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International Journal for Quality in Health Care Advance Access originally published online on March 13, 2008
International Journal for Quality in Health Care 2008 20(3):221-226; doi:10.1093/intqhc/mzn006
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© The Author 2008. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved

Psychometric evaluation of the European Organization for Research and Treatment of Cancer in-patient satisfaction with care questionnaire (‘Sinhala’ version) for use in a South-Asian setting

Harindra Jayasekara1,2, Lalini Rajapaksa3 and Anne Bredart4

1 Epidemiology Unit, Ministry of Health, De Saram Place, Colombo, Sri Lanka
2 Centre for Molecular, Environmental, Genetic, and Analytic Epidemiology, School of Population Health, The University of Melbourne, Carlton, Victoria, Australia
3 Department of Community Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
4 Psycho-Oncology Unit, Institut Curie, Paris, France

Address reprint requests to: Harindra Jayasekara, Centre for Molecular, Environmental, Genetic, and Analytic Epidemiology, School of Population Health, The University of Melbourne, Level 2, 723 Swanston Street, Carlton, Victoria 3053, Australia. Tel: +61 3 8344 0741; Fax: +61 3 9349 5815; E-mail: hdmhjayasekara{at}yahoo.com


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Funding
 Appendix 1
 References
 
Background. Patients' satisfaction with cancer care has not been studied in detail in the South-Asian region in spite of rising cancer incidence.

Objective. To validate the ‘Sinhala’ translation of the European Organization for Research and Treatment of Cancer (EORTC) in-patient satisfaction with care questionnaire (IN-PATSAT32) in Sri Lanka.

Method. We administered the translated version of the IN-PATSAT32 on 343 newly diagnosed adult in-patients with cancers of head and neck, breast, oesophagus, cervix uteri and lung, recruited from seven tertiary care oncology treatment centres in the District of Colombo. Patients with previous cancer diagnoses, too frail/mentally unfit, with evidence of brain metastases and unable/unwilling to give informed consent were excluded. Psychometric testing assessed the hypothesized scale structure, scale reliability, construct validity and acceptability of the IN-PATSAT32.

Results. A high response rate (100%) and low missing data (0.05%) confirmed the acceptability of the IN-PATSAT32. The hypothesized scale structure was confirmed with 100% item-convergent and 98.6% item-discriminant validity, and a scaling success rate, defined as items correlating significantly higher (more than 1.96 standard errors) with its own scale (corrected for overlap) than with another scale, of 97.9%. The Cronbach's alpha coefficient for internal consistency exceeded 0.70 in all scales. Construct validity was confirmed with inter-scale correlations, which were all statistically significant (P < 0.01) and were of moderate-to-high magnitude, evidence that they were measuring distinct dimensions of patient satisfaction.

Conclusion. The translated version of the IN-PATSAT32 has proved to be a reliable and valid measure of satisfaction with cancer care in patients with heterogeneous cancer diagnoses in Sri Lanka.

Keywords: cancer, European Organization for Research and Treatment of Cancer, patient satisfaction, psychometrics, quality of care, validation


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Funding
 Appendix 1
 References
 
The South-East Asia region accounts for more than one-sixth of the mortality and for one-fifth of the burden of disease due to cancer, globally [1]. In Sri Lanka, the mortality and morbidity due to malignant neoplasms have doubled during the last two decades [2]. Despite rising cancer incidence, patients' satisfaction with cancer care has not been studied in detail so far in the region. In contrast, this is advocated in most developed countries in the routine evaluation and monitoring of quality of health care services [3]. In general, patient satisfaction has been regarded as the patients' judgement on all aspects of quality of care [4]. In oncology practice, this multi-dimensional concept can be interpreted as the success of oncology treatment services in meeting cancer patients' needs and expectations [5].

We translated and tested the psychometric properties of the in-patient satisfaction with care questionnaire of the European Organization for Research and Treatment of Cancer (EORTC IN-PATSAT32) as part of a large study into quality-of-life (QOL) and patient satisfaction in Sri Lanka, using study instruments of the EORTC.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Funding
 Appendix 1
 References
 
Study design
The IN-PATSAT32 was evaluated for psychometric properties in a multi-centre, cross-sectional validation study.

Translation, cultural adaptation and content validity of IN-PATSAT32
The IN-PATSAT32 (Appendix 1) is a 32-item self-completion questionnaires consisting of 11 multi-item scales and 3 single items, designed to assess technical and interpersonal skills, information provision and availability of doctors, nurses and other hospital personnel as well as exchange of information among caregivers, waiting time, access, comfort/cleanliness of the facilities and general satisfaction with overall care, using a ‘poor’, ‘fair’, ‘good’, ‘very good’ and ‘excellent’ response scale to rate each questionnaire item. It has been developed in multi-cultural settings and recently validated in an international field study by the EORTC Quality of Life Group [6].

Employing forward–backward translation methodology [7], we translated the IN-PATSAT32 from the original English version into a provisional ‘Sinhala’ version, which was then pilot-tested on a sample of 15 patients with the same cancers as the study population targeted for the psychometric assessment. During pilot-testing, the questionnaire was administered and a structured interview carried out with patients to determine whether the wording used in individual items made any of the items difficult to answer, confusing, difficult to understand, or upsetting/offensive and whether the patient would have asked the question in a different way. On the basis of the interviews, modifications were made to the provisional version, and the final ‘Sinhala’ version was established. This procedure was carried out in collaboration with the EORTC Quality of Life Unit.

A panel of experts comprising clinicians, behavioural scientists, cancer patients and caregivers assessed the content validity of the ‘Sinhala’ version of the IN-PATSAT32 by evaluating each item for relevance in assessing satisfaction with cancer care, appropriateness of the wording and acceptability in the local context. Ratings were made on a 0 (worst) to 10 (best) points scale. All items scored above 7 on all 3 dimensions assessed and were deemed as applicable for use in the Sri Lankan setting, although the items 48 to 50 on provision of information by nurses aroused concern among some members of the panel for acceptability in the local context. Even though these are not primarily the designated tasks of the nurses in the local practice, they were retained as the majority of the experts recommended to do so in order to collect data reflecting patients' perceptions on the subject.

Participants
A consecutive series of 343 adult female and male in-patients, diagnosed with cancers of the lip/oral cavity/pharynx [International Classification of Diseases, 10th revision [8] codes C00-06 and C09-14], breast (C-50), oesophagus (C-15), cervix uteri (C-53) and bronchus and lung (C-34), the most common cancers seen in Sri Lanka, during the last 3 months, were recruited from seven tertiary care health institutions which offered oncology treatment services in the District of Colombo. The sample size calculation was based on the formula proposed by Tabachnik and Fidel [9], according to which the number of observations should be 5–10 times the number of variables in the model for multivariate analysis techniques to generate stable reliability and validity estimates. Patients with previous cancer diagnoses, those who were too frail or mentally unfit to participate, patients with evidence of brain metastases and those who were unable or unwilling to give informed consent were excluded.

Data collection procedure
After obtaining informed written consent, the IN-PATSAT32 was administered in sequence after the QOL core questionnaire of the EORTC (QLQ-C30) [10] and the relevant site-specific QOL module. The IN-PATSAT32 was followed by its standard debriefing questionnaire to assess acceptability, and a sociodemographic questionnaire. This procedure, approved by the central and institutional Ethics Review Committees, was conducted away from the vicinity of the clinic/ward in a separate enclosure with adequate privacy.

Statistical analysis
All scale and single-item scores were linearly transformed to a 0–100 scale with a higher score indicating a higher degree of satisfaction. Scoring systems suggested by the EORTC were used in the analysis [11].

The hypothesized scale structure, scale reliability, construct validity and acceptability of the IN-PATSAT32 were assessed.

Hypothesized scale structure
Multitrait scaling analysis was employed to assess empirically the hypothesized scale structure of the questionnaire by examining the extent to which the items of the questionnaire could be combined into the hypothesized multi-item scales [6, 10]. This technique is based on an examination of item-scale correlations. Evidence of item-convergent validity was defined as a correlation of 0.40 or greater between an item and its own scale (corrected for overlap). Confirmation of item-discriminant validity was based on a comparison of the magnitude of the correlation of an item with its own scale when compared with other scales. Scaling successes were defined as those cases in which an item correlated significantly higher (more than 1.96 standard errors) with its own scale (corrected for overlap) than with another scale.

Scale reliability
The reliability was assessed by testing for internal consistency using Cronbach's alpha coefficient [12]. Cronbach's alpha coefficients of 0.70 or greater were considered satisfactory [13].

Construct validity
The construct validity was assessed with inter-scale correlations [10]. This method involved an examination of the correlations between the various scales of the IN-PATSAT32. It was expected that conceptually related scales of the IN-PATSAT32 would correlate substantially with one another (r ≥ 0.40).

Acceptability
The response rate, percentage of missing data, assistance for completion, time required to complete the questionnaire and details of items considered upsetting, confusing or difficult in the questionnaire were measured to assess the acceptability of the IN-PATSAT32.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Funding
 Appendix 1
 References
 
Patient characteristics
The patients were predominantly females (70.8%), aged 50 years or above (69.1%), and married (84.8%). The most common cancer site was breast (46.9%), and metastases were seen in only 6.1% of the patients (Table 1).


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  		Table 1 Sociodemographic and clinical characteristics of the patients

 
Descriptive statistics
Mean satisfaction scores for doctors ranged from 50.3 (for information provision) to 67.8 (technical skills). Corresponding mean scores were lower for nurses, ranging from 41.9 (information provision) to 61 (technical skills). Overall, the lowest mean score was reported for access to care (38.7), while overall satisfaction with care had a mean score of 64.5 (Table 2).


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  		Table 2 Summary of results for descriptive statistics, multitrait scaling and internal consistency

 
Multitrait scaling analysis
In the overall matrix of multitrait scaling results (not shown in table), all items showed item-convergent validity with their own scales. Out of the 290 tests of item correlation with a scale other than its own, 286 tests (98.6%) showed evidence for item-discriminant validity. Scaling successes were noted in 284 of the tests (97.9%).

All scales showed 100% scaling success rates except for the scales on nurses' technical skills (96.6%), nurses' interpersonal skills (86.6%) and nurses' availability (95%) when multitrait scaling results were summarized for individual scales (Table 2).

Reliability
As shown in Table 2, the Cronbach's alpha coefficients for the scales ranged from 0.79 to 0.96.

Construct validity
Table 3 shows inter-scale correlations among the scales of the IN-PATSAT32. Fifty out of the 55 correlations (90.9%) among the scales of the IN-PATSAT32 had correlation coefficients exceeding 0.40, and all inter-scale correlations were statistically significant (P < 0.01).


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  		Table 3 Inter-scale Pearson's correlation matrix for scales of the IN-PATSAT32

 
Acceptability
None of the eligible patients refused to participate, and the total number of item responses missing was extremely low (5 out of 10 976 possible responses, 0.05%). The time taken by most patients (274, 79.9%) to complete the questionnaire was 10–15 min, with some (68, 20%) requiring assistance for the completion of the questionnaire. Item 53 on exchange of information among caregivers was reported to be confusing and difficult to answer by a few (7, 2%) patients.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Funding
 Appendix 1
 References
 
The majority of patient satisfaction questionnaires have been developed in Anglo-Saxon countries and have rarely been validated across countries and cultures [6, 14]. This has limited the ability to make cross-national comparisons of the perceived quality of health care services. The recently introduced IN-PATSAT32 has overcome this limitation significantly [6]. It has been designed to assess cancer patients' perception of the quality of medical and nursing care, care organization and services received in hospital. The current study aimed to validate the IN-PATSAT32 in a South-Asian setting, a region that increasingly accounts for a large proportion of the global cancer burden [1].

The overall results of the study provided strong support for the psychometric properties of the translated version of the IN-PATSAT32 when used in a Sri Lankan sample of cancer patients with heterogeneous diagnoses. The high response rate and low rate of missing data indicated that the questionnaire was patient-friendly. As expected, the patients who were physically weak or had practical problems such as inability to read and unavailability of spectacles, had to be interviewed. Excellent results for multitrait scaling and internal consistency confirmed the hypothesized scale structure and scale reliability, respectively. Statistically significant (P < 0.01) inter-scale correlations of the IN-PATSAT32 reflected both the conceptual non-orthogonality of the scales and the effect of a relatively large sample size. The magnitude of correlation in most instances was moderate thus showing that the scales though related were assessing distinct dimensions of patient satisfaction.

The three scales assessing satisfaction with nurses' technical and interpersonal skills, and availability, in spite of less than optimal scaling success rates, demonstrated good psychometric properties, overall. The scale on nurses' information provision had the lowest mean score (41.9%) among scales assessing satisfaction with health care providers, a result that underlined the fact that emphasis on nurses providing information to the patients is relatively less in the local healthcare system, as anticipated by the experts during the analysis for content validity. Strong psychometric results for the scale, however, justified retaining the scale in the analysis since reliable and valid data for information provision by nurses could be used to improve the existing system in future.

In conclusion, the ‘Sinhala’ version of the IN-PATSAT32 was well accepted by patients, and the psychometric results provided strong support for the instrument as a reliable and valid measure of patient satisfaction with cancer care in Sri Lanka.


   Funding
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Funding
Appendix 1
 References
 
This study was funded by the World Health Organization Country Office for Sri Lanka through Agreement for Performance of Work No. SE/SRL OSD 001/RB 04/EC 1/P1/A2.


   Appendix 1
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Funding
 Appendix 1
References
 
Items of the EORTC IN-PATSAT32
During your hospital stay, how would you rate doctors, in terms of:

31 Their knowledge and experience of your illness?
32 The treatment and medical follow-up they provided?
33 The attention they paid to your physical problems?
34 Their willingness to listen to all of your concerns?
35 The interest they showed in you personally?
36 The comfort and support they gave you?
37 The information they gave you about your illness?
38 The information they gave you about your medical tests?
39 The information they gave you about your treatment?
40 The frequency of their visits/consultations?
41 The time they devoted to you during visits/consultations?
During your hospital stay, how would you rate nurses, in terms of:
42 The way they carried out your physical examination (took your temperature, felt your pulse,...)?
43 The way they handled your care (gave your medicines, performed injections,...)?
44 The attention they paid to your physical comfort?
45 The interest they showed in you personally?
46 The comfort and support they gave you?
47 Their human qualities (politeness, respect, sensitivity, kindness, patience,...)?
48 The information they gave you about your medical tests?
49 The information they gave you about your care?
50 The information they gave you about your treatment?
51 Their promptness in answering your buzzer calls?
52 The time they devoted to you?
During your hospital stay, how would you rate services & care organisation, in terms of:
53 The exchange of information between caregivers?
54 The kindness and helpfulness of the technical, reception, laboratory personnel,...?
55 The information provided on your admission to the hospital?
56 The information provided on your discharge from the hospital?
57 The waiting time for obtaining results of medical tests?
58 The speed of implementing medical tests and/or treatments?
59 The ease of access (parking, means of transport,...)?
60 The ease of finding one's way to the different departments?
61 The environment of the building (cleanliness, spaciousness, calmness,...)?
Overall
62 How would you rate the care received during your hospital stay?
EORTC IN-PATSAT32

Copyright: EORTC Quality of Life Group

Available for users at http://groups.eortc.be/qol/questionnaires_eortcinpatsat32.htm.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Funding
 Appendix 1
 References
 

  1. World Health Organization. The World Health Report 2000, Health Systems: Improving Performance. (2001) Geneva: WHO.

  2. Ministry of Healthcare. Annual Health Bulletin 2002. (2006) Colombo: Ministry of Healthcare.

  3. World Health Organization. Measuring Consumer Satisfaction with Health Care. (1990) Copenhagen: WHO Regional Office for Europe.

  4. Donabedian A. JAMA (1988) 260. The quality of care: How can it be assessed? 1743–48.[Abstract/Free Full Text]

  5. Sitzia J, Wood N. Soc Sci Med (1997) 45. Patient satisfaction: A review of issues and concepts. 1829–43.[CrossRef][Web of Science][Medline]

  6. Bredart A, Bottomley A, Blazeby JM, et al, on behalf of the European Organisation for Research and Treatment of Cancer Quality of Life Group and Quality of Life Unit. An international prospective study of the EORTC cancer in-patient satisfaction with care measure (EORTC IN-PATSAT32). Eur J Cancer (2005) 41:2120–31.[CrossRef][Web of Science][Medline]

  7. Cull A, Sprangers MAG, Bjordal K, et al, on behalf of the European Organisation for Research and Treatment of Cancer Quality of Life Study Group. EORTC Quality of Life Study Group Translation Procedure (1998) Brussels: EORTC.

  8. World Health Organization. International Statistical Classification of Diseases and Related Health Problems (10th revision). (1992) Geneva: WHO.

  9. Tabachnik BJ, Fidel LS. Using Multivariate Statistics. (1993) London: Harper & Row.

  10. Aaronson NK, Ahmedzai S, Bergman B, et al, for EORTC Study Group on Quality of Life. The European Organisation for Research and Treatment of Cancer QLQ-C30: A quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst (1993) 85:365–76.[Abstract/Free Full Text]

  11. Fayers PM, Aaronson NK, Bjordal K, et al, on behalf of the European Organisation for Research and Treatment of Cancer Quality of Life Study Group. The EORTC QLQ-C30 Scoring Manual (2001) 3rd. Brussels: EORTC.

  12. Cronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrika (1951) 16:297–334.[CrossRef][Web of Science]

  13. Nunnally JC, Bernstein IH. Psychometric theory (1994) USA: McGraw-Hill Inc.

  14. Ware JE, Snyder MK, Wright R, et al. Defining and measuring patient satisfaction with medical care. Eval Prog Plann (1983) 6:247–63.[CrossRef]

Accepted for publication January 18, 2008.


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This Article
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