Psychometric Validation of the PROISCD-CG Scale in Patients With Chronic Gastritis: A Structural Equation Modeling Approach

Psychometric Validation of the PROISCD-CG Scale in Patients With Chronic Gastritis: A Structural Equation Modeling Approach | 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 Psychometric Validation of the PROISCD-CG Scale in Patients With Chronic Gastritis: A Structural Equation Modeling Approach PingGuang Lei, Xin Li, ZaiXue Mu, QiuJu Miao, HuiMin Huang, GuiJin Luo, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8629187/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background: Chronic gastritis (CG) is a common gastrointestinal condition that adversely affects patients’ physical, psychological, and social functioning. With increasing emphasis on patient-centered care, patient-reported outcomes (PROs) have become essential for evaluating disease burden and treatment effectiveness. Compared with conventional quality-of-life (QOL) instruments, PRO scales offer superior sensitivity, symptom specificity, and clinical interpretability. This study assessed the reliability and validity of the Patient-Reported Clinical Outcome Scale for Chronic Gastritis (PROISCD-CG) using structural equation modeling (SEM). Methods: A total of 174 outpatients and inpatients diagnosed with CG between September and December 2022 were surveyed using the PROISCD-CG scale. Internal consistency, split-half reliability, and criterion validity (with SF-36 as the external criterion) were evaluated. SEM was applied to examine and refine factor structures, assess model fit, and evaluate convergent and discriminant validity. Results: The total scale demonstrated strong reliability (Cronbach’s α = 0.87; split-half = 0.77). Criterion validity against SF-36 was acceptable, with moderate correlations across corresponding domains. The initial SEM model showed suboptimal fit, but modifications—removing low-loading items and adding error covariances—substantially improved fit indices (CFI, IFI, GFI approaching 0.80; RMSEA = 0.082). Convergent validity (AVE) and composite reliability (CR) generally met recommended thresholds, and discriminant validity was acceptable. Conclusions: The PROISCD-CG scale exhibits good psychometric properties and can serve as a reliable and valid tool for assessing patient-centered outcomes in CG. Items with low factor loadings require refinement and further testing in larger cohorts. PRO-based evaluation provides advantages over traditional QOL metrics by more precisely capturing symptom burden, functional impairment, and treatment responsiveness. Chronic gastritis Patient-reported outcomes Structural equation modeling Reliability Validity Psychometrics Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Chronic gastritis (CG) is one of the most prevalent gastrointestinal disorders worldwide and is characterized by persistent inflammatory changes of the gastric mucosa resulting from multiple etiologies 1 . Owing to its chronic and recurrent nature, CG is frequently accompanied by long-term gastrointestinal symptoms that substantially impair patients’ physical functioning, psychological well-being, social participation, and overall quality of life 2 – 4 . As healthcare paradigms continue to evolve from a purely biomedical model toward a biopsychosocial and patient-centered approach, greater emphasis has been placed on outcomes that reflect patients’ subjective experiences of disease and treatment. Patient-reported outcome (PRO) refer to health-related information directly reported by patients without interpretation by clinicians or researchers. PRO instruments commonly encompass symptom burden, functional status, activity limitation, health-related quality of life, and treatment perceptions 5 . In chronic digestive diseases such as CG, objective clinical indicators alone often fail to capture the complexity and variability of patient experiences. Consequently, PRO measures provide indispensable complementary information for evaluating disease burden, treatment effectiveness, and long-term management outcomes. Compared with generic quality-of-life (QOL) instruments, disease-specific PRO scales offer several important advantages. Widely used tools such as the SF-36 are designed to assess general health status and may lack sensitivity to disease-specific symptoms or subtle clinical changes 6 . In contrast, PRO instruments tailored to specific conditions directly quantify patients’ perceptions of symptom severity and functional impairment, reduce information bias, and improve the clinical interpretability of outcomes 7 . These advantages make PRO measures particularly valuable for chronic gastritis, where symptom fluctuation and treatment response are highly individualized. Structural equation modeling (SEM) is a powerful multivariate analytical approach that integrates factor analysis and path analysis, allowing for explicit modeling of latent constructs and measurement error 8 . SEM has been increasingly applied in psychometric research due to its superiority over classical test theory in evaluating complex measurement structures and construct validity 9 , 10 . However, SEM-based validation studies of PRO instruments for chronic gastritis remain limited, particularly in the Chinese population. To address this gap, the present study applied SEM to evaluate the psychometric properties of the Patient-Reported Clinical Outcome Scale for Chronic Gastritis (PROISCD-CG), a modular instrument comprising both generic and disease-specific domains. By systematically assessing reliability, validity, and factor structure, this study aims to provide robust evidence supporting the clinical and research utility of the PROISCD-CG scale and to inform further refinement of patient-centered outcome measures in gastroenterology. Methods 1.1 Study Design and Participants This cross-sectional study was conducted between September and December 2022 at the Department of Gastroenterology of the Second Affiliated Hospital of Kunming Medical University and Qujing People’s Hospital. A total of 174 patients diagnosed with chronic gastritis (CG) were consecutively recruited through outpatient and inpatient clinics. Participants were eligible if they: (1) met the diagnostic criteria for CG; (2) were able to communicate normally; and (3) were cognitively capable of independently completing the survey. Exclusion criteria included: (1) history of psychiatric disorders; (2) unwillingness to participate; (3) severe comorbidities such as COPD, severe pulmonary infections, heart failure, or liver/kidney dysfunction; and (4) recent use of medications with gastrointestinal side effects (e.g., oral contraceptives, weight-loss drugs) that might interfere with symptom evaluation. The diagnosis of CG is based on the 2022 Chinese Guidelines for the Diagnosis and Treatment of Chronic Gastritis , combining endoscopic findings and histopathology results, with the latter serving as the definitive diagnostic basis 11 . Ethical approval was obtained from the Ethics Committee of Kunming Medical University (KMMU2021MEC031), and all participants provided written informed consent. 1.2 Research Instruments The Patient-Reported Clinical Outcome Scale for Chronic Gastritis (PROISCD-CG) was developed by Prof. Wanchonghua’s research team in China, using a modular framework consisting of a generic module (four domains: physical health, psychological health, social health, and spiritual/belief health; 30 items) and a disease-specific module (11 items). All items were rated using a five-point Likert scale (1–5). Negative items were reverse-scored using the formula 6 – original score . The PROISCD-CG is a copyrighted instrument (Chinese Copyright Registration No. Guozuo Dengzi-2023-A-00286360). The full scale, scoring manual, and translation report are provided as Supplementary File A (Scale), Supplementary File B (Scoring Rules), and Supplementary File C (Translation and Cultural Adaptation), respectively. To evaluate criterion validity, the SF-36 Health Survey was used as an external reference scale, as it comprehensively reflects physical, emotional, and social dimensions of health. A full description of dimensions and their item composition is shown in Fig. 1 . 1.3 Survey Procedure Before data collection, all interviewers received standardized training. Eligible patients were approached by trained investigators who explained the study purpose and obtained informed consent. Participants independently completed the PROISCD-CG questionnaire; investigators provided neutral clarification for misunderstood items when necessary. Completed questionnaires were checked immediately to ensure no missing responses and were returned for retrieval and verification. The development and validation process of the PROISCD-CG scale is shown in Fig. 2 . 1.4 Statistical Analysis Double data entry and consistency checking were performed using EpiData 3.1 . Statistical analyses were carried out using SPSS 26.0 and AMOS 26.0 . Analyses included: Reliability Testing Internal consistency was assessed using Cronbach’s α coefficients with α > 0.70 considered acceptable 12 . Split-half reliability was calculated to evaluate structural stability. Validity Testing Criterion validity was assessed by correlating PROISCD-CG domain scores with SF-36 domain scores using Pearson correlation coefficients. Sampling adequacy for factor analysis was assessed with KMO values and Bartlett’s sphericity test 13 , 14 . Structural Equation Modeling (SEM) Following the hypothesized factor structure, a confirmatory factor analysis (CFA) model was developed in AMOS. Model fit was evaluated using conventional indices: χ²/df, RMSEA, GFI, CFI, IFI. Interpretation followed recommended thresholds 15 , 16 . Modification indices (MI) were used to guide model refinement, including item deletion and covariance adjustments. Convergent & Discriminant Validity Convergent validity was assessed via factor loadings , composite reliability (CR) , and average variance extracted (AVE) 17 . Discriminant validity was evaluated by comparing the square roots of AVE with inter-domain correlations. Results 2.1 General Characteristics of the Study Participants A total of 174 valid questionnaires were collected in this study. The age of participants ranged from 13 to 85 years, with a mean age of 50.38 ± 15.42 years. Individuals aged 40–60 years accounted for the largest proportion (48.3%). Most respondents were married (89.7%) and of Han ethnicity (89.7%). Regarding educational level, 35.6% had completed primary school, 17.8% junior high school, and 18.4% high school or technical secondary school; 13.2% reported an associate degree, while 14.9% held a bachelor’s degree or above. In terms of occupation, farmers represented the largest group (44.3%), followed by retirees (23.0%), workers (10.3%), and self-employed individuals (6.9%). Concerning household economic status, 62.6% reported a moderate level, 19.5% good, and 17.8% poor. Diagnostic subtypes of chronic gastritis included chronic non-atrophic gastritis (43.7%), chronic non-atrophic gastritis with erosion (26.4%), chronic atrophic gastritis (12.1%), chronic atrophic gastritis with erosion (4.0%), and other conditions (13.8%). Furthermore, 60.9% of participants reported at least one comorbidity. 2.2 Reliability analysis Reliability reflects the internal consistency and stability of a measurement instrument. In this study, Cronbach’s α coefficients were calculated for the overall scale and its subdimensions. As shown in Table 1 , the total scale demonstrated high internal consistency with a Cronbach’s α of 0.87 , indicating excellent reliability. For the subdimensions, all domains except Physical Health (PHD) exhibited Cronbach’s α values greater than 0.70. Within the PHD domain, item PHD3 (“Has your illness or treatment affected your sexual function?”) substantially reduced internal consistency. After removing this item, Cronbach’s α for the PHD domain increased to 0.64 , meeting the minimum requirement for structural equation modeling and therefore PHD3 was excluded from the structural validity testing. Split-half reliability is another important indicator of measurement stability. The split-half reliability coefficient for the total scale was 0.77 , close to the commonly accepted threshold of 0.80. Taken together, these findings suggest that the PROISCD-CG scale demonstrates good internal consistency and acceptable reliability across most dimensions. Table 1 Analysis of Internal Consistency Reliability (Cronbach’s α)) Dimension Item Cronbach's α if Item Deleted Cronbach's α of the Dimension Physical Health Domain (PHD) PHD1 0.418 0.559 PHD2 0.536 PHD3 0.643 PHD4 0.554 PHD5 0.475 PHD6 0.518 PHD7 0.504 PHD8 0.454 Mental Health Domain (MHD) MHD1 0.787 0.775 MHD2 0.781 MHD3 0.774 MHD4 0.732 MHD5 0.718 MHD6 0.710 MHD7 0.742 MHD8 0.748 Social Health Domain (SHD) SHD1 0.672 0.730 SHD2 0.706 SHD3 0.692 SHD4 0.696 SHD5 0.680 SHD6 0.741 SHD7 0.745 SHD8 0.692 Spiritual/Belief Health Domain (SBD) SBD1 0.710 0.737 SBD2 0.694 SBD3 0.772 SBD4 0.699 SBD5 0.648 SBD6 0.649 Specific Domain (SPD) CG1 0.816 0.827 CG2 0.826 CG3 0.804 CG4 0.804 CG5 0.816 CG6 0.828 CG7 0.802 CG8 0.823 CG9 0.807 CG10 0.811 CG11 0.805 Total Scale TOT — 0.871 2.3 Validity Analysis Validity refers to the extent to which an instrument accurately measures the construct it is intended to assess. In this study, we evaluated both criterion validity and construct validity of the PROISCD-CG scale. 2.3.1 Criterion Validity Criterion validity was examined by correlating each dimension of the PROISCD-CG scale with the corresponding domains of the Short Form-36 Health Survey Questionnaire (SF-36), which served as the external criterion. As shown in Table 2 , all dimensions of the PROISCD-CG were positively correlated with SF-36 domains , with correlation coefficients ranging from 0.158 to 0.691 . Except for the associations between the Spiritual Belief Dimension and the Emotional Role Function domain, and between the Specific Module and the Physical Function domain, the correlations between corresponding domains were stronger than cross-domain correlations , indicating acceptable criterion validity. This result is consistent with expectations, as SF-36 is a generic quality-of-life instrument and does not specifically target chronic gastritis. Currently, no CG-specific generic PRO instrument is available , thus the moderate level of correlation observed is reasonable and supports the criterion validity of the PROISCD-CG scale. 2.3.2 Pre-analysis Suitability Testing Before conducting exploratory factor analysis, the Kaiser–Meyer–Olkin (KMO) measure and Bartlett’s test of sphericity were performed to assess sampling adequacy. KMO = 0.78 (> 0.70) indicates that the sample is appropriate for factor analysis. Bartlett’s test was significant (P < 0.05) , suggesting that the correlation matrix is not an identity matrix. These findings confirm the suitability of the dataset for subsequent structural equation modeling and construct validity evaluation. Table 2 Correlation Between the SF-36 Scale and the Chronic Gastritis PRO Scale (n = 174) Dimension PHD MHD SHD SBD General Module(GM) SPD Physical Function 0.426 ** 0.108 0.158 * 0.057 0.232 ** -0.066 Role-Physical 0.113 0.285 ** 0.209 ** 0.145 0.252 ** 0.192 * Bodily Pain 0.329 ** 0.370 ** 0.291 ** 0.115 0.362 ** 0.372 ** General Health 0.379 ** 0.395 ** 0.282 ** 0.233 ** 0.423 ** 0.176 * Vitality 0.561 ** 0.653 ** 0.420 ** 0.352 ** 0.655 ** 0.308 ** Social Functioning 0.410 ** 0.526 ** 0.367 ** 0.169 * 0.486** 0.299 ** Role-Emotional 0.089 0.308 ** 0.217 ** 0.070 0.231** 0.291 ** Mental Health 0.315 ** 0.691 ** 0.363 ** 0.235 ** 0.542 ** 0.418 ** Note : *P < 0.05; **P < 0.01. 2.4 Structural Validity Analysis 2.4.1 Model Fit Indices Based on the predefined dimensional structure of the PROISCD-CG scale, a structural equation model (SEM) was constructed using the items belonging to each latent dimension. The initial model generated by AMOS demonstrated suboptimal fit. Although the chi-square to degrees-of-freedom ratio (χ²/df) met acceptable standards and the RMSEA value reached a marginally acceptable level, key incremental and absolute fit indices—including GFI, IFI, and CFI—did not reach the recommended thresholds. These findings indicated that the hypothesized model required further refinement to better represent the underlying factor structure of the scale (Fig. 3 ). 2.4.2 Model Modification Guided by modification indices (MI) provided by AMOS, several theoretically reasonable adjustments were made to improve model performance. First, items with factor loadings < 0.30 were removed, with the exception of PHD8 (loading 0.28), which was retained due to conceptual relevance. Subsequently, three residual correlations with high MI values—paths “e9→e20,” “e26→e27,” and “e37→e38”—were added sequentially to improve model fit. Following these modifications, the chi-square value (χ²) and χ²/df were reduced, RMSEA approached 0.08, and GFI, CFI, and IFI increased, approaching the acceptable range, indicating that the revised model provided an improved representation of the data (Table 3 , Fig. 4 ). Table 3 Main Fit Indices Before and After Model Modification Model 2 CMIN/DF RMSEA GFI CFI IFI Original Model 1856.363 2.543 0.094 0.649 0.605 0.612 Modified Model 844.450 2.154 0.082 0.759 0.803 0.806 2.4.3 Convergent Validity and Composite Reliability Convergent validity and composite reliability were assessed for each latent construct. Standardized factor loadings ranged from 0.29 to 0.95. Although several items (PHD1, PHD8, MHD8, SBD1, SBD2, CG6, CG8) demonstrated lower loadings, most exceeded the recommended threshold of 0.40. Average Variance Extracted (AVE) values ranged from 0.30 to 0.51. Except for the physical health and specific module dimensions, all AVEs were > 0.40. Composite Reliability (CR) values ranged from 0.68 to 0.83, with all but the physical health dimension surpassing the 0.70 benchmark. Overall, the revised model demonstrated acceptable convergent validity, satisfactory composite reliability, and alignment with psychometric expectations (Table 4 ). Table 4 Convergent Validity and Composite Reliability Values of the Modified Scale Dimension Item Standardized Factor Loading AVE CR Physical Health Domain (PHD) PHD1 0.38 0.39 0.68 PHD8 0.28 PHD6 0.66 PHD7 0.95 Mental Health Domain (MHD) MHD8 0.34 0.51 0.83 MHD4 0.64 MHD5 0.91 MHD6 0.94 MHD7 0.57 Social Health Domain (SHD) SHD3 0.49 0.42 0.78 SHD1 0.64 SHD4 0.55 SHD5 0.77 SHD8 0.80 Spiritual/Belief Health Domain (SBD) SBD5 0.83 0.42 0.76 SBD6 0.91 SBD1 0.29 SBD2 0.39 SBD4 0.59 Specific Domain (SPD) CG11 0.74 0.30 0.82 CG10 0.69 CG9 0.69 CG8 0.40 CG7 0.62 CG6 0.31 CG5 0.45 CG4 0.56 CG3 0.53 CG2 0.42 CG1 0.42 2.4.4 Discriminant Validity Discriminant validity was evaluated by comparing the square roots of AVE values with the inter-construct correlation coefficients. With the exception of the physical health and social health dimensions—whose correlation coefficient exceeded their internal correlations—the square roots of AVEs for all other dimensions were greater than their inter-factor correlations. This indicates adequate discriminant validity for most domains of the revised PROISCD-CG scale. Overall, the discriminant validity of the scale was considered acceptable (Table 5 ). Table 5 Discriminant Validity Analysis Dimension AVE Physical Health Mental Health Social Health Spiritual/Belief Health Specific Domain Physical Health 0.389 0.624 Mental Health 0.512 0.120 0.716 Social Health 0.424 0.785 0.353 0.651 Spiritual/Belief Health 0.419 0.425 0.168 0.569 0.674 Specific Domain 0.299 -0.024 0.482 -0.022 -0.128 0.547 Discussion In this study, we conducted a comprehensive psychometric evaluation of the Patient-Reported Clinical Outcome Scale for Chronic Gastritis (PROISCD-CG) using both classical test theory and structural equation modeling (SEM). The results indicate that the scale demonstrates good overall reliability, acceptable validity, and a reasonably stable factor structure following SEM-guided refinement. These findings support the use of PROISCD-CG as a patient-centered measurement tool for assessing clinical outcomes in individuals with chronic gastritis. Internal consistency analysis showed that the total scale achieved a Cronbach’s α of 0.87, indicating strong overall reliability. Most subdomains met or exceeded commonly accepted thresholds for internal consistency. The physical health (PHD) domain initially exhibited relatively lower reliability; however, removal of item PHD3 led to an improvement in Cronbach’s α. This item addresses sexual function, a topic that may be culturally sensitive and prone to non-response or socially desirable responding, particularly among older or rural populations. Similar challenges have been reported in other patient-reported outcome studies involving sensitive health topics 18 . Aside from this domain, the remaining dimensions—psychological health, social health, spiritual well-being, and the disease-specific module—demonstrated satisfactory internal consistency, with the disease-specific module showing the strongest coherence. These findings suggest that symptom-focused items are particularly effective in capturing the clinical impact of chronic gastritis. Criterion validity was assessed by examining correlations between PROISCD-CG domains and the SF-36, a widely used generic health-related quality-of-life instrument. Moderate correlations were observed between conceptually related domains, which is consistent with expectations. Because the SF-36 is not designed to assess disease-specific symptom burden, strong correlations are neither expected nor necessary to establish criterion validity 19 . Instead, the observed correlation pattern supports the conceptual overlap between general health status and patient-reported outcomes while highlighting the added value of a disease-specific PRO instrument. Notably, weaker correlations were observed in domains related to spiritual well-being and specific gastrointestinal symptoms, underscoring the limitations of generic instruments in capturing dimensions that are particularly relevant to chronic gastritis 20 . Structural validity was further examined using SEM. The initial hypothesized model did not achieve optimal fit across all indices, despite acceptable χ²/df and RMSEA values. Incremental and absolute fit indices such as GFI, CFI, and IFI fell below recommended thresholds, indicating that the original factor structure required refinement. Guided by modification indices and theoretical considerations, items with low factor loadings were removed, and a limited number of correlated error terms were added between items with similar content. These modifications resulted in improved model fit, with fit indices approaching acceptable ranges. The revised model demonstrated generally satisfactory convergent and discriminant validity, as reflected by composite reliability and average variance extracted values. Although several items retained relatively low factor loadings after model modification, most constructs achieved acceptable levels of reliability and validity. Items with low loadings may reflect conceptual overlap, ambiguous wording, or cultural factors influencing patient interpretation 21 . Rather than indicating fundamental flaws in the scale, these findings highlight opportunities for further optimization. Future revisions of the PROISCD-CG may benefit from qualitative item refinement, such as cognitive interviewing, to improve clarity and cultural adaptability while preserving conceptual coverage 22 . The application of SEM represents a methodological strength of this study. Compared with traditional psychometric approaches, SEM allows for explicit modeling of latent constructs and measurement error, providing a more rigorous assessment of construct validity 10 , 15 . By combining SEM with classical reliability and validity analyses, this study offers a robust evaluation of the internal structure of the PROISCD-CG scale. To our knowledge, this is among the few studies in China to apply SEM in the validation of a chronic gastritis–specific patient-reported outcome instrument, thereby contributing methodological insight to the field of gastroenterology outcomes research. Limitations Several limitations of this study should be acknowledged. First, the sample size was relatively modest. Although the number of participants met the minimum requirements for SEM analysis, larger samples—ideally five to ten times the number of measured variables—are recommended to enhance model stability and parameter precision. The limited sample size may have contributed to borderline fit indices in the initial model. Second, the cross-sectional study design precluded evaluation of test–retest reliability and responsiveness, both of which are essential for assessing the temporal stability and sensitivity of PRO instruments. Longitudinal studies are needed to determine whether the PROISCD-CG scale can reliably detect changes in patient status over time or in response to treatment. Third, the study population was recruited from two hospitals within a single region, which may limit the generalizability of the findings. Cultural, socioeconomic, and healthcare-system differences could influence patient responses to certain items, particularly those related to sensitive topics. Future multicenter studies involving more diverse populations are warranted. Finally, several items exhibited relatively low factor loadings even after model modification, suggesting potential redundancy or conceptual ambiguity. These items should be further reviewed and refined through qualitative methods, such as cognitive interviewing, to improve clarity and cultural adaptability. Despite these limitations, the present findings have important clinical and public health implications. Chronic gastritis is a highly prevalent condition that imposes a substantial burden on physical, psychological, and social functioning. Disease-specific PRO instruments provide a structured and patient-centered approach to capturing this burden, complementing objective clinical indicators. In clinical practice, the PROISCD-CG scale may facilitate more comprehensive patient assessment, support individualized treatment planning, and enable monitoring of treatment effectiveness. At the population level, standardized PRO measures can inform health services evaluation and resource allocation. Conclusion In conclusion, the PROISCD-CG scale demonstrates good reliability, acceptable validity, and a refined factor structure following SEM-guided modification. The scale provides a practical and interpretable tool for assessing patient-reported outcomes in chronic gastritis. Further validation in larger, more diverse populations and longitudinal settings is warranted to enhance its applicability and establish its responsiveness to clinical change. This study demonstrates that the PROISCD-CG scale exhibits good internal consistency, acceptable validity, and an improved factor structure following structural equation modeling–guided refinement. The finalized model provides a reliable and clinically interpretable tool for assessing patient-reported outcomes in individuals with chronic gastritis. With further validation in larger and longitudinal studies, the PROISCD-CG scale has the potential to support patient-centered evaluation, treatment monitoring, and outcome assessment in both clinical practice and research settings. Abbreviations CG Chronic gastritis PRO Patient-reported outcome QOL Quality of life PROISCD-CG Patient-Reported Clinical Outcome Scale for Chronic Gastritis SEM Structural equation modeling CFA Confirmatory factor analysis χ²/df Chi-square to degrees of freedom ratio RMSEA Root mean square error of approximation GFI Goodness-of-fit index CFI Comparative fit index IFI Incremental fit index MI Modification indices CR Composite reliability AVE Average variance extracted KMO Kaiser–Meyer–Olkin PHD Physical health domain MHD Mental health domain SHD Social health domain SBD Spiritual/Belief health domain SPD Specific domain Declarations Ethics approval and consent to participate The study was performed in strict accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Kunming Medical University (approval number: KMMU2021MEC031). Adhering to the principle of voluntary participation, all potential participants were given the opportunity to make an informed decision on their participation in the study. All subjects were clearly informed of their right to withdraw from the study at any time without facing adverse consequences. To ensure transparency, the purpose and procedures of the study were fully explained to the subjects before signing the informed consents. Individually identifiable information, such as name and telephone number, was deliberately omitted from the recorded data during the data collection phase to ensure anonymity. Finally, Information collected was subjected to appropriate coding procedures and kept strictly confidential throughout the research process. Consent for publication Written informed consent for publication was obtained from all individual participants included in the study. Availability of data The data supporting this study cannot be made publicly available due to patient privacy concerns. Data are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research was funded by the National Natural Science Foundation of China (Grant No. 72164024), Yunnan Provincial Talent Program for Young Scholar and Technical Reserve Personnel (202305AC160046), First-Class Discipline Team of Kunming Medical University National (2024XKTDTS16), the Philosophy and Social Science Innovation Team of Yunnan Province (2024CX08). Author contributions PingGuang Lei and Xin Li contributed equally. PingGuang Lei,Xin Li,JinQing Ou,and Ying Chen conceived and designed the study. HuiMin Huang,GuiJin Luo,XiRan Xia,and KeYan Wan responsible for data collection. ZaiXue Mu ,Qiu Ju Miao and TianLe Fu performed the formal analysis. PingGuang Lei and Ying Chen developed the methodology. 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BMC Public Health. 2024;24:2507. 10.1186/s12889-024-19990-w . Hertler C, Seiler A, Gramatzki D, Schettle M, Blum D. Sex-specific and gender-specific aspects in patient-reported outcomes. ESMO Open. 2020;5(Suppl 4):e000837. 10.1136/esmoopen-2020-000837 . Overview of the SF-. 36 health survey and the international quality of life assessment (IQOLA) project. J Clin Epidemiol. 1998;51(11):903–12. 10.1016/S0895-4356(98)00081-X . Almeida D, Umuhire D, Gonzalez-Quevedo R, et al. Leveraging patient experience data to guide medicines development, regulation, access decisions and clinical care in the EU. Front Med. 2024;11:1408636. 10.3389/fmed.2024.1408636 . Terwee CB, Prinsen CAC, Chiarotto A, et al. COSMIN methodology for evaluating the content validity of patient-reported outcome measures: A delphi study. Qual Life Res. 2018;27(5):1159–70. 10.1007/s11136-018-1829-0 . Patrick DL, Burke LB, Gwaltney CJ, et al. Content Validity—Establishing and Reporting the Evidence in Newly Developed Patient-Reported Outcomes (PRO) Instruments for Medical Product Evaluation: ISPOR PRO Good Research Practices Task Force Report: Part 1—Eliciting Concepts for a New PRO Instrument. Value Health. 2011;14(8):967–77. 10.1016/j.jval.2011.06.014 . Additional Declarations No competing interests reported. Supplementary Files SupplementaryFileA.OfficialEnglishlanguageversionofthePROISCDCGscale.pdf SupplementaryFileB.ScoringAlgorithmandInterpretation.pdf SupplementaryFileC.TranslationandCulturalAdaptation.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 06 Mar, 2026 Reviewers agreed at journal 01 Mar, 2026 Reviewers invited by journal 24 Feb, 2026 Editor assigned by journal 23 Feb, 2026 Editor invited by journal 29 Jan, 2026 Submission checks completed at journal 28 Jan, 2026 First submitted to journal 28 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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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-8629187","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":596337947,"identity":"dd004c05-b5fa-40c0-9635-1c4ef40a0b74","order_by":0,"name":"PingGuang Lei","email":"","orcid":"","institution":"Shenzhen Bao'an District Songgang People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"PingGuang","middleName":"","lastName":"Lei","suffix":""},{"id":596337948,"identity":"d543be9c-edca-4efd-9091-a7b446d1fd89","order_by":1,"name":"Xin Li","email":"","orcid":"","institution":"Kunming Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xin","middleName":"","lastName":"Li","suffix":""},{"id":596337949,"identity":"eaf8370b-8beb-4c5a-b505-f9921d74e8d0","order_by":2,"name":"ZaiXue Mu","email":"","orcid":"","institution":"Kunming Medical University","correspondingAuthor":false,"prefix":"","firstName":"ZaiXue","middleName":"","lastName":"Mu","suffix":""},{"id":596337950,"identity":"1b32e441-e241-4060-a4fb-481eddfa3f94","order_by":3,"name":"QiuJu Miao","email":"","orcid":"","institution":"Chuxiong Medical College","correspondingAuthor":false,"prefix":"","firstName":"QiuJu","middleName":"","lastName":"Miao","suffix":""},{"id":596337951,"identity":"452e2615-9b85-4558-8a7b-3c6116d3da5d","order_by":4,"name":"HuiMin Huang","email":"","orcid":"","institution":"Shenzhen Bao'an District Songgang People's 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Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYDACCRBhwMDAzwPhMzYQrUWyhzQtIF1niNXCP7v52GOegjt2m8+cTt3Mw2Aju+EA87MHeC25cyzdmMfgWfK2s73bbvMwpBlvOMBmboBPi4FEjpk0j8HhZLPzvCAthxM3HOBhk8CvJf8bWItxP1jLf2K05LCBtNgZ8IIddoCwFokbaWaScwwOJ0icObvt5hyDZOOZh9nM8Grhn5H8TOLNn8P2/D252268qbCT7Tve/AyvFhBgAkZ8YgPEnUDMTEg9EDD+YGCwJ0LdKBgFo2AUjFQAAEZySUVCbFh6AAAAAElFTkSuQmCC","orcid":"","institution":"Kunming Medical University","correspondingAuthor":true,"prefix":"","firstName":"Ying","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2026-01-18 04:53:01","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8629187/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8629187/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103582526,"identity":"0b76f33a-9077-425d-bcc2-3c7e81f5eb56","added_by":"auto","created_at":"2026-02-27 10:28:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":42071,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eItems Corresponding to Each Dimension of the Scale\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Onlinefloatimage12.png","url":"https://assets-eu.researchsquare.com/files/rs-8629187/v1/28ad65cb31e521138509b97d.png"},{"id":103582525,"identity":"8a4a6d12-ebbc-4118-8b26-65e6ddaefef9","added_by":"auto","created_at":"2026-02-27 10:28:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":96749,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDevelopment and validation process of the PROISCD-CG scale.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Onlinefloatimage22.png","url":"https://assets-eu.researchsquare.com/files/rs-8629187/v1/dc4bd9b28de4927b20beb836.png"},{"id":103582532,"identity":"cb6d202f-dbda-4222-bded-021bb5ff2839","added_by":"auto","created_at":"2026-02-27 10:28:05","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":72268,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStructural Diagram of the Original Scale Model\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8629187/v1/44d915d32b9411eaedbfe2e8.png"},{"id":103582527,"identity":"4e8add94-4557-408d-862e-3dace34e085a","added_by":"auto","created_at":"2026-02-27 10:28:04","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":52293,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStructural Diagram of the Modified Model\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8629187/v1/788e3efd1b438bb67115a50b.png"},{"id":104407459,"identity":"f628fb7f-d403-47c3-9ce1-3a346f34c961","added_by":"auto","created_at":"2026-03-11 12:38:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2036165,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8629187/v1/6aa74768-41f3-4cae-9a41-ea9ad5ec2612.pdf"},{"id":104398711,"identity":"8e86d6a0-5af2-44de-ad92-37b001695795","added_by":"auto","created_at":"2026-03-11 12:03:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":94629,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFileA.OfficialEnglishlanguageversionofthePROISCDCGscale.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8629187/v1/198bdb931a36c093b3fad076.pdf"},{"id":103582530,"identity":"05e005e3-9a77-4f15-8712-9cd0b05097d2","added_by":"auto","created_at":"2026-02-27 10:28:04","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":78628,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFileB.ScoringAlgorithmandInterpretation.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8629187/v1/a12866a4eabb33e41d3cdecd.pdf"},{"id":103582529,"identity":"eac2fe6d-e9ff-4e2c-9ee8-707ebd7f5ece","added_by":"auto","created_at":"2026-02-27 10:28:04","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":65523,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFileC.TranslationandCulturalAdaptation.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8629187/v1/e7bc74b63b9ab32fd5c24a34.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Psychometric Validation of the PROISCD-CG Scale in Patients With Chronic Gastritis: A Structural Equation Modeling Approach","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChronic gastritis (CG) is one of the most prevalent gastrointestinal disorders worldwide and is characterized by persistent inflammatory changes of the gastric mucosa resulting from multiple etiologies\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Owing to its chronic and recurrent nature, CG is frequently accompanied by long-term gastrointestinal symptoms that substantially impair patients’ physical functioning, psychological well-being, social participation, and overall quality of life\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. As healthcare paradigms continue to evolve from a purely biomedical model toward a biopsychosocial and patient-centered approach, greater emphasis has been placed on outcomes that reflect patients’ subjective experiences of disease and treatment.\u003c/p\u003e \u003cp\u003ePatient-reported outcome (PRO) refer to health-related information directly reported by patients without interpretation by clinicians or researchers. PRO instruments commonly encompass symptom burden, functional status, activity limitation, health-related quality of life, and treatment perceptions\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. In chronic digestive diseases such as CG, objective clinical indicators alone often fail to capture the complexity and variability of patient experiences. Consequently, PRO measures provide indispensable complementary information for evaluating disease burden, treatment effectiveness, and long-term management outcomes.\u003c/p\u003e \u003cp\u003eCompared with generic quality-of-life (QOL) instruments, disease-specific PRO scales offer several important advantages. Widely used tools such as the SF-36 are designed to assess general health status and may lack sensitivity to disease-specific symptoms or subtle clinical changes\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. In contrast, PRO instruments tailored to specific conditions directly quantify patients’ perceptions of symptom severity and functional impairment, reduce information bias, and improve the clinical interpretability of outcomes\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. These advantages make PRO measures particularly valuable for chronic gastritis, where symptom fluctuation and treatment response are highly individualized.\u003c/p\u003e \u003cp\u003eStructural equation modeling (SEM) is a powerful multivariate analytical approach that integrates factor analysis and path analysis, allowing for explicit modeling of latent constructs and measurement error\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. SEM has been increasingly applied in psychometric research due to its superiority over classical test theory in evaluating complex measurement structures and construct validity\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. However, SEM-based validation studies of PRO instruments for chronic gastritis remain limited, particularly in the Chinese population.\u003c/p\u003e \u003cp\u003eTo address this gap, the present study applied SEM to evaluate the psychometric properties of the Patient-Reported Clinical Outcome Scale for Chronic Gastritis (PROISCD-CG), a modular instrument comprising both generic and disease-specific domains. By systematically assessing reliability, validity, and factor structure, this study aims to provide robust evidence supporting the clinical and research utility of the PROISCD-CG scale and to inform further refinement of patient-centered outcome measures in gastroenterology.\u003c/p\u003e "},{"header":"Methods","content":"\u003ch2\u003e1.1 Study Design and Participants\u003c/h2\u003e\u003cp\u003eThis cross-sectional study was conducted between September and December 2022 at the Department of Gastroenterology of the Second Affiliated Hospital of Kunming Medical University and Qujing People’s Hospital. A total of \u003cb\u003e174 patients\u003c/b\u003e diagnosed with chronic gastritis (CG) were consecutively recruited through outpatient and inpatient clinics. Participants were eligible if they: (1) met the diagnostic criteria for CG; (2) were able to communicate normally; and (3) were cognitively capable of independently completing the survey. Exclusion criteria included: (1) history of psychiatric disorders; (2) unwillingness to participate; (3) severe comorbidities such as COPD, severe pulmonary infections, heart failure, or liver/kidney dysfunction; and (4) recent use of medications with gastrointestinal side effects (e.g., oral contraceptives, weight-loss drugs) that might interfere with symptom evaluation.\u003c/p\u003e\u003cp\u003eThe diagnosis of CG is based on the \u003cb\u003e2022 Chinese Guidelines for the Diagnosis and Treatment of Chronic Gastritis\u003c/b\u003e, combining endoscopic findings and histopathology results, with the latter serving as the definitive diagnostic basis\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e was obtained from the Ethics Committee of Kunming Medical University (KMMU2021MEC031), and all participants provided written informed consent.\u003c/p\u003e\u003ch2\u003e1.2 Research Instruments\u003c/h2\u003e\u003cp\u003eThe \u003cb\u003ePatient-Reported Clinical Outcome Scale for Chronic Gastritis (PROISCD-CG)\u003c/b\u003e was developed by Prof. Wanchonghua’s research team in China, using a modular framework consisting of a \u003cb\u003egeneric module\u003c/b\u003e (four domains: physical health, psychological health, social health, and spiritual/belief health; 30 items) and a \u003cb\u003edisease-specific module\u003c/b\u003e (11 items). All items were rated using a \u003cb\u003efive-point Likert scale\u003c/b\u003e (1–5). Negative items were reverse-scored using the formula \u003cem\u003e6 – original score\u003c/em\u003e.\u003c/p\u003e\u003cp\u003eThe PROISCD-CG is a copyrighted instrument (Chinese Copyright Registration No. Guozuo Dengzi-2023-A-00286360). The full scale, scoring manual, and translation report are provided as \u003cb\u003eSupplementary File A\u003c/b\u003e (Scale), \u003cb\u003eSupplementary File B\u003c/b\u003e (Scoring Rules), and \u003cb\u003eSupplementary File C\u003c/b\u003e (Translation and Cultural Adaptation), respectively.\u003c/p\u003e\u003cp\u003eTo evaluate criterion validity, the \u003cb\u003eSF-36 Health Survey\u003c/b\u003e was used as an external reference scale, as it comprehensively reflects physical, emotional, and social dimensions of health.\u003c/p\u003e\u003cp\u003eA full description of dimensions and their item composition is shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003ch2\u003e1.3 Survey Procedure\u003c/h2\u003e\u003cp\u003eBefore data collection, all interviewers received standardized training. Eligible patients were approached by trained investigators who explained the study purpose and obtained informed consent. Participants independently completed the PROISCD-CG questionnaire; investigators provided neutral clarification for misunderstood items when necessary. Completed questionnaires were checked immediately to ensure no missing responses and were returned for retrieval and verification. The development and validation process of the PROISCD-CG scale is shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003ch2\u003e1.4 Statistical Analysis\u003c/h2\u003e\u003cp\u003eDouble data entry and consistency checking were performed using \u003cb\u003eEpiData 3.1\u003c/b\u003e. Statistical analyses were carried out using \u003cb\u003eSPSS 26.0\u003c/b\u003e and \u003cb\u003eAMOS 26.0\u003c/b\u003e.\u003c/p\u003e\u003cp\u003eAnalyses included:\u003c/p\u003e\u003cp\u003e \u003cb\u003eReliability Testing\u003c/b\u003e \u003c/p\u003e\u003cp\u003eInternal consistency was assessed using Cronbach’s α coefficients with α \u0026gt; 0.70 considered acceptable\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eSplit-half reliability was calculated to evaluate structural stability.\u003c/p\u003e\u003cp\u003e \u003cb\u003eValidity Testing\u003c/b\u003e \u003c/p\u003e\u003cp\u003eCriterion validity was assessed by correlating PROISCD-CG domain scores with SF-36 domain scores using Pearson correlation coefficients. Sampling adequacy for factor analysis was assessed with KMO values and Bartlett’s sphericity test\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e \u003cb\u003eStructural Equation Modeling (SEM)\u003c/b\u003e \u003c/p\u003e\u003cp\u003eFollowing the hypothesized factor structure, a confirmatory factor analysis (CFA) model was developed in AMOS. Model fit was evaluated using conventional indices: χ²/df, RMSEA, GFI, CFI, IFI. Interpretation followed recommended thresholds\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eModification indices (MI) were used to guide model refinement, including item deletion and covariance adjustments.\u003c/p\u003e\u003cp\u003e \u003cb\u003eConvergent \u0026amp; Discriminant Validity\u003c/b\u003e \u003c/p\u003e\u003cp\u003eConvergent validity was assessed via \u003cb\u003efactor loadings\u003c/b\u003e, \u003cb\u003ecomposite reliability (CR)\u003c/b\u003e, and \u003cb\u003eaverage variance extracted (AVE)\u003c/b\u003e\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eDiscriminant validity was evaluated by comparing the square roots of AVE with inter-domain correlations.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.1 General Characteristics of the Study Participants\u003c/h2\u003e \u003cp\u003eA total of 174 valid questionnaires were collected in this study. The age of participants ranged from 13 to 85 years, with a mean age of 50.38\u0026thinsp;\u0026plusmn;\u0026thinsp;15.42 years. Individuals aged 40\u0026ndash;60 years accounted for the largest proportion (48.3%). Most respondents were married (89.7%) and of Han ethnicity (89.7%).\u003c/p\u003e \u003cp\u003eRegarding educational level, 35.6% had completed primary school, 17.8% junior high school, and 18.4% high school or technical secondary school; 13.2% reported an associate degree, while 14.9% held a bachelor\u0026rsquo;s degree or above.\u003c/p\u003e \u003cp\u003eIn terms of occupation, farmers represented the largest group (44.3%), followed by retirees (23.0%), workers (10.3%), and self-employed individuals (6.9%). Concerning household economic status, 62.6% reported a moderate level, 19.5% good, and 17.8% poor.\u003c/p\u003e \u003cp\u003eDiagnostic subtypes of chronic gastritis included chronic non-atrophic gastritis (43.7%), chronic non-atrophic gastritis with erosion (26.4%), chronic atrophic gastritis (12.1%), chronic atrophic gastritis with erosion (4.0%), and other conditions (13.8%). Furthermore, 60.9% of participants reported at least one comorbidity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Reliability analysis\u003c/h2\u003e \u003cp\u003eReliability reflects the internal consistency and stability of a measurement instrument. In this study, Cronbach\u0026rsquo;s α coefficients were calculated for the overall scale and its subdimensions. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the total scale demonstrated high internal consistency with a Cronbach\u0026rsquo;s α of \u003cb\u003e0.87\u003c/b\u003e, indicating excellent reliability.\u003c/p\u003e \u003cp\u003eFor the subdimensions, all domains except Physical Health (PHD) exhibited Cronbach\u0026rsquo;s α values greater than 0.70. Within the PHD domain, item PHD3 (\u0026ldquo;Has your illness or treatment affected your sexual function?\u0026rdquo;) substantially reduced internal consistency. After removing this item, Cronbach\u0026rsquo;s α for the PHD domain increased to \u003cb\u003e0.64\u003c/b\u003e, meeting the minimum requirement for structural equation modeling and therefore PHD3 was excluded from the structural validity testing.\u003c/p\u003e \u003cp\u003eSplit-half reliability is another important indicator of measurement stability. The split-half reliability coefficient for the total scale was \u003cb\u003e0.77\u003c/b\u003e, close to the commonly accepted threshold of 0.80. Taken together, these findings suggest that the PROISCD-CG scale demonstrates \u003cb\u003egood internal consistency and acceptable reliability\u003c/b\u003e across most dimensions.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnalysis of Internal Consistency Reliability (Cronbach\u0026rsquo;s α))\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDimension\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCronbach's α if Item Deleted\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCronbach's α of the Dimension\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e\u003cb\u003ePhysical Health Domain (PHD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHD1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.418\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e0.559\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHD2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.536\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHD3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.643\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHD4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.554\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHD5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.475\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHD6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.518\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHD7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.504\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHD8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.454\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e\u003cb\u003eMental Health Domain\u003c/b\u003e (MHD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMHD1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.787\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e0.775\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMHD2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.781\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMHD3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.774\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMHD4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.732\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMHD5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.718\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMHD6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.710\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMHD7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.742\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMHD8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.748\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e\u003cb\u003eSocial Health Domain (SHD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSHD1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.672\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e0.730\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSHD2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.706\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSHD3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.692\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSHD4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.696\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSHD5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.680\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSHD6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.741\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSHD7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.745\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSHD8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.692\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u003cb\u003eSpiritual/Belief Health Domain (SBD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSBD1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.710\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e0.737\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSBD2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.694\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSBD3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.772\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSBD4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.699\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSBD5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.648\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSBD6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.649\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"10\" rowspan=\"11\"\u003e \u003cp\u003e\u003cb\u003eSpecific Domain\u003c/b\u003e (SPD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.816\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"10\" rowspan=\"11\"\u003e \u003cp\u003e0.827\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.826\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.804\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.804\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.816\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.828\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.802\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.823\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.807\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.811\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.805\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal Scale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTOT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.871\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Validity Analysis\u003c/h2\u003e \u003cp\u003eValidity refers to the extent to which an instrument accurately measures the construct it is intended to assess. In this study, we evaluated both \u003cb\u003ecriterion validity\u003c/b\u003e and \u003cb\u003econstruct validity\u003c/b\u003e of the PROISCD-CG scale.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e2.3.1 Criterion Validity\u003c/h2\u003e \u003cp\u003eCriterion validity was examined by correlating each dimension of the PROISCD-CG scale with the corresponding domains of the Short Form-36 Health Survey Questionnaire (SF-36), which served as the external criterion. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cb\u003eall dimensions of the PROISCD-CG were positively correlated with SF-36 domains\u003c/b\u003e, with correlation coefficients ranging from \u003cb\u003e0.158 to 0.691\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eExcept for the associations between the \u003cb\u003eSpiritual Belief Dimension\u003c/b\u003e and the \u003cb\u003eEmotional Role Function\u003c/b\u003e domain, and between the \u003cb\u003eSpecific Module\u003c/b\u003e and the \u003cb\u003ePhysical Function\u003c/b\u003e domain, \u003cb\u003ethe correlations between corresponding domains were stronger than cross-domain correlations\u003c/b\u003e, indicating acceptable criterion validity.\u003c/p\u003e \u003cp\u003eThis result is consistent with expectations, as SF-36 is a generic quality-of-life instrument and does not specifically target chronic gastritis. Currently, \u003cb\u003eno CG-specific generic PRO instrument is available\u003c/b\u003e, thus the moderate level of correlation observed is reasonable and supports the criterion validity of the PROISCD-CG scale.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e2.3.2 Pre-analysis Suitability Testing\u003c/h2\u003e \u003cp\u003eBefore conducting exploratory factor analysis, the \u003cb\u003eKaiser\u0026ndash;Meyer\u0026ndash;Olkin (KMO) measure\u003c/b\u003e and \u003cb\u003eBartlett\u0026rsquo;s test of sphericity\u003c/b\u003e were performed to assess sampling adequacy.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eKMO\u0026thinsp;=\u0026thinsp;0.78 (\u0026gt;\u0026thinsp;0.70)\u003c/b\u003e indicates that the sample is appropriate for factor analysis.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eBartlett\u0026rsquo;s test was significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/b\u003e, suggesting that the correlation matrix is not an identity matrix.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThese findings confirm the suitability of the dataset for subsequent structural equation modeling and construct validity evaluation.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation Between the SF-36 Scale and the Chronic Gastritis PRO Scale (n\u0026thinsp;=\u0026thinsp;174)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDimension\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMHD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSHD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSBD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGeneral Module(GM)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSPD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical Function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.426\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.158\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.057\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.232\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.066\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRole-Physical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.285\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.209\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.252\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.192\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBodily Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.329\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.370\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.291\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.362\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.372\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.379\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.395\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.282\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.233\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.423\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.176\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVitality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.561\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.653\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.420\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.352\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.655\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.308\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Functioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.410\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.526\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.367\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.169\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.486**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.299\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRole-Emotional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.089\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.308\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.217\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.070\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.231**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.291\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMental Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.315\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.691\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.363\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.235\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.542\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.418\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cb\u003eNote\u003c/b\u003e:\u0026nbsp;*P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; **P\u0026thinsp;\u0026lt;\u0026thinsp;0.01.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Structural Validity Analysis\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e2.4.1 Model Fit Indices\u003c/h2\u003e \u003cp\u003eBased on the predefined dimensional structure of the PROISCD-CG scale, a structural equation model (SEM) was constructed using the items belonging to each latent dimension. The initial model generated by AMOS demonstrated suboptimal fit. Although the chi-square to degrees-of-freedom ratio (χ\u0026sup2;/df) met acceptable standards and the RMSEA value reached a marginally acceptable level, key incremental and absolute fit indices\u0026mdash;including GFI, IFI, and CFI\u0026mdash;did not reach the recommended thresholds.\u003c/p\u003e \u003cp\u003eThese findings indicated that the hypothesized model required further refinement to better represent the underlying factor structure of the scale (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e2.4.2 Model Modification\u003c/h2\u003e \u003cp\u003e Guided by modification indices (MI) provided by AMOS, several theoretically reasonable adjustments were made to improve model performance. First, items with factor loadings\u0026thinsp;\u0026lt;\u0026thinsp;0.30 were removed, with the exception of PHD8 (loading 0.28), which was retained due to conceptual relevance. Subsequently, three residual correlations with high MI values\u0026mdash;paths \u0026ldquo;e9\u0026rarr;e20,\u0026rdquo; \u0026ldquo;e26\u0026rarr;e27,\u0026rdquo; and \u0026ldquo;e37\u0026rarr;e38\u0026rdquo;\u0026mdash;were added sequentially to improve model fit.\u003c/p\u003e \u003cp\u003eFollowing these modifications, the chi-square value (χ\u0026sup2;) and χ\u0026sup2;/df were reduced, RMSEA approached 0.08, and GFI, CFI, and IFI increased, approaching the acceptable range, indicating that the revised model provided an improved representation of the data (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMain Fit Indices Before and After Model Modification\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003c/span\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCMIN/DF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRMSEA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGFI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCFI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIFI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOriginal Model\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1856.363\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.543\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.094\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.649\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.605\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.612\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModified Model\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e844.450\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.082\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.759\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.803\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.806\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e2.4.3 Convergent Validity and Composite Reliability\u003c/h2\u003e \u003cp\u003eConvergent validity and composite reliability were assessed for each latent construct. Standardized factor loadings ranged from 0.29 to 0.95. Although several items (PHD1, PHD8, MHD8, SBD1, SBD2, CG6, CG8) demonstrated lower loadings, most exceeded the recommended threshold of 0.40.\u003c/p\u003e \u003cp\u003eAverage Variance Extracted (AVE) values ranged from 0.30 to 0.51. Except for the physical health and specific module dimensions, all AVEs were \u0026gt;\u0026thinsp;0.40. Composite Reliability (CR) values ranged from 0.68 to 0.83, with all but the physical health dimension surpassing the 0.70 benchmark.\u003c/p\u003e \u003cp\u003eOverall, the revised model demonstrated acceptable convergent validity, satisfactory composite reliability, and alignment with psychometric expectations (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eConvergent Validity and Composite Reliability Values of the Modified Scale\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDimension\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandardized Factor Loading\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAVE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCR\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003ePhysical Health Domain (PHD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHD1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHD8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHD6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHD7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eMental Health Domain\u003c/b\u003e (MHD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMHD8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMHD4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMHD5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMHD6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMHD7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eSocial Health Domain (SHD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSHD3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSHD1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSHD4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSHD5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSHD8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eSpiritual/Belief Health Domain (SBD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSBD5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSBD6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSBD1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSBD2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSBD4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"10\" rowspan=\"11\"\u003e \u003cp\u003e\u003cb\u003eSpecific Domain\u003c/b\u003e(SPD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"10\" rowspan=\"11\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"10\" rowspan=\"11\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e2.4.4 Discriminant Validity\u003c/h2\u003e \u003cp\u003eDiscriminant validity was evaluated by comparing the square roots of AVE values with the inter-construct correlation coefficients.\u003c/p\u003e \u003cp\u003eWith the exception of the physical health and social health dimensions\u0026mdash;whose correlation coefficient exceeded their internal correlations\u0026mdash;the square roots of AVEs for all other dimensions were greater than their inter-factor correlations. This indicates adequate discriminant validity for most domains of the revised PROISCD-CG scale.\u003c/p\u003e \u003cp\u003eOverall, the discriminant validity of the scale was considered acceptable (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDiscriminant Validity Analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDimension\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAVE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhysical Health\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMental Health\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSocial Health\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSpiritual/Belief Health\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSpecific Domain\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhysical Health\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.389\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.624\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMental Health\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.512\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.716\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSocial Health\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.424\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.785\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.353\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.651\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpiritual/Belief Health\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.419\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.425\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.569\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.674\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpecific Domain\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.299\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.482\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.547\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we conducted a comprehensive psychometric evaluation of the Patient-Reported Clinical Outcome Scale for Chronic Gastritis (PROISCD-CG) using both classical test theory and structural equation modeling (SEM). The results indicate that the scale demonstrates good overall reliability, acceptable validity, and a reasonably stable factor structure following SEM-guided refinement. These findings support the use of PROISCD-CG as a patient-centered measurement tool for assessing clinical outcomes in individuals with chronic gastritis.\u003c/p\u003e \u003cp\u003eInternal consistency analysis showed that the total scale achieved a Cronbach\u0026rsquo;s α of 0.87, indicating strong overall reliability. Most subdomains met or exceeded commonly accepted thresholds for internal consistency. The physical health (PHD) domain initially exhibited relatively lower reliability; however, removal of item PHD3 led to an improvement in Cronbach\u0026rsquo;s α. This item addresses sexual function, a topic that may be culturally sensitive and prone to non-response or socially desirable responding, particularly among older or rural populations. Similar challenges have been reported in other patient-reported outcome studies involving sensitive health topics\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAside from this domain, the remaining dimensions\u0026mdash;psychological health, social health, spiritual well-being, and the disease-specific module\u0026mdash;demonstrated satisfactory internal consistency, with the disease-specific module showing the strongest coherence. These findings suggest that symptom-focused items are particularly effective in capturing the clinical impact of chronic gastritis.\u003c/p\u003e \u003cp\u003eCriterion validity was assessed by examining correlations between PROISCD-CG domains and the SF-36, a widely used generic health-related quality-of-life instrument. Moderate correlations were observed between conceptually related domains, which is consistent with expectations. Because the SF-36 is not designed to assess disease-specific symptom burden, strong correlations are neither expected nor necessary to establish criterion validity\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eInstead, the observed correlation pattern supports the conceptual overlap between general health status and patient-reported outcomes while highlighting the added value of a disease-specific PRO instrument. Notably, weaker correlations were observed in domains related to spiritual well-being and specific gastrointestinal symptoms, underscoring the limitations of generic instruments in capturing dimensions that are particularly relevant to chronic gastritis\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eStructural validity was further examined using SEM. The initial hypothesized model did not achieve optimal fit across all indices, despite acceptable χ\u0026sup2;/df and RMSEA values. Incremental and absolute fit indices such as GFI, CFI, and IFI fell below recommended thresholds, indicating that the original factor structure required refinement. Guided by modification indices and theoretical considerations, items with low factor loadings were removed, and a limited number of correlated error terms were added between items with similar content. These modifications resulted in improved model fit, with fit indices approaching acceptable ranges. The revised model demonstrated generally satisfactory convergent and discriminant validity, as reflected by composite reliability and average variance extracted values.\u003c/p\u003e \u003cp\u003eAlthough several items retained relatively low factor loadings after model modification, most constructs achieved acceptable levels of reliability and validity. Items with low loadings may reflect conceptual overlap, ambiguous wording, or cultural factors influencing patient interpretation\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Rather than indicating fundamental flaws in the scale, these findings highlight opportunities for further optimization. Future revisions of the PROISCD-CG may benefit from qualitative item refinement, such as cognitive interviewing, to improve clarity and cultural adaptability while preserving conceptual coverage\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe application of SEM represents a methodological strength of this study. Compared with traditional psychometric approaches, SEM allows for explicit modeling of latent constructs and measurement error, providing a more rigorous assessment of construct validity\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. By combining SEM with classical reliability and validity analyses, this study offers a robust evaluation of the internal structure of the PROISCD-CG scale. To our knowledge, this is among the few studies in China to apply SEM in the validation of a chronic gastritis\u0026ndash;specific patient-reported outcome instrument, thereby contributing methodological insight to the field of gastroenterology outcomes research.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSeveral limitations of this study should be acknowledged. First, the sample size was relatively modest. Although the number of participants met the minimum requirements for SEM analysis, larger samples\u0026mdash;ideally five to ten times the number of measured variables\u0026mdash;are recommended to enhance model stability and parameter precision. The limited sample size may have contributed to borderline fit indices in the initial model.\u003c/p\u003e \u003cp\u003eSecond, the cross-sectional study design precluded evaluation of test\u0026ndash;retest reliability and responsiveness, both of which are essential for assessing the temporal stability and sensitivity of PRO instruments. Longitudinal studies are needed to determine whether the PROISCD-CG scale can reliably detect changes in patient status over time or in response to treatment.\u003c/p\u003e \u003cp\u003eThird, the study population was recruited from two hospitals within a single region, which may limit the generalizability of the findings. Cultural, socioeconomic, and healthcare-system differences could influence patient responses to certain items, particularly those related to sensitive topics. Future multicenter studies involving more diverse populations are warranted.\u003c/p\u003e \u003cp\u003eFinally, several items exhibited relatively low factor loadings even after model modification, suggesting potential redundancy or conceptual ambiguity. These items should be further reviewed and refined through qualitative methods, such as cognitive interviewing, to improve clarity and cultural adaptability.\u003c/p\u003e \u003cp\u003eDespite these limitations, the present findings have important clinical and public health implications. Chronic gastritis is a highly prevalent condition that imposes a substantial burden on physical, psychological, and social functioning. Disease-specific PRO instruments provide a structured and patient-centered approach to capturing this burden, complementing objective clinical indicators. In clinical practice, the PROISCD-CG scale may facilitate more comprehensive patient assessment, support individualized treatment planning, and enable monitoring of treatment effectiveness. At the population level, standardized PRO measures can inform health services evaluation and resource allocation.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, the PROISCD-CG scale demonstrates good reliability, acceptable validity, and a refined factor structure following SEM-guided modification. The scale provides a practical and interpretable tool for assessing patient-reported outcomes in chronic gastritis. Further validation in larger, more diverse populations and longitudinal settings is warranted to enhance its applicability and establish its responsiveness to clinical change.\u003c/p\u003e \u003cp\u003e This study demonstrates that the PROISCD-CG scale exhibits good internal consistency, acceptable validity, and an improved factor structure following structural equation modeling\u0026ndash;guided refinement. The finalized model provides a reliable and clinically interpretable tool for assessing patient-reported outcomes in individuals with chronic gastritis. With further validation in larger and longitudinal studies, the PROISCD-CG scale has the potential to support patient-centered evaluation, treatment monitoring, and outcome assessment in both clinical practice and research settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCG\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eChronic gastritis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePRO\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatient-reported outcome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eQOL\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eQuality of life\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePROISCD-CG\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatient-Reported Clinical Outcome Scale for Chronic Gastritis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSEM\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStructural equation modeling\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCFA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfirmatory factor analysis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eχ\u0026sup2;/df\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eChi-square to degrees of freedom ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eRMSEA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRoot mean square error of approximation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eGFI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGoodness-of-fit index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCFI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComparative fit index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eIFI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIncremental fit index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eModification indices\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComposite reliability\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eAVE\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAverage variance extracted\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eKMO\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKaiser\u0026ndash;Meyer\u0026ndash;Olkin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePHD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePhysical health domain\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMHD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMental health domain\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSHD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSocial health domain\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSBD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSpiritual/Belief health domain\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSPD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSpecific domain\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was performed in strict accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Kunming Medical University (approval number: KMMU2021MEC031). Adhering to the principle of voluntary participation, all potential participants were given the opportunity to make an informed decision on their participation in the study. All subjects were clearly informed of their right to withdraw from the study at any time without facing adverse consequences. To ensure transparency, the purpose and procedures of the study were fully explained to the subjects before signing the informed consents. Individually identifiable information, such as name and telephone number, was deliberately omitted from the recorded data during the data collection phase to ensure anonymity. Finally, Information collected was subjected to appropriate coding procedures and kept strictly confidential throughout the research process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting this study cannot be made publicly available due to patient privacy concerns. Data are available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by the National Natural Science Foundation of China (Grant No. 72164024), Yunnan Provincial Talent Program for Young Scholar and Technical Reserve Personnel (202305AC160046), First-Class Discipline Team of Kunming Medical University National (2024XKTDTS16), the Philosophy and Social Science Innovation Team of Yunnan Province (2024CX08).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePingGuang Lei and Xin Li contributed equally.\u003c/p\u003e\n\u003cp\u003ePingGuang Lei,Xin Li,JinQing Ou,and Ying Chen conceived and designed the study. HuiMin Huang,GuiJin Luo,XiRan Xia,and KeYan Wan responsible for data collection. ZaiXue Mu ,Qiu Ju Miao and TianLe Fu performed the formal analysis. PingGuang Lei and Ying Chen developed the methodology. Xin Li and Ying Chen wrote the original draft, and all authors contributed to reviewing and editing the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely thank the study participants and data collectors for their essential collaboration in this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSipponen P, Maaroos HI. Chronic gastritis. 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Value Health. 2011;14(8):967\u0026ndash;77. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jval.2011.06.014\u003c/span\u003e\u003cspan address=\"10.1016/j.jval.2011.06.014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Chronic gastritis, Patient-reported outcomes, Structural equation modeling, Reliability, Validity, Psychometrics","lastPublishedDoi":"10.21203/rs.3.rs-8629187/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8629187/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eChronic gastritis (CG) is a common gastrointestinal condition that adversely affects patients\u0026rsquo; physical, psychological, and social functioning. With increasing emphasis on patient-centered care, patient-reported outcomes (PROs) have become essential for evaluating disease burden and treatment effectiveness. Compared with conventional quality-of-life (QOL) instruments, PRO scales offer superior sensitivity, symptom specificity, and clinical interpretability. This study assessed the reliability and validity of the Patient-Reported Clinical Outcome Scale for Chronic Gastritis (PROISCD-CG) using structural equation modeling (SEM).\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eA total of 174 outpatients and inpatients diagnosed with CG between September and December 2022 were surveyed using the PROISCD-CG scale. Internal consistency, split-half reliability, and criterion validity (with SF-36 as the external criterion) were evaluated. SEM was applied to examine and refine factor structures, assess model fit, and evaluate convergent and discriminant validity.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eThe total scale demonstrated strong reliability (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.87; split-half\u0026thinsp;=\u0026thinsp;0.77). Criterion validity against SF-36 was acceptable, with moderate correlations across corresponding domains. The initial SEM model showed suboptimal fit, but modifications\u0026mdash;removing low-loading items and adding error covariances\u0026mdash;substantially improved fit indices (CFI, IFI, GFI approaching 0.80; RMSEA\u0026thinsp;=\u0026thinsp;0.082). Convergent validity (AVE) and composite reliability (CR) generally met recommended thresholds, and discriminant validity was acceptable.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eThe PROISCD-CG scale exhibits good psychometric properties and can serve as a reliable and valid tool for assessing patient-centered outcomes in CG. Items with low factor loadings require refinement and further testing in larger cohorts. PRO-based evaluation provides advantages over traditional QOL metrics by more precisely capturing symptom burden, functional impairment, and treatment responsiveness.\u003c/p\u003e","manuscriptTitle":"Psychometric Validation of the PROISCD-CG Scale in Patients With Chronic Gastritis: A Structural Equation Modeling Approach","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-27 10:27:59","doi":"10.21203/rs.3.rs-8629187/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-06T12:07:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"61283062567499005042582685961255178006","date":"2026-03-01T10:35:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-24T06:55:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-23T08:25:47+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-29T09:15:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-28T13:56:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Gastroenterology","date":"2026-01-28T12:36:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0dd830a4-acbc-401a-b662-c003f839d68b","owner":[],"postedDate":"February 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-27T10:27:59+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-27 10:27:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8629187","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8629187","identity":"rs-8629187","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}