Introduction: Factor Analysis
The development of children’s cancer has been an uncertain matter for a number of years. Uncertainty arises during the treatment and diagnosis of cancer in children and adults. It does arise in the case of an unknown outcome of a given child who is being treated or diagnosed. It is also evident in the case of varying intensity and timing of toxicities and recovery, unpredictable illness trajectory, and ambiguous symptoms. Uncertainty is the inability to relate an illness and the diagnosis whenever needed. This may result from individual factors that influence the patient and illness specification. Stewart carried out a study where he used qualitative analysis in studying the uncertainty associated with children undergoing cancer treatment. He compiled evidence that children at the age of 9 years are able to recognize and respond to the uncertainty associated with cancer and treatment. The response they exhibit affects their psychosocial life adversely. Mishel came up with the Mishel uncertainty in Illness Scale (MUIS), which is used to test adult and children related illnesses. Mishel theory of uncertainty focused on adult illnesses and the uncertainty arising from the diagnosis of such illnesses. The scale, however, did not measure uncertainty in children with cancer.
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The Children Uncertainty Illness Scale (CUIS) was later developed, which measured chronic diseases in children and adolescents. This instrument has been reliable in the diagnosis of multiple chronic diseases in children and adolescents. The only limitation is that the construct being measured is the same as that of the adults. This means that there is no specification that has been made to cater for children and adolescents. The Limitations of using Mishel Uncertainty Illness Scale and Children Uncertainty Illness Scale led to the development of Uncertainty scale for kids (USK). To determine the reliability and validity of the instrument that is being implemented, children were being categorized into different sets and diagnosed separately. USK is the new instrument that has been developed to cater for the limitations of the other two scales. It was developed from qualitative data from earlier studies of uncertainty in children undergoing cancer treatment. There are 22 items used to analyze the scale instrument. In the development of uncertainty scale for kids’ instrument, two teams of experts were set up to verify the validity and reliability of the instrument. The 22 items were distributed as follows: six children had cancer, three were adolescent between the age of fourteen and sixteen, and three were children between the age of eight and eleven years who were being treated for cancer. The second batch of experts consisted of four masters prepared nursing clinicians with specialized skills in children cancer. All these items were to be reviewed before they are being used in the analysis of uncertainty in children with cancer.
In the development of the uncertainty scale for kids, 22 items were used which were either treated for cancer or already had cancer. The scale may have limited reliability because of using only 22 items. This happens mostly when the scale is applied to a large number of children in different countries. The other limitation of the USK is that it does not indicate the uncertainty that may arise when different kinds of cancer are being diagnosed. In the scale, the breakdown of the type of cancer that kids or young people are diagnosed with is not shown. The quantitative data used in the development of USK is indexed in MUSC. It is known for being ambiguous, unpredictable, and inconsistent. The dimensionality of the USK was developed using the exploratory factor analysis because of lack of prior identification of the USK dimension.
Describe and critique the reliability of the uncertainty scale
To analyze the reliability of the USK, it was administered to children between the age of eight and eighteen years. The children were undergoing cancer related treatment. Item analysis was either done by item total correlation or interitem. For internal consistency evaluation, cronbach’s alpha was used. The participants of this test were children who were at their early stages of cancer diagnosis. They were undergoing stem cell transplantation or post relapse. To ensure that the uncertainty scale for kids was reliable, 25 people from a single institution were requested to feel the uncertainty scale for kids for a second time. Findings using the uncertainty scale for kids indicated a strong internal consistency of croncach alpha of 0.94. From the first week test, re- test done indicated that reliability was moderately stronger with r = 0.64 and p = 0.005.
The results indicated that uncertainty scale for kids was more reliable than the Mishel uncertainty in illness scale and children uncertainty in illness scale. The instrument would be advocated in measuring the uncertainty in children with cancer. Uncertainty in children may cause a lot of stress and trauma. The uncertainty scale for kids has been found to be more reliable than the other instruments, but its reliability has been tested on a limited number of participants. Only 25 participants were involved. The sample size was small, but the same test should be carried out using a large sample size in order to validate the results. The outcome of the test should be compared with the earlier results of the small sample size to assess if there is consistency.
Describe and critique strength of the evidence for the scale’s validity
The validity of the evidence obtained was to determine the association between the time the child is diagnosed with cancer, phase of treatment, which is continuous remission verses active disease, level of cancer knowledge, psychological distress and the intensity of treatment. From the findings, content validity of uncertainty scale for kids (USK) was better compared to the content validity of MUIS and CUIS. Out of the 22 items used in the uncertainty scale of kids, 20 of them were accepted to be good. There were about five to six experts in children cancer who participated. The two remaining items were rewarded substantially. This was achieved after incorporating the children’s opinion regarding why the items were irrelevant and how they were to be improved. The six experts suggested that the 22 items were relevant. The children did not suggest of any additional content to the items. However, the 22 items were to be subjected to further psychometric evaluation.
The results of content validity of the uncertainty scale for kids indicated that the items used in the scale gave the best outcomes and did not need further improvement. This can never be the case because no item can be 100 percent relevant. In the near future, the instrument has to be improved to cater for the changing needs and circumstances of uncertainty related to cancer in children.
From the psychometric evaluation, validity of the uncertainty scale of kids is measured by the association of diagnosis, phase of treatment, intensity of treatment, level of cancer knowledge and psychological distress. The phases of treatment are either continuous, remission or active disease and anxiety.
From the results taken after using the uncertainty scale for kids (USK), the scores were moderately correlated with anxiety. This was indicated by correlation coefficient r = 0.56 at where p˂0.01. The depressive symptoms were also moderately correlated by r=0.59 p˂0.01. The scores of the uncertainty scale of kids indicated that the instrument was not correlated with the phases of treatment in both the continuous remission and active disease. Uncertainty scale for kids was not correlated significantly with time. This is because diagnosis and the cancer knowledge vary significantly from one patient to another; the valences of the scores of USK were in the expected direction. Using the post hoc exploratory analysis, cancer knowledge was significantly correlated with age by r=0.36, p˂0.01. This means that as age of the children increases, knowledge of cancer among children will increase too, thus cancer knowledge among children has a close relationship with the age of the children.
Using the uncertainty scale for kids, when age for children was controlled, it had significantly weak correlation with cancer knowledge (r=-0.27, p=0.02). The uncertainty scale for kids’ instruments suggests that cancer knowledge among children at all ages is available and as they grow up, cancer knowledge is the same. This is not true, since children are able to learn about cancer when they are much older, or when explained by parents, teachers or doctors when diagnosed with cancer.
Using the results of the scores from the uncertainty scale of the kids, shows that the USK score is not correlated with the various parameters used in psychometric evaluation of validity. They have no significant correlation with treatment, cancer knowledge, and the phases of treatment for a cancer patient. The sample size of 72 children is quite small to come up with the correlation between age of the children and either the treatment, phases of treatment or cancer knowledge.
Given the psychometric evaluation criteria, in evaluating how new instruments measure uncertainty in children with cancer, uncertainty scale for kid’s instruments, is a reliable instrument in measuring the uncertainty in children with cancer. The results show that data from the children used as a sample for the test was taken into consideration and their suggestions were incorporated in the development of the uncertainty scale for kids. The construct validity of this instrument is well demonstrated by the correlation of the uncertainty scale for kids with anxiety and depression symptoms. This indicates that in the absence of different management strategies, uncertainty will give rise to psychological distress to both the adults and the children.
The one limitation in the development of the uncertainty scale for kids, and analysis of the performance of this instrument is that the sample size used was small to reflect the outcome in the larger population. The instrument should be adopted in measuring the uncertainty in children with cancer. Its adoption will be based on how best it works together with other instruments earlier adopted like the Mishel uncertainty illness scale and children uncertainty illness scale.