Translating and validating an instrument for measuring patients’ satisfaction with primary care physicians in Palestine: The case of EUROPEP

Introduction

The evaluation of primary healthcare (PHC) usually focuses on structural and process measures, while aspects related to the views of patients have recently been attracting more attention [1], [2]. There are different studies in Arab countries about patients’ satisfaction with PHC, using different kinds of instruments [3], [4]. In European countries, EUROPEP has recently received wide attention following its creation by EQUIP, the quality of care network of WONCA Europe. EUROPEP has been validated in different international settings and is used for collecting information regarding patients’ evaluation of the care provided by general practitioners (GPs) [5]. This paper reports on the procedure of translating and validating EUROPEP into Arabic as a first step before applying this instrument in PHC settings in Palestine.

Methods

Instrument

EUROPEP consists of 23 items, explored by using a five-point Likert scale. The questionnaire covers two main aspects: clinical behaviour (items 1–16) and organization of care (items 17–23) [5].

Translation

Permission to translate EUROPEP into Arabic was obtained from the instrument's developers. Forward and backward translation and cultural adaptation were conducted according to standard methods [6]. The Arabic version was pilot tested using a cognitive debriefing method with 10 patients [7].

Validation

Setting

The research took place in the PHC centres that belong to the Ministry of Health (MOH) and to the United Nations Relief and Works Agency (UNRWA) in the Gaza Strip, Palestine. The study was carried out in Autumn 2005.

Participants and data collection

Patients attending GP services in the above-mentioned centres were considered eligible. The sample size of 1067 was determined based on a requirement for 95% confidence limits (95% CI) with 3% maximum error of estimate and a conservative estimate of proportion of 50% [8]. The study sample was multi-stratified, the first stratum being the governorates, the second being the localities, and the third the clinics. An exit interview was conducted with 1043 patients. Content validity was done by using a panel of 12 experts who gave their feedback through a scale ranging from “excellent” to “poor” for each item. Internal consistency was determined by checking the components of the questionnaire against each other using Cronbach's alpha [9]. To check the structure validity, an exploratory factor analysis using varimax rotation and subsequent Cronbach's alpha was performed [10].

Ethics

The Helsinki Committee, MOH, and UNRWA granted approval for carrying out this research. A consent letter was presented to the patients prior to the interview.

Results

Response rate

Out of the 1043 patients, 974 agreed to answer the questionnaire (response rate 93.4%). Statistical analysis was performed on the data of 956 patients because the interview was interrupted with 18 patients whose condition deteriorated.

Validation

All 12 experts rated each item of EUROPEP in Arabic as excellent, giving a high level of content validity. The internal consistency of all items was very good, Cronbach's alpha being 0.83 (95% CI 0.81–0.84). Internal consistency for the clinical behaviour dimension was 0.80 (95% CI 0.78–0.82), higher than the value of 0.61 (95% CI 0.54–0.62) for the organization of care dimension. The exploratory factor analysis yielded six factors with eigenvalues >1.0 responsible for 56% of the variance and rotation converged in 11 iterations (see Table I).

Table I.  Exploratory factors analysis for the Arabic EUROPEP: rotated component matrix for six factors.

Order^a	Dimensions	Loading factors	Eigenvalue	Explained variance (%)	Cronbach's alpha (95% CI)
	I. Doctor–patient relationship		2.02	8.77	0.68 (0.64–0.71)
2	Interest in your personal situation	0.67
3	Making it easy for you to tell him/her about your problem	0.68
5	Listening to you	0.77
	II. Commitment of physician		1.39	6.05
6	Keeping your records and data confidential
	III. Information and support		3.43	14.93	0.75 (0.73–0.77)
4	Involving you in decisions about your medical care	0.66
7	Quick relief of your symptoms	0.62
8	Helping you to feel well so that you can perform your normal daily activities	0.52
12	Explaining the purpose of tests and treatments	0.66
13	Telling you what you wanted to know about your symptoms and/or illness	0.73
14	Helping you deal with emotional problems related to your health status	0.44
17	Preparing you for what to expect from specialist or hospital care	0.50
	IV. Medical service		1.71	7.43	0.62 (0.57–0.65)
9	Thoroughness	0.49
10	Your physical examination	0.74
11	Offering you services for preventing disease (e.g., screening, health checks, immunizations)	0.43
18	The helpfulness of the staff (other than the doctor)	0.42
23	Providing quick services for urgent health problems	0.53
	V. Organization of care and availability		2.57	11.19	0.67 (0.64–0.70)
1	Making you feel you had time during consultation	0.66
15	Helping you understand the importance of following his/her advice	0.67
16	Knowing what s/he had done or told you during contacts	0.65
19	Getting an appointment to suit you	0.52
22	Time in the waiting room	0.61
	VI. Accessibility		1.68	7.32	0.67 (0.62–0.70)
20	Getting through to the clinic on the telephone	0.82
21	Being able to speak to the GP on the telephone	0.84

^aOriginal order of items in the English-language version of EUROPEP.

Discussion

The improvement of quality of PHC in Arab countries requires more than political support, administrative support, and funding; it also requires research capacity and reliable instruments for evaluating primary care acceptance in the population. Although there are several instruments that can be used to evaluate PHC services, EUROPEP was chosen because it is a well-tested instrument with implementation in several countries, providing information at an international level. In our study, the response rate for each item was excellent when compared to European response rates. The response rate for each EUROPEP item in different studies ranges between 71.5% and 98.5% [5]. The validation process revealed a satisfactory level for Cronbach's alpha. The clinical behaviour dimension seemed more reliable than the organization of care dimension, which is similar to the results of other studies in Europe [5]. The six extracted dimensions cover different aspects of general practice care. The Arabic EUROPEP is expected to be a practical instrument for evaluation of general practice care in PHC settings from the patient's point of view in Palestine and other Arab countries.

Acknowledgements

Thanks are due to IKY and the Palestinian American Research Centre for financial support, to Mrs Ada Markaki for editing this article, and to the staff of the Department of Social Medicine at the University of Crete and Mr Khaleel Al Said for their support.