Validation of the primary care experiences survey developed with Indigenous patients with type 2 diabetes in Canada (original) (raw)

Background Health disparities experienced among Indigenous populations in Canada arise from complex historical and social causes. Addressing health disparities requires a multi-sectoral approach, including measures for Indigenous patient healthcare experiences. The Canadian Institute for Health Information published Measuring Patient Experiences in Primary Health Care Survey to evaluate care experiences among general populations; it is not known whether this survey tool is appropriate to measure Indigenous people's experiences of healthcare. As part of a large research project known as Educating for Equity (E4E), we developed an Indigenous patient experiences with diabetes care survey from existing validated primary care assessment tools, adapting items to the domains of the E4E Care Framework that addresses social and cultural factors that impact Indigenous health. This study describes the development of this Indigenous patient experiences survey, assessing the tool's validity and reliability. Method A consensus approach was used to establish the face validity of the survey and ease of completion. The survey was administered in three on-and offreserve practices in Northern Ontario during 2015 and 2016. In total, 154 completed surveys were collected for data analysis. Exploratory factor analysis was performed to assess the survey's structure. Internal consistency, item convergent validity and discriminant validity were assessed to determine internal reliability and correlation of items within each scale and between scales. Results The Indigenous patient experiences survey consists of two sections: a patient demographic section of eight items and healthcare experience section of 36 items on Likert scales. Exploratory factor analysis identi ed seven main and sub-scales that align with the survey's conceptual domains. Two items were removed due to insu cient loading scores. All main and sub-scales obtained acceptable internal reliability (Cronbach's α: 0.7-0.957), item convergent validity (AVE: 0.4-0.7; CR: 0.78-0.99), and discriminant validity (√ AVE: 0.66-0.85). Conclusion The Indigenous patient experiences survey maps out the construct concepts of the E4E Care Framework: provider-patient relationship, provider cultural competence and social sensitivity, patient diabetic-related psychosocial self-e cacy, and patient-centred continuity of care. Study results indicate this culturally-tailored instrument is reliable and valid for measuring primary care experiences of Indigenous patients with diabetes in Ontario, Canada. Methods Participants Patients were recruited from one on-reserve and two off-reserve family medicine clinics located in Northern Ontario. Patients were eligible to participate in the survey if they were 18 years of age or above, had type 2 diabetes, self-identi ed as Indigenous, and saw the same family physician during the study time from September 2014 to April 2016. Survey administration and data collection Prior to a clinical appointment, the practice receptionist identi ed patients who were eligible to participate in the survey, informed them about the study, and asked if they were willing to participate in the patient survey. If a patient was interested, the receptionist would provide an information sheet outlining the purpose of the study and a consent form with instruction to sign if agreeable to participation. The receptionist collected the signed consent prior to the clinical appointment. Following the appointment, the patient was instructed to complete the survey. Onsite clinical support staff would provide assistance in reading and interpreting survey questions upon request. At the end of each day, the receptionist or o ce staff collected completed surveys and submitted them to the site research lead. All completed surveys were mailed via Express Post to a project team member (HH) in Ontario. Data analysis Data analysis was based on the shorter version of the IPES (plus T2DM) that was administered in the second round. The rst round responses to the 23 questions that were removed for the second round were not included. The purpose of the validation was to assess congruence between the proposed conceptual scales for the IPES (plus T2DM) and the underlying structure of this survey identi ed by empirical results. Validation involved four steps: (1) Exploratory factor analysis (EFA) was used to explore the survey's structure. Principal factor analysis was performed to identify the factor structure and observe if the survey items fell into the conceptual domains based on factor loadings.[34] Three criteria were used to determine retained items and factors. First, an item with loading above 0.35, no secondary loading above 0.35, and its communalities extraction score above 0.4 was considered for retaining. Communalities extraction score between 0-0.4 suggests that the variables may struggle to load signi cantly on any factor and indicates the candidate variable for removal after examination of the pattern matrix. Second, each factor had a minimum three retained items. Third, all retained items under each factor should share the same concept or construct. [34, 35] (2) Internal consistency reliability analysis was performed to assess the internal consistency of items within each scale by Cronbach's coe cient alpha (α). Cronbach's coe cient alpha is based on the covariance among individual items within a scale and the number of items. It ranges from 0 (indicating no internal consistency reliability) to 1 (indicating full internal consistency reliability), where the minimum accepted Cronbach's coe cient alpha is cut at 0.7. [34, 36] In addition, item-total correlation, which is the relationship between an item and its scale, was observed. If an item-total correlation is small, then this item is not considered to be measuring the construct that is measured by other items in the same scale. In this study, the cutoff for item-total correlation was 0.3. [34] (3) Item convergent validity and discriminant validity were assessed to identify the correlation levels of each individual item with its conceptual scale and with other conceptual scales. Item convergent validity was observed by average variance extracted (AVE) and composite reliability (CR) [37-39]. AVE "re ects the