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Cross-cultural adaptation and validation of the Chinese version of the quality of communication questionnaire

BMC Palliative Care volume 24, Article number: 140 (2025) Cite this article

Abstract

Background

Effective clinician-patient communication is essential for delivering quality end-of-life care. However, there are no validated measures to assess the quality of end-of-life communication for Chinese patients.

Methods

This study aims to cross-culturally adapt and validate the patient-reported Quality of Communication Questionnaire (QOC) for Chinese speaking patients. The QOC was translated and adapted using a standardized methodology consisting of forward translations, backward translations, expert panel review, and testing with patients. We conducted a cross-sectional study to perform principal component, content validity, internal consistency, convergent and discriminant validity analyses of the 16-item Chinese QOC (C-QOC). Subjects were Chinese-speaking advanced cancer (n = 82) and advanced chronic kidney disease (n = 68) patients attending outpatient clinics in five hospitals or receiving home-based palliative care in Hong Kong.

Results

The content validity of the C-QOC was established by an expert panel. The C-QOC has a 3-component structure (general communication skills, communication about illness trajectory, and end-of-life care planning subscales) and demonstrated good internal consistency (Cronbach’s α = 0.88; subscales 0.84–0.90). Convergent validity was supported by positive association between C-QOC score and overall clinician communication quality (r = 0.47, p < 0.001) and clinician comfort in discussing dying (r = 0.63, p < 0.001). Discriminant validity was demonstrated by the stronger association between overall clinician communication quality and general communication skills, compared to the other two subscales.

Conclusions

The C-QOC is a valid, reliable, and culturally relevant instrument for evaluating the quality of clinician end-of-life care communication by Chinese patients with advanced cancer and chronic kidney disease.

Peer Review reports

Introduction

Effective clinician-patient communication is important for providing quality end-of-life care. High-quality end-of-life care communication facilitates goal-concordant care, enhances patients’ quality of life, and improves satisfaction with care among patients and their families [1–2]. However, such communication is frequently hindered by patient and clinician discomfort with discussions about dying, challenges in prognostication, time constraints, and clinicians’ insufficient training in communication skills [3, 4, 5].

Patients with serious illnesses frequently report that conversations with clinicians fail to satisfy their information needs or adequately address fears and concerns about dying [6, 7]. Cultural factors further shape preferences for end-of-life communication. Within Chinese cultural contexts, where Confucian traditions emphasize family harmony, patients often prefer family involvement in end-of-life decisions, and family interests may supersede individual autonomy [4, 8, 9].

Assessing the quality of clinicians’ communication in end-of-life care is critical for monitoring current practices and evaluating interventions aimed at improving patient-provider communication. While various tools have been developed to assess clinical communication broadly [10, 11, 12, 13], evaluating communication in end-of-life contexts necessitates an instrument that addresses the specific communication needs of patients nearing the end of life and align with the cultural context. Currently, no validated measures exist to evaluate clinician end-of-life care communication for Chinese-speaking populations, highlighting a critical gap in both research and practice.

The Quality of Communication Questionnaire (QOC) is a patient-reported measure originally developed in the United States to assess physician communication about end-of-life care, grounded in empirical research identifying aspects of clinician communication valued by seriously ill patients [14, 15, 16, 17]. The original instrument has demonstrated good internal consistency and construct validity, leading to subsequent cultural adaptations for Portuguese, Italian, and Korean populations [18, 19, 20, 21]. The QOC has been widely used in studies involving patients with life-limiting illnesses, including advanced chronic obstructive pulmonary disease (COPD), chronic heart failure, chronic kidney disease (CKD), and multiple sclerosis [22, 23, 24, 25].

In this study, we aimed to translate and cross-culturally adapt the QOC for Chinese-speaking patients and evaluate the structural validity and psychometric properties of the Chinese version of QOC (C-QOC). Our goal was to establish its utility as a patient-centered measure of end-of-life care communication for Chinese-speaking patients with advanced CKD and cancer. Our focus on these populations was twofold. First, clinicians caring for these patients more routinely engage in end-of-life discussions in our setting. Second, as these patient groups follow distinct disease trajectories (progressive organ failure versus oncological decline), validating the C-QOC across both cohorts may support its broader applicability in diverse clinical settings.

Methods

Translation and cross-cultural adaptation of the QOC

The original QOC consisted of 17 questions rated on a numerical rating scale (0–10) and has two subscales, general communication skills and end-of-life care communication. With permission from the original QOC developers, cross-cultural adaptation of the QOC for Chinese-speaking patients was performed in accordance with the guidelines proposed by Beaton et al. (Fig. 1) [26]. Initially, two bilingual researchers independently translated the QOC into Chinese. The two translators and a research team member then produced a synthesized version. Next, the synthesized version was back-translated to English by two other translators without knowledge of the original version. All versions were submitted to an expert panel comprising of two palliative care specialists, a palliative care nurse, a geriatrician, a professor of methodology with expertise in end-of-life care, and the four translators. Each panel member rated the items of the synthesized translated version on four criteria: semantic equivalence (Do the words mean the same thing? ), conceptual equivalence (Do the words hold similar conceptual meaning in this culture? ), clarity (How clear is the wording? ), and relevance (How relevant is the item to what the tool is measuring in this culture/setting? ). The panel made recommendations on item revisions, discussed and reached consensus on any discrepancies, and developed a prefinal 18-item version of the questionnaire.

The prefinal version was pilot tested with 10 advanced cancer patients. The pilot testing confirmed that all scale instructions, questions, and response options were understood by the patients. The prefinal version and synthesized translation were then submitted to the original QOC developers for comment and approval.

Fig. 1
figure 1

Flowchart of the translation and cross-cultural adaptation of the Quality of Communication Questionnaire. QOC: Quality of communication

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Item revision

As the C-QOC is intended to assess doctor and nurse communication, the word “doctor” in the original QOC was modified to the Chinese term for “healthcare provider” (“醫護人員”). Additionally, given there is no equivalent term for “loved ones” in Chinese in items 3 and 13, the original developer suggested that the Chinese term for “relatives” (“親屬”) would more closely reflect the intended meaning of the term. The C-QOC also included the addition of a new item recommended by the expert panel “Talking to you about the trajectory of your illness” given the importance of explaining the illness trajectory in end-of-life care communication. The panel did not propose additional changes to the items to align with the Chinese cultural context.

Participants and settings

Adult patients ≥ 18 years of age were eligible if they were Chinese-speaking and identified by their clinician as having a diagnosis of advanced cancer or advanced CKD and with whom end-of-life care was discussed. Patients who lacked decision-making capacity as indicated by their clinician were excluded. This study was approved by the Institutional Review Board of The University of Hong Kong/Hospital Authority Hong Kong West Cluster and Hospital Authority Kowloon West Cluster.

A cross-sectional survey was conducted. Participants were recruited from May 2020 to May 2023, with intermittent periods when recruitment was halted due to the COVID-19 pandemic in Hong Kong. Written informed consent was obtained from all participants. The target sample size was between 90 and 180 subjects based on the recommended minimum of 5 to 10 subjects per item for factor analysis [27, 28].

Research staff recruited advanced cancer patients attending an integrated hematology-oncology/palliative care clinic or a stand-alone palliative care outpatient clinic in two public hospitals or receiving home-based palliative care. Advanced CKD patients were recruited from nephrology outpatient clinics in three public hospitals. The participants were interviewed in-person immediately after the clinic consultation or home visit or by telephone within one week after the visit.

Instruments and variable

Chinese version of quality of communication questionnaire (C-QOC)

The C-QOC consisted of 18 items. Participants rated the communication of the doctor or nurse from their most recent encounter for each item on a scale of 0–10 (with 0 indicating “the very worst” and 10 indicating “the very best”). Patients were given two additional response options, “Didn’t do” (if the provider did not demonstrate the item), or “Don’t know” (if unsure of how to rate the provider on a particular item).

Communication items

Two communication items were included for validation analyses: “Overall, how would you rate this healthcare provider’s communication with you?” and “How comfortable do you feel your healthcare provider is talking about dying?”, both on a scale from 0 to 10.

Patient-related variables

We surveyed patients on their demographic information, self-perceived health status, who accompanied them at the consultation, and whether they had knowledge of and completed advance directives. We surveyed clinicians on the patient’s estimated life expectancy and performance status using Eastern Cooperative Oncology Group (ECOG) Score [29].

Information preference

We surveyed patients on an item from the Information Styles Questionnaire related to their preference on the type of health-related information desired from clinicians (‘only sufficient to care for myself’, ‘only good news,’ ‘all information good or bad.’) [30].

Content validity

We assessed the content validity of the C-QOC by averaging ratings from five content experts across four criteria: semantic equivalence, conceptual equivalence, clarity, and relevance. The item-content validity index (I-CVI) was computed as the percentage of experts rating each item as “relevant” or “very relevant.” The scale-level content validity index (S-CVI) was calculated as the average of I-CVIs across all items [31]. An S-CVI of 1 (indicating unanimous agreement) is considered the threshold for adequacy for a panel of three to five experts [32].

Statistical analysis

Descriptive statistics were used to summarize participants’ characteristics. For validation analyses, two items (items 3 & 13) addressing clinician communication with family members were excluded, mirroring the approach used in the original QOC validation study. These items were considered inapplicable to patients attending consultations alone or without family/friend involvement. Original item means were calculated after removing responses with missing values. Transformed item means were calculated by first removing missing values and imputing a score of 0 for any “Didn’t do” responses, consistent with the original scale validation protocol. The C-QOC summary score (range: 0-100) was calculated by totalling the scores for all items, dividing by the total number of items, and multiplying by 100.

Principal component analysis (PCA) was performed to explore the measurement structure of the C-QOC items. To determine the adequacy of the data for PCA, we assessed whether the Kaiser-Meyer-Olkin (KMO) value was > 0.80 and Bartlett’s Test of Sphericity yielded a significant result (p < 0.05) [33, 34]. Missing data were processed by listwise deletion. Sensitivity analyses were performed by repeating PCA with three alternative missing data approaches: median imputation, individual mean imputation, and multiple imputation.

We employed parallel analyses to determine the number of factors to extract. Oblimin rotation was applied since the factors were assumed to correlate. Items with factor loadings ≥ 0.4 were retained as indicators of adequate item-factor associations [35]. The cancer and CKD patient samples were initially analysed separately. As both groups yielded a similar factor structure, the datasets were combined for subsequent analyses to enhance analytical power. To determine whether omission of the two family communication items (3 and 13) may have affected the component structure, PCA was repeated in the subgroup of patients accompanied by family/friends.

Internal consistency was assessed using Cronbach’s α for the overall scale and each subscale, with coefficients ≥ 0.70 indicating good internal consistency [27]. To determine the performance of each item, we calculated item-total correlations, where values of ≥ 0.30 were considered satisfactory [27].

To test the associations between the C-QOC and other questionnaire items, we used Spearman correlations for ordinal variables and Kruskal-Wallis test for categorical variables. Convergent validity was evaluated by examining hypothesized positive associations between the C-QOC and measures of overall clinician communication quality and comfort in discussing dying.

Discriminant validity was assessed through known-group validation, testing whether overall clinician communication quality correlated most strongly with the general communication skills subscale, as in the original QOC. We also assessed whether there was a lack of association between the C-QOC with patient information preference, an unrelated construct.

Data analyses were performed using IBM SPSS (version 26.0), with a two-sided significance level set at p < 0.05.

Results

Participant characteristics

One hundred fifty patients enrolled, including 82 cancer patients (93% participation rate) and 68 CKD patients (97% participation rate). Baseline characteristics are shown in Table 1.

Table 1 Baseline characteristics of participants
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Mean age of the cancer sample was 75.5 and 56% were female. Fifty-eight (71%) were diagnosed with solid organ malignancies and 24 (29%) with hematological malignancies. Over 90% had a prognosis of less than a year and 9% had completed an advance directive. Mean age of the CKD sample was 72.0 and 24% were female. 62% had a prognosis of less than a year and none had completed an advance directive. Only about half in both samples reported prior knowledge of advance directives. The majority of patients attended the consultation accompanied by a family member.

Content validity

The C-QOC demonstrated excellent content validity. Average scale rating of semantic equivalence was 3.94 (individual item ratings: 3.8-4.0) out of a maximum of 4, and clarity had an average rating of 4.0 (all items rated 4.0). For cultural validity, conceptual equivalence and relevance both scored 3.97 (individual item ratings: 3.8-4.0). Both I-CVI and S-CVI achieved full scores of 1.

Item descriptive

A total of 162 C-QOC surveys were included in the validation analyses, with 12 patients completing evaluations for two distinct clinicians. The mean administration time for the C-QOC was 7.4 min (SD = 3.63). Table 2 presents the 16-item C-QOC item scores and summary score. Transformed item means ranged from 2.91 to 9.15 and mean C-QOC summary score was 61.3 (SD = 21.9). Four items were marked as “Didn’t do” by over half of participants: “Talking to you about how long you might have to live”, “Talking to you about what dying might be like,” “Asking about the things in life that are important to you,” and “Asking about your spiritual or religious beliefs.”

Table 2 Item descriptive for combined Cancer and CKD patient samples (N = 162)
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Factor structure

PCA revealed a robust three-component structure (Table 3). The KMO value was 0.803, and Bartlett’s Test of Sphericity confirmed suitability for factor analysis (χ² = 1607.02, p < 0.001). The three-component structure was consistent across cancer, CKD, and combined samples:

Table 3 Principal component analyses for cancer, CKD, and combined samples
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Component 1: General communication skills (6 items): Focused on general communication skills for effective end-of-life care communication.

Component 2: Communication about illness trajectory (4 items): Addressed information-sharing of illness trajectory/prognosis and emotional exploration.

Component 3: End-of-life care planning (6 items): Encompassed discussions of dying, values exploration, and shared decision-making.

In the combined sample, the three components accounted for 64.6%, 68.3%, and 65.1% of variance in the 16 items, respectively. Sensitivity analyses (using median imputation, individual mean substitution, and multiple imputation) and subgroup analysis (patients accompanied by family/friends) consistently replicated the same component structure (Supplementary Tables 1–4). The item, “Talking about what dying might be like” showed cross-loadings (> 0.40) on components 2 and 3, but was retained in component 3 due to stronger loadings across all samples.

Comparing subscale performance for the combined sample, the general communication skills subscale has the highest mean (8.82; SD = 1.3), followed by communication about illness trajectory (4.82; SD = 3.37) and end-of-life care planning (3.83; SD = 3.63).

Reliability

The C-QOC demonstrated good internal consistency (Table 4). Cronbach’s α was 0.884 for the overall scale. For the general communication skills, communication about illness trajectory, and end-of-life care planning subscales, Cronbach’s α was 0.894, 0.842, and 0.884, respectively. Item-total correlations were strong (0.40–0.69) for 13 items and moderate (0.30–0.39) for the remaining 3 items. Cronbach’s α remained stable (0.855 to 0.871) when individual items were sequentially removed.

Table 4 Internal consistency of Chinese version of the quality of communication questionnaire
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Convergent and discriminant validity

Convergent validity of the C-QOC was supported by significant positive correlations between C-QOC summary scores and both overall clinician communication quality (ρ = 0.467, p < 0.001) and clinician comfort in discussing dying (ρ = 0.634, p < 0.001) (Table 5).

Table 5 Convergent and discriminant validity
Full size table

Discriminant validity was evidenced by stronger association between overall clinician communication quality and general communication skills subscale (ρ = 0.73, p < 0.001) compared with communication about illness trajectory (ρ = 0.411, p < 0.001) and end-of-life care planning (ρ = 0.226, p = 0.004). As hypothesized, the C-QOC showed no significant association with unrelated measures such as patient information preferences.

Discussion

This study describes the cross-cultural adaptation process of the QOC for Chinese-speaking patients and evaluates the psychometric properties of the 16-item C-QOC.

The expert panel confirmed the clarity and cultural relevance of all items for end-of-life care communication in Chinese populations. Minimal revisions were required beyond adding one item addressing communication on illness trajectory. Patients reported ease of understanding of the tool and the administration time (mean: 7.4 min) was satisfactory.

Divergent factor structure: methodological and cultural considerations

PCA of the 16-item C-QOC revealed a three-component structure (general communication skills, communication about illness trajectory, and end-of-life care planning). This diverges from the two-component structure of the original QOC (general communication skills and end-of-life communication) [17]. While both scales shared the six items in the general communication skills subscale, the C-QOC redistributed the end-of-life care communication items into two distinct subscales, reflecting nuanced methodological and cultural differences.

The structural differences between the C-QOC and original QOC may stem from the following factors: item variation, temporal specificity, and cultural norms. First, differences in item inclusion between the C-QOC and original QOC (16 vs. 13 items, respectively) likely contributed to structural variation. The fewer items in the original QOC compared to C-QOC resulted from two key modifications: (1) the addition of a new item in the C-QOC (“Talking to you about the trajectory of your illness”) and (2) the exclusion of two items from the original QOC (“Respecting things in your life that are important to you” and “Respecting your spiritual or religious beliefs”) that had a high rate of missing values in the U.S. sample but not the Chinese cohort [17].

Another methodological consideration involves temporal specificity in rating the clinicians. In the original QOC, patients evaluated their doctor’s communication without reference to a specific encounter, potentially reflecting their cumulative impressions across multiple consultations. By contrast, the C-QOC instructed patients to rate their provider’s communication based on their most recent clinical interaction. This temporal specificity may have narrowed respondents’ focus to the clinician’s communication during a single encounter, leading to the emergence of two distinct subscales within end-of-life care communication.

Cultural differences in end-of-life care communication norms between Chinese and U.S. clinicians further contributed to these findings. Compared to the U.S. cohort, the Chinese cohort ratings for some items in Component 2 related to sharing information on illness trajectory were notably higher, while ratings for some items in Component 3 related to patient involvement in decision-making and eliciting patient’s values were lower. This pattern aligns with cultural norms shaping clinician-patient dynamics in Chinese cultures.

Wang observed that Chinese patients were more likely than U.S. patients to endorse a doctor-dominant communication style [36]. This is characterized by an authoritative doctor who delivers information on the diagnoses, prognoses, and directs treatment decisions based on the doctor’s views with limited input from the patient. Confucian values are aligned with family-centered decision-making and clinician authority, which may discourage explicit invitations for patients to share personal preferences, particularly in end-of-life contexts [8, 9, 37, 38, 39]. Additionally, cultural taboos around death may further explain the reluctance to explore end-of-life preferences [4, 37, 38, 39]. Validation of the C-QOC with more diverse patient groups and clinicians is needed to determine the stability of the factor structure of the scale.

Psychometric performance of C-QOC

The C-QOC demonstrated strong internal consistency and validity. Convergent validity was supported by significant correlations with overall clinician communication quality and even stronger association with clinician comfort in discussing dying. The stronger association with clinician comfort in discussing dying highlights the importance of clinician willingness to openly discuss end-of-life care topics with patients for high-quality end-of-life care communication.

Global patterns in end-of-life communication

Despite differences in cultural norms around end-of-life care communication, we also found some similarities across cultures. Our finding of lower scores in the illness trajectory communication and end-of-life care planning subscales are consistent with international studies demonstrating clinician reluctance to discuss prognosis, patient’s values, and spirituality [18, 19, 20, 21, 22, 23, 40]. This trend– observed in the U.S., the Netherlands, and Brazil– reflect cross-cultural barriers such as fear of causing distress, family preferences for non-disclosure, time constraints, and inadequate training in end-of-life communication [4, 23, 41, 42, 43]. Targeted communication skills training and systems-based changes that promote quality end-of-life care communication could mitigate these challenges.

Strengths and limitations

This study rigorously followed guideline-based translation and cultural adaptation processes, ensuring linguistic validity of the C-QOC. Psychometric evaluation of the C-QOC was conducted in accordance with the COSMIN guidelines [44]. However, the study only sampled advanced cancer and CKD patients, which may limit the scale’s generalizability to a broader patient population. Test-retest reliability and responsiveness to change remained unexamined. Finally, we did not compare patient assessment of clinician communication against observer ratings which could provide a more comprehensive understanding of the scale’s validity.

Conclusion

The C-QOC is a valid, reliable, and culturally relevant patient-reported measure of clinician end-of-life care communication for Chinese-speaking patients. Future research should explore its stability, generalizability across diverse populations, and utility in communication training and clinical practice.

Data availability

The data that support the findings of this study are stored confidentially and are available from the corresponding author upon reasonable request.

Abbreviations

CKD:

Chronic kidney disease

COPD:

Chronic obstructive pulmonary disease

ECOG:

Eastern Cooperative Oncology Group

I-CVI:

Item-content validity index

KMO:

Kaiser-Meyer-Olkin

PCA:

Principal component analysis

C-QOC:

Chinese version of Quality of Communication Questionnaire

S-CVI:

Scale-level-content validity index

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Acknowledgements

We dedicate this work to the memory of Dr. Randall Curtis, whose visionary work as a clinician, researcher, teacher, and mentor profoundly shaped the field of palliative care. As the original developer of the QOC, Dr. Curtis provided instrumental guidance during the cultural adaptation process of the Chinese QOC. His tireless advocacy for compassionate communication with seriously ill patients and families continues to inspire our efforts. We would like to thank our expert panel members for their invaluable insights and all patients who graciously gave their time to participate in this study.

Funding

This work was supported by The University of Hong Kong Faculty Start-up Fund (Grant number 006027001). The funding source had no role in the conduct of the research or preparation of the article.

Author information

Authors and Affiliations

  1. Division of Geriatrics, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China

    Jacqueline K. Yuen & Steven T. Chu

  2. School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China

    Jacqueline K. Yuen

  3. School of Nursing, Li Ka Shing Faculty of Medicine, Chinese University of Hong Kong, Hong Kong SAR, China

    Helen Y. L. Chan

  4. Haven of Hope Sister Annie Skau Holistic Care Centre, Hong Kong SAR, China

    Tracy W. T. Chen

  5. Palliative Care Unit, Department of Medicine and Geriatrics, Caritas Medical Centre, Hong Kong SAR, China

    Annie O. L. Kwok & Doris M. W. Tse

  6. School of Nursing, The Hong Kong Polytechnic University, Hong Kong SAR, China

    Doris Y. P. Leung

  7. Division of Haematology-Oncology, Medical Oncology and Haemopoietic Stem Cell Transplantation, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China

    Harinder S. Gill

  8. Palliative Medical Unit, Grantham Hospital, Hong Kong SAR, China

    Kwok-wai Tsang

  9. Division of Nephrology, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China

    Desmond Y. H. Yap

  10. Renal Unit, Tung Wah Hospital, Hong Kong SAR, China

    Terence Yip

  11. Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, USA

    Robert M. Arnold

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  1. Jacqueline K. Yuen
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Contributions

Study concept and design: JKY, HYLC, RMA. Acquisition of data: JKY, TWTC, STC, AOLK, HSG, KWT, DMT, DYHY, TY. Analysis and interpretation of data: JKY, HYC, STC, DYPL, RMA. Drafting of the manuscript: JKY, STC. Critical revision of the manuscript for important intellectual content: JKY, HYLC, TWTC, STC, AOLK, DYPL, HSG, KWT, DMWT, DYHY, TY, RMA. All authors reviewed and approved the manuscript.

Corresponding author

Correspondence to Jacqueline K. Yuen.

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Ethics approval and consent to participate

This study was conducted in accordance with the Declaration of Helsinki. This study was approved by the Institutional Review Board of The University of Hong Kong/Hospital Authority Hong Kong West Cluster (Ref no: UW 20–406) and Hospital Authority Kowloon West Cluster (Ref no: KW/EX-21-068). All participants received an information sheet with the study information, and signed a consent form to confirm their voluntary participation.

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Not applicable.

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The authors declare no competing interests.

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Yuen, J.K., Chan, H.Y., Chen, T.W. et al. Cross-cultural adaptation and validation of the Chinese version of the quality of communication questionnaire. BMC Palliat Care 24, 140 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12904-025-01786-3

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BMC Palliative Care

ISSN: 1472-684X

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