due to the influence of traditional Chinese culture and under-development of palliative care services as well as a medical specialty, most patients and their families lack sufficient knowledge about palliative care and have low motivation to engage in such care [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Furthermore, there are no clear referral criteria for palliative care to guide access in mainland China [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Therefore, to effectively meet the growing need for support for people suffering with advanced cancer, it is imperative to introduce resources and process early to identify individuals with palliative care needs and a pathway for referral. The SPICT-CH has the potential as a screening instrument for early identifying individuals with palliative care needs. This could help to provide evidence-based support for establishing referral criteria for palliative care and improve the accessibility to palliative care in mainland China. Future research should focus on the accuracy in identifying patients with any advanced non-communicable diseases, and how it can be embedded in routine clinical practice to improve palliative care coverage. In addition, current screening instruments are in the format of traditional paper-based. However, artificial intelligence applications such as ChatGPT and big data have developed rapidly, which can not only structure data, but also process unstructured data in the patient's medical record system, and even images and pictures. These methods have the potential to significantly improve the efficiency and accuracy of identification, while reducing the burden on clinicians.\u003c/p\u003e \u003cp\u003eThe usefulness of the instrument was also measured by its ease of use in routine clinical practice, including its acceptance, and feasibility of application [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In the pretest phase, we considered the amount of time needed to complete the assessment and the assessor's content comprehension. Our results indicated that the completion time of the instrument was acceptable, closely aligning with the time reported in previous studies [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Additionally, assessors stated that the instrument was easy to understand and complete. Therefore, it is suitable to use SPICT-CH in mainland China\u0026rsquo;s busy routine clinical practices without imposing excessive workload on clinicians.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003eStudy strengths and limitations\u003c/h2\u003e \u003cp\u003eOur major strength is that we used a rigorous cross-cultural approach in collaboration with multiple professionals form different disciplines to systematically adapt the SPICT for use in mainland China.\u003c/p\u003e \u003cp\u003eThis study has some limitations. Firstly, we did not perform criterion validity due to the absence of a similar instrument serving as a gold standard to identify people needing palliative care in mainland China. Secondly, only nurses were involved in the validation phase of SPICT-CH, we recommend caution when interpreting the validation results. Although nurses are the healthcare professionals who have the most contact with patients, many nurses expressed that patients are more likely to communicate with their doctors about their treatment plans and needs. Finally, the generalizability of the results is limited because we only recruited cancer patients in an inpatient setting for validation SPICT-CH.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003e The Chinese version of the SPICT has the potential to identify cancer patients with palliative care needs in a hospital setting. It has good content validity and acceptable internal consistency and inter-rater reliability. Therefore, the next step is to test the SPICT-CH in clinical daily practice, especially its accuracy in identifying the need for palliative care. Additionally, we recommend further studies to evaluate the effectiveness of SPICT-CH in diverse disease populations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eContributors Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have contributed to the study and have read and approved the submitted version of the manuscript. Zhishan Xie designed the study, contributed to data collection and analysis, and drafted the articles.Chongmei Huang, Siyuan Tang and Jinfeng Ding supervised the study design, contributed to the methods and critically revised the articles. Lin Xiao and\u0026nbsp;Claire\u0026nbsp;E\u0026nbsp;Johnson\u0026nbsp;critically revised the articles.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge Dr.Minghui Tan and Dr.Jinnan Xiao who were engaged in the translation of SPICT, and Qing Wang who were engaged in the data collection. We also are grateful to the expert committee members.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by the Graduate Innovation Project of Central South University. (No.1053320221830)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Nursing and Behavioral Medicine Research Ethics Review Committee of the School of Nursing, Central South University (No. E2022209) on December 22, 2022. All participants gave written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset used and analyzed during the current study can be obtained from the corresponding author upon a reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSung, H., Ferlay, J., Siegel, R. L., Laversanne, M., Soerjomataram, I., Jemal, A., \u0026amp; Bray, F. (2021). Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. 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Revista de saude publica, 52, 3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.11606/s1518-8787.2018052000398\u003c/span\u003e\u003cspan address=\"10.11606/s1518-8787.2018052000398\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 Characteristics of patients\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"52.98372513562387%\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.01627486437613%\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"52.98372513562387%\"\u003e\n \u003cp\u003eTotal patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.01627486437613%\"\u003e\n \u003cp\u003e212(100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"52.98372513562387%\" valign=\"top\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Male\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.01627486437613%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e117(55.2%)\u003c/p\u003e\n \u003cp\u003e95(44.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"52.98372513562387%\" valign=\"top\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003cp\u003e\u0026le;\u0026nbsp;44\u003c/p\u003e\n \u003cp\u003e45-59\u003c/p\u003e\n \u003cp\u003e\u0026ge;\u0026nbsp;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.01627486437613%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e32(15.1%)\u003c/p\u003e\n \u003cp\u003e96(45.3%)\u003c/p\u003e\n \u003cp\u003e84(39.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"52.98372513562387%\" valign=\"top\"\u003e\n \u003cp\u003eEducational level\u003c/p\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003cp\u003eJunior Secondary\u003c/p\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003cp\u003eHigher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.01627486437613%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e76(35.8%)\u003c/p\u003e\n \u003cp\u003e98(46.2%)\u003c/p\u003e\n \u003cp\u003e23(10.9%)\u003c/p\u003e\n \u003cp\u003e15(7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"52.98372513562387%\" valign=\"top\"\u003e\n \u003cp\u003eCancer type\u003c/p\u003e\n \u003cp\u003eLung\u003c/p\u003e\n \u003cp\u003eColorectal\u003c/p\u003e\n \u003cp\u003eBreast and gynecological\u003c/p\u003e\n \u003cp\u003eNasopharyngeal\u003c/p\u003e\n \u003cp\u003eEsophageal\u003c/p\u003e\n \u003cp\u003eGastric\u003c/p\u003e\n \u003cp\u003eLiver\u003c/p\u003e\n \u003cp\u003eMixed\u003c/p\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.01627486437613%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e69(32.5%)\u003c/p\u003e\n \u003cp\u003e48(22.6%)\u003c/p\u003e\n \u003cp\u003e44(20.8%)\u003c/p\u003e\n \u003cp\u003e14(6.6%)\u003c/p\u003e\n \u003cp\u003e6(2.8%)\u003c/p\u003e\n \u003cp\u003e6(2.8%)\u003c/p\u003e\n \u003cp\u003e5(2.4%)\u003c/p\u003e\n \u003cp\u003e7(3.3%)\u003c/p\u003e\n \u003cp\u003e16(7.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"52.98372513562387%\" valign=\"top\"\u003e\n \u003cp\u003ePathological classification\u003c/p\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003cp\u003eIV\u003c/p\u003e\n \u003cp\u003eunknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.01627486437613%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4(1.9%)\u003c/p\u003e\n \u003cp\u003e45(21.2%)\u003c/p\u003e\n \u003cp\u003e77(36.3%)\u003c/p\u003e\n \u003cp\u003e82(38.7%)\u003c/p\u003e\n \u003cp\u003e4(1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"52.98372513562387%\" valign=\"top\"\u003e\n \u003cp\u003eCo-morbidities\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;unknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.01627486437613%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e116(54.7%)\u003c/p\u003e\n \u003cp\u003e93(43.9%)\u003c/p\u003e\n \u003cp\u003e3(1.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"52.98372513562387%\" valign=\"top\"\u003e\n \u003cp\u003eTreatment\u003c/p\u003e\n \u003cp\u003eOperation\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Chemoradiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.01627486437613%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e38(17.9%)\u003c/p\u003e\n \u003cp\u003e174(82.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"52.98372513562387%\" valign=\"top\"\u003e\n \u003cp\u003eRe-admission within 30 days\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.01627486437613%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e77(36.3%)\u003c/p\u003e\n \u003cp\u003e135(63.7%)\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\u003eTable 2 Content validity of SPICT-CH on evaluation of the expert panel\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.13978494623656%\" rowspan=\"2\"\u003e\n \u003cp\u003eItem\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.53763440860215%\" colspan=\"5\"\u003e\n \u003cp\u003eExpert rating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.182795698924732%\" rowspan=\"2\"\u003e\n \u003cp\u003eNumber of experts with a rating of 3 or 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.21505376344086%\" rowspan=\"2\"\u003e\n \u003cp\u003eI-CVI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.13978494623656%\" rowspan=\"2\"\u003e\n \u003cp\u003ePc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.182795698924732%\" rowspan=\"2\"\u003e\n \u003cp\u003eKappa-adjusted I-CVI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.602150537634408%\" rowspan=\"2\"\u003e\n \u003cp\u003eEvaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.841269841269842%\"\u003e\n \u003cp\u003eExpert A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.486772486772487%\"\u003e\n \u003cp\u003eExpert B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.105820105820104%\"\u003e\n \u003cp\u003eExpert C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.105820105820104%\"\u003e\n \u003cp\u003eExpert D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.46031746031746%\"\u003e\n \u003cp\u003eExpert E\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e1-1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e1-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e1-3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e1-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e1-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e1-6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e1-7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e2-1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e2-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e2-3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.156\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e2-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e2-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e2-6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e2-7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e2-8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e2-9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e2-10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e2-11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e2-12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.156\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e2-13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e(continue)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 Content validity of SPICT-CH on evaluation of the expert panel (continue)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.13978494623656%\" rowspan=\"2\"\u003e\n \u003cp\u003eItem\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.53763440860215%\" colspan=\"5\"\u003e\n \u003cp\u003eExpert rating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.182795698924732%\" rowspan=\"2\"\u003e\n \u003cp\u003eNumber of experts with a rating of 3 or 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.21505376344086%\" rowspan=\"2\"\u003e\n \u003cp\u003eI-CVI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.13978494623656%\" rowspan=\"2\"\u003e\n \u003cp\u003ePc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.182795698924732%\" rowspan=\"2\"\u003e\n \u003cp\u003eKappa-adjusted I-CVI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.602150537634408%\" rowspan=\"2\"\u003e\n \u003cp\u003eEvaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.841269841269842%\"\u003e\n \u003cp\u003eExpert A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.486772486772487%\"\u003e\n \u003cp\u003eExpert B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.105820105820104%\"\u003e\n \u003cp\u003eExpert C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.105820105820104%\"\u003e\n \u003cp\u003eExpert D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.46031746031746%\"\u003e\n \u003cp\u003eExpert E\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e2-14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e2-15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e2-16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e2-17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e2-18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e2-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e2-20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e2-21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e2-22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e2-23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e3-1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e3-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e3-3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e3-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e3-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e3-6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.055853920515574%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.089151450053706%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.129967776584317%\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17078410311493%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.592910848549947%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eI-CVI,\u0026nbsp;Item-level Content Validity Index;\u003c/p\u003e\n\u003cp\u003eTable 3 Rater agreement for the SPICT-CH\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"633\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.007898894154819%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.429699842022117%\" valign=\"top\"\u003e\n \u003cp\u003eFleiss-Kappa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.85308056872038%\" valign=\"top\"\u003e\n \u003cp\u003e95% Confidence Interval\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.42654028436019%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.85308056872038%\" valign=\"top\"\u003e\n \u003cp\u003eAgreement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.429699842022117%\" valign=\"top\"\u003e\n \u003cp\u003eDisagreement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.007898894154819%\" valign=\"top\"\u003e\n \u003cp\u003eSPICT-CH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.429699842022117%\" valign=\"top\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.85308056872038%\" valign=\"top\"\u003e\n \u003cp\u003e0.71-0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.42654028436019%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.85308056872038%\" valign=\"top\"\u003e\n \u003cp\u003ePositive 26.42%\u003c/p\u003e\n \u003cp\u003eNegative 60.85%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.429699842022117%\" valign=\"top\"\u003e\n \u003cp\u003e12.74%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Palliative care, SPICT, Chinese, Screening instrument","lastPublishedDoi":"10.21203/rs.3.rs-3889285/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3889285/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eIntroduction\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePeople diagnosed with cancer are the most frequent users of palliative care. However, there are no specific standards for early identifying patients with palliative care needs in mainland China. The Supportive and Palliative Care Indicators tool (SPICT) can identify patients with cancer who are in need of palliative care across healthcare settings.\u003c/p\u003e\u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTo translate, cross-cultural adapt and validate the SPICT in a Chinese healthcare context.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethod\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWe translated and culturally adapted the SPICT from English into Chinese, following both Beaton's and WHO's recommendations: 1) initial translation, 2) synthesis, 3) back translation, 4) expert committee review, and 5) pretest. The psychometric properties (e.g., content validity, internal consistency, and inter-rater reliability) were analyzed. Between January and August 2023, a convenience sample of 212 hospitalized cancer patients was assessed by two nurses within 24 hours to determine the inter-rater reliability and stability of the Chinese version of SPICT (SPICT-CH).\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAll items were retained in response to expert review, resulting in a total of 36 items. The Scale-Content Validity Index/Ave (S-CVI/Ave) of the SPICT-CH was 0.98, demonstrating very strong content validity. The SPICT-CH exhibited good coherence (Cronbach\u0026rsquo;s alpha\u0026thinsp;=\u0026thinsp;0.76) and reliability (Kappa\u0026thinsp;=\u0026thinsp;0.71, 95% CI 0.71\u0026ndash;0.72, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe SPICT-CH has good content validity and acceptable reliability in assessing cancer patients within a Chinese hospital setting. This instrument can be effectively integrated into routine clinical practice to early identify patients who need palliative care in mainland China.\u003c/p\u003e","manuscriptTitle":"Translation, Cross-Cultural Adaptation and Validation of the Chinese version of Supportive and Palliative Care Indicators tool (SPICT-CH) to Identify Cancer Patients with Palliative Care Needs ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-29 16:28:10","doi":"10.21203/rs.3.rs-3889285/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"22ea0932-bec7-48a4-89ca-bb4bb382aa18","owner":[],"postedDate":"January 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-02-20T20:59:49+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-29 16:28:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3889285","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3889285","identity":"rs-3889285","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}