Ancient Stoic Endurance Meets Modern Science: A New Chinese Scale for Older Adults with Knee Arthritis

Stoicism, the ancient philosophy of enduring hardship with quiet resolve, has long shaped how people respond to illness. In China, where Confucian and Daoist traditions prize restraint, self-discipline, and acceptance, stoic attitudes can profoundly influence whether an older adult with aching knees seeks treatment early or silently endures pain for years. A new study published in BMC Geriatrics has taken a major step toward measuring these attitudes scientifically, reporting the first cross-cultural adaptation and psychometric evaluation of the Pathak-Wieten Stoicism Ideology Scale (PW-SIS) specifically for Chinese older people living with knee osteoarthritis.

Knee osteoarthritis is one of the most common and disabling joint conditions worldwide, and its burden falls disproportionately on aging populations. The disease is progressive, but early care-seeking, weight management, exercise, and timely medical intervention can dramatically slow its trajectory and preserve mobility. The problem, the researchers argue, is that stoic ideology generates expectations about ideal health-related behaviors: people who believe suffering should be borne silently may delay seeking care until joint damage is advanced. Measuring stoicism in this population, therefore, is not an abstract philosophical exercise but a practical tool for designing culturally sensitive psychological strategies that encourage earlier knee care.

The research team, led by Xiaojie Xie, Libin An, Jun Shan, and corresponding author Wentao Li, with affiliations at Dalian University and Nantong University, set out to translate the original PW-SIS into Chinese and rigorously test whether it works as intended among adults aged 60 and over with knee osteoarthritis. Their work followed the World Health Organization’s established guidelines for cross-cultural adaptation, a multi-stage process designed to ensure that a questionnaire does not merely change language but genuinely retains its meaning across cultural boundaries.

That process involved several carefully sequenced steps. First, the scale underwent forward translation into Chinese. A panel of experts then reviewed the translated items for clarity, cultural relevance, and fidelity to the original construct. Next came back translation, in which an independent translator rendered the Chinese version back into English, allowing the team to compare it against the source instrument and detect any drift in meaning. Finally, the researchers conducted pre-testing and cognitive interviewing, asking participants to think aloud as they answered each item, so that misunderstandings, awkward phrasing, or culturally incongruent concepts could be identified and corrected before formal data collection began.

With the adapted Chinese version in hand, the team recruited 231 participants aged 60 and older in China between January and March 2025 to evaluate the scale’s reliability and validity. Reliability, in psychometric terms, refers to the consistency of a measurement instrument: whether it produces stable, reproducible scores across items and over time. Validity refers to whether the instrument actually measures what it claims to measure. Both properties are essential before any questionnaire can be used in clinical practice or research, and the study assessed validity across four dimensions: content validity, structural validity, convergent validity, and criterion-related validity.

The reliability results were strikingly strong. Cronbach’s alpha, a statistic that ranges from 0 to 1 and reflects how coherently a set of items measures a single underlying construct, reached 0.92 for the total scale, well above the conventional threshold of 0.70 for acceptable internal consistency. The four subscales, which capture distinct facets of stoic ideology, also performed admirably: endurance scored 0.89, taciturnity 0.88, serenity 0.82, and death acceptance 0.82. Test-retest reliability, which examines whether respondents give similar answers when the same instrument is administered on separate occasions, was 0.89, indicating that the scale yields highly stable scores over time among older Chinese adults.

Content validity, which assesses whether the items adequately represent the concept of stoicism as understood by experts and respondents, was confirmed through validity indices computed at both the item and scale levels. The item-content validity index ranged from 0.83 to 1.00 across the scale’s items, and the average scale-level content validity index stood at 0.94, both comfortably exceeding accepted benchmarks. These figures suggest that experts judged nearly every item as relevant, clear, and culturally appropriate for the target population, a critical finding when transporting a psychological construct rooted in Western philosophical tradition into a Chinese cultural context.

The structural analysis provided equally compelling evidence. Exploratory factor analysis, a statistical technique that uncovers latent dimensions underlying a set of observed items, identified four dimensions comprising 12 items, with a cumulative variance contribution rate of 78.63 percent, meaning that this compact four-factor structure accounts for the vast majority of the variability in respondents’ answers. Confirmatory factor analysis, which tests whether a predefined factor structure fits the observed data, demonstrated very good model fit: the root mean square error of approximation was 0.05, the goodness-of-fit index was 0.94, and the Tucker-Lewis Index reached 0.98. Values of this kind indicate that the Chinese version preserved the same four-dimensional architecture as the original instrument, encompassing endurance, taciturnity, serenity, and death acceptance.

The four subscales themselves offer a nuanced portrait of stoic ideology in later life. Endurance reflects the disposition to persevere through physical hardship rather than complain or seek relief. Taciturnity captures the tendency to keep suffering private, saying little about one’s pain even to family members or clinicians. Serenity describes emotional equanimity in the face of illness, while death acceptance concerns a calm orientation toward mortality, which can shape how older adults weigh invasive treatments against quality of life. Together, these dimensions explain why two patients with identical radiographic severity of knee osteoarthritis may behave so differently: one may attend rehabilitation diligently, while the other silently endures until walking becomes impossible.

The authors conclude that the 12-item Chinese version of the PW-SIS demonstrates satisfactory reliability and validity and can be adopted to evaluate stoicism ideology among elderly individuals in China. The practical implications extend well beyond psychometrics. Clinicians and nurses could use the scale to identify patients whose stoic beliefs put them at risk of delayed care-seeking, then tailor communication strategies accordingly, for instance, by framing early treatment as an act of strength and self-discipline rather than as an admission of weakness. The study also received ethics approval from the Research Ethics Committee of the Faculty of Nursing at Chiang Mai University, and all participants provided written informed consent in accordance with the Declaration of Helsinki. As populations across Asia age rapidly and knee osteoarthritis becomes an ever-larger driver of disability, instruments like this adapted scale may prove essential for bridging the gap between ancient cultural values and modern, timely joint care.

Subject of Research: Cross-cultural validation of a stoicism ideology scale for older Chinese adults with knee osteoarthritis

Article Title: Cross-cultural validation and psychometrics’ assessment of Pathak-Wieten Stoicism Ideology Scale among Chinese older people with knee osteoarthritis

Article References: Xie, X., An, L., Shan, J., & Li, W. (2026). Cross-cultural validation and psychometrics’ assessment of Pathak-Wieten Stoicism Ideology Scale among Chinese older people with knee osteoarthritis. BMC Geriatrics. https://doi.org/10.1186/s12877-026-08392-9

Image Credits: AI Generated

DOI: 10.1186/s12877-026-08392-9

Keywords: stoicism, psychometrics, knee osteoarthritis, older adults, cross-cultural validation, scale translation, reliability, validity, factor analysis, care-seeking behavior, China, geriatrics