Development and Validation of the PICC-Related Thrombosis Prevention Behavior Intention Questionnaire for Breast Cancer Patients Undergoing Chemotherapy
Objective: To develop the PICC-related thrombosis prevention behavior intention questionnaire (PTBQ) for breast cancer patients with chemotherapy and to assess its reliability and validity. Methods: Based on the theory of planned behavior, the initial item pool for the questionnaire was developed through a systematic review and semi-structured interviews. The Delphi method was applied to refine the items, forming the preliminary questionnaire. From July to August 2024, 321 patients were recruited via convenience sampling for item analysis, exploratory factor analysis (EFA), and reliability testing. Between September and December 2024, another 469 patients participated in confirmatory factor analysis (CFA). This study adhered to STROBE guidelines. Results: The final questionnaire included 5 dimensions and 26 items. Exploratory factor analysis extracted 5 common factors, the factor loading of each item ranged from 0.509 to 0.834, and the cumulative variance contribution rate was 60.267%. The overall average content validity index of the questionnaire was 0.985. The total Cronbach's a coefficient of the questionnaire was 0.892, the split-half reliability was 0.955, and the test-retest reliability was 0.965. The results of confirmatory factor analysis showed that the model fit was acceptable, and the questionnaire structure was stable. Conclusions: The PTBQ for breast cancer patients with chemotherapy has good validity and reliability, and the structure of the questionnaire is stable. The PTBQ provides a psychometrically robust instrument to evaluate patient perceptions and support targeted behavioral strategies.
[1] Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179-211. https://doi.org/10.1016/0749-5978(91)90020-t
[2] Ajzen, I. (2002). Residual effects of past on later behavior: Habituation and reasoned action perspectives. Personality and Social Psychology Review, 6(2), 107-122. https://doi.org/10.1207/s15327957pspr0602_02
[3] Ajzen, I. (2006). Constructing a theory of planned behavior questionnaire. Retrieved March 14, 2024, from https://www.researchgate.net/publication/235913732_Constructing_a_Theory_of_Planned_Behavior_Questionnaire
[4] Ajzen, I. (2011). The theory of planned behaviour: Reactions and reflections. Psychology & Health, 26(9), 1113-1127. https://doi.org/10.1080/08870446.2011.613995
[5] Ajzen, I. (2020). The theory of planned behavior: Frequently asked questions. Human Behavior and Emerging Technologies, 2(4), 314-324. https://doi.org/10.1002/hbe2.195
[6] An, J., Peng, C., Tang, H., Liu, X., & Peng, F. (2021). New advances in the research of resistance to neoadjuvant chemotherapy in breast cancer. International Journal of Molecular Sciences, 22(17), 9644. https://doi.org/10.3390/ijms22179644
[7] Armitage, C. J., & Conner, M. (2001). Efficacy of the theory of planned behaviour: A meta-analytic review. British Journal of Social Psychology, 40(4), 471-499. https://doi.org/10.1348/014466601164939
[8] Austin, P. C., & Steyerberg, E. W. (2015). The number of subjects per variable required in linear regression analyses. Journal of Clinical Epidemiology, 68(6), 627-636. https://doi.org/10.1016/j.jclinepi.2014.12.014
[9] Blanchard, C. M., Courneya, K. S., Rodgers, W. M., & Murnaghan, D. M. (2002). Determinants of exercise intention and behavior in survivors of breast and prostate cancer: An application of the theory of planned behavior. Cancer Nursing, 25(2), 88-95. https://doi.org/10.1097/00002820-200204000-00002
[10] Bosnjak, M., Ajzen, I., & Schmidt, P. (2020). The theory of planned behavior: Selected recent advances and applications. Europe's Journal of Psychology, 16(3), 352-356. https://doi.org/10.5964/ejop.v16i3.3107
[11] Britt, K. L., Cuzick, J., & Phillips, K. A. (2020). Key steps for effective breast cancer prevention. Nature Reviews Cancer, 20(8), 417-436. https://doi.org/10.1038/s41568-020-0266-x
[12] Cook, D. A., & Beckman, T. J. (2006). Current concepts in validity and reliability for psychometric instruments: Theory and application. The American Journal of Medicine, 119(2), 166.e7-166.e16. https://doi.org/10.1016/j.amjmed.2005.10.036
[13] Conner, M., Warren, R., Close, S., & Sparks, P. (1999). Alcohol consumption and the theory of planned behavior: An examination of the cognitive mediation of past behaviorid. Journal of Applied Social Psychology, 29(8), 1676-1704. https://doi.org/10.1111/j.1559-1816.1999.tb02046.x
[14] Conner, M., Sheeran, P., Norman, P., & Armitage, C. J. (2000). Temporal stability as a moderator of relationships in the theory of planned behaviour. British Journal of Social Psychology, 39(4), 469-493. https://doi.org/10.1348/014466600164598
[15] Courneya, K. S., & Friedenreich, C. M. (1999). Utility of the theory of planned behavior for understanding exercise during breast cancer treatment. Psycho-oncology, 8(2), 112-122. https://doi.org/10.1002/(SICI)1099-1611(199903/04)8:2112::AID-PON341>3.0.CO;2-L
[16] Davis, L. L. (1992). Instrument review: Getting the most from a panel of experts. Applied Nursing Research, 5(4), 194-197. https://doi.org/10.1016/s0897-1897(05)80008-4
[17] Fu, J., Cai, W., Zeng, B., He, L., Bao, L., Lin, Z., Lin, F., Hu, W., Lin, L., Huang, H., Zheng, S., Chen, L., Zhou, W., Lin, Y., & Fu, F. (2022). Development and validation of a predictive model for peripherally inserted central catheter-related thrombosis in breast cancer patients based on artificial neural network: A prospective cohort study. International Journal of Nursing Studies, 135, 104341. https://doi.org/10.1016/j.ijnurstu.2022.104341
[18] Fu, M. R. (2010). Cancer survivors' views of lymphoedema management. Journal of Lymphoedema, 5(2), 39-48. https://pubmed.ncbi.nlm.nih.gov/25505492/
[19] Han, B., Zheng, R., Zeng, H., Wang, S., Sun, K., Chen, R., Li, L., Wei, W., & He, J. (2024). Cancer incidence and mortality in China, 2022. Journal of the National Cancer Center, 4(1), 47-53. https://doi.org/10.1016/j.jncc.2024.01.006
[20] Hu, Y., Chen, X., Fan, J., Huang, Y., Ye, J., Gu, F., & Li, Y. (2023). The subjective will and psychological experience of home-based exercise in lung cancer patients during interval of chemotherapy: A qualitative study. Journal of Multidisciplinary Healthcare, 16, 663-674. https://doi.org/10.2147/jmdh.s403185
[21] Hung, C. C., Chen, C. M., Chang, Y. H., Lee, S. H., Chang, C. H., & Chen, Y. J. (2024). Development and validation of a Chinese version chronic wound health-related quality of life instrument: A methodological study. Journal of Clinical Nursing, 33(5), 1820-1829. https://doi.org/10.1111/jocn.16948
[22] International Agency for Research on Cancer. (2024). Global Cancer Observatory. Retrieved February 17, 2024, from: https://gco.iarc.who.int/media/globocan/factsheets/cancers/20-breast-fact-sheet
[23] Javadi, M., Kadkhodaee, M., Yaghoubi, M., Maroufi, M., & Shams, A. (2013). Applying theory of planned behavior in predicting of patient safety behaviors of nurses. Materia Socio-Medica, 25(1), 52-55. https://doi.org/10.5455/msm.2013.25.52-55
[24] Li, Q. L., Yan, M. Q., Lin, C., & Lu, Z. Q. (2012). A qualitative study on experience of cancer patients determined to receive PICC placement. Journal of Nursing Science, 27(5), 40-42. https://doi.org/10.3870/hlxzz.2012.05.040
[25] Li, S., Gao, Y., Lin, Y., Wu, W., Fang, Q., Ni, X., Zhou, Y., Hong, M., Zhang, R., & Lou, Y. (2023). Development and preliminary testing of the cancer-related fatigue comprehensive assessment scale in cancer survivors. Journal of Clinical Nursing, 32(7-8), 1186-1217. https://doi.org/10.1111/jocn.16272
[26] Li, W., Li, X., Chen, T., Deng, X., Zhu, J., Guo, J., Li, Y., & Ye, M. (2023). Factors affecting lung cancer patients' intention to perform early postoperative exercise: A qualitative study based on theory of planned behavior. Supportive Care in Cancer, 31(11), 649. https://doi.org/10.1007/s00520-023-08107-5
[27] Liu, K., Zhou, Y., Xie, W., Gu, Z., Jin, Y., Ye, X., Chen, X., Fan, B., Wang, H., & Cui, Y. (2018). Handgrip exercise reduces peripherally-inserted central catheter-related venous thrombosis in patients with solid cancers: A randomized controlled trial. International Journal of Nursing Studies, 86, 99-106. https://doi.org/10.1016/j.ijnurstu.2018.06.004
[28] Meng, F., Fan, S., Guo, L., Jia, Z., Chang, H., & Liu, F. (2024). Incidence and risk factors of PICC-related thrombosis in breast cancer: A meta-analysis. Japanese Journal of Clinical Oncology, 54(8), 863-872. https://doi.org/10.1093/jjco/hyae055
[29] Mikkelsen, M. K., Nielsen, D. L., Vinther, A., Lund, C. M., & Jarden, M. (2019). Attitudes towards physical activity and exercise in older patients with advanced cancer during oncological treatment–a qualitative interview study. European Journal of Oncology Nursing, 41, 16-23. https://doi.org/10.1016/j.ejon.2019.04.005
[30] Min, J., Yu, Y. W., Lee, J., Yeon, S., Park, H. N., Lee, J. S., Courneya, K. S., Park, H. S., Kim, S. I., & Jeon, J. Y. (2022). Application of the theory of planned behavior to understand physical activity intentions and behavior among Korean breast cancer survivors. Supportive Care in Cancer, 30(11), 8885-8893. https://doi.org/10.1007/s00520-022-07258-1
[31] Nickel, B., Gorski, L., Kleidon, T., Kyes, A., DeVries, M., Keogh, S., Meyer, B., Sarver, M. J., Crickman, R., Ong, J., Clare, S., & Hagle, M. E. (2024). Infusion therapy standards of practice, 9th edition. Journal of Infusion Nursing, 47(1S), S1-S285. https://doi.org/10.1097/nan.0000000000000532
[32] Norman, P., & Conner, M. (2005). The theory of planned behavior and exercise: Evidence for the mediating and moderating roles of planning on intention-behavior relationships. Journal of Sport and Exercise Psychology, 27(4), 488-504. https://doi.org/10.1123/jsep.27.4.488
[33] Park, K. H., Loibl, S., Sohn, J., Park, Y. H., Jiang, Z., Tadjoedin, H., Nag, S., Saji, S., Md Yusof, M., Villegas, E. M. B., Lim, E. H., Lu, Y. S., Ithimakin, S., Tseng, L. M., Dejthevaporn, T., Chen, T. W., Lee, S. C., Galvez, C., Malwinder, S., … Harbeck, N. (2024). Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with early breast cancer. ESMO Open, 9(5), 102974. https://doi.org/10.1016/j.esmoop.2024.102974
[34] Pondé, N. F., Zardavas, D., & Piccart, M. (2019). Progress in adjuvant systemic therapy for breast cancer. Nature Reviews Clinical Oncology, 16(1), 27-44. https://doi.org/10.1038/s41571-018-0089-9
[35] Prabawanti, C., Dijkstra, A., Riono, P., & Hartana, G. (2015). A survey on HIV-related health-seeking behaviors among transgender individuals in Jakarta, based on the theory of planned behavior. BMC Public Health, 15(1), 1138. https://doi.org/10.1186/s12889-015-2480-0
[36] Rhodes, R. E, & Courneya, K. S. (2003). Modelling the theory of planned behaviour and past behaviour. Psychology, Health & Medicine, 8(1), 57-69. https://doi.org/10.1080/1354850021000059269
[37] Richards, J. A., & Johnson, M. P. (2014). A case for theoretical integration: combining constructs from the theory of planned behavior and the extended parallel process model to predict exercise intentions. Sage Open, 4(2): 2158244014534830. https://doi.org/10.1177/2158244014534830
[38] Rogers, J. W., Fleming, M., Tipton, J., Ward, A., Garey, K. W., & Pitman, E. P. (2017). Investigating inpatient medication administration using the theory of planned behavior. American Journal of Health-System Pharmacy, 74(24), 2065-2070. https://doi.org/10.2146/ajhp160502
[39] Sang, D., Li, S., Fan, S., Zhang, J., Su, Y., Zhang, X., Wang, Y., Feng, H., Hao, Y., Liu, Y., Li, M., & Yuan, P. (2025). Rivaroxaban prophylaxis in peripherally inserted central catheter-related thrombosis in breast cancer patients. Archives of Medical Research, 56(6), 103242. https://doi.org/10.1016/j.arcmed.2025.103242
[40] Shen, S. J., & Liu, C. M. (2023). Chemotherapy for early-stage breast cancer: The more the better? The Lancet, 401(10384), 1243-1245. https://doi.org/10.1016/s0140-6736(23)00094-6
[41] Tao, L., Wang, M., Zhang, X., Du, X., & Fu, L. (2020). Exercise adherence in breast cancer patients: A cross-sectional questionnaire survey. Medicine, 99(22), e20427. https://doi.org/10.1097/MD.0000000000020427
[42] Vallance, J. K., Courneya, K. S., Plotnikoff, R. C., & MacKey, J. R. (2008). Analyzing theoretical mechanisms of physical activity behavior change in breast cancer survivors: Results from the activity promotion (ACTION) trial. Annals of Behavioral Medicine, 35(2), 150-158. https://doi.org/10.1007/s12160-008-9019-x
[43] Via-Clavero, G., Guàrdia-Olmos, J., Gallart-Vivé, E., Arias-Rivera, S., Castanera-Duro, A., & Delgado-Hito, P. (2019). Development and initial validation of a theory of planned behaviour questionnaire to assess critical care nurses' intention to use physical restraints. Journal of Advanced Nursing, 75(9), 2036-2049. https://doi.org/10.1111/jan.14046
[44] Wang, H., & Mao, X. (2020). Evaluation of the efficacy of neoadjuvant chemotherapy for breast cancer. Drug Design, Development and Therapy, 14, 2423-2433. https://doi.org/10.2147/dDDT.s253961
[45] Wang, Y. L., Wei, L. F., Li, W., & Ben, Y. L. (2017). The qualitative study of breast cancer patients reject PICC catheterization. Modern Nurse, 1(6), 6-7. https://doi.org/10.3969/j.issn.1006-6411.2017.06.003
[46] Wang, Z., Li, X., Zhang, F., Sun, J., Lian, C., Sun, J., Liu, Y., Zhao, J., & Chen, X. (2025). Development and validation of a Chinese version of an information needs questionnaire for patients with breast cancer undergoing radiotherapy. Journal of Clinical Nursing, 34(7), 2690-2701. https://doi.org/10.1111/jocn.17682
[47] Wilson, B. E., Jacob, S., Yap, M. L., Ferlay, J., Bray, F., & Barton, M. B. (2019). Estimates of global chemotherapy demands and corresponding physician workforce requirements for 2018 and 2040: A population-based study. The Lancet Oncology, 20(6), 769-780. https://doi.org/10.1016/s1470-2045(19)30163-9
[48] Wilson, S. R., Strub, P., Buist, A. S., Knowles, S. B., Lavori, P. W., Lapidus, J., & Vollmer, W. M. (2010). Shared treatment decision making improves adherence and outcomes in poorly controlled asthma. American Journal of Respiratory and Critical Care Medicine, 181(6), 566-577. https://doi.org/10.1164/rccm.200906-0907OC
[49] Wolf, E. J., Harrington, K. M., Clark, S. L., & Miller, M. W. (2013). Sample size requirements for structural equation models: An evaluation of power, bias, and solution propriety. Educational and Psychological Measurement, 73(6), 913-934. https://doi.org/10.1177/0013164413495237
[50] Wu, X., Liang, X., Li, Y., & Zheng, R. (2024). Development and testing of the knowledge–attitudes–practices questionnaire for nurses on the perioperative pulmonary rehabilitation of patients with lung cancer. Asia-Pacific Journal of Oncology Nursing, 11(4), 100387. https://doi.org/10.1016/j.apjon.2024.100387
[51] Zhang, N., Xu, Y., Lu, Q., Zhu, L., An, R., Zhou, X., Wang, Y., Ma, Y., Deng, H., Guo, H., Wang, L., Sun, J., Bo, H., & Wang, X. (2024a). Exploring the behavioral intentions of PICC-related thrombosis prevention in breast cancer patients undergoing chemotherapy: A qualitative study based on theory of planned behavior. Supportive Care in Cancer, 32(10), 635. https://doi.org/10.1007/s00520-024-08827-2
[52] Zhang, N., Xu, Y., Zhu, L. Y., Wang, Y., Lu, Q., An, R., Zhou, X. Y., Wang, X. J., & Ma, Y. (2024b). Quality appraisal of clinical guidelines for peripherally inserted central catheter-related thrombosis prophylaxis in patients: A systematic review. BMJ Open, 14(11), e084330. https://doi.org/10.1136/bmjopen-2024-084330