Developing the Parenting Concerns Scale and assessment of its validity and reliability

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However, the early recognition of this complicated psychological burden has not been adequately explored due to the lack of a valid and reliable scale. This research aims to provide a scientifically valid and reliable assessment tool for evaluating parenting concerns among cancer survivors. Methods Based on literature review and Semi-structured qualitative interview, the item pool for the scale was generated, the preliminary scale through two rounds of Delphi expert consultation. Convenience sampling was used to select 380 cancer survivors in a tertiary hospital from September 2022 to December 2022 as the study subjects to examine the reliability and validity of the scale. Results A 14-item scale with 3-factor structure was identified through exploratory factor analyses. A total of 376 questionnaires were distributed, and 365 valid questionnaires were collected, resulting in a valid response rate of 97.07%. Three common factors were extracted through two rounds of exploratory factor analysis, with cumulative variance contribution rates of 57.427% and 61.629%. Based on modification indices, the model was revised, then confirmatory factor analysis indicated good overall model fit (χ2/df = 1.940, RMSEA = 0.069, CFI = 0.939, TLI = 0.929, IFI = 0.940). The Cronbach's α coefficient of the scale was 0.906. The split-half reliability of the scale was 0.704. The test-retest reliability was 0.821. Conclusion The Parenting Concerns Assessment Scale for cancer survivors demonstrates good reliability and validity, making it a suitable tool for assessing the parenting concerns level in cancer survivors. cancer survivors parenting concerns scale reliability validity 1. Introductions A cancer survivor refers to an individual from the moment of cancer diagnosis until the end of life, regardless of whether they have received treatment or whether the treatment was successful[ 1 ].With the continuous refinement and advancement of early cancer screening and therapeutic approaches, the population of cancer survivors is increasing and demonstrating a younger demographic profile[ 2 , 3 ]. Among this large and unique population of cancer survivors, it is relatively common for individuals to raise minor children while undergoing anticancer treatment(G et al., 2023;L et al., 2021). Research have shown( Ke et al., 2010) that approximately 20% of patients, while coping with the disease, also bear the responsibility of caring for minor children. The parental role not only influences treatment-related decision-making but also exacerbates patients’ psychological distress. Compared with cancer survivors without child-rearing responsibilities, those raising children exhibit a significantly higher prevalence of anxiety and depression[ 7 ].This psychological state, referred to as“parenting concerns”,is broadly defined as parents’ worries about the potential impact of cancer on their children or their own ability to provide care(MI et al. 2012).Parenting concerns impose considerable psychological burdens on cancer survivors, who, while worrying about disease treatment, simultaneously fear for the healthy development of their minor children. This dual burden contributes to elevated levels of anxiety and depression among patients[ 9 ]. It reported that parents may experience feelings of guilt and concern due to being unable to fully meet their children’s basic needs, and such distress can persist not only during the diagnostic period but for up to six years thereafter. Moreover, the parenting concerns of cancer survivors can adversely affect their children, leading to negative emotions such as depression and anxiety in their minor children. Compared with other diseases, cancer is characterized by a high genetic risk, a tendency for recurrence, and substantial economic burden, making parenting concerns more likely to arise. The psychological distress associated with parenting concerns among cancer survivors should not be overlooked[ 10 ]. Therefore, from the perspective of medical humanities and patient-centered care, addressing the parenting concerns of cancer survivors during oncological treatment holds both social significance and practical value in meeting the needs of patients and their families. Parenting concerns among cancer survivors primarily manifest as confusion about communicating the illness to their children, worries about their children’s health, the need for emotional support, and the experience of financial strain[ 11 , 12 ]. The unique stressors faced by cancer survivors as parents stem from concerns also about their children’s future, uncertainty regarding their own health, and the challenge of balancing family responsibilities with medical demands during treatment[ 13 ]. The complex psychological state of parenting concerns among cancer survivors is often influenced by multiple factors. Regarding disease-related factors, survivors diagnosed at a later stage, those with comorbidities, and those with a poorer prognosis tend to experience more pronounced psychological distress associated with parenting concerns[ 14 , 15 ]. Family-related factors play a crucial role in shaping the parenting concerns of cancer survivors, with family support being essential for alleviating their psychological distress[ 16 ]. Studies have shown[ 17 ] that communication and support among family members can help cancer survivors cope more effectively with the disease and improve their psychological well-being. Increased financial burden has been associated with heightened anxiety and worry in patients, therefore, better family economic conditions can contribute to the promotion of psychological health among cancer survivors[ 18 ]. Demographic factors also represent a significant influence on the parenting concerns of cancer survivors, with mothers experiencing more intense parenting concerns than fathers[ 19 ]. Moreover, the younger the average age of a survivor’s youngest child, the higher the level of parenting concerns reported[ 15 , 20 ]. In addition, negative cognitive regulation strategies among cancer survivors are positively correlated with the level of parenting concerns, and the severity of depression can further influence their parenting-related psychological state[ 21 ]. Therefore, given the complex psychological nature of parenting concerns in cancer survivors, it is imperative for healthcare professionals to conduct thorough assessments and develop effective, individualized intervention strategies tailored to the context of China. However, there are currently few tools available in China for assessing parenting concerns among cancer survivors, and the existing instruments each have their own limitations. The most commonly used measure for evaluating parenting concerns in cancer survivors is the Parenting Concerns Questionnaire developed by Muriel in 2012[ 22 ], which comprises three dimensions and a total of 15 items. The 15 item PCQ demonstrates good internal consistency (Cronbach’s α = .83) and encompasses three measurement dimensions: practical impact of the illness on children, emotional impact of illness on children was, concerns about co-parent. In 2021, Kang Tingting translated the Parenting Concerns Questionnaire (PCQ) into Chinese and conducted reliability and validity testing, reporting a Cronbach’s α coefficient of 0.850 for the Chinese version. However, the sample population used in the development of this scale primarily comprised well-educated women, and its specificity for different populations remains to be verified. Moreover, the PCQ was developed within a foreign cultural context, where approaches to child education differ from those in China. In China, rooted in Confucian culture, the family is the central unit, and parents hold a stronger sense of responsibility for raising and educating their children, with greater emphasis on their children’s academic performance and education. Cancer survivors in China often worry that their illness and treatment may have a negative impact on their children, particularly concerning academic achievement, social skills, and fulfillment of family responsibilities—domains that are not reflected in the PCQ. For other related scales, the assessment of parenting concerns in cancer survivors generally lacks specificity and requires validation in large samples. Therefore, there is currently no specific instrument capable of effectively and comprehensively evaluating parenting concerns among Chinese cancer survivors. It is necessary to develop a localized assessment tool tailored to China’s cultural context. This study aims to develop such a culturally adapted instrument to effectively and comprehensively assess the level of parenting concerns in cancer survivors, raise awareness among healthcare providers, patients, family members, and the wider society, and meet the supportive care needs of cancer survivors experiencing parenting concerns, will further expand both the breadth and depth of supportive care for oncology patients. 2. Methods 2.1 The formation of the initial item pool. 2.1.1 Establishing a research group The research group consisted of five members, including two chief nurses specializing in oncology, one charge nurse, and two postgraduate students. The main tasks of the group included conducting literature reviews, determining the item pool, preparing the expert inquiry questionnaire, collecting questionnaires, organizing and analyzing the opinions and rating results obtained from the expert consultations, developing the final scale. 2.1.2 Conducting a literature search and constructing the item pool The research team systematically searched databases including PubMed, Web of Science, Embase, Cochrane Library, SCOPUS, CNKI, Wanfang Medical Online, and VIP Chinese Journal Database, with the search period spanning from the establishment of each database to August 2022. After repeated preliminary searches, the final search terms are determined as: ("cancer" OR "tumor" OR" neoplasm "OR" cancer survivor) AND ("raising children" OR "nurture" OR "parenting concerns" OR "parents" OR "father" OR "mother" OR "mom" OR "child" OR "parent-child" OR "mother-child" OR "father-child") AND ("qualitative research" OR "interview" OR "feeling" OR "experience") NOT ("childhood cancer" OR "pediatric oncology" OR " children with cancer"). A total of 14,839 articles were initially retrieved. After removing duplicates, two rounds of screening, and quality assessment, 19 articles related to parenting concerns among cancer patients were finally included. Based on theoretical frameworks and literature analysis, the research team conducted discussions and preliminarily developed an initial item pool for the Parenting Concerns Scale for Cancer Survivors, consisting of 34 items with three factors. 2.2 Delphi expert consultation 2.2.1The criteria of Selection of experts Based on the research needs of the project, the following selection criteria have been established: (1) Having more than 8 years of work experience in the field of cancer, (2) Holding a senior or higher professional title, (3) Holding a bachelor's degree or higher, (4) A high level of field knowledge before this survey. 2.2.2 The formulation of the expert consultation questionnaire Following literature review and group discussions, an initial item pool for the scale was developed, and subsequently a Delphi expert consultation questionnaire was constructed. The consultation questionnaire consisted of: (1) an introductory letter to experts (introducing the background, objectives, procedures of the study and the requirements for completing the questionnaire); (2) the questionnaire itself (the experts were asked to use the LIKERT 5-point scale to score the ‘importance’ of the primary items and the ‘reasonableness’ of the secondary items in which the higher the score, the higher the degree of ‘importance and reasonableness.’); and (3) an expert information survey form (The expert information survey form included the name, age, gender, education, professional title, position, field of expertise, year of experience, judgement basis and familiarity with each item.). 2.2.3 The implementation of the Delphi expert consultation In this study, each round of the Delphi expert consultation was conducted at intervals of 2–4 weeks to allow sufficient time for experts to respond to the questionnaires. Prior to the initiation of the consultation, the researchers contacted the experts via WeChat or email to explain the study objectives and obtain their consent. Within two weeks after the completion of the first-round questionnaire, the researchers summarized and analyzed the experts’ ratings and suggestions. Items were screened according to predetermined criteria, and textual recommendations were reviewed by the research team to determine whether to add, delete, or revise items. Based on the results of the first round, the questionnaire was revised and the second round of consultation was initiated. If consensus was reached after two rounds, the consultation process was terminated; if opinions remained divergent, additional rounds were conducted until the desired level of consensus was achieved. The Delphi consultation process in this study was concluded once expert consensus had been reached[ 23 ]. 2.3 Cognitive interviewing Cognitive interviewing can help researchers determine whether respondents correctly understand the content, playing a critical role in the testing, development, evaluation, and refinement of questionnaires. It allows for the assessment of the consistency with which the target population interprets the scale items and helps minimize avoidable measurement errors[ 24 ]. 2.3.1 The method of cognitive interviewing In this study, patients’ cognitive processes were explored using verbal probing. Researchers posed questions, and patients provided responses. When patients’ answers appeared unclear or ambiguous, the researchers employed appropriate follow-up probes to gain a more accurate understanding of the patients’ cognitive processes. 2.3.2 Inclusion and exclusion criteria for cognitive interview participants The inclusion criteria: (1) diagnosed with cancer; (2) having at least one child under the age of 18; (3) voluntary participation in the study with signed informed consent. The exclusion criteria: (1) minor patients; (2) cognitive impairment, psychiatric disorders, or non-cooperation. The withdrawal criteria:(1) patients unable to continue participation due to physical condition during the study; (2) withdrawal for any other reason. 2.3.3 Data collection for cognitive interview Before conducting the cognitive interviews, researchers informed participants of the purpose, methods, potential benefits, and risks of the study. Participants were required to sign an informed consent form, indicating their understanding and willingness to participate. They completed the scale based on their own comprehension. Upon completion, the scale was revised and refined as necessary according to participants’ feedback. The number of interview rounds was determined by the principle of data saturation[ 25 ].The interview guide consisted of five questions:(1) Were you able to understand these items? Were there any words that were difficult to comprehend? (2) Are there any parenting concerns you have experienced that were not mentioned but you feel should be included? (3) How did you determine your choice of response options? Could you describe the differences between the options? (4) Did you find any options that were difficult to decide upon? (5) Do you think there are any items that require modification? 2.4 The analysis of scale item 2.4.1 Participants A convenience sampling method was employed to recruit participants from a tertiary hospital in Zhejiang Province, with inclusion and exclusion criteria consistent with those of the cognitive interviews. The required sample size for exploratory factor analysis was estimated at 5–10 times the number of items, corresponding to 125–250 participants in this study. Considering a 20% attrition rate, the target sample size was set at 150–300 participants. During the confirmatory factor analysis stage, 170 questionnaires were distributed, of which 170 were collected and 165 were deemed valid, yielding an effective response rate of 97.59%. 2.4.2 Instruments (1) General information questionnaire: designed by the research team, including variables such as sex, age, educational level, marital status, income level, cancer stage, and information about children. (2) Parenting concerns scale for cancer survivors: self-developed by the researchers and preliminarily constructed through two rounds of expert consultation and cognitive interviews. 2.4.3 Research methods 2.4.3.1 Item analysis Critical ratio method: The total scores of all participants were ranked from highest to lowest, with the top 27% designated as the high-score group and the bottom 27% as the low-score group. Independent t-tests were performed for each item, if the p-value was lower than the predetermined significance level, the null hypothesis was rejected, indicating a statistically significant difference. Criteria for item deletion included non-significant group differences or t<0.3,indicationg poor item discrimination. Correlation coefficient method: Item-total correlations were calculated, with items deleted if the correlation coefficient was r0.05). 2.4.3.2 Exploratory factor analysis (EFA) In the EFA, the cumulative variance explained by the extracted common factors was required to exceed 40%. Each retained item was expected to have a factor loading greater than 0.5 on one factor and relatively low loading on other factors, with no fewer than two items per factor. Varimax orthogonal rotation was applied, and common factors were extracted based on eigenvalues greater than 1. Items were deleted if their factor loading was 0.3 on two or more factors with differences 0.5;(2) in cases of cross-loading, the difference between the loadings > 0.15;(3) each factor contained at least three items. 2.5 Reliability and validity testing 2.5.1 Participants The inclusion and exclusion criteria were consistent with those used in the cognitive interviews. Following exploratory factor analysis, four items were deleted, leaving 21 items. The required sample size was estimated as 5–10 times the number of items, corresponding to 105–210 participants. Considering a 20% attrition rate, the target sample size was set at 126–252 participants. A total of 210 questionnaires were distributed, and 206 were collected. After excluding six invalid questionnaires that showed patterned responses, 200 valid questionnaires were included in the final analysis, yielding an effective response rate of 95.24%. 2.5.2 Research instruments Two instruments were used in this study: (1) General information questionnaire, designed by the research team, including variables such as sex, age, educational level, marital status, income level, cancer stage, and information about children. (2) Parenting concerns scale for cancer survivors (final version), developed by the researchers, consisting of three dimensions—concerns about children’s development, concerns about caregiving ability, and concerns about support systems—with a total of 21 items.2.5.3 Statistical analysis 2.5.3.1 Validity analysis Content validity: Content validity was evaluated using the content validity index (CVI), including the item-level CVI (I-CVI) and the scale-level CVI (S-CVI). When the number of experts is>6, an I-CVI ≥ 0.78 and an S-CVI ≥ 0.90 are considered acceptable. Construct validity: Construct validity was assessed using confirmatory factor analysis (CFA). The χ 2 /df <3 indicates an acceptable model fit, RMSEA<0.08 suggest good fit, and CFI, TLI, and IFI values range from 0 to 1, with higher values indicating better model fit[ 26 ]. 2.5.3.2 Reliability analysis Internal consistency reliability: a Cronbach’s α coefficient above 0.70 indicates good internal consistency among scales items. Split-half reliability: split-half reliability was assessed by calculating the correlation between two subscales, formed by dividing the items into odd- and even- numbered groups, Correlation coefficients ≥ 0.70 are generally considered acceptable. Test-retest reliability: a subset of patients completed the same scale again after 2–4 weeks. A correlation coefficient ≥ 0.70 between the two administrations was regarded as acceptable. 3. Result 3.1 The result of Delphi expert consultation 3.1.1 The general information of experts According to the research objectives, the selection criteria were established. A total of twenty experts was invited to participate in the Delphi consultation, including eighteen experts from seven hospitals (two tertiary cancer specialty hospitals, one tertiary pediatric specialty hospital, four tertiary general hospitals) and two experts from medical universities. All selected experts had an average of more than ten years of professional experience. Among them, nine were engaged in clinical nursing, one in clinical medicine, seven in nursing management, two in nursing education, one in research in institute. The general characteristics of the experts are presented in Table 1 . Table 1 Basic Information Table For Correspondence Experts(N = 20) Items Number of people(n) Composition ratio (%) Age(years) 30–39 1 5 40–49 9 45 50years~ 10 50 Professional work experience (in years) 10–19 4 20 20–29 4 20 30~ 12 60 Education Doctoral students 3 15 Master’s degree 7 35 Undergraduate 10 50 Title Senior 11 55 Associate senior 7 35 Intermediate 2 10 Professional field Clinical care 9 45 Clinical medicine 1 5 Care management 7 35 Nursing education 2 10 Social psychology 1 5 Position Clinical doctor 1 5 Clinical nurse 16 80 Nursing teacher 2 10 Researcher 1 5 3.1.2 Positive coefficient and authority coefficient of expert Two rounds of Delphi consultation were conducted in this study, with a 100% valid response rate in both rounds, including a high level of expert engagement. In the first round, the coefficients were as follows: Cr = 0.838, Ca = 0.895 and Cs = 0.780; in the second round, Cr = 0.865, Ca = 0.900, and Cs = 0.830. The authority coefficient of expert (Cr) exceeded 0.700 in both round, suggesting that the experts possessed a high degree of authority in the relevant fields, and that the results were reliable[ 27 ]. The Kendall’s W values for two rounds were 0.217 and 0.232(p<0.001), with the coefficient in the second round higher than that in the first, indicating greater consistency among expert opinions and improved consensus on the items[ 28 ]. Relevant data presented in Table 2 . Table 2 Expert Coordination Coefficients (Kendall’s W) Across Delphi Rounds The first round The second round Overall index Kendall’s W χ 2 p Kendall’s W χ 2 p 0.217 143.417 P<0.001 0.235 116.482 P<0.001 3.1.3 Modification status of the items Regarding the dimensions, five experts indicated that Dimension 1 and Dimension 2 under the primary indicators were not independent but rather overlapping, and that the description of Dimension 3 was inaccurate. After discussion within the research team, the expert’s suggestions were adopted: Dimension 1 was revised to “Concerns about children’s development”; Dimension 2 to “Concerns about caregiving ability”; and Dimension 3 to “Concerns about support systems.” With respect to the items, five items were deleted, six items were merged, five items were added, and eleven items were modified, resulting in a scale structure comprising three dimensions and 24 items. The specific revisions were as follows: deleted items (5): I worry that illness will cause my child to mature prematurely; I worry that my illness will place a burden on my child; I worry that my child will be unable to cope with the impact of cancer; I worry about the lack of parenting support from the community and I worry about not being understood by my child. Merged items (6): I worry that my child is overly concerned about my illness, I worry about being unable to take care of my child’s daily life activities, I worry about being unable to fulfill my original family role, I do not know how to answer my child’s questions about cancer, I worry that my spouse has insufficient ability to care for our child and I worry about the impact on my child’s academic performance. Items retained after expert feedback (2): I worry about the impact on my child’s social interactions and I lack strategies to disclose my illness to my child. Although these two items were questioned by experts, they both met the criterion of coefficient of variation <0.25, and group discussion suggested that such concerns are commonly experienced among parents with cancer. Therefore, the items were retained for the second round of expert consultation. Based on the results of the first round, the second-round Delphi questionnaire was developed. The indices from the second all met the predefined standards, and expert opinions gradually converged toward consensus. Based on the results of the second-round Delphi consultation and subsequent research team discussions, revisions were made to the wording and structure of the scale items. The item “I worry that my illness will reduce the family’s economic resources and create pressure on my child” was modified for subject consistency to “I worry that I will be unable to provide sufficient financial support for my child.” The Item “I lack strategies to disclose my illness to my child” was revised to “I do not know where to obtain strategies for disclosing my illness to my child.” In addition, the item “I worry that my parental role will influence my treatment decision” was categorized under Dimension 2. After two rounds of expert consultation, a scale structure comprising three dimensions and 24 items was finalized. 3.2 The result of Cognitive Interview Patients of different genders, ages, marital statuses, numbers of minor children, educational levels, cancer types, and cancer stages were purposively sampled for the interviews. In the first round of cognitive interviews, 10 cancer survivors were recruited as participants, with each interview lasting 10–15 minutes. The general information of the participants is presented in Table 3 . The results showed that most patients considered the items clear and easy to understand, while four participants raised concerns regarding certain items. Two participants indicated that the item “I worry that my spouse is unable to care for our child adequately” was vague, as spousal caregiving could involve multiple aspects. After discussion, the research team refined the item into two separate statements: “I worry that my spouse cannot adequately provide for my child’s daily living needs” and “I worry that my spouse cannot adequately provide for my child’s emotional needs.” Additionally, two participants noted that the item “I worry about the impact on my child’s academic performance” was not applicable if the child was not yet in school. The research team therefore decided that patients whose children were not of school age should select the option “1.” No additional comments were raised in the second round of cognitive interviews, and participants reported that the revised items were clear and suitable for use in the survey. The pretest version of the Parenting Concerns Scale for Cancer Survivors was thus finalized, consisting of three dimensions and 25 items. Table 3 General characteristics of patients participating in cognitive interviews(n = 10) Variable Category Number of people Composition ratio Sex Male 4 40.00 Female 6 60.00 Age(years) 20–30 2 20.00 30–40 3 30.00 >40 5 50.00 Marital Married 8 80.00 Divorced 2 20.00 Number of minor children 1–2 8 80.00 ≥ 3 2 20.00 Education level Primary school or below 3 30.00 Junior high school 2 20.00 Senior high school 2 20.00 Junior college 1 10.00 Bachelor’s degree 1 10.00 Master’s degree or above 1 10.00 Cancer type Breast cancer 2 20.00 Cervical cancer 2 20.00 Lung cancer 3 30.00 Thyroid cancer 2 20.00 Colorectal cancer 1 10.00 Cancer stage I 1 10.00 II 6 60.00 III 1 10.00 IV 2 20.00 3.3 The result of the scale item analysis 3.3.1 The general information of research objects In the exploratory factor analysis stage, 170 questionnaires were distributed and 170 were collected. After excluding five invalid questionnaires with patterned responses, 165 valid questionnaires were included in the analysis, yielding ranged in age from 27 to 56 years, with a mean age of 39.42 ± 5.18 years. The sample included 46 male and 119 female cancer survivors. Most participants had two minor children, with the majority of children aged 6–12 years. In terms of occupational status, most patients were employed, and the predominant educational level was junior high school. Spouses were the primary caregivers. The study sample covered high-incidence cancers in women (e.g., breast cancer, cervical cancer), cancers with high incidence and mortality in the respiratory system (e.g., lung cancer), head and neck cancers with high prevalence (e.g., thyroid cancer, nasopharyngeal carcinoma), hematologic malignancies (e.g., lymphoma), high-incidence gastrointestinal cancers (e.g., liver cancer, colorectal cancer, gastric cancer), as well as urologic cancers (e.g., kidney cancer). Most patients were diagnosed at stage II. The general characteristics of the participants are presented in Table 4 . Table 4 The general information table of research objects (n = 165) Category N (%) Category N (%) Sex Education level Mela 46(27.9%) Primary school or below 18(10.9%) Female 119(72.1%) Junior high school 50(30.3%) Age Senior high school 23(13.9%) 20–30 10(6.1%) Junior college 27(16.4%) 31–40 78(47.3%) Bachelor’s degree 42(25.5%) >40 77(46.7%) Master’s degree or above 5(3.0%) Marital status Caregiver Married 148(89.7%) Spouse 126(76.4%) Single 0(0%) Other 31(18.8%) Divorced 17(10.3%) None 8(4.8%) Widowed 0(0%) Cancer type The number of minor children Breast cancer 55(33.3%) 1 56(33.9%) Cervical cancer 14(8.5%) 2 104(63%) Lung cancer 8(4.8%) 3 4(2.4%) Thyroid cancer 21(12.7%) >3 1(0.6%) Nasopharyngeal carcinoma 31(18.8%) Type of medical insurance Lymphoma 2(1.2%) Urban–rural residents’ medical insurance 60(36.4%) Liver cancer 6(3.6%) Employee medical insurance 93(56.4%) Colorectal cancer 10(6.1%) Self-paying 12(7.3%) Gastric cancer 14(8.5%) Employment status Kidney cancer 4(2.4%) Employed 91(55.2%) Comorbidity Unemployed 74(44.8%) Yes 25(15.2%) Monthly household income No 140(84.8%) 10000 46(27.9%) I 26(15.8%) II 62(37.6%) III 34(20.6%) IV 43(26.1%) 3.3.2 The result of the analysis of scale item 3.3.2.1 Critical Ratio Results The results showed that the critical ratios for all items in the scale were greater than 3, indicating no items needed to be deleted. Details are presented in Table 5 . Table 5 The statistical measures of the critical ratio for each item(n = 165) Item t p Item t p 1 9.288 <0.001 14 9.608 <0.001 2 11.018 <0.001 15 7.521 <0.001 3 9.146 <0.001 16 11.437 <0.001 4 9.089 <0.001 17 5.152 <0.001 5 9.616 <0.001 18 7.891 <0.001 6 9.008 <0.001 19 7.166 <0.001 7 9.859 <0.001 20 6.853 <0.001 8 9.274 <0.001 21 8.656 <0.001 9 11.606 <0.001 22 3.727 <0.001 10 7.646 <0.001 23 6.953 <0.001 11 12.411 <0.001 24 5.443 <0.001 12 10.900 <0.001 25 6.070 <0.001 13 10.065 <0.001 3.3.2.2Correlation Coefficient Results The results demonstrated that all item–total correlation coefficients exceeded 0.3; therefore, all items were retained. Details are presented in Table 6 . Table 6 Correlation coefficient between each item's score and the total score of the scale. (n = 165) Item r Item r Item r Item r Item r 1 0.636** 6 0.603** 11 0.677** 16 0.617** 21 0.564** 2 0.667** 7 0.662** 12 0.655** 17 0.468** 22 0.344** 3 0.669** 8 0.624** 13 0.594** 18 0.579** 23 0.519** 4 0.601** 9 0.688** 14 0.622** 19 0.483** 24 0.481** 5 0.641** 10 0.500** 15 0.524** 20 0.529** 25 0.531** 3.3.3Result of exploratory factor analysis After item analysis, 25items were retained for exploratory factor analysis (EFA). The result showed a KMO value of 0.890 and a Bartlett’s test of sphericity of χ 2 = 2370.625, p<0.001, indicating that the data were suitable for EFA. Three factors were extracted, with a cumulative variance contribution rate of 57.427%. Item 9 showed cross-loadings on Factor 1 (0.538) and Factor 2 (0.509) and was deleted. Items 8,19 and 22 had loadings <0.50 across all factors and were deleted. In total, four items were removed, leaving three factors with 21 items. Then, a second EFA was conducted on the remaining 21 items. The results showed that all items had factor loadings > 0.50, with no cross-loadings observed. The cumulative variance contribution rate of the three factors was 61.629%, indicating that the scale demonstrated good construct validity. 3.4Reliability and validity testing of scale 3.4.1The general characteristic of Participants In the confirmatory factor analysis (CFA) stage, 210 questionnaires were distributed and 206 were collected. After excluding six invalid questionnaires with patterned responses, 200 valid questionnaires were included in the final analysis, yielding an effective response rate of 95.24%. Among the 200 participants, patients ranged in age from 27 to 56 years, with a mean age of 39.41 years. The sample included 67 male and 133 female cancer survivors. Most patients had two minor children, with the majority of children aged 6–12 years. Regarding occupational status, most patients were employed, and the predominant educational level was junior high school. Spouses were the primary caregivers. The study sample covered high-incidence cancers in women (e.g., breast cancer, cervical cancer), cancers with high incidence and mortality in the respiratory system (e.g., lung cancer), head and neck cancers with high prevalence (e.g., thyroid cancer, nasopharyngeal carcinoma), hematologic malignancies (e.g., lymphoma), high-incidence gastrointestinal cancers (e.g., liver cancer, colorectal cancer, gastric cancer), as well as urologic cancers (e.g., kidney cancer). Most patients were diagnosed at stage III. The general characteristics of the participants are presented in Table 6 . Table 6 The general information table of research objects(n = 200) Category N (%) Category N (%) Sex Education level Mela 67(33.5%) Primary school or below 30(15.0%) Female 133(66.5%) Junior high school 52(26.0%) Age Senior high school 33(16.5%) 20–30 13(6. 5%) Junior college 38(19.0%) 31–40 102(51.0%) Bachelor’s degree 43(21.5%) >40 85(42.5%) Master’s degree or above 4(2.0%) Marital status Caregiver Married 183(91.5%) Spouse 143(71.5%) Single 1(0.5%) Other 53(26.5%) Divorced 16(8.0%) None 4(2.0%) Widowed 0(0%) Cancer type The number of minor children Breast cancer 46(23.0%) 1 74(37.0%) Cervical cancer 21(10.5%) 2 115(57.5%) Lung cancer 19(9.5%) 3 10(5.0%) Thyroid cancer 37(18.5%) >3 1(0.5%) Nasopharyngeal carcinoma 9(4.5%) The age of minor children(years) Lymphoma 11(5.5%) <6 56(28.0%) Liver cancer 13(6.5%) 6–12 92(46.0%) Colorectal cancer 24(12.0%) 13–18 52(26.0%) Gastric cancer 11(5.5%) Type of medical insurance Kidney cancer 9(4.5%) Urban–rural residents’ medical insurance 82(41.0%) Comorbidity Employee medical insurance 111(55.5%) Yes 32(16.0%) Self-paying 7(3.5%) No 168(84.0%) Employment status Tumor origin Employed 124(62.0%) Primary 156(78.0%) Unemployed 76(38.0%) Secondary 44(22.0%) Monthly household income Cancer stage 10000 76(38.0%) 3.4.2Validity analysis result 3.4.2.1Content validity All 21 items were rated as either 3 or 4 points. Therefore, both the item-level content validity index(I-CV) and the scale-level content validity (S-CVI) were equal to 1 in this study. 3.4.1.2Construct Validity Confirmatory factor analysis (CFA) was conducted on the data from 200 questionnaires using AMOS software. The initial model fit indices were as follows: χ²/df = 2.655, RMSEA = 0.091, and CFI, TLI, and IFI values were 0.890, 0.875, and 0.891, respectively, suggesting that four indices were suboptimal. Based on modification indices, the model was revised. The modified model demonstrated improved fit: χ²/df = 1.940, RMSEA = 0.069, with CFI, TLI, and IFI values of 0.939, 0.929, and 0.940, respectively, indicating good model fit. The factor loadings of all items on their corresponding latent variables met the required thresholds, the average variance extracted (AVE) for each latent variable exceeded 0.50, and the composite reliability (CR) values were all > 0.80, indicating good convergent validity. Discriminant validity was assessed using the square root of AVE. In the correlation matrix, the correlation coefficient between concerns about children’s development and concerns about caregiving ability was 0.619; between concerns about children’s development and concerns about support systems was 0.417; and between concerns about caregiving ability and concerns about support systems was 0.460. All of these values were lower than the square root of the corresponding AVE on the diagonal, indicating that the scale demonstrated good discriminant validity. 3.4.3 Reliability Analysis Results 3.4.3.1 Internal Consistency Reliability As shown in Table 7 , the Cronbach’s α coefficient for the overall scale was 0.906, and the coefficients for each dimension ranged from 0.832 to 0.895, all meeting the criterion for satisfactory internal consistency. 3.4.3.2 Split-Half Reliability As presented in Table 7 , the split-half reliability coefficient for the overall scale was 0.704, and the coefficients for each factor ranged from 0.754 to 0.835, indicating good split-half reliability. 3.4.3.3 Test–Retest Reliability As shown in Table 7 , the test–retest reliability coefficient for the overall scale was 0.821, and the coefficients for each factor ranged from 0.791 to 0.842, suggesting that the scale developed in this study demonstrated good test–retest reliability. Table 7 The table of reliability statistics Dimension Cronbach’s α Split-Half Reliability Test–Retest Reliability Concerns about children’s development 0.895 0.8335 0.842 Concerns about caregiving ability 0.832 0.754 0.791 Concerns about support systems 0.857 0.805 0.838 Overall scale 0.906 0.704 0.821 4. Discussion Through an extensive review of domestic and international literature on parenting concerns among cancer survivors, the researcher found that the psychological burden associated with parenting concerns in this population cannot be ignored, and there is a clear need for supportive care. Therefore, it is necessary to develop an assessment scale applicable in clinical settings to effectively evaluate the parenting concerns of cancer survivors. Currently, available instruments for measuring parenting concerns among cancer survivors each have inherent limitations. Although the Chinese version of the Parenting Concerns Questionnaire (PCQ) has been developed, it has not been widely applied among cancer patients in China, nor has it undergone rigorous large-sample psychometric testing and validation; therefore, its applicability to Chinese cancer patients remains uncertain. Moreover, the questionnaire does not address issues related to children’s schooling and education, limiting the comprehensiveness of the assessment. Specifically, the PSI-SF and PSS demonstrate limitations regarding their applicability across different populations[ 29 , 30 ], the RCACS and RCAC-M fail to provide a comprehensive assessment of parenting concerns[ 31 , 32 ], and the PBA and CCPCS have not yet been validated in large-sample studies[ 33 , 34 ]. The lack of a robust and comprehensive assessment tool hampers healthcare professionals’ ability to identify and evaluate the parenting concerns of cancer survivors in clinical practice. Thus, it is essential to construct a more complete instrument for assessing such psychological distress. However, no localized tool tailored to the Chinese cultural context currently exists. Therefore, the scale in this study especially developed for Chinese cancer survivors is a helpful and useful tool for assessing Chinses cancer survivors’ parenting concerns. In this study, the development of the Parenting Concerns Scale for Cancer Survivors was guided by theoretical frameworks, specifically family systems theory and social ecological systems theory. These frameworks provided a basis for comprehensively analyzing and understanding the psychological status of parenting concerns among cancer survivors, thereby enhancing the scientific rigor and reliability of the scale development process. The selection of experts plays a crucial role in ensuring the reliability of the Delphi consultation[ 35 ]. In this study, 20 experts were recruited according to predefined selection criteria. Given that parenting concerns involve issues related to children’s education, the panel included not only clinical nursing experts but also nursing education experts working in academic institutions and specialists in psychosocial fields. The response rate was 100% across both rounds of Delphi consultation. In the first round, 80% of the experts provided comments, while in the second round, 40% contributed suggestions, indicating a high level of engagement. This study strictly adhered to the Delphi methodology, and the Kendall’s W values for the two rounds were 0.217 and 0.232, respectively. The higher coefficient in the second round demonstrated that experts’ opinions on the items became more consistent[ 36 ]. Therefore, the expert consultation stage in this study ensured credible input and strong content reliability. Cognitive interviewing is a method used to explore respondents’ cognitive processes when answering questions. As an important tool in the development, revision, and adaptation of scales, it playing a critical role in improving the quality and reliability of instruments[ 37 ]. In this study, purposive sampling was applied to recruit patients of different genders, ages, marital statuses, numbers of minor children, educational levels, cancer types, and cancer stages for the interviews, ensuring representativeness of the participants. Results of the first round of cognitive interview revealed that some participants raised concerns regarding specific items. In the second round of cognitive interviews, participants reported no additional concerns, suggesting that the revised items were clear and suitable for use in the survey. Through processes such as rewriting, deleting, replacing, or reordering items, cognitive interviewing improved the applicability of the pretest version of the Parenting Concerns Scale for Cancer Survivors. In this study, internal consistency reliability, split-half reliability, and test-retest reliability were used to evaluate the stability and consistency of the scale. The Cronbach’s α coefficients for the total scale and for the three dimensions—concerns about children’s growth, concerns about self-care ability, and concerns about the support system—were 0.906, 0.895, 0.832, and 0.857, respectively. The split-half reliability of the subscales ranged from 0.754 to 0.835, and the test–retest reliability ranged from 0.791 to 0.842, indicating good internal consistency and stability of the Parenting Concerns Scale for Cancer Survivors. The quality of items is critical for constructing a scale with sound reliability and validity[ 38 ]. In this study, item screening was conducted using the correlation coefficient method and the critical ratio method, while exploratory factor analysis (EFA) was applied to examine whether the data aligned with the hypothesized factor structure. Factor loadings reflect the strength of association between an item and its corresponding factor; high loadings (absolute value > 0.50) indicate a strong association and good representativeness within that dimension[ 39 ]. Accordingly, items with factor loadings 0.30 on two or more factors with differences 0.50; in cases of cross-loading, a difference > 0.15 between loadings; and at least three items loading on each factor. These criteria ensured that the final items had strong importance and good discriminative power[ 40 ]. In this study, two rounds of EFA extracted three common factors, with a cumulative variance contribution rate of 61.629%. Content validity is a key factor to ensure that a measurement tool accurately and effectively fulfills its intended purpose. In this study, item evaluation was conducted using expert judgment, the I-CVI and S-CVI are both 1.0, demonstrating excellent content validity[ 41 ]. Construct validity refers to whether the correspondence between factors and items in a measurement tool aligns with the hypothesized structure, and whether the internal components of the measurement are consistent with the theoretical domain being assessed[ 42 ]. In this study, two rounds of exploratory factor analysis extracted three common factors, with a cumulative variance contribution of 61.629%. Confirmatory factor analysis (CFA) was further conducted for validation. The initial model fit indices were: χ²/df = 2.655, RMSEA = 0.091, and CFI, TLI, and IFI values of 0.890, 0.875, and 0.891, respectively. These results indicated that the initial model fit was suboptimal, with four indicators performing inadequately. Therefore, model modifications were implemented. The revised model yielded χ²/df = 1.940, RMSEA = 0.069, and CFI, TLI, and IFI values of 0.939, 0.929, and 0.940, all of which met the acceptable thresholds for model fit, suggesting a good overall model fit. Regarding convergent validity, all item factor loadings for the latent variables met the required thresholds, with AVE>0.50 and CR>0.80, indicating satisfactory convergent validity. For discriminant validity, the correlations between the three dimensions were all lower than the square root of the corresponding AVE values on the diagonal, confirming good discriminant validity. In summary, the Parenting Concerns Scale for Cancer Survivors demonstrated strong psychometric properties, with satisfactory reliability and validity, enabling accurate and effective assessment of parenting concerns in three domains: concerns about children’s growth, concerns about self-care ability, and concerns about the support system. The final version of this scale comprises three dimensions—concerns about children’s growth, concerns about self-care ability, and concerns about the support system—with a total of 21 items. The number of items is moderate, and the wording is simple and easy for patients to understand. In this study, both the response rate and the rate of valid completion exceeded 95%, and the total completion time was less than 15 minutes. These findings indicate that the scale can be administered without increasing the burden on patients or significantly adding to the workload of clinical healthcare professionals, thus demonstrating good feasibility. 5. Limitations and future direction Although this study makes important contributions to development and validation of the Parenting Concerns Scale for Cancer Survivors, some limitations should be considered regarding the generalizability of the results. The participated in this study were recruited in one hospital in China, therefore, the reliability and validity of the scale are limited to this population. In the future, the research team should widen the scope of sampling in more cities to ensure the scale be more widely applied and verified in more areas of the country, so that this scale can be better improved and revised in the future. 6. Conclusion The present study successfully developed Parenting Concerns Scale for Cancer Survivors, which consist of three dimensions: concern about children’s growth (8 items), concerns about self-care ability (8 items), and concerns about the support system (5 items), yielding a total of 21 items. Guided by family systems theory and social ecological systems theory, the scale was constructed through a comprehensive literature review, followed by expert consultation and cognitive interview to refine item content. Rigorous statistical and professional analyses confirmed that the scale demonstrates satisfactory reliability and validity, as well as practical applicability for assessing parenting concerns among cancer survivors. Overall, this study provides a solid foundation for the evaluation of parenting concerns in this population, contributing to a deeper understanding of their psychological burden. Furthermore, the development of this scale lays the groundwork for designing targeted intervention programs aimed at alleviating parenting-related distress and improving the psychosocial well-being of cancer survivors. Declarations Ethics approval and consent to participate The study involving human participants was reviewed and approved by the Ethics Committee of Zhejiang Cancer Hospital (Approval No.: IRB-2022-444). Participants were informed about the study before giving their consent and completing the questionnaire. The article uses correct referencing for all cited materials, and the Declaration of Helsinki was followed at all stages of this research. Consent for publication Not applicable Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding No external funding Authors’ contributions Study conception and design: M.Z.; Data collection and analysis: M.Z.、L.Y.、 J.Z.; Drafting of the article: M.Z.、L.Y.; Critical revision of the article: Z.J. Acknowledgements We thank all the participants for their contribution in this study. References Me D. Nurse Faculty Beliefs and Teaching Practices for the Care of the Cancer Survivor in Undergraduate Nursing Curricula. J cancer education: official J Am Association Cancer Educ. 2017;32. https://doi.org/10.1007/s13187-016-1074-6 . Gd JI. Cancer Survivor Health Needs for Women. Prim Care. 2018;45. https://doi.org/10.1016/j.pop.2018.07.005 . Rs Z, Sw Z, Kx S, Sm RC. W, L L, [Cancer statistics in China, 2016]. 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09:40:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1861720,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7865081/v1/4f8a0e7a-9a85-4088-bae9-ed5e1aa87828.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Developing the Parenting Concerns Scale and assessment of its validity and reliability","fulltext":[{"header":"1. Introductions","content":"\u003cp\u003eA cancer survivor refers to an individual from the moment of cancer diagnosis until the end of life, regardless of whether they have received treatment or whether the treatment was successful[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].With the continuous refinement and advancement of early cancer screening and therapeutic approaches, the population of cancer survivors is increasing and demonstrating a younger demographic profile[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Among this large and unique population of cancer survivors, it is relatively common for individuals to raise minor children while undergoing anticancer treatment(G et al., 2023;L et al., 2021). Research have shown( Ke et al., 2010) that approximately 20% of patients, while coping with the disease, also bear the responsibility of caring for minor children. The parental role not only influences treatment-related decision-making but also exacerbates patients\u0026rsquo; psychological distress. Compared with cancer survivors without child-rearing responsibilities, those raising children exhibit a significantly higher prevalence of anxiety and depression[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].This psychological state, referred to as\u0026ldquo;parenting concerns\u0026rdquo;,is broadly defined as parents\u0026rsquo; worries about the potential impact of cancer on their children or their own ability to provide care(MI et al. 2012).Parenting concerns impose considerable psychological burdens on cancer survivors, who, while worrying about disease treatment, simultaneously fear for the healthy development of their minor children. This dual burden contributes to elevated levels of anxiety and depression among patients[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. It reported that parents may experience feelings of guilt and concern due to being unable to fully meet their children\u0026rsquo;s basic needs, and such distress can persist not only during the diagnostic period but for up to six years thereafter. Moreover, the parenting concerns of cancer survivors can adversely affect their children, leading to negative emotions such as depression and anxiety in their minor children. Compared with other diseases, cancer is characterized by a high genetic risk, a tendency for recurrence, and substantial economic burden, making parenting concerns more likely to arise. The psychological distress associated with parenting concerns among cancer survivors should not be overlooked[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Therefore, from the perspective of medical humanities and patient-centered care, addressing the parenting concerns of cancer survivors during oncological treatment holds both social significance and practical value in meeting the needs of patients and their families.\u003c/p\u003e\u003cp\u003eParenting concerns among cancer survivors primarily manifest as confusion about communicating the illness to their children, worries about their children\u0026rsquo;s health, the need for emotional support, and the experience of financial strain[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The unique stressors faced by cancer survivors as parents stem from concerns also about their children\u0026rsquo;s future, uncertainty regarding their own health, and the challenge of balancing family responsibilities with medical demands during treatment[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The complex psychological state of parenting concerns among cancer survivors is often influenced by multiple factors. Regarding disease-related factors, survivors diagnosed at a later stage, those with comorbidities, and those with a poorer prognosis tend to experience more pronounced psychological distress associated with parenting concerns[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Family-related factors play a crucial role in shaping the parenting concerns of cancer survivors, with family support being essential for alleviating their psychological distress[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Studies have shown[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] that communication and support among family members can help cancer survivors cope more effectively with the disease and improve their psychological well-being. Increased financial burden has been associated with heightened anxiety and worry in patients, therefore, better family economic conditions can contribute to the promotion of psychological health among cancer survivors[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Demographic factors also represent a significant influence on the parenting concerns of cancer survivors, with mothers experiencing more intense parenting concerns than fathers[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Moreover, the younger the average age of a survivor\u0026rsquo;s youngest child, the higher the level of parenting concerns reported[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In addition, negative cognitive regulation strategies among cancer survivors are positively correlated with the level of parenting concerns, and the severity of depression can further influence their parenting-related psychological state[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Therefore, given the complex psychological nature of parenting concerns in cancer survivors, it is imperative for healthcare professionals to conduct thorough assessments and develop effective, individualized intervention strategies tailored to the context of China.\u003c/p\u003e\u003cp\u003eHowever, there are currently few tools available in China for assessing parenting concerns among cancer survivors, and the existing instruments each have their own limitations. The most commonly used measure for evaluating parenting concerns in cancer survivors is the Parenting Concerns Questionnaire developed by Muriel in 2012[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], which comprises three dimensions and a total of 15 items. The 15 item PCQ demonstrates good internal consistency (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;.83) and encompasses three measurement dimensions: practical impact of the illness on children, emotional impact of illness on children was, concerns about co-parent. In 2021, Kang Tingting translated the Parenting Concerns Questionnaire (PCQ) into Chinese and conducted reliability and validity testing, reporting a Cronbach\u0026rsquo;s α coefficient of 0.850 for the Chinese version. However, the sample population used in the development of this scale primarily comprised well-educated women, and its specificity for different populations remains to be verified. Moreover, the PCQ was developed within a foreign cultural context, where approaches to child education differ from those in China. In China, rooted in Confucian culture, the family is the central unit, and parents hold a stronger sense of responsibility for raising and educating their children, with greater emphasis on their children\u0026rsquo;s academic performance and education. Cancer survivors in China often worry that their illness and treatment may have a negative impact on their children, particularly concerning academic achievement, social skills, and fulfillment of family responsibilities\u0026mdash;domains that are not reflected in the PCQ. For other related scales, the assessment of parenting concerns in cancer survivors generally lacks specificity and requires validation in large samples. Therefore, there is currently no specific instrument capable of effectively and comprehensively evaluating parenting concerns among Chinese cancer survivors. It is necessary to develop a localized assessment tool tailored to China\u0026rsquo;s cultural context. This study aims to develop such a culturally adapted instrument to effectively and comprehensively assess the level of parenting concerns in cancer survivors, raise awareness among healthcare providers, patients, family members, and the wider society, and meet the supportive care needs of cancer survivors experiencing parenting concerns, will further expand both the breadth and depth of supportive care for oncology patients.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 The formation of the initial item pool.\u003c/h2\u003e\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e\u003ch2\u003e2.1.1 Establishing a research group\u003c/h2\u003e\u003cp\u003eThe research group consisted of five members, including two chief nurses specializing in oncology, one charge nurse, and two postgraduate students. The main tasks of the group included conducting literature reviews, determining the item pool, preparing the expert inquiry questionnaire, collecting questionnaires, organizing and analyzing the opinions and rating results obtained from the expert consultations, developing the final scale.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section3\"\u003e\u003ch2\u003e2.1.2 Conducting a literature search and constructing the item pool\u003c/h2\u003e\u003cp\u003eThe research team systematically searched databases including PubMed, Web of Science, Embase, Cochrane Library, SCOPUS, CNKI, Wanfang Medical Online, and VIP Chinese Journal Database, with the search period spanning from the establishment of each database to August 2022. After repeated preliminary searches, the final search terms are determined as: (\"cancer\" OR \"tumor\" OR\" neoplasm \"OR\" cancer survivor) AND (\"raising children\" OR \"nurture\" OR \"parenting concerns\" OR \"parents\" OR \"father\" OR \"mother\" OR \"mom\" OR \"child\" OR \"parent-child\" OR \"mother-child\" OR \"father-child\") AND (\"qualitative research\" OR \"interview\" OR \"feeling\" OR \"experience\") NOT (\"childhood cancer\" OR \"pediatric oncology\" OR \" children with cancer\"). A total of 14,839 articles were initially retrieved. After removing duplicates, two rounds of screening, and quality assessment, 19 articles related to parenting concerns among cancer patients were finally included. Based on theoretical frameworks and literature analysis, the research team conducted discussions and preliminarily developed an initial item pool for the Parenting Concerns Scale for Cancer Survivors, consisting of 34 items with three factors.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Delphi expert consultation\u003c/h2\u003e\u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\u003ch2\u003e2.2.1The criteria of Selection of experts\u003c/h2\u003e\u003cp\u003eBased on the research needs of the project, the following selection criteria have been established: (1) Having more than 8 years of work experience in the field of cancer, (2) Holding a senior or higher professional title, (3) Holding a bachelor's degree or higher, (4) A high level of field knowledge before this survey.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\u003ch2\u003e2.2.2 The formulation of the expert consultation questionnaire\u003c/h2\u003e\u003cp\u003eFollowing literature review and group discussions, an initial item pool for the scale was developed, and subsequently a Delphi expert consultation questionnaire was constructed. The consultation questionnaire consisted of: (1) an introductory letter to experts (introducing the background, objectives, procedures of the study and the requirements for completing the questionnaire); (2) the questionnaire itself (the experts were asked to use the LIKERT 5-point scale to score the \u0026lsquo;importance\u0026rsquo; of the primary items and the \u0026lsquo;reasonableness\u0026rsquo; of the secondary items in which the higher the score, the higher the degree of \u0026lsquo;importance and reasonableness.\u0026rsquo;); and (3) an expert information survey form (The expert information survey form included the name, age, gender, education, professional title, position, field of expertise, year of experience, judgement basis and familiarity with each item.).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003e2.2.3 The implementation of the Delphi expert consultation\u003c/h2\u003e\u003cp\u003eIn this study, each round of the Delphi expert consultation was conducted at intervals of 2\u0026ndash;4 weeks to allow sufficient time for experts to respond to the questionnaires. Prior to the initiation of the consultation, the researchers contacted the experts via WeChat or email to explain the study objectives and obtain their consent. Within two weeks after the completion of the first-round questionnaire, the researchers summarized and analyzed the experts\u0026rsquo; ratings and suggestions. Items were screened according to predetermined criteria, and textual recommendations were reviewed by the research team to determine whether to add, delete, or revise items. Based on the results of the first round, the questionnaire was revised and the second round of consultation was initiated. If consensus was reached after two rounds, the consultation process was terminated; if opinions remained divergent, additional rounds were conducted until the desired level of consensus was achieved. The Delphi consultation process in this study was concluded once expert consensus had been reached[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Cognitive interviewing\u003c/h2\u003e\u003cp\u003eCognitive interviewing can help researchers determine whether respondents correctly understand the content, playing a critical role in the testing, development, evaluation, and refinement of questionnaires. It allows for the assessment of the consistency with which the target population interprets the scale items and helps minimize avoidable measurement errors[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section3\"\u003e\u003ch2\u003e2.3.1 The method of cognitive interviewing\u003c/h2\u003e\u003cp\u003e In this study, patients\u0026rsquo; cognitive processes were explored using verbal probing. Researchers posed questions, and patients provided responses. When patients\u0026rsquo; answers appeared unclear or ambiguous, the researchers employed appropriate follow-up probes to gain a more accurate understanding of the patients\u0026rsquo; cognitive processes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003e2.3.2 Inclusion and exclusion criteria for cognitive interview participants\u003c/h2\u003e\u003cp\u003eThe inclusion criteria: (1) diagnosed with cancer; (2) having at least one child under the age of 18; (3) voluntary participation in the study with signed informed consent. The exclusion criteria: (1) minor patients; (2) cognitive impairment, psychiatric disorders, or non-cooperation. The withdrawal criteria:(1) patients unable to continue participation due to physical condition during the study; (2) withdrawal for any other reason.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\u003ch2\u003e2.3.3 Data collection for cognitive interview\u003c/h2\u003e\u003cp\u003eBefore conducting the cognitive interviews, researchers informed participants of the purpose, methods, potential benefits, and risks of the study. Participants were required to sign an informed consent form, indicating their understanding and willingness to participate. They completed the scale based on their own comprehension. Upon completion, the scale was revised and refined as necessary according to participants\u0026rsquo; feedback. The number of interview rounds was determined by the principle of data saturation[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].The interview guide consisted of five questions:(1) Were you able to understand these items? Were there any words that were difficult to comprehend? (2) Are there any parenting concerns you have experienced that were not mentioned but you feel should be included? (3) How did you determine your choice of response options? Could you describe the differences between the options? (4) Did you find any options that were difficult to decide upon? (5) Do you think there are any items that require modification?\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e2.4 The analysis of scale item\u003c/h2\u003e\u003cdiv id=\"Sec15\" class=\"Section3\"\u003e\u003ch2\u003e2.4.1 Participants\u003c/h2\u003e\u003cp\u003eA convenience sampling method was employed to recruit participants from a tertiary hospital in Zhejiang Province, with inclusion and exclusion criteria consistent with those of the cognitive interviews. The required sample size for exploratory factor analysis was estimated at 5\u0026ndash;10 times the number of items, corresponding to 125\u0026ndash;250 participants in this study. Considering a 20% attrition rate, the target sample size was set at 150\u0026ndash;300 participants. During the confirmatory factor analysis stage, 170 questionnaires were distributed, of which 170 were collected and 165 were deemed valid, yielding an effective response rate of 97.59%.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\u003ch2\u003e2.4.2 Instruments\u003c/h2\u003e\u003cp\u003e(1) General information questionnaire: designed by the research team, including variables such as sex, age, educational level, marital status, income level, cancer stage, and information about children.\u003c/p\u003e\u003cp\u003e(2) Parenting concerns scale for cancer survivors: self-developed by the researchers and preliminarily constructed through two rounds of expert consultation and cognitive interviews.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section3\"\u003e\u003ch2\u003e2.4.3 Research methods\u003c/h2\u003e\u003cdiv id=\"Sec18\" class=\"Section4\"\u003e\u003ch2\u003e2.4.3.1 Item analysis\u003c/h2\u003e\u003cp\u003eCritical ratio method: The total scores of all participants were ranked from highest to lowest, with the top 27% designated as the high-score group and the bottom 27% as the low-score group. Independent t-tests were performed for each item, if the p-value was lower than the predetermined significance level, the null hypothesis was rejected, indicating a statistically significant difference. Criteria for item deletion included non-significant group differences or t\u0026lt;0.3,indicationg poor item discrimination.\u003c/p\u003e\u003cp\u003eCorrelation coefficient method: Item-total correlations were calculated, with items deleted if the correlation coefficient was r\u0026lt;0.3 and the correlation between the item and the total score did not reach statistical significance(p\u0026gt;0.05).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section4\"\u003e\u003ch2\u003e2.4.3.2 Exploratory factor analysis (EFA)\u003c/h2\u003e\u003cp\u003eIn the EFA, the cumulative variance explained by the extracted common factors was required to exceed 40%. Each retained item was expected to have a factor loading greater than 0.5 on one factor and relatively low loading on other factors, with no fewer than two items per factor. Varimax orthogonal rotation was applied, and common factors were extracted based on eigenvalues greater than 1. Items were deleted if their factor loading was \u0026lt;\u0026thinsp;0.5, or if cross-loading occurred (i.e., loadings\u0026thinsp;\u0026gt;\u0026thinsp;0.3 on two or more factors with differences\u0026thinsp;\u0026lt;\u0026thinsp;0.3). Criteria for item retention were as follows:(1) factor loading\u0026thinsp;\u0026gt;\u0026thinsp;0.5;(2) in cases of cross-loading, the difference between the loadings\u0026thinsp;\u0026gt;\u0026thinsp;0.15;(3) each factor contained at least three items.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Reliability and validity testing\u003c/h2\u003e\u003cdiv id=\"Sec21\" class=\"Section3\"\u003e\u003ch2\u003e2.5.1 Participants\u003c/h2\u003e\u003cp\u003eThe inclusion and exclusion criteria were consistent with those used in the cognitive interviews. Following exploratory factor analysis, four items were deleted, leaving 21 items. The required sample size was estimated as 5\u0026ndash;10 times the number of items, corresponding to 105\u0026ndash;210 participants. Considering a 20% attrition rate, the target sample size was set at 126\u0026ndash;252 participants. A total of 210 questionnaires were distributed, and 206 were collected. After excluding six invalid questionnaires that showed patterned responses, 200 valid questionnaires were included in the final analysis, yielding an effective response rate of 95.24%.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section3\"\u003e\u003ch2\u003e2.5.2 Research instruments\u003c/h2\u003e\u003cp\u003eTwo instruments were used in this study: (1) General information questionnaire, designed by the research team, including variables such as sex, age, educational level, marital status, income level, cancer stage, and information about children. (2) Parenting concerns scale for cancer survivors (final version), developed by the researchers, consisting of three dimensions\u0026mdash;concerns about children\u0026rsquo;s development, concerns about caregiving ability, and concerns about support systems\u0026mdash;with a total of 21 items.2.5.3 Statistical analysis\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section4\"\u003e\u003ch2\u003e2.5.3.1 Validity analysis\u003c/h2\u003e\u003cp\u003eContent validity: Content validity was evaluated using the content validity index (CVI), including the item-level CVI (I-CVI) and the scale-level CVI (S-CVI). When the number of experts is\u0026gt;6, an I-CVI\u0026thinsp;\u0026ge;\u0026thinsp;0.78 and an S-CVI\u0026thinsp;\u0026ge;\u0026thinsp;0.90 are considered acceptable.\u003c/p\u003e\u003cp\u003eConstruct validity: Construct validity was assessed using confirmatory factor analysis (CFA). The χ\u003csup\u003e2\u003c/sup\u003e/df \u0026lt;3 indicates an acceptable model fit, RMSEA\u0026lt;0.08 suggest good fit, and CFI, TLI, and IFI values range from 0 to 1, with higher values indicating better model fit[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section4\"\u003e\u003ch2\u003e2.5.3.2 Reliability analysis\u003c/h2\u003e\u003cp\u003eInternal consistency reliability: a Cronbach\u0026rsquo;s α coefficient above 0.70 indicates good internal consistency among scales items.\u003c/p\u003e\u003cp\u003eSplit-half reliability: split-half reliability was assessed by calculating the correlation between two subscales, formed by dividing the items into odd- and even- numbered groups, Correlation coefficients\u0026thinsp;\u0026ge;\u0026thinsp;0.70 are generally considered acceptable.\u003c/p\u003e\u003cp\u003eTest-retest reliability: a subset of patients completed the same scale again after 2\u0026ndash;4 weeks. A correlation coefficient\u0026thinsp;\u0026ge;\u0026thinsp;0.70 between the two administrations was regarded as acceptable.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"3. Result","content":"\u003cdiv id=\"Sec26\" class=\"Section2\"\u003e\u003ch2\u003e3.1 The result of Delphi expert consultation\u003c/h2\u003e\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\u003ch2\u003e3.1.1 The general information of experts\u003c/h2\u003e\u003cp\u003eAccording to the research objectives, the selection criteria were established. A total of twenty experts was invited to participate in the Delphi consultation, including eighteen experts from seven hospitals (two tertiary cancer specialty hospitals, one tertiary pediatric specialty hospital, four tertiary general hospitals) and two experts from medical universities. All selected experts had an average of more than ten years of professional experience. Among them, nine were engaged in clinical nursing, one in clinical medicine, seven in nursing management, two in nursing education, one in research in institute. The general characteristics of the experts are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBasic Information Table For Correspondence Experts(N\u0026thinsp;=\u0026thinsp;20)\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=\"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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItems\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNumber of people(n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eComposition ratio (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge(years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30\u0026ndash;39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40\u0026ndash;49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50years~\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProfessional work experience (in years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u0026ndash;19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u0026ndash;29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30~\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDoctoral students\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMaster\u0026rsquo;s degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUndergraduate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTitle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSenior\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAssociate senior\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntermediate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProfessional field\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eClinical care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eClinical medicine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCare management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNursing education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSocial psychology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePosition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eClinical doctor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eClinical nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e80\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNursing teacher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eResearcher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\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=\"Sec28\" class=\"Section3\"\u003e\u003ch2\u003e3.1.2 Positive coefficient and authority coefficient of expert\u003c/h2\u003e\u003cp\u003eTwo rounds of Delphi consultation were conducted in this study, with a 100% valid response rate in both rounds, including a high level of expert engagement. In the first round, the coefficients were as follows: Cr\u0026thinsp;=\u0026thinsp;0.838, Ca\u0026thinsp;=\u0026thinsp;0.895 and Cs\u0026thinsp;=\u0026thinsp;0.780; in the second round, Cr\u0026thinsp;=\u0026thinsp;0.865, Ca\u0026thinsp;=\u0026thinsp;0.900, and Cs\u0026thinsp;=\u0026thinsp;0.830. The authority coefficient of expert (Cr) exceeded 0.700 in both round, suggesting that the experts possessed a high degree of authority in the relevant fields, and that the results were reliable[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The Kendall\u0026rsquo;s W values for two rounds were 0.217 and 0.232(p\u0026lt;0.001), with the coefficient in the second round higher than that in the first, indicating greater consistency among expert opinions and improved consensus on the items[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Relevant data presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\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\u003eExpert Coordination Coefficients (Kendall\u0026rsquo;s W) Across Delphi Rounds\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=\"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=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eThe first round\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eThe second round\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eOverall index\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKendall\u0026rsquo;s W\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eKendall\u0026rsquo;s W\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.217\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e143.417\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.235\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e116.482\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eP\u0026lt;0.001\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=\"Sec29\" class=\"Section3\"\u003e\u003ch2\u003e3.1.3 Modification status of the items\u003c/h2\u003e\u003cp\u003eRegarding the dimensions, five experts indicated that Dimension 1 and Dimension 2 under the primary indicators were not independent but rather overlapping, and that the description of Dimension 3 was inaccurate. After discussion within the research team, the expert\u0026rsquo;s suggestions were adopted: Dimension 1 was revised to \u0026ldquo;Concerns about children\u0026rsquo;s development\u0026rdquo;; Dimension 2 to \u0026ldquo;Concerns about caregiving ability\u0026rdquo;; and Dimension 3 to \u0026ldquo;Concerns about support systems.\u0026rdquo; With respect to the items, five items were deleted, six items were merged, five items were added, and eleven items were modified, resulting in a scale structure comprising three dimensions and 24 items.\u003c/p\u003e\u003cp\u003eThe specific revisions were as follows: deleted items (5): I worry that illness will cause my child to mature prematurely; I worry that my illness will place a burden on my child; I worry that my child will be unable to cope with the impact of cancer; I worry about the lack of parenting support from the community and I worry about not being understood by my child. Merged items (6): I worry that my child is overly concerned about my illness, I worry about being unable to take care of my child\u0026rsquo;s daily life activities, I worry about being unable to fulfill my original family role, I do not know how to answer my child\u0026rsquo;s questions about cancer, I worry that my spouse has insufficient ability to care for our child and I worry about the impact on my child\u0026rsquo;s academic performance. Items retained after expert feedback (2): I worry about the impact on my child\u0026rsquo;s social interactions and I lack strategies to disclose my illness to my child. Although these two items were questioned by experts, they both met the criterion of coefficient of variation \u0026lt;0.25, and group discussion suggested that such concerns are commonly experienced among parents with cancer. Therefore, the items were retained for the second round of expert consultation. Based on the results of the first round, the second-round Delphi questionnaire was developed. The indices from the second all met the predefined standards, and expert opinions gradually converged toward consensus. Based on the results of the second-round Delphi consultation and subsequent research team discussions, revisions were made to the wording and structure of the scale items. The item \u0026ldquo;I worry that my illness will reduce the family\u0026rsquo;s economic resources and create pressure on my child\u0026rdquo; was modified for subject consistency to \u0026ldquo;I worry that I will be unable to provide sufficient financial support for my child.\u0026rdquo; The Item \u0026ldquo;I lack strategies to disclose my illness to my child\u0026rdquo; was revised to \u0026ldquo;I do not know where to obtain strategies for disclosing my illness to my child.\u0026rdquo; In addition, the item \u0026ldquo;I worry that my parental role will influence my treatment decision\u0026rdquo; was categorized under Dimension 2. After two rounds of expert consultation, a scale structure comprising three dimensions and 24 items was finalized.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec30\" class=\"Section2\"\u003e\u003ch2\u003e3.2 The result of Cognitive Interview\u003c/h2\u003e\u003cp\u003ePatients of different genders, ages, marital statuses, numbers of minor children, educational levels, cancer types, and cancer stages were purposively sampled for the interviews. In the first round of cognitive interviews, 10 cancer survivors were recruited as participants, with each interview lasting 10\u0026ndash;15 minutes. The general information of the participants is presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The results showed that most patients considered the items clear and easy to understand, while four participants raised concerns regarding certain items. Two participants indicated that the item \u0026ldquo;I worry that my spouse is unable to care for our child adequately\u0026rdquo; was vague, as spousal caregiving could involve multiple aspects. After discussion, the research team refined the item into two separate statements: \u0026ldquo;I worry that my spouse cannot adequately provide for my child\u0026rsquo;s daily living needs\u0026rdquo; and \u0026ldquo;I worry that my spouse cannot adequately provide for my child\u0026rsquo;s emotional needs.\u0026rdquo; Additionally, two participants noted that the item \u0026ldquo;I worry about the impact on my child\u0026rsquo;s academic performance\u0026rdquo; was not applicable if the child was not yet in school. The research team therefore decided that patients whose children were not of school age should select the option \u0026ldquo;1.\u0026rdquo; No additional comments were raised in the second round of cognitive interviews, and participants reported that the revised items were clear and suitable for use in the survey. The pretest version of the Parenting Concerns Scale for Cancer Survivors was thus finalized, consisting of three dimensions and 25 items.\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\u003eGeneral characteristics of patients participating in cognitive interviews(n\u0026thinsp;=\u0026thinsp;10)\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=\"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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNumber of people\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eComposition ratio\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e40.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e60.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge(years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u0026ndash;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30\u0026ndash;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e30.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e80.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDivorced\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of minor children\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u0026ndash;2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e80.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary school or below\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e30.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eJunior high school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSenior high school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eJunior college\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMaster\u0026rsquo;s degree or above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCancer type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBreast cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCervical cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLung cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e30.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThyroid cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eColorectal cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCancer stage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eII\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e60.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIII\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20.00\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=\"Sec31\" class=\"Section2\"\u003e\u003ch2\u003e3.3 The result of the scale item analysis\u003c/h2\u003e\u003cdiv id=\"Sec32\" class=\"Section3\"\u003e\u003ch2\u003e3.3.1 The general information of research objects\u003c/h2\u003e\u003cp\u003eIn the exploratory factor analysis stage, 170 questionnaires were distributed and 170 were collected. After excluding five invalid questionnaires with patterned responses, 165 valid questionnaires were included in the analysis, yielding ranged in age from 27 to 56 years, with a mean age of 39.42\u0026thinsp;\u0026plusmn;\u0026thinsp;5.18 years. The sample included 46 male and 119 female cancer survivors. Most participants had two minor children, with the majority of children aged 6\u0026ndash;12 years. In terms of occupational status, most patients were employed, and the predominant educational level was junior high school. Spouses were the primary caregivers. The study sample covered high-incidence cancers in women (e.g., breast cancer, cervical cancer), cancers with high incidence and mortality in the respiratory system (e.g., lung cancer), head and neck cancers with high prevalence (e.g., thyroid cancer, nasopharyngeal carcinoma), hematologic malignancies (e.g., lymphoma), high-incidence gastrointestinal cancers (e.g., liver cancer, colorectal cancer, gastric cancer), as well as urologic cancers (e.g., kidney cancer). Most patients were diagnosed at stage II. The general characteristics of the participants are presented in 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\u003eThe general information table of research objects (n\u0026thinsp;=\u0026thinsp;165)\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\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN (%)\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\u003eSex\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMela\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46(27.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrimary school or below\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e18(10.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e119(72.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eJunior high school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e50(30.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSenior high school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e23(13.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u0026ndash;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10(6.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eJunior college\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e27(16.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e31\u0026ndash;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e78(47.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e42(25.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e77(46.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMaster\u0026rsquo;s degree or above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5(3.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eCaregiver\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e148(89.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSpouse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e126(76.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e31(18.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDivorced\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17(10.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8(4.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWidowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eCancer type\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eThe number of minor children\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBreast cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e55(33.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e56(33.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCervical cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e14(8.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e104(63%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLung cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8(4.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(2.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eThyroid cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e21(12.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1(0.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNasopharyngeal carcinoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e31(18.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eType of medical insurance\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLymphoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2(1.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrban\u0026ndash;rural residents\u0026rsquo; medical insurance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e60(36.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLiver cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6(3.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmployee medical insurance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e93(56.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eColorectal cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10(6.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-paying\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12(7.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGastric cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e14(8.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEmployment status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eKidney cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4(2.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e91(55.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eComorbidity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnemployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e74(44.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e25(15.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMonthly household income\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e140(84.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;2000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14(8.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eTumor origin\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2000\u0026ndash;5000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37(22.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e124(75.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5001\u0026ndash;8000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40(24.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e41(24.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8001\u0026ndash;10000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28(17.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eCancer stage\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;10000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46(27.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e26(15.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eII\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e62(37.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIII\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e34(20.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e43(26.1%)\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=\"Sec33\" class=\"Section3\"\u003e\u003ch2\u003e3.3.2 The result of the analysis of scale item\u003c/h2\u003e\u003cdiv id=\"Sec34\" class=\"Section4\"\u003e\u003ch2\u003e3.3.2.1 Critical Ratio Results\u003c/h2\u003e\u003cp\u003eThe results showed that the critical ratios for all items in the scale were greater than 3, indicating no items needed to be deleted. Details are presented in 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\u003eThe statistical measures of the critical ratio for each item(n\u0026thinsp;=\u0026thinsp;165)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003et\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eItem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003et\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.288\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.608\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11.018\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.521\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.146\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e11.437\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.089\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.152\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.616\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.891\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.008\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.166\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.859\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6.853\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.274\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.656\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11.606\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.727\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7.646\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6.953\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.411\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.443\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.900\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6.070\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.065\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;0.001\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\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec35\" class=\"Section4\"\u003e\u003ch2\u003e3.3.2.2Correlation Coefficient Results\u003c/h2\u003e\u003cp\u003eThe results demonstrated that all item\u0026ndash;total correlation coefficients exceeded 0.3; therefore, all items were retained. Details are presented in Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCorrelation coefficient between each item's score and the total score of the scale. (n\u0026thinsp;=\u0026thinsp;165)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"10\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"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\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003er\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eItem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003er\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eItem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003er\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eItem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003er\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eItem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003er\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.636**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.603**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.677**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.617**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.564**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.667**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.662**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.655**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.468**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.344**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.669**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.624**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.594**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.579**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.519**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.601**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.688**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.622**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.483**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.481**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.641**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.500**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.524**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.529**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.531**\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\u003cdiv id=\"Sec36\" class=\"Section3\"\u003e\u003ch2\u003e3.3.3Result of exploratory factor analysis\u003c/h2\u003e\u003cp\u003eAfter item analysis, 25items were retained for exploratory factor analysis (EFA). The result showed a KMO value of 0.890 and a Bartlett\u0026rsquo;s test of sphericity of χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;2370.625, p\u0026lt;0.001, indicating that the data were suitable for EFA. Three factors were extracted, with a cumulative variance contribution rate of 57.427%. Item 9 showed cross-loadings on Factor 1 (0.538) and Factor 2 (0.509) and was deleted. Items 8,19 and 22 had loadings \u0026lt;0.50 across all factors and were deleted. In total, four items were removed, leaving three factors with 21 items. Then, a second EFA was conducted on the remaining 21 items. The results showed that all items had factor loadings\u0026thinsp;\u0026gt;\u0026thinsp;0.50, with no cross-loadings observed. The cumulative variance contribution rate of the three factors was 61.629%, indicating that the scale demonstrated good construct validity.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec37\" class=\"Section2\"\u003e\u003ch2\u003e3.4Reliability and validity testing of scale\u003c/h2\u003e\u003cdiv id=\"Sec38\" class=\"Section3\"\u003e\u003ch2\u003e3.4.1The general characteristic of Participants\u003c/h2\u003e\u003cp\u003eIn the confirmatory factor analysis (CFA) stage, 210 questionnaires were distributed and 206 were collected. After excluding six invalid questionnaires with patterned responses, 200 valid questionnaires were included in the final analysis, yielding an effective response rate of 95.24%. Among the 200 participants, patients ranged in age from 27 to 56 years, with a mean age of 39.41 years. The sample included 67 male and 133 female cancer survivors. Most patients had two minor children, with the majority of children aged 6\u0026ndash;12 years. Regarding occupational status, most patients were employed, and the predominant educational level was junior high school. Spouses were the primary caregivers. The study sample covered high-incidence cancers in women (e.g., breast cancer, cervical cancer), cancers with high incidence and mortality in the respiratory system (e.g., lung cancer), head and neck cancers with high prevalence (e.g., thyroid cancer, nasopharyngeal carcinoma), hematologic malignancies (e.g., lymphoma), high-incidence gastrointestinal cancers (e.g., liver cancer, colorectal cancer, gastric cancer), as well as urologic cancers (e.g., kidney cancer). Most patients were diagnosed at stage III. The general characteristics of the participants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe general information table of research objects(n\u0026thinsp;=\u0026thinsp;200)\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\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN (%)\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\u003eSex\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMela\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e67(33.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrimary school or below\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e30(15.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e133(66.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eJunior high school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e52(26.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSenior high school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e33(16.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u0026ndash;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13(6. 5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eJunior college\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e38(19.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e31\u0026ndash;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e102(51.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e43(21.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e85(42.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMaster\u0026rsquo;s degree or above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4(2.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eCaregiver\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e183(91.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSpouse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e143(71.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1(0.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e53(26.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDivorced\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16(8.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4(2.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWidowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eCancer type\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eThe number of minor children\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBreast cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e46(23.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e74(37.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCervical cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e21(10.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e115(57.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLung cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e19(9.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10(5.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eThyroid cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e37(18.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1(0.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNasopharyngeal carcinoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9(4.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eThe age of minor children(years)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLymphoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11(5.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e56(28.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLiver cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13(6.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u0026ndash;12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e92(46.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eColorectal cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e24(12.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u0026ndash;18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52(26.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGastric cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11(5.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eType of medical insurance\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eKidney cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9(4.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrban\u0026ndash;rural residents\u0026rsquo; medical insurance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82(41.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eComorbidity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmployee medical insurance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e111(55.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e32(16.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-paying\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7(3.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e168(84.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEmployment status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eTumor origin\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e124(62.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e156(78.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnemployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e76(38.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e44(22.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMonthly household income\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eCancer stage\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;2000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17(8.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e49(24.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2000\u0026ndash;5000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e47(23.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eII\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e51(25.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5001\u0026ndash;8000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40(20.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIII\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e57(28.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8001\u0026ndash;10000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20(10.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e43(21.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;10000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e76(38.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\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=\"Sec39\" class=\"Section3\"\u003e\u003ch2\u003e3.4.2Validity analysis result\u003c/h2\u003e\u003cdiv id=\"Sec40\" class=\"Section4\"\u003e\u003ch2\u003e3.4.2.1Content validity\u003c/h2\u003e\u003cp\u003eAll 21 items were rated as either 3 or 4 points. Therefore, both the item-level content validity index(I-CV) and the scale-level content validity (S-CVI) were equal to 1 in this study.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec41\" class=\"Section4\"\u003e\u003ch2\u003e3.4.1.2Construct Validity\u003c/h2\u003e\u003cp\u003eConfirmatory factor analysis (CFA) was conducted on the data from 200 questionnaires using AMOS software. The initial model fit indices were as follows: χ\u0026sup2;/df\u0026thinsp;=\u0026thinsp;2.655, RMSEA\u0026thinsp;=\u0026thinsp;0.091, and CFI, TLI, and IFI values were 0.890, 0.875, and 0.891, respectively, suggesting that four indices were suboptimal. Based on modification indices, the model was revised. The modified model demonstrated improved fit: χ\u0026sup2;/df\u0026thinsp;=\u0026thinsp;1.940, RMSEA\u0026thinsp;=\u0026thinsp;0.069, with CFI, TLI, and IFI values of 0.939, 0.929, and 0.940, respectively, indicating good model fit. The factor loadings of all items on their corresponding latent variables met the required thresholds, the average variance extracted (AVE) for each latent variable exceeded 0.50, and the composite reliability (CR) values were all \u0026gt;\u0026thinsp;0.80, indicating good convergent validity. Discriminant validity was assessed using the square root of AVE. In the correlation matrix, the correlation coefficient between concerns about children\u0026rsquo;s development and concerns about caregiving ability was 0.619; between concerns about children\u0026rsquo;s development and concerns about support systems was 0.417; and between concerns about caregiving ability and concerns about support systems was 0.460. All of these values were lower than the square root of the corresponding AVE on the diagonal, indicating that the scale demonstrated good discriminant validity.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec42\" class=\"Section3\"\u003e\u003ch2\u003e3.4.3 Reliability Analysis Results\u003c/h2\u003e\u003cdiv id=\"Sec43\" class=\"Section4\"\u003e\u003ch2\u003e3.4.3.1 Internal Consistency Reliability\u003c/h2\u003e\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e7\u003c/span\u003e, the Cronbach\u0026rsquo;s α coefficient for the overall scale was 0.906, and the coefficients for each dimension ranged from 0.832 to 0.895, all meeting the criterion for satisfactory internal consistency.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec44\" class=\"Section4\"\u003e\u003ch2\u003e3.4.3.2 Split-Half Reliability\u003c/h2\u003e\u003cp\u003eAs presented in Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e7\u003c/span\u003e, the split-half reliability coefficient for the overall scale was 0.704, and the coefficients for each factor ranged from 0.754 to 0.835, indicating good split-half reliability.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec45\" class=\"Section4\"\u003e\u003ch2\u003e3.4.3.3 Test\u0026ndash;Retest Reliability\u003c/h2\u003e\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e7\u003c/span\u003e, the test\u0026ndash;retest reliability coefficient for the overall scale was 0.821, and the coefficients for each factor ranged from 0.791 to 0.842, suggesting that the scale developed in this study demonstrated good test\u0026ndash;retest reliability.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe table of reliability statistics\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=\"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\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\u003eCronbach\u0026rsquo;s α\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSplit-Half Reliability\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTest\u0026ndash;Retest Reliability\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConcerns about children\u0026rsquo;s development\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.895\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.8335\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.842\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConcerns about caregiving ability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.832\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.754\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.791\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConcerns about support systems\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.857\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.805\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.838\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverall scale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.906\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.704\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.821\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\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThrough an extensive review of domestic and international literature on parenting concerns among cancer survivors, the researcher found that the psychological burden associated with parenting concerns in this population cannot be ignored, and there is a clear need for supportive care. Therefore, it is necessary to develop an assessment scale applicable in clinical settings to effectively evaluate the parenting concerns of cancer survivors. Currently, available instruments for measuring parenting concerns among cancer survivors each have inherent limitations. Although the Chinese version of the Parenting Concerns Questionnaire (PCQ) has been developed, it has not been widely applied among cancer patients in China, nor has it undergone rigorous large-sample psychometric testing and validation; therefore, its applicability to Chinese cancer patients remains uncertain. Moreover, the questionnaire does not address issues related to children\u0026rsquo;s schooling and education, limiting the comprehensiveness of the assessment. Specifically, the PSI-SF and PSS demonstrate limitations regarding their applicability across different populations[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], the RCACS and RCAC-M fail to provide a comprehensive assessment of parenting concerns[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], and the PBA and CCPCS have not yet been validated in large-sample studies[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The lack of a robust and comprehensive assessment tool hampers healthcare professionals\u0026rsquo; ability to identify and evaluate the parenting concerns of cancer survivors in clinical practice. Thus, it is essential to construct a more complete instrument for assessing such psychological distress. However, no localized tool tailored to the Chinese cultural context currently exists. Therefore, the scale in this study especially developed for Chinese cancer survivors is a helpful and useful tool for assessing Chinses cancer survivors\u0026rsquo; parenting concerns.\u003c/p\u003e\u003cp\u003eIn this study, the development of the Parenting Concerns Scale for Cancer Survivors was guided by theoretical frameworks, specifically family systems theory and social ecological systems theory. These frameworks provided a basis for comprehensively analyzing and understanding the psychological status of parenting concerns among cancer survivors, thereby enhancing the scientific rigor and reliability of the scale development process. The selection of experts plays a crucial role in ensuring the reliability of the Delphi consultation[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In this study, 20 experts were recruited according to predefined selection criteria. Given that parenting concerns involve issues related to children\u0026rsquo;s education, the panel included not only clinical nursing experts but also nursing education experts working in academic institutions and specialists in psychosocial fields. The response rate was 100% across both rounds of Delphi consultation. In the first round, 80% of the experts provided comments, while in the second round, 40% contributed suggestions, indicating a high level of engagement. This study strictly adhered to the Delphi methodology, and the Kendall\u0026rsquo;s W values for the two rounds were 0.217 and 0.232, respectively. The higher coefficient in the second round demonstrated that experts\u0026rsquo; opinions on the items became more consistent[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Therefore, the expert consultation stage in this study ensured credible input and strong content reliability.\u003c/p\u003e\u003cp\u003eCognitive interviewing is a method used to explore respondents\u0026rsquo; cognitive processes when answering questions. As an important tool in the development, revision, and adaptation of scales, it playing a critical role in improving the quality and reliability of instruments[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. In this study, purposive sampling was applied to recruit patients of different genders, ages, marital statuses, numbers of minor children, educational levels, cancer types, and cancer stages for the interviews, ensuring representativeness of the participants. Results of the first round of cognitive interview revealed that some participants raised concerns regarding specific items. In the second round of cognitive interviews, participants reported no additional concerns, suggesting that the revised items were clear and suitable for use in the survey. Through processes such as rewriting, deleting, replacing, or reordering items, cognitive interviewing improved the applicability of the pretest version of the Parenting Concerns Scale for Cancer Survivors.\u003c/p\u003e\u003cp\u003eIn this study, internal consistency reliability, split-half reliability, and test-retest reliability were used to evaluate the stability and consistency of the scale. The Cronbach\u0026rsquo;s α coefficients for the total scale and for the three dimensions\u0026mdash;concerns about children\u0026rsquo;s growth, concerns about self-care ability, and concerns about the support system\u0026mdash;were 0.906, 0.895, 0.832, and 0.857, respectively. The split-half reliability of the subscales ranged from 0.754 to 0.835, and the test\u0026ndash;retest reliability ranged from 0.791 to 0.842, indicating good internal consistency and stability of the Parenting Concerns Scale for Cancer Survivors.\u003c/p\u003e\u003cp\u003eThe quality of items is critical for constructing a scale with sound reliability and validity[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. In this study, item screening was conducted using the correlation coefficient method and the critical ratio method, while exploratory factor analysis (EFA) was applied to examine whether the data aligned with the hypothesized factor structure. Factor loadings reflect the strength of association between an item and its corresponding factor; high loadings (absolute value\u0026thinsp;\u0026gt;\u0026thinsp;0.50) indicate a strong association and good representativeness within that dimension[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Accordingly, items with factor loadings\u0026thinsp;\u0026lt;\u0026thinsp;0.50, or with cross-loadings (loadings\u0026thinsp;\u0026gt;\u0026thinsp;0.30 on two or more factors with differences\u0026thinsp;\u0026lt;\u0026thinsp;0.30), were deleted. Only items meeting the following criteria were retained: factor loading\u0026thinsp;\u0026gt;\u0026thinsp;0.50; in cases of cross-loading, a difference\u0026thinsp;\u0026gt;\u0026thinsp;0.15 between loadings; and at least three items loading on each factor. These criteria ensured that the final items had strong importance and good discriminative power[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. In this study, two rounds of EFA extracted three common factors, with a cumulative variance contribution rate of 61.629%.\u003c/p\u003e\u003cp\u003eContent validity is a key factor to ensure that a measurement tool accurately and effectively fulfills its intended purpose. In this study, item evaluation was conducted using expert judgment, the I-CVI and S-CVI are both 1.0, demonstrating excellent content validity[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Construct validity refers to whether the correspondence between factors and items in a measurement tool aligns with the hypothesized structure, and whether the internal components of the measurement are consistent with the theoretical domain being assessed[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. In this study, two rounds of exploratory factor analysis extracted three common factors, with a cumulative variance contribution of 61.629%. Confirmatory factor analysis (CFA) was further conducted for validation. The initial model fit indices were: χ\u0026sup2;/df\u0026thinsp;=\u0026thinsp;2.655, RMSEA\u0026thinsp;=\u0026thinsp;0.091, and CFI, TLI, and IFI values of 0.890, 0.875, and 0.891, respectively. These results indicated that the initial model fit was suboptimal, with four indicators performing inadequately. Therefore, model modifications were implemented. The revised model yielded χ\u0026sup2;/df\u0026thinsp;=\u0026thinsp;1.940, RMSEA\u0026thinsp;=\u0026thinsp;0.069, and CFI, TLI, and IFI values of 0.939, 0.929, and 0.940, all of which met the acceptable thresholds for model fit, suggesting a good overall model fit. Regarding convergent validity, all item factor loadings for the latent variables met the required thresholds, with AVE\u0026gt;0.50 and CR\u0026gt;0.80, indicating satisfactory convergent validity. For discriminant validity, the correlations between the three dimensions were all lower than the square root of the corresponding AVE values on the diagonal, confirming good discriminant validity. In summary, the Parenting Concerns Scale for Cancer Survivors demonstrated strong psychometric properties, with satisfactory reliability and validity, enabling accurate and effective assessment of parenting concerns in three domains: concerns about children\u0026rsquo;s growth, concerns about self-care ability, and concerns about the support system.\u003c/p\u003e\u003cp\u003eThe final version of this scale comprises three dimensions\u0026mdash;concerns about children\u0026rsquo;s growth, concerns about self-care ability, and concerns about the support system\u0026mdash;with a total of 21 items. The number of items is moderate, and the wording is simple and easy for patients to understand. In this study, both the response rate and the rate of valid completion exceeded 95%, and the total completion time was less than 15 minutes. These findings indicate that the scale can be administered without increasing the burden on patients or significantly adding to the workload of clinical healthcare professionals, thus demonstrating good feasibility.\u003c/p\u003e"},{"header":"5. Limitations and future direction","content":"\u003cp\u003eAlthough this study makes important contributions to development and validation of the Parenting Concerns Scale for Cancer Survivors, some limitations should be considered regarding the generalizability of the results. The participated in this study were recruited in one hospital in China, therefore, the reliability and validity of the scale are limited to this population. In the future, the research team should widen the scope of sampling in more cities to ensure the scale be more widely applied and verified in more areas of the country, so that this scale can be better improved and revised in the future.\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eThe present study successfully developed Parenting Concerns Scale for Cancer Survivors, which consist of three dimensions: concern about children\u0026rsquo;s growth (8 items), concerns about self-care ability (8 items), and concerns about the support system (5 items), yielding a total of 21 items. Guided by family systems theory and social ecological systems theory, the scale was constructed through a comprehensive literature review, followed by expert consultation and cognitive interview to refine item content. Rigorous statistical and professional analyses confirmed that the scale demonstrates satisfactory reliability and validity, as well as practical applicability for assessing parenting concerns among cancer survivors. Overall, this study provides a solid foundation for the evaluation of parenting concerns in this population, contributing to a deeper understanding of their psychological burden. Furthermore, the development of this scale lays the groundwork for designing targeted intervention programs aimed at alleviating parenting-related distress and improving the psychosocial well-being of cancer survivors.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study involving human participants was reviewed and approved by the Ethics Committee of Zhejiang Cancer Hospital (Approval No.: IRB-2022-444). Participants were informed about the study before giving their consent and completing the questionnaire. The article uses correct referencing for all cited materials, and the Declaration of Helsinki was followed at all stages of this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\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\u003eNo external funding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy conception and design: M.Z.; Data collection and analysis: M.Z.、L.Y.、 J.Z.; Drafting of the article: M.Z.、L.Y.; Critical revision of the article: Z.J.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all the participants for their contribution in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMe D. 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COSMIN guideline for systematic reviews of patient-reported outcome measures. Qual Life Res. 2018;27:1147\u0026ndash;57. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11136-018-1798-3\u003c/span\u003e\u003cspan address=\"10.1007/s11136-018-1798-3\" 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":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"cancer survivors, parenting concerns, scale, reliability, validity","lastPublishedDoi":"10.21203/rs.3.rs-7865081/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7865081/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eParenting concerns impose considerable psychological burdens on cancer survivors, who, while worrying about disease treatment, simultaneously fear for the healthy development of their minor children. However, the early recognition of this complicated psychological burden has not been adequately explored due to the lack of a valid and reliable scale. This research aims to provide a scientifically valid and reliable assessment tool for evaluating parenting concerns among cancer survivors.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eBased on literature review and Semi-structured qualitative interview, the item pool for the scale was generated, the preliminary scale through two rounds of Delphi expert consultation. Convenience sampling was used to select 380 cancer survivors in a tertiary hospital from September 2022 to December 2022 as the study subjects to examine the reliability and validity of the scale.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA 14-item scale with 3-factor structure was identified through exploratory factor analyses. A total of 376 questionnaires were distributed, and 365 valid questionnaires were collected, resulting in a valid response rate of 97.07%. Three common factors were extracted through two rounds of exploratory factor analysis, with cumulative variance contribution rates of 57.427% and 61.629%. Based on modification indices, the model was revised, then confirmatory factor analysis indicated good overall model fit (χ2/df\u0026thinsp;=\u0026thinsp;1.940, RMSEA\u0026thinsp;=\u0026thinsp;0.069, CFI\u0026thinsp;=\u0026thinsp;0.939, TLI\u0026thinsp;=\u0026thinsp;0.929, IFI\u0026thinsp;=\u0026thinsp;0.940). The Cronbach's α coefficient of the scale was 0.906. The split-half reliability of the scale was 0.704. The test-retest reliability was 0.821.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe Parenting Concerns Assessment Scale for cancer survivors demonstrates good reliability and validity, making it a suitable tool for assessing the parenting concerns level in cancer survivors.\u003c/p\u003e","manuscriptTitle":"Developing the Parenting Concerns Scale and assessment of its validity and reliability","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-24 08:39:53","doi":"10.21203/rs.3.rs-7865081/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-11T10:27:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-10T01:38:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-24T14:24:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"209938404086364847915303694942154241327","date":"2025-11-16T21:51:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"175528537610335309243045684815254789320","date":"2025-11-13T09:00:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"243674000287445090752096923555681583826","date":"2025-11-12T14:31:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-12T12:05:31+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-23T09:11:13+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-20T22:29:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-20T22:28:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2025-10-15T07:26:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a3e789e7-a823-4818-b220-94999eca3255","owner":[],"postedDate":"November 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T09:08:59+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-24 08:39:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7865081","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7865081","identity":"rs-7865081","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}