|ORIGINAL RESEARCH ARTICLE
|Year : 2015 | Volume
| Issue : 1 | Page : 35-40
Translation and validation of patient-practitioner orientation scale in Sri Lanka
Rasnayaka Mudiyanselage Mudiyanse1, Ranjith Wasantha Pallegama2, Thilak Jayalath3, Sisira Dharmaratne4, Edward Krupat5
1 Department of Pediatrics, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
2 Department of Basic Sciences, Faculty of Dental Sciences, University of Peradeniya, Peradeniya, Sri Lanka
3 Department of Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
4 Medical Education Unit, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
5 Center for Evaluation, Harvard Medical School, Boston, USA
|Date of Web Publication||31-Jul-2015|
Rasnayaka Mudiyanselage Mudiyanse
Senior Lecturer in Pediatrics, Department of Pediatrics, Faculty of Medicine, University of Peradeniya
Source of Support: None, Conflict of Interest: None
Background: Practice of family medicine and patient centeredness does not get the deserved attention in clinical practice and teaching in Sri Lanka. Non-availability of tools for assessment of patient centeredness deters the process of curricular development and research. The Patient-Practitioner Orientation Scale (PPOS) is a self-administered tool that assesses patient-centeredness in both health care professionals and patients. This study has translated and validated the PPOS to Sinhala language. Methods: Translation and cross-cultural adaptation were carried out using forward and backward translation method. The psychometric properties of a pretested new Sinhala version of PPOS (PPOS-Sinhala) was tested in a convenience sample of 1367 patients and health professionals. Temporal stability was tested in a sub-sample of 140 individuals. The comparability of the PPOS scores and association with sex and level of education with those reported for Western populations were examined to establish construct validity. Results: The sample included 543 medical students, 67 doctors, 335 allied health students and 422 patients. Cronbach's alpha for these groups ranged from 0.48 to 0.53 for sharing, 0.42 to 0.53 for caring, and 0.62 to 0.65 for total score. Intraclass correlation coefficients of 0.56, 0.6, and 0.4 were observed for the Total, Sharing, and Caring sub-scales, respectively. PPOS scores did not vary significantly for men and women. Health professionals exhibited higher scores than patients. Age was negatively associated and education level was positively associated with PPOS. Discussion: PPOS-Sinhala is stable, sufficiently valid and reliable to evaluate patient centeredness among Sinhala speaking health care professionals and patients. Lower internal consistency is found for a few items in the instrument which requires further development. PPOS scores and their correlates for this Sri Lankan population were more similar to that found in other populations in this region than for scores and correlates found in the US.
Keywords: Caring attitudes, medical education, medical curriculum, patient-practitioner orientation scale, patient-centered attitudes, sharing attitudes, Sinhala translation
|How to cite this article:|
Mudiyanse RM, Pallegama RW, Jayalath T, Dharmaratne S, Krupat E. Translation and validation of patient-practitioner orientation scale in Sri Lanka. Educ Health 2015;28:35-40
| Background|| |
The traditional biomedical approach of medicine is based on Western science and addresses a patient's separate problems and principally focuses on the disease rather than the patient as a whole.  Such an approach tends to assign decision making power to the doctor, thus can be called a doctor-centered or disease-centered care.  A more modern approach to medical practice; biopsychosocial model has seen a shift away from the disease-centered model toward the patient-centered model, one that involves establishing a more egalitarian rather than authoritarian relationship between doctor and patient. ,,,,,,,
The biopsychosocial model of medical practice, which underpins the concept of patient-centered care, recognizes the art of medicine; here two human beings embark upon a task for relieving pain and suffering. Managing such a relationship also requires a scientific approach. ,, Interactions necessitate exploring patients' feelings, emotions and expectations, and evaluating the patient as a whole. A growing body of literature reveals that patient-centered care is associated with many positive outcomes including patient satisfaction, effective communication, therapeutic adherence, reduced malpractice claims, physician satisfaction, reduction in consultation time, and lower cost. ,, However patient-centred practice is not practiced seen in many countries, including Sri Lanka. ,,
With the increasing realization of the advantages of patient-centered care, teaching this approach has been emphasized worldwide. Promoting patient-centered attitudes among caregivers has been recognized by patients as well as physicians. ,, With this popularity, numerous instruments have been developed to assess the patient's perception of their doctor's orientation toward the patient. These instruments include: Patient Reaction Assessment (PRA),  Perceived Involvement in Care Scale (PICS) - Lerman 1995,  Component of Primary Care Instrument (CPCI) - Flocke US 1998,  Patient-Practitioner Orientation Scale (PPOS),  Patient perception of patient-centeredness (PPPC),  and Consultation Care Measure (CCM). 
We selected the PPOS that evaluates patient centeredness along caring and sharing dimensions among healthcare professionals as well as patients. This is a self-administered questionnaire with 18 Likert items of which 9 evaluate caring attitudes and the rest evaluate sharing attitudes. Caring refers to the extent of the respondent's belief about the importance of emotions, good interpersonal relationships and treating the patient as a whole rather than as a medical condition during doctor patient encounters. Sharing reflects the willingness to share information and power with patients as well as willingness to share control in decision-making. The PPOS has the advantage over other instruments of being able to assess the attitudes of students, doctors, other health care professionals and patients using the same instrument without modifications. ,,,,,,,, The PPOS has been translated and validated in a number of populations worldwide. ,,,
The island of Sri Lanka has a population of 20,653 million, of whom 74% speak the Sinhala language. The literacy rate is 91%. There are 14,125 doctors and 27,494 nurses providing health care services in the country.  The medium of communication in all the medical schools in the country is English. However, the mother tongue of most students is either Sinhala or Tamil and students follow the school curriculum in their respective native languages. Familiarity of the language is of central importance for psychometric assessment when a self-report instrument is used. Hence, translation of PPOS from the English language to Sinhala language is an important pre-requisite for measuring patient centeredness among Sri Lankans. In this study PPOS was translated to Sinhala language and validated while evaluating caring, sharing and total PPOS scores of different groups of Sinhala speaking people in Sri Lanka.
| Methods|| |
Permission was obtained from the original author of the PPOS, who is also a collaborator in this study. The study was conducted at the Faculty of Medicine, University of Peradeniya, Sri Lanka. Ethical clearance was obtained from the Ethical Review Committee of the Faculty of Medicine of the University of Peradeniya, and verbal informed consent was obtained from all participants that included medical students, doctors, allied health staff, patients and members of general public before administering the questionnaire. Medical students were approached at the end of routine lectures, and doctors and allied health staff was approached at the end of their continuing education lectures. Following a 2-min introduction on the topic and the purpose of the study a common verbal invitation was made to all individuals to participate in the study. Those who consented to participate were asked to remain in the lecture hall while others proceeded on with their personal schedules. Patients were approached while waiting in the outpatient department, and members of general public were approached at four occasions: Two wedding ceremonies and two religious ceremonies. The researcher addressed the entire group briefly, responded to their questions and those who gave consent for the study were invited to a separate room to be administered the questionnaire.
The guidelines recommended for cross-cultural adaptation of self-reported measures were followed in the process of translation, adaptation and validation of the PPOS to Sinhala language. , In Phase I of the study, the translation of PPOS to Sinhala language, cultural adaptation and pretesting was carried out. In Phase II of the study, testing of the psychometric properties of the PPOS-Sinhala was carried out on a sample of 1380 participants.
Phase I: Translation and cultural adaptation of the PPOS
The translation was carried out according to the following steps.
(i) Forward translation of the original English version was performed by four translators. The third author served as an "informed" translator and three others (another clinician and two language expert who had no knowledge in the concept being quantified) functioned as translators. (ii) The four translators and the principal investigator synthesized the translations to a composite document using the original questionnaire as a guide. (iii) The back translation of the translated version was done by another independent translator who was fluent in both languages. (iv) Comments were sought from experts to maintain the face validity and to make sure that the questionnaire was understood by a 14-year-old child (an 8 th grader) speaking the Sinhala language. (v) The back translation and the original English questionnaire were sent to a native English speaker, the fifth author of the study, for comparison and recommendations and thus the translated pre-final version of PPOS was finalized. (vi) The pre-final version of PPOS was pre-tested on a group of 30 adult patients (15 males) from the Out Patient Department, Clinic and in-ward patients of the Teaching Hospital Peradeniya. Subsequently, they were interviewed about every item of the questionnaire and necessary minor adjustments were made.
Phase II: Testing for retention of psychometric properties
Testing of the PPOS-Sinhala for retention of psychometric properties (internal consistency, temporal stability, and construct validity and responsiveness) was carried out on a sample of 1380 participants representing all groups (medical students, doctors, allied health staff, and patients) with whom we may use the PPOS-Sinhala in the future. An attempt was made to include an approximately equal number of male and female participants in each subgroup. To assess test/retest reliability, the questionnaire was administered twice to a sub-sample of nurses (n=42) and medical students (n=98) on two different days with an intervening interval of two weeks. According to the quality criteria proposed for the measurement properties of health status questionnaires (Terwee et al.  ) a patient sample of 400 in each group was considered adequate. During the administration, the PPOS-Sinhala was administered to 1380 participants that included medical students, doctors, allied health staff and patients. First, third, and final year medical students of the Faculty of Medicine Peradeniya were approached. The lead investigator trained other investigators and written instructions helped maintain uniformity in the questionnaire's administration. All subject groups were convenience samples.
Data management and analysis
Statistical Package for Social Sciences (SPSS) version 11.5 for Windows was used for data analysis. Questionnaires from 13 participants were discarded due to incomplete responses and the remaining 1367 were included in the analysis. The scores were calculated using the standard scoring methods proposed by the author of the original PPOS. Descriptive statistics were calculated for the total score of PPOS and the Sharing and Caring components of the PPOS for the different participant groups. The Kolmogorov-Smirnov test and exploratory statistics revealed that the distributions of the scores on sharing, caring and the total score of PPOS did not conform to normality standards. Hence, nonparametric tests were used for further analysis.
Cronbach's alpha was calculated as a measure of internal consistency. PPOS scores of males and females were compared using the Mann-Whitney U test and the association with age was explored using Spearman correlation coefficient to establish construct validity. Item to total and component to total correlations were performed using Spearman correlation coefficient to substantiate these observations. To establish test the test-retest reliability, the intraclass correlation coefficient (ICC) were calculated with the scores obtained from a sample of 140 young healthy adults at baseline and after a two week period.
The Kruskal-Wallis test was used to compare sharing, caring and total PPOS scores among different categories of participants, with post-hoc multiple comparisons performed using the Mann-Whitney U test with the Bonferroni adjustment. The "floor or ceiling effects" (examined using frequency distributions) and the descriptive statistics were calculated to provide evidence of adequate interpretability.
| Results|| |
At the end of the phase I of the study (translation and cultural adaptation), the researchers and translators were satisfied with the face validity of the PPOS-Sinhala. In phase II of the study, the analysed sample included a total of 1367 subjects with 532 (39%) males and 835 (61%) females with a mean age of 33.14 (13.5 SD) years. The sample included 543 medical students (185 first years students, 173 third years students and 185 fifth years students with a mean age of 23 ± 2.3 SD years), 67 practicing doctors (mean age, 33.5 ± 8.9 SD years), 335 nurses, physiotherapists and medical laboratory technicians (mean age, 33.8 ± 11.3 SD) years, 206 patients attending hospital clinics and 216 healthy individuals in the public (422 individual in total representing patients, with a mean age, 44.5 ± 14.1SD years). Most participants (66%) were university graduates, and the others were individual who had completed 12 years of school education (18.3%) or had not (13.7%). Descriptive statistics for the PPOS scores of the participant groups are presented in [Table 1].
|Table 1: Distribution of scores (Mean ± SD) of sharing, caring and total of PPOS of participants|
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For Sharing, item-to-total correlation [Table 2] varied from 0.2 to 0.47 (P < 0.05) and for total PPOS from 0.12 to 0.46 (P < 0.05). For Caring, item-to-total [Table 2] correlation varied from 0.14 to 0.48 (P < 0.05) and for total PPOS from 0.21 to 0.43 (P < 0.05). The correlation coefficient for the association between Sharing and Caring scores was 0.4 (P < 0.001). Both Sharing and Caring components had very high correlations to the total PPOS (r = 0.8, P < 0.001).
The respective Cronbach's alpha calculated for Sharing, Caring and Total PPOS score were: For the total sample (0.5, 0.52 and 0.63); for medical students (0.48, 0.53 and 0.61); for doctors (0.52, 0.42 and 0.54); for allied health staff (0.52, 0.24 and 0.52); and for patients and public (0.53, 0.43 and 0.65). In the total sample, elimination of the item 9 improved the Cronbach's alpha of Sharing from 0.49 to 0.56, elimination of item 17 on the Caring scale improved it from 0.51 to 0.56, and on the total PPOS, and elimination of the item 17 improved it from 0.63 to 0.66.
There was no relationship with respondent's sex and the Sharing, Caring and Total scores for any of the subgroups [Table 1]. Medical students, doctors and allied health staff reported higher scores on Sharing, Caring and the Total PPOS score than patients (P < 0.001 after Bonferroni adjustment). Older subjects exhibited lower PPOS scores than younger people as revealed by statistically significant negative association obtained for Sharing (r=-0.23, P = 0.001), Caring (r=-0.27, P = 0.001) and the Total score (r=-0.29, P = 0.001) with age.
Kruskal-Wallis test revealed that the level of education had a significant association with Caring and Total scores (P < 0.001) [Table 3]. Post-hoc multiple comparisons performed using Mann-Whitney test with Bonferroni adjustment (taking alpha as 0.017) revealed that participants with a university degree had significantly higher Sharing, Caring and Total PPOS scores than all other groups (P < 0.001). Those who had completed a General Certificate of Education - Advanced/Level had higher Caring and Total PPOS scores than those who had not completed school education (P < 0.001). "Floor or ceiling effects" were observed for less than 1% of respondents who had the highest or lowest scores possible for Sharing, Caring or the Total PPOS, within the accepted limits of 15%.  ICC calculated between the scores reported by the 140 participants of the subsample that repeated the test two weeks apart were moderate to high for Sharing (0.61), Caring (0.43) and Total PPOS score (0.56) reflecting adequate temporal stability.
| Discussion|| |
The concept of patient-centered care is not new; in fact, some suggest the seeds of patient-centeredness can be traced to period back as far as the time of Hippocrates within Western medical traditions ., The experts had introduced the view that each patient has to be understood as a unique human being. , With increasing recognition of its benefits, imparting patient-centered care has become an obligation for medical educators, and the development and utilization of sets of common instruments such as the PPOS, each tested and validated within its own cultural context, is important for evaluating educational interventions. ,, Beginning with this premise, the present study evaluated the psychometric properties of the translated and culturally adapted Sinhala version of the PPOS on a variety of populations, including medical students, doctors, allied health staff and patients.
The translated Sinhala version of the PPOS (PPOS-Sinhala) exhibited lower than desirable internal consistency, with moderate Cronbach's alphas for Caring and Sharing and Total scores. These values, which are lower than those reported in other studies, are of some concern and the elimination of several items (e.g., item 9 and 17) improves the alpha levels. , However, the adequately high ICC reported by the sub sample taking the PPOS-Sinhala two weeks apart provides evidence of solid test-retest reliability, suggesting the presence of temporal stability of the PPOS-Sinhala. Combined with the above observations and the moderate item to total and high component to total correlations observed, it is reasonable to conclude that the internal consistency of this newly translated tool has to be monitored over time, but is sufficiently reliable to collect further data with this instrument.
The association of Sharing, Caring and Total PPOS scores with the age and level of education observed in the present study is comparable to the relationships reported in several other countries. ,,,,,,,, Higher levels of education and younger age are associated with higher PPOS scores not only in Sri Lanka, but also in the US, UK and Japan. In addition, the observation of higher Caring scores than Sharing scores in our samples was consistent with observations made in previous investigations. ,,, In the absence of a gold standard to assess the criterian validity of the Sinhala version of the PPOS, these observations provide evidence for the adequacy of construct validity of the the PPOS-Sinhala.
This investigation reported slightly lower Total, Caring and Sharing scores for medical students and allied health staff compared with doctors. However, the lowest PPOS values were seen among patients and the general public, which is also consistent with the observations made in other countries.  Doctors in our sample had slightly lower Sharing, Caring and Total PPOS values than those reported in the USA, Sweden, the UK and Brazil ,,,, and slightly higher scores than have been reported in Nepal, India, Malaysia and Greece. ,,,, Medical students in our sample also had slightly lower PPOS scores than in the US, UK and Brazil, but they were higher than in Singapore and Greece. It is interesting to note that PPOS values in our sample are even higher than economically stronger Malaysia and Greece. These observations may reflect a number of sociocultural influences, among them the education system and child rearing practices of the different societies.
Observation of rather smaller Cronbach's alpha values is a major limitation of the present study. However, items that need revision have been recognized. Not having a gold standard to examine the construct validity makes further evaluation even more difficult. But the associations observed with age and sexes provide adequate evidence for good construct validity.
| Conclusion|| |
The translated Sinhala language version of the PPOS (PPOS-Sinhala) is a valid and stable tool, with moderate levels of reliability as tested for the first time in this sample of health professionals and patients. The observation that our patients have lower PPOS values while doctors having slightly higher PPOS values compared with other countries in the region has implications in clinical practice. In light of previously reported findings that congruence of attitudes between physicians and patients contributes to patient satisfaction,  the finding that education level showed a positive association with the PPOS scores and that age exhibited a significant negative association suggests that practitioners might want to adapt to patients of different types and adjust the manner in which they act with their patients who vary in age and education.
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[Table 1], [Table 2], [Table 3]
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