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Spanish-Language Version of the MedRisk Instrument for Measuring Patient Satisfaction With Physical Therapy Care (MRPS): Preliminary Validation

PF Beattie, PT, PhD, OCS, is Clinical Associate Professor, Program in Physical Therapy, Department of Exercise Science, Arnold School of Public Health, and the Department of Developmental Biology and Anatomy, School of Medicine, University of South Carolina, Columbia, SC 29208 (USA)
RM Nelson, PT, PhD, FAPTA, is Professor, Department of Physical Therapy, Lebanon Valley College, Annville, Pa, and Vice President, Expert Clinical Benchmarks, LLC, King of Prussia, Pa
A Lis, PT, MS, is Associate Clinical Director, Program of Ergonomics and Biomechanics, Occupational and Industrial Orthopedic Center, NYU Hospital for Joint Diseases, and Instructor, New York University, New York, NY

Address all correspondence to Dr Beattie at: pbeattie{at}gwm.sc.edu

Submitted October 18, 2006; Accepted January 31, 2007

	Abstract

 
Background and Purpose: An instrument that provides valid measurements of satisfaction with physical therapy care for Spanish-speaking patients will enhance communication and ensure their representation in quality assurance analyses and research on health care disparities. The purpose of this investigation was to provide preliminary information on the factor structure, group- and individual-level reliability, and criterion-referenced validity of measurements obtained from a Spanish-language version of the MedRisk Instrument for Measuring Patient Satisfaction With Physical Therapy Care (MRPS).

Subjects: A total of 203 Spanish-speaking patients in the New York City area participated in this study.

Methods: Consenting subjects completed a 20-item MRPS after discharge from outpatient physical therapy care. Several translators performed "forward" and "backward" translation of the MRPS, followed by consensus agreement on item structure. Factor structure was investigated using item-correlation and exploratory factor analysis. Group-level reliability for single test administration was assessed using the Cronbach alpha, and individual-level reliability was assessed by calculating the standard error of the measure (SEM). Concurrent validity was tested by comparing the item scores and mean scores of factors to global measures of satisfaction.

Results: The means of individual item scores (1–5) ranged from 3.22 for "I did not wait too long" to 4.80 for "My therapist treated me respectfully." There were no sex-based differences in item scores. Exploratory factor analysis suggested a 2-factor solution: a 7-item "external" factor and a 3-item "internal" factor. The correlations (r) of the mean scores from these factors with the 2 global measures ranged from .59 to .82. The SEM was 0.16 for the internal factor and 0.25 for the external factor.

Discussion and Conclusion: The underlying factor structure of the Spanish-language version of the MRPS was identical to the English-language version. Our findings provide preliminary support for the reliability and validity of measurements obtained from the Spanish-language version of the MRPS. Further study is needed to assess the stability of these findings in other samples. As with English-speaking patients, Spanish-speaking patient's satisfaction with physical therapy care is most strongly linked to the professional behavior of the clinician.

	Introduction

Top Abstract Introduction Method Results Discussion Conclusions References

 
A 2003 report by the US Census Bureau estimated that 45 million people in the US population speak a language other than English in the home.¹ Within this group, approximately 28 million people speak Spanish as a primary language, and as many as 50% of these people have limited English-language proficiency.^2–4 Many people in this population have low incomes and limited literacy skills that place them at risk to receive substandard medical care.^1,5 Strategies to overcome the communication barriers between health care providers and patients typically include the use of various types of interpreters (clinic staff, family members, or professional interpreters). These strategies can be problematic, however, because the use of interpreters may violate patient confidentiality and can result in important errors in translation.³

A mechanism that may greatly assist communication between providers and Spanish-speaking patients is the use of valid self-report questionnaires that have been appropriately translated. These instruments may be a valuable way to enhance the exchange of meaningful information without violating patient confidentiality and will provide data to ensure that these patients are represented in quality assurance evaluations and clinical research. Several commonly used measures that are relevant to physical therapy care, such as the Roland-Morris Back Pain Disability Questionnaire⁶ and the Fear-Avoidance Beliefs Questionnaire,⁷ have been translated from English to Spanish and have shown evidence of reliability and validity. Measures that reflect many other important areas of clinical practice for Spanish-speaking patients, however, are not available.⁸

One important dimension of patient management that lacks a validated Spanish-language measure is patient satisfaction with physical therapy care. Accurate assessment of patient satisfaction with care can provide valuable information that may improve the patient's health care experience and outcomes, and can assist in business decisions regarding practice.^9–20 Recent work has suggested that Spanish-speaking patients are less satisfied with medical care than are English-speaking patients.^3,21,22 Whether this is also true for Spanish-speaking patients receiving physical therapy care is unknown; however, this is an important area to address.

Several English-language measures used to assess patient satisfaction with physical therapy care have been derived and have undergone preliminary validation.^23–26 Measurements obtained from one of these instruments, the MedRisk Instrument for Measuring Patient Satisfaction With Physical Therapy Care (MRPS), have demonstrated content- and criterion-referenced validity during subsequent testing on an independent data set.²⁷ The MRPS includes 2 items that are used as global references and 10 additional items divided into an Internal subscale (7 items), which reflects the interaction of the patient with the therapist, and an External subscale (3 items), which reflects the interaction of the patient with the receptionist as well as the comfort of the waiting room. This factor structure has been suggested by exploratory factor analysis on an initial sample of subjects (N=1,889) receiving outpatient physical therapy care,²³ and has been supported by confirmatory factor analysis on a second sample of subjects (N=1,149) who also were receiving outpatient physical therapy care.²⁷

Measurements from this instrument have been shown to have a low degree of error and are highly correlated to global measures of patient satisfaction.^23,27 This instrument has the advantage of being succinct and easy to score, and it yields measurements with evidence of reliability and validity when administered to English-speaking patients. The purposes of this investigation were to provide preliminary information regarding the factor structure, group- and individual-level reliability, and criterion-referenced validity of measures obtained from a Spanish-language version of the MRPS. If measurements from a Spanish-language version of this instrument have evidence of reliability and validity, the MRPS could be a valuable tool for clinicians who treat Spanish-speaking patients.

	Method

Top Abstract Introduction Method Results Discussion Conclusions References

 
Instrument Development

A 20-item version of the MRPS (18 items and 2 global measures), previously used during pilot testing of the English-language version and was subsequently reduced to the 12-item MRPS, was translated into Spanish using a "forward" and "backward" translation and consensus agreement approach described by Hurtado et al.² We chose to use the original 20-item version of the MRPS for preliminary testing because it would allow us to assess a larger array of items than the validated 12-item MRPS. We were not sure whether any cultural factors might be missed if we used only the 12-item MRPS instrument.

We used a total of 4 translators who were fluent in Spanish and English. Three of the translators were health care providers in the New York City area and one was a Spanish language professor. Each translation was done independently. The translators were instructed to emphasize the conceptual meaning of each item rather than the literal equivalence.²⁸ Consistent with the original English-language version of the MRPS, the choice of wording of each item was targeted at a reading level of approximately 14 years of age.

The first 2 translators translated the 20-item MRPS from English to Spanish. Upon completion of this task, these 2 translators and one of the authors (AL) reviewed the translated instrument and, after brief modifications, agreed upon a preliminary version. This preliminary Spanish-language instrument was then reviewed by 2 bilingual people who confirmed that its clarity of expression, use of common language, and conceptual meaning were adequate. The second pair of translators then translated this version back into English. This "backward" translation was then reviewed by all 4 translators and one of the authors (AL). Slight modifications were made, and the process of forward and backward translation was repeated in the fashion described above. Following this, consensus was achieved by all 4 translators and one of the authors (AL) that the Spanish-language version was an appropriate representation of the original instrument. The instrument was then pilot-tested for face validity and feasibility by having several Spanish-speaking patients who were receiving physical therapy care complete the instrument and make comments.

Subjects

Patients who were more than 18 years of age and had been discharged from outpatient physical therapy care at 1 of 5 facilities in the New York City area were eligible for this study. All subjects had to be able to read and write in Spanish and consider Spanish to be their preferred language. Data were collected between June 2004 and July 2006.

The rights of all subjects were protected. All subjects signed a consent form in Spanish that had been approved by the institutional review boards of MedRisk Inc and New York University. Patient names and any identifying subject characteristics were not included in the database.

Procedure

Upon completion of their course of care, subjects were asked to complete a measure of patient satisfaction with care, and were offered a choice of an English or Spanish version of the MRPS based on personal preference. In addition to completing the MRPS, subjects provided information regarding their age, sex, and location of primary symptoms. Subjects were instructed to place the completed instrument in a box in the waiting room. At approximate 6-week intervals, completed instruments were collected by a staff member who was not involved in this study, and they were mailed to a study coordinator at the Department of Physical Therapy, Lebanon Valley College, in Annville, Pa, who entered the data into a database. Only Spanish-language instruments were used for the current study. At quarterly intervals, each clinic was given a synopsis of the collected data in tables and charts that detailed the overall satisfaction with care and the satisfaction level on each question.

Data Analysis

Subjects whose completed questionnaires contained missing item responses were not included in the analysis. Responses to 3 items that had been negatively worded were recoded as positive (ie, responses of 1=5, 2= 4, 4=2, and 5=1). Descriptive statistics were then calculated and assumptions of normality were confirmed for continuous variables. The presence of sex-based differences in age and in the mean scores for each of the 20 items was assessed using an independent t test.

Factor Structure

An inter-item correlation matrix was generated to determine the correlation of each of the 18 items to the 2 global measures. Those items that were not significantly correlated to both of the global items were removed from further analysis. An exploratory factor analysis, using principal components analysis (PCA) with varimax rotation, was then performed using those items that remained in the data set. The number of potential factors was suggested by the number of eigenvalues that were >1.0.^23,26,29 A scree plot was used to investigate this further using visual estimation. Items on the rotated solution that loaded >.60 on one factor and <.40 on any other factor were retained.^30,31 We chose this rule because it represents a conservative inclusion criterion³¹ and is consistent with our previous study,²³ thus allowing us to make comparisons.

Reliability

Reliability of measurements was examined in 2 ways. Group-level reliability was addressed by calculating a Cronbach alpha^32–34 for each factor that was proposed by PCA. Roddey et al³² and Anastasi³³ have proposed that this statistic estimates the reliability of measurements obtained from subscales after a single administration of the test, and that it is useful in assessing group-level reliability of responses that may change over short periods of time.

Individual-level reliability was addressed by calculating the standard error of the measure (SEM) for the mean score of each factor proposed by PCA.^32,35 The SEM provides an estimate of the likely degree of measurement error expressed in the same units as the measure of interest. To calculate the SEM for each factor proposed by PCA the following formula was used:

where SD=the standard deviation of the mean score for the factor.^32,35 Following this a 95% confidence interval of the SEM was derived by adding and subtracting 1.96 x SEM to the observed scores. This 95% confidence interval is useful to determine the range of measures between which the true score is likely to be. For example, if the observed score is 4.00 and the SEM is 0.12, there is a 95% probability that the true score is between 3.76 and 4.24 (4.00 – 0.24 and 4.00 + 0.24).

Criterion-Referenced Validity

Criterion-referenced validity was addressed by determining the correlation (r) between individual item scores and mean scores for factors with the two global measures of satisfaction.³¹ All calculations were performed using SPSS version 14.0.^*

	Results

Top Abstract Introduction Method Results Discussion Conclusions References

 
A total of 250 questionnaires were returned. Of these, 47 (18.8%) contained missing item responses and were not used. A total of 203 questionnaires were used for this analysis. Of the total number of subjects, 161 (79.3%) were female and 42 (20.7%) were male. The mean age for female subjects was 59.12 years (SD=11.1) compared with 50.9 years (SD=14.0) for male subjects (P<.01). The primary location of the subjects' symptoms is summarized in Table 1. Mean scores for individual items were graded from 1 to 5 (1=strongly disagree, 5=strongly agree) and ranged from 3.22 (SD=1.7) for "I did not wait too long" to 4.80 (SD=0.62) for "My therapist treated me respectfully" (Tab. 2). There were no sex-based differences in the mean scores of individual items.

	Discussion

Top Abstract Introduction Method Results Discussion Conclusions References

 
The results of the exploratory factor analysis performed on our data set reveals a proposed factor structure for the Spanish-language version of the MRPS that is identical to the factor structure of the previously validated, 12-item English-language version of the MRPS. In our current sample, factor loadings ranged from .65 to .77 for the internal subscale and from .69 to .75 for the external subscale. In the initial validation of the 12-item English-language version of the MRPS, factor loadings following PCA with varimax rotation ranged from .75 to .87 for the internal subscale and from .73 to .78 for the external subscale.

The factor structure of the internal and external factors in the Spanish-language version of the MRPS has moderate to high alpha values, suggesting internal consistency and group-level reliability for a single administration of the instrument. Individual-level reliability is supported by low SEM values, suggesting a low degree of error in measurement. In our sample, there was a 95% certainty that the true value was within ±0.31 of the observed value for the internal factor and ±0.49 of the observed value for the external factor.

Criterion-referenced validity is supported by the moderately high correlations between the mean scores of the factors and the global measures. The magnitude of the correlation of individual items (Tab. 3) and the 2 subscales (Tab. 5) to the global measures was almost identical to the findings in our previous work.²³ This finding is encouraging regarding the construct validity and cross-language validation of our instrument. The strength of the correlations, however, is moderate, indicating that other variables, which we did not sample, also are likely to influence satisfaction (ie, our instrument does not completely describe the construct of patient satisfaction).

The degree of agreement between the measurement properties of English- and Spanish-language instruments developed to assess patient satisfaction with medical care vary. Hayes and Baker²⁸ reported that the Spanish-language version of the Interpersonal Aspects of Care Measure completed by patients receiving emergency care yielded much lower reliability coefficients than the English-language version. Miceli,³⁶ however, reported that English- and Spanish-language versions of a measure of satisfaction with inpatient medical care had the same underlying factor structure. The findings of our study are promising, and suggest that, despite language differences and possible cultural variations between samples, the English- and Spanish-language versions of the MRPS measure similar underlying factors. These observations are, however, preliminary, and confirmatory factor analyses on independent samples of other Spanish-speaking patients are needed to provide more evidence of the validity of this factor structure.

Our results are consistent with our previous work^23,27 and that of other researchers,^24–26 which describe high degrees of patient satisfaction for English-speaking patients receiving physical therapy care. We believe this is the first report of satisfaction with physical therapy care for Spanish-speaking patients. Our findings suggest that substantial similarities exist between Spanish-speaking and English-speaking patients regarding perceptions that are most closely linked to satisfaction with care. Items that most closely address the professionalism of the provider^37–41 (ie, spending adequate time with the patient, listening and answering questions, treating the patient with respect, and providing detailed explanations of treatment) are more closely linked to satisfaction than are clinic location, equipment, or available parking.

The generalizability of our findings in this preliminary study is limited. Data were obtained solely from patients in the New York City area who were receiving outpatient care. It is not known whether Spanish-speaking patients in other regions or countries or those receiving inpatient or home care would report similar responses. We did not collect information regarding the ethnicity or degree of acculturation⁴² of our subjects; therefore, we can not determine if these factors influenced responses. Our subjects were primarily female and middle-aged. It is unknown if samples composed of younger or older subjects, or composed primarily of males, would yield similar results.

The measurement properties of the Spanish version of the MRPS support its use for assessment of patient satisfaction with care at the time of discharge from physical therapy. We, however, have not provided evidence of the predictive validity or test-retest reliability of measurements obtained by this instrument; therefore, the appropriateness of its use for repeated assessments over time is unknown.

	Conclusions

Top Abstract Introduction Method Results Discussion Conclusions References

 
Preliminary assessment of the Spanish-language version of the MRPS instrument suggests an identical factor structure and very similar measurement properties to the previously validated English-language version of the MRPS. Further study is needed to assess the stability of these findings in other samples. Consistent with previous observations on English-speaking patients, the satisfaction of Spanish-speaking patients with physical therapy care is most strongly linked to the professional behavior of the clinician (ie, treating the patient with respect and providing meaningful information).

	Footnotes

 
All authors provided concept/idea/project design. Dr Beattie provided writing and data analysis. Ms Lis provided data collection, subjects, facilities/equipment, and institutional liaisons. Dr Nelson provided project management, fund procurement, and clerical support. The authors acknowledge the assistance of Kristopher Gazsi, Richard Kassler, John Corcoran, Fionna Moore, Rhonda Reininger, Dr Angel Tuninetti, and all staff members who participated in the collection of the data at the clinics of the NYU Hospital for Joint Diseases. They also thank Claire Coyne for her valuable assistance in preparing the manuscript.

MedRisk Inc provided funds for data entry for this project. All data were collected in clinics that were not associated with MedRisk Inc or Expert Clinical Benchmarks LLC.

^* SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

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This Article Abstract Full Text (PDF) All Versions of this Article: ptj.20060313v1 87/6/793    most recent Submit a response Alert me when this article is cited Alert me when Rapid Responses are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Beattie, P. F Articles by Lis, A. Search for Related Content PubMed PubMed Citation Articles by Beattie, P. F Articles by Lis, A.