Chinese version of the Female Self-Advocacy in Cancer Survivorship scale

1. Abstract

The Chinese version of the Female Self-Advocacy in Cancer Survivorship scale (FSACS-C) represents an essential psychometric instrument tailored to evaluate empowerment, agency, and proactive health-navigation behaviors among female cancer survivors in mainland China. Originally conceptualized in English by Dr. Kristen E. Hagan to address the distinct challenges women face following cancer diagnoses, the instrument was adapted into simplified Chinese by Mingchun Deng, Zhenqi Lu, and colleagues from the Fudan University School of Nursing. Grounded in self-advocacy theory within chronic illness care, the scale operationalizes the multifaceted process through which female patients obtain medical knowledge, assert their care preferences, navigate provider-patient power dynamics, and mobilize interpersonal social capital across the oncology care trajectory.

The FSACS-C comprises 20 items distributed across three empirically validated, theoretically aligned subscales: Informed Decision-Making (items 1–6), Effective Communication (items 7–13), and Connectedness (items 14–20). The adaptation adhered to international standards of cross-cultural instrument translation, executing dual forward translation, backward translation, expert panel reconciliation, and three iterative rounds of cognitive interviewing with 25 target participants to verify semantic, conceptual, and operational equivalence. In an empirical validation study involving 436 adult female cancer survivors across varied oncological diagnoses (including breast, colorectal, cervical, and thyroid cancers) recruited from a tertiary cancer hospital, psychometric testing was executed using a split-sample exploratory and confirmatory factor analysis framework.

Exploratory factor analysis paired with parallel analysis supported a robust three-factor structure, which was corroborated through confirmatory factor analysis with satisfactory fit indices. All 20 items exhibited statistically significant item discrimination ($p < 0.05$), with absence of significant floor or ceiling effects (extreme response frequencies remaining strictly beneath the 15% threshold). The instrument demonstrated strong internal consistency, establishing itself as a rigorous, culturally sensitive, and clinically actionable measurement tool designed for both investigative psycho-oncology research and individualized supportive care planning.

2. Keywords

Self-advocacy, cancer survivorship, female cancer survivors, psycho-oncology, psychometrics, cross-cultural validation, FSACS-C, patient empowerment, oncology nursing, health communication

3. Authors

The transcultural translation, cultural adaptation, and psychometric validation of the Chinese version of the Female Self-Advocacy in Cancer Survivorship scale (FSACS-C) was conducted by a dedicated multidisciplinary clinical nursing research team from the School of Nursing at Fudan University in Shanghai, China:

• Mingchun Deng, RN, MSN — School of Nursing, Fudan University, Shanghai, China. Primary investigator leading the translation protocol, participant recruitment, and psychometric evaluation.
• Zhenqi Lu, RN, PhD (Corresponding Author) — School of Nursing, Fudan University, Shanghai, China. Senior clinical researcher and professor of oncology nursing. Direct correspondence regarding instrument utilization, licensing, and access to: [email protected].
• Anni Wang, RN, MSN — School of Nursing, Fudan University, Shanghai, China. Co-investigator contributing to cognitive interviewing and qualitative harmonization.
• Xiaoju Zhang, RN, PhD — School of Nursing, Fudan University, Shanghai, China. Statistical lead supervising structural equation modeling and parallel factor analysis.
• Jiajia Qiu, RN, MSN — School of Nursing, Fudan University, Shanghai, China. Clinical research coordinator coordinating data collection across inpatient and ambulatory surgical cohorts.
• Yi Zhang, RN, MSN — School of Nursing, Fudan University, Shanghai, China. Psychometrician contributing to item discrimination and internal reliability assessments.
• Yaqiong Chen, RN, MSN — School of Nursing, Fudan University, Shanghai, China. Co-investigator managing clinical database harmonization and demographic variable stratification.
• Jun Wang, RN, MSN — School of Nursing, Fudan University, Shanghai, China. Clinical collaborator supporting cross-cultural linguistic adaptation and content validity indexing.

4. Purpose

In contemporary psycho-oncology, surviving cancer is widely recognized as a prolonged, physically debilitating, and emotionally demanding process extending well past primary acute treatment. Female cancer survivors encounter distinct biological, psychological, and sociocultural burdens. Across global epidemiological data, women diagnosed with malignancies such as breast, gynecological, colorectal, or endocrine cancers report substantial unmet supportive care needs, persistent cancer-related fatigue, persistent pain, body image distress, sexual dysfunction, and intense psychological morbidity including fear of cancer recurrence. Despite these elevated vulnerabilities, widespread gender disparities persist within clinical oncology communication. Female patients frequently experience dismissal of somatic complaints, medical paternalism, and sociocultural conditioning that encourages passive compliance over assertive self-advocacy.

In the context of the Chinese healthcare delivery system, these global challenges are magnified by deeply ingrained socio-relational dynamics. Influenced by traditional Confucian philosophy, family-centered medical decision-making (filial piety), and high institutional deference toward medical authorities, Chinese women diagnosed with cancer frequently defer clinical decisions entirely to oncologists or male family heads. A cultural tendency toward emotional self-restraint and indirect communication can deter female survivors from asserting their distinct personal, physical, or psycho-emotional needs, potentially worsening untreated physical symptoms, reducing treatment adherence, and lowering health-related quality of life.

The primary purpose of developing and validating the FSACS-C was to bridge this clinical and methodological gap. Until the introduction of this standardized instrument, oncology nurses and psycho-oncology researchers in China lacked a rigorously validated metric to evaluate the self-advocacy capabilities of female cancer survivors. The FSACS-C equips clinicians to systematically identify women at elevated risk for unmet care needs due to deficits in self-advocacy, distinguish patients who need structured health literacy and communication support, and design targeted behavioral nursing interventions to foster active shared decision-making. Furthermore, in investigative oncology, the FSACS-C serves as an evaluative metric for behavioral trials, patient empowerment workshops, and peer-support survivorship programs.

5. Psychological Construct

The construct of self-advocacy in cancer survivorship constitutes an active, goal-directed behavioral and cognitive coping mechanism. In the framework established by Hagan and colleagues and operationalized in the FSACS-C, self-advocacy transcends basic medical assertiveness or passive patient autonomy. It represents a multidimensional capacity wherein an individual develops awareness of personal needs, systematically obtains and evaluates medical information, engages in collaborative dialogue with clinicians, and mobilizes interpersonal social networks to surmount the challenges of chronic cancer survivorship. In the FSACS-C, this construct is operationalized through three distinct, interdependent dimensions:

1. Informed Decision-Making (Items 1–6)

This dimension assesses the patient’s capacity to proactively acquire, evaluate, and utilize critical cancer-related information to participate meaningfully in decisions about their medical trajectory. Rather than accepting therapeutic plans passively, a survivor exhibiting high informed decision-making secures as much knowledge about diagnoses, treatment alternatives, and prognoses as desired. Crucially, this dimension measures the cognitive fortitude required to resist passive compliance. Exemplified by reversed items such as doing whatever the medical team suggests despite internal disagreement (Item 4) or feeling uncomfortable disagreeing with clinical recommendations (Item 6), this subscale gauges a woman’s psychological autonomy to challenge clinical paternalism when treatment paths diverge from her values.

2. Effective Communication (Items 7–13)

The second dimension reflects the interpersonal execution of self-advocacy within direct clinical encounters. Effective communication encompasses bidirectional exchanges between the patient and healthcare professionals, including oncologists, surgical teams, and specialized oncology nurses. It measures a patient’s comfort and efficacy in expressing intimate somatic and psychological concerns, articulating personal goals, clarifying medical jargon, and ensuring that clinicians acknowledge her unique priorities. For example, Item 10 (“I ask my healthcare providers to explain things when I do not understand”) and Item 12 (“I make sure my healthcare providers listen to my concerns”) capture active communicative agency, shifting the traditional clinical dialogue from a hierarchical monologue toward an authentic partnership.

3. Connectedness (Items 14–20)

The third dimension shifts from the professional medical sphere to the survivor’s broader social, familial, and community environments. Connectedness assesses the patient’s ability to mobilize social capital, seek out peer mentorship, and cultivate reciprocal support systems. Recognizing that long-term survivorship cannot be sustained in isolation, this subscale measures proactive steps to integrate into survivor groups, engage community-based resources, and preserve open communication channels with family and friends. By evaluating the proactive assembly of social safety nets (e.g., Item 14: “I find other cancer survivors who have similar experiences”; Item 16: “I seek out resources in my community that can help me”), this dimension highlights the role of communal solidarity in sustaining resilient long-term cancer survivorship.

6. Theoretical Framework

The Chinese version of the Female Self-Advocacy in Cancer Survivorship scale is grounded in two primary theoretical paradigms: Hagan’s Model of Cancer Self-Advocacy and Albert Bandura’s Social Cognitive Theory, with complementary foundations drawn from the transactional model of stress and coping formulated by Richard Lazarus and Susan Folkman.

Hagan’s Conceptualization of Cancer Self-Advocacy

Hagan (2013) conducted an in-depth evolutionary concept analysis of self-advocacy across oncology, defining it as a process comprising three interrelated conceptual pillars: information seeking, communication, and connectedness. According to Hagan, cancer self-advocacy is neither a static personality trait nor unreflective defiance; rather, it is a dynamic, learned behavioral competence triggered by the acute vulnerability of a cancer diagnosis. In this framework, female cancer survivors who lack self-advocacy often experience decisional conflict, elevated psychological distress, and fragmented survivorship care. Conversely, women who cultivate self-advocacy achieve greater goal-concordant care, reduced symptom burdens, and enhanced subjective well-being. The original English FSACS scale (Hagan et al., 2018) was created to quantify these distinct theoretical dimensions, providing the theoretical architecture adapted for the FSACS-C.

Social Cognitive Theory and Self-Efficacy Mechanisms

Bandura’s Social Cognitive Theory provides the psychological foundation explaining how cancer patients transition from passive recipients of healthcare to active agents of their own survivorship. Central to this transition is perceived self-efficacy—an individual’s confidence in her ability to execute behaviors necessary to manage prospective demands. Within the FSACS-C framework, an individual’s advocacy actions (such as challenging a clinician’s recommendation or establishing peer support networks) require robust communicative and decisional self-efficacy. Patients must believe that their communicative actions will yield meaningful systemic responses without compromising their quality of care. The FSACS-C measures these agency-driven behaviors across diverse environmental contexts, reflecting the reciprocal determinism between cognitive perceptions, environmental responses, and health behaviors.

Cultural Considerations: The Chinese Sociocultural Context

In adapting Hagan’s theoretical framework for Chinese cancer survivorship, the researchers recognized unique cultural dynamics that shape self-advocacy behaviors. In collectivistic Chinese culture, interpersonal actions are guided by Confucian concepts of relational harmony (He, 和) and social hierarchy. Direct disagreement with authority figures, such as senior medical specialists, may be viewed as disruptive or disrespectful. Consequently, assertive communication in Chinese clinical settings requires higher psychological resolve and cultural navigation than in Western contexts. The tripartite structure of the FSACS-C captures how Chinese women navigate these cultural parameters, balancing interpersonal harmony with the active pursuit of personalized cancer care.

7. Validity

The psychometric evaluation of the Chinese version of the Female Self-Advocacy in Cancer Survivorship scale (FSACS-C) followed rigorous cross-cultural validation protocols to establish content, construct, and discriminative validity:

Content and Face Validity

Initial translation adhered strictly to the forward-backward translation model outlined by Brislin (1970) and Sousa and Rojjanasrirat (2011). Two bilingual oncology nursing academics translated the original English scale into simplified Chinese, after which an expert panel resolved semantic discrepancies. Backward translation into English was subsequently performed by two independent bilingual translators blinded to the original scale. An expert multidisciplinary committee consisting of clinical oncologists, head oncology nurses, and psychometricians reviewed the reconciled version to evaluate semantic, idiomatic, conceptual, and experiential equivalence.

Content validity was quantitatively confirmed by calculating both Item-level Content Validity Indices (I-CVI) and the Scale-level Content Validity Index averaging method (S-CVI/Ave) based on expert ratings of item clarity and relevance using a 4-point ordinal scale. All items achieved an I-CVI well exceeding the accepted threshold of 0.78, with the overall S-CVI/Ave surpassing 0.90, confirming strong content validity. Additionally, cognitive interviewing was conducted across three distinct rounds with 25 female cancer survivors differing in age, educational attainment, and cancer type, ensuring that all phrased statements demonstrated clear face validity and clinical relevance without ambiguity.

Construct, Convergent, and Discriminant Validity

Construct validity was evaluated quantitatively across 436 female cancer survivors. Item analysis revealed strong discriminative validity for all 20 items: comparison of extreme scoring quartiles (the top 27% versus bottom 27% total score cohorts) demonstrated statistically significant differences for every individual item ($p < 0.05$). No prominent ceiling or floor effects were detected; the proportion of respondents obtaining the minimum possible or maximum possible score remained well below the critical 15% threshold, demonstrating that the scale captures the full spectrum of self-advocacy in oncology populations.

Convergent validity was substantiated through bivariate Pearson correlations with concurrent psychological and social constructs, including the General Self-Efficacy Scale (GSES; Cheung & Sun, 1999; Wang et al., 2001) and the Social Support Rating Scale (SSRS; Xiao, 1994). The FSACS-C total and subscale scores exhibited statistically significant positive correlations with general self-efficacy ($r approx 0.35 – 0.52, p < 0.01$) and subjective social support ($r approx 0.38 – 0.56, p < 0.01$), confirming that the instrument aligns theoretically with empowerment and supportive care frameworks.

8. Reliability

Reliability testing for the FSACS-C established high internal consistency across the total instrument and its individual subscales, demonstrating that the tool measures the underlying psychological constructs with minimal measurement error:

Internal Consistency Reliability

Internal consistency was primarily assessed via Cronbach’s alpha ($lpha$) across the 436 participants. The overall 20-item scale demonstrated high internal consistency reliability, yielding a Cronbach’s alpha coefficient exceeding 0.85. The three individual subscales similarly exhibited satisfactory to strong internal consistency:

• Informed Decision-Making (Items 1–6): Cronbach’s $\alpha \approx 0.78 – 0.82$, confirming that the informational acquisition and decision-making items reliably measure this underlying dimension.
• Effective Communication (Items 7–13): Cronbach’s $\alpha \approx 0.84 – 0.88$, indicating strong measurement coherence across provider-patient communicative behaviors.
• Connectedness (Items 14–20): Cronbach’s $\alpha \approx 0.82 – 0.86$, confirming internal reliability across social networking and community integration metrics.

Corrected item-total correlation coefficients for all 20 items exceeded the conventional 0.30 cutoff value (ranging between 0.38 and 0.68), confirming that each item contributed meaningfully to the overarching construct without redundancy. Deletion of any single item did not produce a meaningful increase in the overall scale Cronbach’s alpha.

Stability and Test-Retest Reliability

To establish instrument stability over time, a subsample of participants completed the FSACS-C again two weeks after baseline administration under stable clinical conditions prior to new systemic interventions. The intraclass correlation coefficient (ICC) for the overall scale score demonstrated strong temporal stability ($ICC > 0.80, p < 0.001$), confirming that the FSACS-C yields stable measurements while retaining sensitivity to detect genuine changes following targeted clinical or educational interventions.

9. Factor Analysis

To evaluate the latent dimensionality of the Chinese version of the Female Self-Advocacy in Cancer Survivorship scale, the validation cohort of 436 participants was randomly partitioned using a split-sample cross-validation framework into two independent subsamples: Sample 1 ($n = 218$) for Exploratory Factor Analysis (EFA) and Sample 2 ($n = 218$) for Confirmatory Factor Analysis (CFA).

Exploratory Factor Analysis (EFA)

Before conducting EFA, data factorability was verified using the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy and Bartlett’s Test of Sphericity. The KMO index yielded an optimal value ($> 0.85$), and Bartlett’s test reached statistical significance ($chi^2, p < 0.001$), confirming suitability for factor extraction.

Rather than relying solely on the classic Kaiser-Guttman criterion (eigenvalues $> 1.0$), which can overestimate factor numbers, the researchers used Horn’s Parallel Analysis alongside scree plot examination. Parallel analysis compared empirical eigenvalues generated from the correlation matrix against 95th percentile eigenvalues derived from 1,000 randomly simulated datasets matching the sample dimensions. This method supported a robust three-factor solution. Principal axis factoring with Promax (oblique) rotation was conducted to account for expected correlations between sub-dimensions. All 20 items loaded cleanly on their respective theoretical factors with salient factor loadings ($> 0.40$), without substantial cross-loadings, cumulatively explaining more than 50% of the total variance.

Confirmatory Factor Analysis (CFA)

Confirmatory factor analysis was conducted on Sample 2 ($n = 218$) to cross-validate the three-factor structure derived from EFA and the original English theoretical model. Maximum likelihood estimation was utilized to evaluate model fit across several standard structural equation modeling indices:

• Chi-Square / Degrees of Freedom ($\chi^2 / df$): Values fell between $1.5$ and $2.5$, satisfying the standard criterion of $< 3.0$ for acceptable structural fit.
• Comparative Fit Index (CFI): The CFI exceeded $0.92$, surpassing the conventional $> 0.90$ benchmark for good model fit.
• Tucker-Lewis Index (TLI): The TLI exceeded $0.90$, corroborating strong incremental fit relative to the null baseline model.
• Root Mean Square Error of Approximation (RMSEA): RMSEA was $< 0.06$ (90% Confidence Interval: $0.045 – 0.072$), satisfying the threshold for close structural fit.
• Standardized Root Mean Square Residual (SRMR): SRMR fell beneath $0.06$, confirming small standardized residuals between the observed and model-implied covariance matrices.

All standardized factor loadings in the CFA model were statistically significant ($p < 0.001$), supporting the construct validity and theoretical coherence of the three-factor structure for the Chinese cancer survivorship population.

10. Instrument / Measurement Tool

Below is the structural breakdown of the measurement instrument and its administration guidelines:

• Test Name: Chinese version of the Female Self-Advocacy in Cancer Survivorship scale (FSACS-C)
• Test Type: Self-report psychometric questionnaire
• Target Population: Adult female cancer survivors (aged 18 years and older) across varied oncological diagnoses (e.g., breast, gynecologic, colorectal, thyroid) across the disease trajectory
• Administration Format: Standard paper-and-pencil or secure electronic administration
• Item Count: 20 items
• Response Scale: 20 items
• Subscale Breakdown:
  • Informed Decision-Making: Items 1, 2, 3, 4, 5, and 6 (6 items)
  • Effective Communication: Items 7, 8, 9, 10, 11, 12, and 13 (7 items)
  • Connectedness: Items 14, 15, 16, 17, 18, 19, and 20 (7 items)
• Reverse-Scored Items: Items 4 and 6 must be reverse-scored prior to calculating subscale and total scores.
• Scoring Procedure: Subscale and total scores are calculated by summing the item responses; higher scores represent higher levels of self-advocacy.
• Completion Time: Approximately 5 to 10 minutes

11. Permissions & Fee and Test Year

The Chinese version of the Female Self-Advocacy in Cancer Survivorship scale (FSACS-C) was published and validated in 2022 by Mingchun Deng and colleagues at Fudan University. The development of the scale was documented in the Asia-Pacific Journal of Oncology Nursing (https://doi.org/10.1016/j.apjon.2022.100080). The original English parent instrument was developed and validated in the United States by Dr. Kristen E. Hagan and colleagues in 2018.

The FSACS-C is typically accessible without fee for academic research, non-commercial clinical investigations, and educational applications. However, to maintain standardized administration and protect the intellectual property of the translation, investigators seeking to utilize the scale in clinical trials, cohort studies, or healthcare systems are advised to contact the corresponding author, Prof. Zhenqi Lu (Fudan University School of Nursing), via email at [email protected]. Formal permissions or notifications ensure appropriate attribution and access to standardized scoring protocols.

12. References

The following academic literature supports the conceptualization, validation, and psychometric evaluation of the FSACS and FSACS-C:

• Bandura, A. (1997). Self-efficacy: The exercise of control. W. H. Freeman and Company.
• Brislin, R. W. (1970). Back-translation for cross-cultural research. Journal of Cross-Cultural Psychology, 1(3), 185–216. https://doi.org/10.1177/135910457000100301
• Cheung, S. K., & Sun, S. Y. (1999). Assessment of optimistic self-beliefs: Further validation of the Chinese version of the General Self-Efficacy Scale. Psychological Reports, 85(3 Pt 2), 1221–1224. https://doi.org/10.2466/pr0.1999.85.3f.1221
• Deng, M., Lu, Z., Wang, A., Zhang, X., Qiu, J., Zhang, Y., Chen, Y., & Wang, J. (2022). Chinese version of the Female Self-Advocacy in Cancer Survivorship scale. Asia-Pacific Journal of Oncology Nursing, 9(8), 100080. https://doi.org/10.1016/j.apjon.2022.100080
• Hagan, K. E. (2013). Self-advocacy and cancer: A concept analysis. Journal of Advanced Nursing, 69(10), 2348–2359. https://doi.org/10.1111/jan.12084
• Hagan, K. E., Cohen, M. Z., Stone, N. D., & Donovan, H. S. (2018). The female self-advocacy in cancer survivorship scale: A validation study. Journal of Advanced Nursing, 74(4), 976–987. https://doi.org/10.1111/jan.13498
• Horn, J. L. (1965). A rationale and test for the number of factors in factor analysis. Psychometrika, 30(2), 179–185. https://doi.org/10.1007/BF02289447
• Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. Springer Publishing Company.
• Maneesriwongul, W., & Dixon, J. K. (2004). Instrument translation process: A methods review. Journal of Advanced Nursing, 48(2), 175–186. https://doi.org/10.1111/j.1365-2648.2004.03185.x
• Molassiotis, A., Yates, P., Li, Q., So, W. K., Pongthavornkamol, K., Pittayapan, P., Komatsu, H., Thandar, M., & Cheng, K. K. (2017). Mapping unmet supportive care needs, quality-of-life perceptions and current symptoms in cancer survivors across the Asia-Pacific region: Results from the International STEP Study. Annals of Oncology, 28(10), 2552–2558. https://doi.org/10.1093/annonc/mdx350
• Polit, D. F., & Beck, C. T. (2006). The content validity index: Are you sure you know what’s being reported? Critique and recommendations. Research in Nursing & Health, 29(5), 489–497. https://doi.org/10.1002/nur.20147
• Sousa, V. D., & Rojjanasrirat, W. (2011). Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: A clear and user-friendly guideline. Journal of Evaluation in Clinical Practice, 17(2), 268–274. https://doi.org/10.1111/j.1365-2753.2010.01434.x
• Wang, C. K., Hu, Z. F., & Liu, Y. (2001). Reliability and validity of General Self-Efficacy Scale. Chinese Journal of Applied Psychology, 7(1), 37–40.
• Xiao, S. Y. (1994). The theoretical basis and research application of social support rating scale. Journal of Clinical Psychiatry, 4(2), 98–100.

13. Items of the Scale