Cross-cultural validation of the Patient–Practitioner Orientation Scale (PPOS)

doi:10.1016/j.pec.2012.11.014

Patient Education and Counseling

Volume 91, Issue 1, April 2013, Pages 37-43

https://doi.org/10.1016/j.pec.2012.11.014 Get rights and content

Abstract

Objectives

Translate, adapt and validate the Patient–Practitioner Orientation Scale (PPOS) for use in Brazil.

Methods

The PPOS was translated to Portuguese using a modified Delphi technique. The final version was applied to 360 participants. Reliability (test–retest and internal consistency) and construct validity (explanatory and confirmatory factor analysis) were assessed.

Results

Only two items did not reach pre-established criteria agreement in Delphi technique. In pre-testing, seven items were modified. Internal consistency (Cronbach's alpha = 0.605) and test–retest reliability (intraclass correlation coefficient = 0.670) were adequate. In explanatory factor analysis, one item did not achieve a loading factor, one item was considered factorially complex and two items were inconsistent with a priori factors. Confirmatory factor analysis provided an acceptable adjustment for the observed variables (χ²/df = 2.33; GFI = 0.91; AGFI = 0.89; CFI = 0.84; NFI = 0.75; NNFI = 0.81; RMSEA = 0.062 (p = 0.016) and SRMR = 0.065).

Conclusions

The Brazilian version PPOS (B-PPOS) showed acceptable validity and adequate reliability.

Practice implications

The use of the B-PPOS in national and cross-cultural studies may contribute to the evaluation and monitoring of the attitudes of doctors, medical students and patients toward their professional relationships in research and practice.

Introduction

Patient-centered clinical practice is a holistic concept in which components interact and unite in a unique way in each patient doctor encounter. In this approach, doctors are able to use communication skills that explore the patients’ main reason for the visit, concerns and need for information; seek an integrated understanding of the patients’ world, that is, their whole person, emotional needs and life issues; find common ground on what the problem is and mutually agree on management; enhance prevention and health promotion and enhances the continuing relationship between the patient and the doctor [1]. Patient-centered communication has been considered crucial to high-quality health care [2] and it is associated with higher patients’ and physicians’ satisfaction, better biomedical outcomes related to patient adherence to treatment [3], [4], [5], decreased prescription-related adverse effects and self-management of chronic diseases [6], [7], [8], [9], [10], [11]. Patient centeredness is also related to a decrease in patient complaints, complementary diagnostic exams and specialist referrals. Lower costs for health systems and patients are observed when practitioners and patients hold patient-centered attitudes [12], [13], [14], [15].

Assessing such attitudes has become increasingly important in the context of health care and medical education. The Patient–Practitioner Orientation Scale (PPOS) [16], [17] is an instrument originally designed to assess physicians’, medical students’ and patients’ attitudes toward their roles in medical care. It contrasts a patient-oriented attitude with a doctor-oriented attitude among respondents. This scale has been extensively used in the US and has been translated into several languages around the world [18], [19], [20], [21], [22], [23], [24], [25]. Although this instrument has already been translated and used previously in other cultures, their cultural adaptation and psychometric properties has neither been tested nor reported. In the studies by Lee et al. [24] and Wahlqvist et al. [25], the reliability of PPOS has shown acceptable values.

Translation issues regarding the PPOS in non-English speaking cultures raise important challenges in cross-cultural research. The need for new psychometrically and linguistically valid versions of questionnaires must be addressed in translation and cultural adaptation studies. Questionnaire items must not only be translated well linguistically, but the cultural use of the language must also be taken into account so as to produce an instrument as valid and reliable as the original one. Therefore, providing sophisticated ways to assure the underlying structure and cultural equivalence of the original instrument in another language and culture is urged in international comparative studies [26], [27].

This study aimed to translate, culturally adapt and validate the PPOS to the Portuguese spoken in Brazil through a rigorous and meticulous translation technique. This paper involves an effort to assure not only a linguistically but also a culturally relevant version of the PPOS.

Section snippets

Description of the instrument

The PPOS (Patient–Practitioner Orientation Scale) [16], [17] is a doctor–patient orientation scale capable of assessing doctors’, medical students’ and patients’ attitudes toward the doctor–patient relationship. The scale contains 18 items that reflect two domains related to the patient: Sharing and Caring. The 9-item Sharing domain assesses whether respondents believe that power and control should be shared between doctors and patients as well as the degree to which the doctor should share

Participants’ characteristics

We included 360 participants in the study equally divided into three groups: resident doctors, medical students and patients. Sixty-one patients (50.8%) had completed high school (Table 1).

Delphi technique

During the review stage, five items reached consensus in the first round, seven items in the second round, three items in the third round and three items in the fourth round. In the second round, a question that aimed to clarify the meaning of the word “status” was introduced and the question reached

Discussion

In this study, the PPOS was translated and adapted to Brazilian Portuguese, and the Brazilian version (B-PPOS) was demonstrated to be reliable and valid. Although the PPOS and other instruments have been translated and adapted in other countries, few previous studies have used such rigorous and meticulous translation techniques as ours to assure cultural relevance as well as linguistic accuracy. The translation, cultural adaptation and validation of the PPOS in Brazil have followed

Conflict of interest

The authors state that there are no conflict of interests.

Acknowledgements

We thank resident doctors, medical students and patients who participated in this study for their dedication and contributions to testing the B-PPOS.

We confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story.

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Preference for patient-centered communication among the citizens of the Visegrad countries
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Citation Excerpt :
Therefore, the lower Caring and Sharing scores can be explained by the respondent’s selection, likely due to the higher variance of the people filling out the questionnaire. Other translation and validation processes have found similar correlation between the general public and the PPOS values [33,35]. Citizens of the four countries expressed similar preference for the communication style of the practitioner.
The aim of the study was to investigate and compare the preferences that citizens of four Visegrad countries hold concerning the communication between patient and provider.
The patient-practitioner orientation scale was used on a general population in our research, which consists of the Sharing and Caring subscales and assesses patient-centered or doctor-centered orientation toward communication. The statistical analysis included 4000 respondents of citizens from the Czech Republic, Slovakia, Poland and Hungary. When comparing the various demographic data and the four countries with each other univariate and multivariate logistic regressions were performed.
Being female, middle aged, having a higher education and a poor health status were associated with significantly higher Sharing and Caring scores. Also, Hungarian citizens had a significantly higher Caring score compared to the other three countries.
Key demographic variables were identified that affect how citizens perceive the communication between patient and provider. With the exception of Caring among Hungarian citizens, no differences were observed among the Visegrad countries.
These findings have potential implications for understanding the preferences of the citizens and thus better promote a more patient-centered communication.
Resident physicians' attitudes and confidence in communicating with patients: A pilot study at a Japanese university hospital
2014, Patient Education and Counseling
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Scoring is based on a 6-point Likert scale ranging from “strongly agree” to “strongly disagree,” with higher scores indicating a more patient-centered orientation. The scale has been translated and validated in non-Western countries as well [16–21]. Translation into Japanese was performed following the standard procedure of translating scales [22].
This study aimed to explore the relationships among physicians’ confidence in conducting medical interviews, their attitudes toward the patient–physician relationship, and undergraduate training in communication skills among resident physicians in Japan.
Participants were 63 first-year resident physicians at a university hospital in Tokyo. The Physician Confidence in the Medical Interview scale (PCMI) was constructed based on the framework of the Calgary–Cambridge Guide. Additionally, participants’ attitudes toward the patient–physician relationship (Patient–Practitioner Orientation Scale; PPOS), undergraduate experience of communication skills training, and demographic characteristics were assessed through a self-reported questionnaire.
The internal consistency of the PCMI and PPOS scales were adequate. As expected from the undergraduate curriculum for medical interviews in Japan, residents had relatively higher confidence in their communication skills with respect to gathering information and building the relationship, whereas less confident about sharing information and planning treatment. The PCMI was associated with a more patient-centered attitude as measured by the PPOS.
These scales could be useful tools to measure physicians’ confidence and attitudes in communicating with patients and to explore their changes through medical education.
Residency programs should consider including systematic training and assessment in communication skills related to sharing information and planning treatment.
A Virtual Community of Practice to Improve Primary Health Care Professionals’ Attitudes Toward Patient Empowerment (e-MPODERA): A Cluster Randomized Trial
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A ceiling effect cannot be ruled out, especially for the Caring subscale, which also showed a low internal consistency (Cronbach α = 0.48). A psychometric analysis of baseline data showed an unsatisfactory functioning of several items,24 as observed in other studies.25,26 Post hoc analysis showed a greater effect for female HCPs (P value of the interaction = .061).
We aimed to evaluate the effectiveness of a virtual community of practice (vCoP) in improving primary health care professionals' (HCPs') attitudes toward empowering patients with chronic disease.
We conducted a cluster randomized controlled trial. Practices were units of randomization, and primary HCPs and patients were units of analysis. Sixty-three practices in Madrid, Catalonia, and the Canary Islands were randomly allocated to the intervention or control groups. Randominzation of practices was performed after HCP and patient recruitment. The patients and statistician were anonymized to group allocation; it was not possible to anonymize HCPs. The intervention was a 12-month multicomponent tailored vCoP built on the Web 2.0 concept and focused on skills toward patient empowerment. The primary outcome was Patient-Provider Orientation Scale (PPOS) score at baseline and at 12 months. The secondary outcome was the Patient Activation Measure (PAM) score.
A total of 321 HCPs and 1,921 patients were assessed. The intervention had a positive effect on PPOS total score (0.14 points higher in the vCoP arm; 95% CI, 0.03–0.25; P = .011) and the PPOS Sharing subscale (0.3 points higher in the vCoP arm; 95% CI, 0.15–0.44; P < .001). No effect was found for the PPOS Caring subscale, and no significant differences were found for PAM scores.
A vCoP led to a minor increase in the PPOS Sharing component and the total score but not in the Caring component. However, considerable uncertainty remains, given the observed attrition and other limitations of the study. Further research is needed on the effectiveness of the vCoP model and on how to improve HCP engagement.
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Factors affecting physicians' attitudes towards patient-centred care: a cross-sectional survey in Beijing
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AssessmentCross-cultural validation of the Patient–Practitioner Orientation Scale (PPOS)

Abstract

Objectives

Methods

Results

Conclusions

Practice implications

Introduction

Section snippets

Description of the instrument

Participants’ characteristics

Delphi technique

Discussion

Conflict of interest

Acknowledgements

Ophthalmology

Soc Sci Med

Patient Educ Couns

Patient Educ Couns

Patient Educ Couns

Patient Educ Couns

Towards a global definition of patient-centred care

Br Med J

Beliefs about control in the physician–patient relationship: effect on communication in medical encounters

J Gen Intern Med

Physician communication and patient adherence to treatment: a meta-analysis

Med Care

Patient centered primary care is associated with patient hypertension medication adherence

J Behav Med

Communication styles in the cancer consultation: preferences for a patient-centred approach

Psychooncology

Patient-centered care and adherence: definitions and applications to improve outcomes

J Am Acad Nurse Pract

Patient preference for and reports of provider behavior: impact of symmetry on patient outcomes

Health Psychol

Developing physician communication skills for patient-centered care

Health Affair (Millwood)

The Science of patient-centered-care

J Fam Pract

The impact of patient-centered care on outcomes

J Fam Pract

Patient-centered communication and diagnostic testing

Ann Fam Med

Patient-centredness and its correlates among first-year medical students

Int J Psychiatry Med

Patient role orientations, doctor–patient fit and visit satisfaction

Psychol Health

Brazilian medical students’ attitudes towards patient-centered care

Med Teach

Medical student attitudes toward the doctor–patient relationship

Med Educ

Patient involvement in clinical decision making: the effect of GP attitude on patient satisfaction

Health Expect

Assessment
Cross-cultural validation of the Patient–Practitioner Orientation Scale (PPOS)