Recent advances in medical technology have dramatically improved the survival rate for most types of childhood cancer. However, many survivors of childhood cancer experience physical and psychological after-effects of cancer and its treatment.1,2
Of all the after-effects, cancer-related fatigue is the most common problem reported by survivors during their recovery.3 Experiencing cancer-related fatigue can be very difficult for survivors as it can intensify other long-lasting effects of cancer treatment, such as nausea and pain.4 Evidence also suggests that fatigue may be associated with depressed mood and sleep disturbance in children undergoing cancer treatment5,6 and those surviving childhood cancer.3,7 Significantly, cancer-related fatigue can severely limit children’s ability to perform daily activities, including studying and playing. Children may need to schedule short breaks into their daily activities,8 which can negatively affect their quality of life.9,10
Although regular physical exercise has been identified as an effective way to minimize or even reverse the effects of cancer-related fatigue,11,12 adopting a sedentary lifestyle remains a common problem among the survivors of childhood cancer.13 Florin et al13 found that 52.8% of the survivors of childhood cancer in the United States did not meet the level of regular physical activity proposed by the Centers for Disease Control and Prevention. Chung et al14 found similarly low levels of physical activity among childhood cancer survivors in Hong Kong: 35.8% did not perform regular physical exercise, and only 18% were thinking of starting to exercise regularly within the next 6 months. The key issues preventing them from engaging in regular physical exercise were cancer-related fatigue and decreased muscle strength and endurance.
The results of these studies have significant implications for health promotion initiatives. Developing an appropriate intervention to reduce cancer-related fatigue and raise awareness of the importance of regular physical exercise is crucial for promoting the health of childhood cancer survivors and enhancing their quality of life. A reliable and valid instrument that can accurately assess the level of fatigue in children with cancer and those surviving the disease is a prerequisite for planning, developing, and evaluating the intervention.
The Fatigue Scale for Children (FS-C) is a promising instrument that has been widely used by researchers and healthcare professionals to measure cancer-related fatigue.15 It was developed according to the results of a qualitative study that explored patients’, parents’ and healthcare professionals’ perspectives on the characteristics of fatigue experienced by children hospitalized with cancer.16
Hockenberry et al16 examined the psychometric properties of the FS-C in a study of 149 children who were receiving cancer treatment and found that the instrument achieved high internal consistency (Cronbach’s α = .84), appropriate convergent validity (positively associated with the score for depression, with r = 0.56), and good construct validity (strong correlations between child-reported fatigue and perceptions of parents and nurses). Exploratory factor analysis indicated that the FS-C scale contained 3 underlying factors, namely, (1) not able to function, (2) lack of energy, and (3) altered mood.
The psychometric properties of the scale have since been evaluated in various studies, all of which generally supported the FS-C to be a suitable instrument for assessing fatigue in children with cancer.15 Nonetheless, and despite the fact that the FS-C has been translated into different languages and empirically tested in different populations including Chinese population in Taiwan,17 it has not been used with Hong Kong Chinese children. Hong Kong was a former British colony, and therefore, its culture was born in a sophisticated fusion of East and West. Unlike Hong Kong, Taiwan has strong Chinese roots historically and fundamentally Chinese in its cultural orientation. Because the cultural context in which Hong Kong Chinese children live is slightly different from that of children in Taiwan, the experience of illness and symptoms, in particular, the impact of cancer and its treatments, is likely to differ from that of children in Taiwan. Moreover, the official Chinese language in Taiwan is Mandarin Chinese, whereas in Hong Kong is Cantonese Chinese. Because of linguistic differences, directly applying the Taiwan Chinese version to measure cancer-related fatigue for Hong Kong Chinese children may lead to inaccurate results.18 In addition, the FS-C was originally developed to document children’s fatigue level during cancer treatment, when patients experience the highest level of fatigue. It is unclear whether the FS-C can also be used to measure fatigue in patients who have completed cancer treatment.16 This study aimed to examine the sematic and content equivalences and psychometric properties of a Chinese version of the FS-C by using a translated scale to assess fatigue in Hong Kong Chinese children who had survived cancer and evaluating the factorial structure of the scale using confirmatory factor analysis (CFA).
A cross-sectional study design was used to assess the psychometric properties of the Chinese version of the FS-C. Survivors of childhood cancer who had their follow-up in the public acute care hospital were invited to participate.
Survivors of childhood cancer who met the inclusion criteria were eligible to participate. The inclusion criteria were (1) at least 6 months since all cancer treatments had been completed; (2) aged 7 to 12 years; and (3) able to speak Cantonese and read Chinese. Children with evidence of second malignancy or with cognitive or behavioral problems in their medical records were excluded.
To examine construct validity using the known-groups technique, a group of children hospitalized with cancer (n = 50) and another group of healthy children (n = 50) were recruited from the pediatric oncology unit and a community center, respectively. The inclusion criteria for these 2 groups were (1) aged 7 to 12 years and (2) able to read Chinese and speak Cantonese. In addition, for the group of children hospitalized with cancer, they should be diagnosed with cancer within the previous 6 months and undergoing active treatment. For the group of healthy children, they should not have any history of chronic illness.
There is no agreement on sample size for CFA,19 although it is generally accepted that a larger sample size is needed when the data are not normally distributed.20 Gorsuch argues that there should be at least 5 subjects per item of the scale, and a minimum of 200 subjects is required for CFA.21 Given that there are 14 items in the FS-C, this study aimed to recruit 200 childhood cancer survivors.
Parents were asked to document the past medical condition of their children on a demographic sheet. The information included diagnosis, cancer treatment received, number of times of relapse, and the date children had completed treatment.
THE CHINESE VERSION OF THE FATIGUE SCALE—CHILD
The FS-C was designed to assess the severity of fatigue for cancer patients aged 7 to 12 years. The scale contains 14 items evaluated on a 5-point Likert scale in relation to their incidence during the previous week (1-week recall) and scored from 1 to 5 (1 = “not at all,” 2 = “a little,” 3 = “some,” 4 = “quite a bit,” 5 = “a lot”); total possible scores thus range from 14 to 70, with higher scores indicating higher levels of fatigue.16 Hockenberry et al16 examined the psychometric properties of the English version and confirmed that it is a reliable and valid instrument for measuring fatigue among children with cancer, with a Cronbach’s α coefficient of .84 and convergent validity of r = 0.56, P < .01.
THE CHINESE VERSION OF THE CENTER FOR EPIDEMIOLOGIC STUDIES DEPRESSION SCALE FOR CHILDREN
The Center for Epidemiologic Studies Depression Scale for Children was designed to assess depressive symptoms in children aged 6 to 17 years. It comprises 20 items measured on a 4-point Likert scale (0 = “not at all,” 1 = “a little,” 2 = “sometimes,” 3 = “a lot”). The possible range of scores is from 0 to 60, with higher scores representing higher levels of depression.22 Li et al23 examined the psychometric properties of the scale and determined that it is a reliable and valid instrument, with a Cronbach’s α coefficient of .82, convergent validity of r = 0.63, P < .01, and discriminant validity of r = − 0.52, P < .01.
THE CHINESE VERSION OF THE PEDIATRIC QUALITY OF LIFE INVENTORY 4.0 GENERIC CORE SCALE
The Pediatric Quality of Life Inventory Version 4.0 Generic Core Scale (PedsQL 4.0) was designed to measure children’s health-related quality of life. It comprises 23 items rated on a 5-point Likert scale.24 These items can be categorized into 4 domains: physical functioning (8 items), emotional functioning (5 items), social functioning (5 items), and school functioning (5 items). The total possible range of scores is from 0 to 100, with higher scores indicating better quality of life. Chan et al25 conducted a rigorous assessment of the scale’s psychometric properties and reported a Cronbach’s α coefficient of .86 and test-retest reliability at a 2-week interval ranging from r = 0.62 to 0.81.
A review of the literature reveals that there are 2 available versions of the FS-C: original 14-item FS-C16 and the revised 10-item FS-C.26 We found that the 14-item questionnaire is user-friendly in that Hong Kong Chinese children aged 7 to 12 years easily comprehend and are quick to complete it (generally requires 5–8 minutes to complete). Most importantly, there was a concern that some items of the original version relevant to the concept of fatigue for Hong Kong Chinese children who had survived cancer had been deleted from its short form. After a thorough discussion, we decided to translate and validate the original version of the FS-C.
The 14-item FS-C was translated according to the recommendations suggested by Bracken and Barona.27 A researcher translated the questionnaire from English to Chinese, then a bilingual translator (who did not see the original English version) translated the Chinese version back into English. A comparison was then made between the original and retranslated English versions to determine whether the meaning of the items was retained. Discrepancies were resolved by an expert panel composed of a pediatric oncology specialist, 2 researchers specializing in pediatric oncology, and 3 lecturers teaching at the local university, all of whom were bilingual and had experience in translating and validating research instruments.
Ethical approval was obtained from the institutional review board of the university before commencement. To attract eligible participants, advertisements containing the details of the study were posted in the pediatric outpatient clinic, pediatric oncology ward, and a community center. Children having their medical follow-ups in the clinic or receiving cancer treatments in the ward who were interested in taking part in the study expressed their willingness to the nurses working there. Similarly, the healthy children in the community center who were interested in participating contacted the staff there. Informed consents were then obtained from the parents, and the children were invited to sign the child’s assent forms.
After demographic data had been recorded, children who had survived cancer were asked to respond to a set of questionnaires, including the FS-C, CES-DC, and PedsQL. Children receiving cancer treatments and the healthy children in the community only had to complete the FS-C.
The expert panel was asked to evaluate the semantic equivalence of every item of the Chinese version of the FS-C on a 4-point Likert scale (1 = “not equivalent” 2 = “somewhat equivalent,” 3 = “quite equivalent,” 4 = “highly equivalent”). Any item receiving a rating of 1 or 2 from 20% of panel members was deemed not appropriate.
Content equivalence of the Chinese version of the FS-C was also assessed by the expert panel. Members were asked to rate the relevance of each item on a 4-point Likert scale, with higher ratings representing greater relevance to the construct of fatigue. Previous studies have indicated that an instrument used in scientific research should have a content validity index (CVI) of at least 0.8 for items28 and 0.78 for scale.29
The internal consistency of the Chinese version of the FS-C was assessed using Cronbach’s α. To evaluate stability, 40 participants were randomly selected from the pool and asked to respond to the translated FS-C again after 2 weeks, via telephone follow-up. Test-retest reliability of the Chinese version of the FS-C was then measured by calculating the intraclass correlation coefficient.
CONSTRUCT VALIDITY TESTING
To assess the known-groups validity, 1-way between-groups analysis of variance (ANOVA) was used to determine whether there were differences in fatigue level between the survivors of childhood cancer (n = 50, randomly selected from the pool), those receiving cancer treatments, and the healthy children. It was expected that the survivors of childhood cancer would report lower scores of the FS-C than those receiving cancer treatments but higher scores than those of the healthy children.
Convergent validity was established by finding correlation between scores on the FS-C and the CES-DC. As children experiencing a higher level of fatigue generally exhibit more depressive symptoms,30 it was anticipated that there would be a negative correlation between scores on the FS-C and the CES-DC.
Discriminant validity was demonstrated by finding correlation between scores on the FS-C and the PedsQL. As previous studies have indicated that children with a higher level of fatigue report lower quality of life,30 it was expected that a positive correlation would be observed between the scores on the FS-C and the PedsQL.
To determine whether the 3-factor structure proposed by Hockenberry et al16 adequately fits the data obtained by the translated FS-C, CFA was performed using AMOS version 20.0 for Windows. Before the analysis, the suitability of data for CFA was assessed by Bartlett’s test of sphericity and the Kaiser-Meyer-Olkin measure of sampling adequacy. The parameters were estimated by the generally weighted least-squares method using the asymptotic covariance matrix. Various fit statistics were used to assess the overall fit of the model, including the ratio of χ2 to degrees of freedom (χ2/df ratio), root mean square error of approximation (RMSEA), comparative fit index (CFI), and goodness-of-fit index (GFI). The χ2/df ratio is used to measure global fit, and a value between 1 and 5 indicates good fit. The RMSEA is used to assess model fit based on the population discrepancy function. MacCallum31 recommended that researchers should consider this index to be the most important indicator for evaluating model fit when the χ2 statistic indicates poor fit. Although an RMSEA of less than 0.05 is generally considered to indicate superior fit, scholars have argued that a value up to 0.08 suggests reasonable fit for a model in the general population.32 The CFI is used to evaluate the model against an independent model. Its value ranges from 0 to 1, with 0.95 or higher representing good fit.33 The GFI is used to assess the global fitness of data to a theoretical model. A value of 0.9 or higher indicates a good model-data fit.34
As shown in Table 1, 52.5% of participants (children who had survived cancer) in the study were male, 33.5% of the participants had suffered from leukemia, 23.0% from lymphoma, and 17.5% from brain and spinal tumors. The most frequent treatment received by the survivors (44.5%) and children hospitalized with cancer (42.0%) was chemotherapy. The mean time of recovery for the survivors was 4.2 years. In addition, there were no statistically significant differences in any of the demographic among those children who had survived cancer, those receiving cancer treatments, and those healthy children (Table 1).
The sematic equivalence for items ranged from 83% to 100%, indicating that the meanings of the translated items were equivalent to those of the original items.
The CVI was 0.71 for scale and from 0.17 to 1.00 for items, suggesting that most items, except item 8, were relevant to the concept of fatigue for Hong Kong Chinese children who had survived cancer. After removing item 8 from the analysis, the CVI was 0.83 for scale and ranged from 0.83 to 1.00 for items.
A Cronbach’s α of .88 confirmed the internal consistency of the Chinese version of the FS-C (14 items), thus supporting its use for research purposes.35 The intraclass correlation coefficient at 1-week interval was 0.93, indicating high test-retest reliability. The corrected item-total correlations ranged from 0.20 to 0.75. All of the items were highly correlated with the scale except item 8, which had a correlation of 0.20. After a thorough discussion among the panel members, it was removed from the scale. Cronbach’s α for the remaining 13 items was .91.
Results of ANOVA are shown in Table 2. The mean level of fatigue reported by the survivors was significantly lower than that of the children currently receiving cancer treatment, but statistically significantly higher than that of the healthy comparison group, with P < .05 for both. This supports the Chinese version of the FS-C having good known-group validity.
The Pearson product-moment correlation was used to analyze intercorrelations between the scores of the Chinese versions of the FS-C, CES-DC, and PedsQL. With reference to the guideline of Cohen,36 the values of 0.10 to 0.29, 0.30 to 0.49, and 0.50 to 1.0 are interpreted as small, medium, and strong correlations, respectively. The result indicated that there was a strong positive correlation between the Chinese versions of the FS-C and CES-DC, with r = 0.53 and P < .01, demonstrating that children experiencing higher levels of cancer-related fatigue reported more depressive symptoms. Moreover, a strong negative correlation was found between the scores of the Chinese versions of the FS-C and PedsQL, with r = −0.54 and P < .01, indicating that those experiencing more fatigue reported lower quality of life. The convergent validity and discriminant validity of the scales are therefore supported.
CONFIRMATORY FACTOR ANALYSIS
Confirmatory factor analysis was performed to evaluate the factorial structure of the Chinese version of the FS-C. In line with the result found by Hockenberry et al,16 a 3-factor model was proposed.
The Kaiser-Meyer-Olkin value was 0.92, which exceeded the cutoff point of 0.5, demonstrating that the sample was adequate.37 In addition, Bartlett’s test of sphericity indicated that the correlation matrix was not an identity matrix.38 The correlation matrix is factorable.
The paths between and among latent variables, observed variables, and residuals are shown in the Figure. As illustrated, the factor loadings ranged from 0.62 to 0.85, indicating that there are positive correlations between the observed and latent variables. The residuals ranged from 0.14 to 0.53, suggesting that the measurement error of this translated instrument is small.
The fit indices of this model are shown in Table 3. The χ2/df ratio, RMSEA, CFI, and GFI were 3.24, 0.05, 0.95, and 0.92, respectively, indicating that the proposed model adequately fits the data obtained using the Chinese version of the FS-C.
Fatigue is one of the most common after-effects of cancer treatment, and it adversely affects childhood cancer survivors’ physical and psychological functioning, leading to poor quality of life. An instrument to accurately measure the fatigue level for survivors of childhood cancer is lacking, yet the availability of such an instrument is a prerequisite for developing and evaluating interventions designed to reduce fatigue. This study addressed this gap by assessing the psychometric properties of the FS-C among Hong Kong Chinese children who had survived cancer.
The Cronbach’s α and intraclass correlation coefficients supported the internal consistency and test-retest reliability of the Chinese version of the FS-C, which is suitable for clinical use and research purposes. However, when analyzing correlations between the scores of every item and of the scale, the value was particularly low for item 8 (“I have been mad”), suggesting that it measures a different construct. This can probably be explained by the cultural incongruence between Hong Kong and the West. In Hong Kong, most people are influenced by the philosophy of Confucianism,39,40 which emphasizes achieving balance and harmony through the notions of chung and yung in everyday living.14 Under the influence of this philosophical value, many children surviving cancer might prefer to keep themselves calm and in control in dealing with their medical condition.39 Given this context, Hong Kong Chinese children might be less likely than Western children to manifest negative emotions, particularly a loss of temper, if they experience cancer-related fatigue. This expectation is supported by the findings of this study: in response to item 8, only a small percentage of participants reported “about half the time” (12.4%), “quite a bit” (4.1%), or “all the time” (1.4%). In addition, when assessing the content equivalence of the Chinese version of the FS-C, the value of CVI for this item was low, suggesting that it might not be relevant to the concept of cancer-related fatigue among the Hong Kong Chinese children. After a thorough discussion, the panel members decided to remove this item from the scale.
The known-group method was used to estimate the construct validity of the Chinese version of the FS-C. It is not unexpected that children undergoing cancer treatment should experience a higher level of fatigue than those surviving cancer, and their healthy comparison group should report the lowest level of fatigue. The result of a 1-way between-groups ANOVA supported good construct validity, showing that the Chinese version of the FS-C is a valid instrument that can help differentiate various groups of children with different levels of fatigue.
The convergent validity and discriminant validity of the Chinese version of the scale were confirmed by the Pearson correlation coefficients. Consistent with the literature, a strong positive correlation was found between the scores of the Chinese versions of the FS-C and CES-DC, showing that children who had higher levels of fatigue were more prone to depression.6 In addition, in accordance with the results of Western studies, a strong negative correlation was observed between the scores of the Chinese versions of the FS-C and PedsQL, indicating that the survivors’ quality of life was adversely affected by cancer-related fatigue.41 These findings support the construct validity of the Chinese translations.
The factorial structure was examined by CFA. The good-fit indices supported the proposed factor model, indicating that the underlying structure of the Chinese version of the FS-C was congruent with the original English version. This is probably due to the fact that cancer-related fatigue is a deliberating health condition that has a serious impact on children’s usual functioning.42 The cultural discrepancies between the West and Hong Kong may therefore slightly influence the survivors’ perception of fatigue, and the presentation of symptoms is rather similar.
Strengths and Limitations
The major strength of this study is to address the gap in the literature by adding further evidence that the Chinese version of the FS-C can be used as a reliable and valid tool in assessing cancer-related fatigue among Chinese children who have survived cancer. Moreover, using CFA, this study confirms the hypothesized configuration of the factor structure of the Chinese version of the FS-C.
Although this study provides empirical evidence in this area, the potential to generalize the findings is undermined by the fact that the participants were recruited from a single setting. Future study may consider recruiting subjects from more than 1 setting so as to enhance the generalizability of findings. Another limitation is that we recruited subjects with different cancer diagnoses and treatment received. One may argue that the survivorship experience is likely to be different among children with different diagnoses and treatment received. Future research may consider using homogeneous rather than heterogeneous sampling method.
Implications for Nursing Practice
One of the most important implications of this study is that the translated scale can be used to document and monitor the fatigue level of Hong Kong Chinese childhood cancer survivors and to evaluate the effectiveness of interventions on reducing fatigue. Another important implication is that the results of the study supply further evidence that children surviving cancer but reporting higher levels of fatigue after remission exhibit more depressive symptoms and report a lower quality of life. There is thus a compelling need for healthcare professionals to provide long-term follow-up for children who have survived cancer, in particular to monitor and document their levels of fatigue and the complications arising from the adverse effects of treatment. Given that cancer-related fatigue can have far-reaching effects, developing an appropriate intervention that advocates the adoption and maintenance of regular physical exercise among childhood cancer survivors is of paramount importance. Having an instrument that can accurately assess cancer-related fatigue is essential before any intervention can be planned and evaluated.
This study provides empirical evidence that the Chinese version of the FS-C is a reliable and valid instrument for measuring fatigue among Hong Kong Chinese children who have survived cancer. It also confirms that the underlying factor structure of the Chinese version of the scale is congruent with the original version. Most importantly, the FS-C can be used as a reliable and valid tool for assessing cancer-related fatigue among Hong Kong Chinese children who have survived cancer.
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