The Effect of Reading Ability and Response Formats on Patients' Abilities to Respond to a Patient Satisfaction Scale

Reverse-Coded Items Do Not Work in Spanish: Data From Four Samples Using Established Measures

The potential for suboptimal psychometric performance of reverse-coded items may be particularly pronounced when scales are translated and administered in Spanish with these problems exacerbated in youth respondents. This is a significant concern, given the rapid rise in Hispanic-American and Spanish-speaking individuals in the US and their rightful, growing representation in psychological research and clinical care. The aim of this study was to examine the psychometric performance of reverse-coded items across four Spanish-speaking samples spanning developmental stages including youth, college students, and parents (N = 1,084; Adolescents n = 107; M = 19.79; SD = 2.09; 41.1% female; Caregivers n = 58; M = 40.79; SD = 7.94; 60.3% female; Spanish-speaking adults in the US n = 157; M = 33.4; SD = 9.5; 68.8% female; and College students living in Latin America n = 783; M = 21.04; SD = 3.13; 69.2% female) and four scales (Big Five Inventory; Strengths and Difficulties Questionnaire; Difficulties in Emotion Regulation Scale; Beck Hopelessness Scale); we expected reverse-coded items would demonstrate inadequate item–total correlations and their inclusion would compromise scale internal consistency. Hypotheses were supported with evidence of poor psychometric performance for at least two reverse-coded items on each instrument, such that un-reversing the items improved their item–total correlations. Across every instrument, alpha was either improved by excluding reverse-coded items or by including them in an un-reversed fashion and, overall, there was a moderate, negative effect of reverse-coded items on scale alphas. In growing consensus with previous authors, we recommend that reverse-coded items not be included in Spanish scales.

The Impact of Item Feature and Response Preference in a Mixed-Format Design

A combination of positively and negatively worded items (termed a mixed-format design) has been widely adopted in personality and attitude assessments. While advocates claim that the inclusion of positively and negatively worded items will encourage respondents to process the items more carefully and avoid response preference, others have reported that negatively worded (NW) items may induce a nuisance factor and contaminate scale scores. The present study examined the extent of the impact of the NW-item feature and further investigated whether a mixed-format design could effectively control acquiescence and the preference for extreme response options using two datasets (Attitude toward Peace Walls, and International Personality Item Pool). A proposed multidimensional item response model was implemented to simultaneously estimate the impact of item feature and response preference. The results suggested that NW items induced an impact on item responses and that affirmative preference was negligible, regardless of the proportion of NW items in a scale. However, participants' extremity preference was large in both balanced and imbalanced mixed-format designs. It concludes that the impact of the NW-item feature is not negligible in a mixed-format scale, which exhibits good control of acquiescence but not extremity preference.

Post-survey Likert constructions: an adaptive method for generalizing perceptions of environmental variability

Environmental perceptions are inherently based on an individual's existing knowledge, experiences, and future expectations. Methods for measuring environmental perception, therefore, must capture a range of experiences while also being flexible enough to integrate these experiences into a coherent unit for analysis. Many research topics require cross-cultural comparisons in order to corroborate findings; however, assessments of environmental perception are often place- and context-specific. We propose here post-survey Likert constructions (PSLCs), using semi-structured interviews to construct a five-point scale system from multiple household responses after the completion of interviews. This method is able to capture the natural variability in the population using the respondents' own language and characterizations of phenomena. We applied this method to measure the perceived environmental variability of residents living in a dynamic flooding landscape in the Okavango Delta, Botswana. The PSLC method captures the differences in environmental perception in a location with different settlement and cultural histories, multiple language groups, and different environmental conditions. The method easily transfers to other environments and populations, allowing for potential cross-cultural comparisons of perceived environmental variability. This publication responds to calls for increased transparency in reporting the development, execution, advantages, and disadvantages of methods related to environmental change.

Response tendencies due to item wording using eye-tracking methodology accounting for individual differences and item characteristics

The discrepancy of the scores on responses to negatively and positively worded items has led to hypotheses of inattention, confusion, difficulty, and differential processing of negatively worded items. The present study, utilizing eye-tracking methodology, aimed to fill an explanatory gap regarding response behavior, providing observations on the item-level response process. It experimentally examined characteristics of the items (wording type, self-relevance) and characteristics of the respondents (neuroticism, verbal abilities, and mood) for their impact on response outcomes. A sample of 87 university students completed a computerized version of a questionnaire with items presented in four alternative wording types: positive, negative, negated positive, and negated negative; half of the items referred to attitudes toward the self and the other half to attitudes toward others. Participants' eye movements during item completion were recorded with the Gazepoint-GP3-HD desk-mounted eye tracker. In linear mixed effects models, wording type and self-relevance were found to relate to response time, time of viewing and revisits to the body of the items and the response options, indicating that there were effects at the stages of comprehension and selection of response. Neuroticism was associated with differential item responses, suggesting a role in later levels of the response process, the retrieval, judgment, and response selection stages. Eye-tracking measures can enhance the examination of response tendencies with regards to item content, item wording, and person characteristics.

Psychometric properties of a brief self-reported health-related quality of life measure (HRQoL-IDD) for persons with intellectual and developmental disabilities

Background

To encourage self‐determination and address health disparities among persons with intellectual and developmental disabilities, clinicians and researchers rely on self‐reported measures like health‐related quality of life (HRQoL). This study evaluated the psychometric properties of a theory‐driven self‐reported HRQoL measure for adults requiring mild to moderate support related to intellectual and developmental disabilities.

Method

224 volunteers completed 42 quality of life items developed with extensive input from persons with intellectual and developmental disabilities, family members/caregivers, and providers. The 5‐point Likert scale format with visual images of fluid‐filled cups represented the range of responses.

Results

Exploratory and Unrestricted Factor Analyses yielded 16 HRQoL items with 4 subscales: Functional Well‐Being, Emotional Well‐Being, Social Well‐Being, and Healthy Decision‐making. The HRQoL‐IDD explained 62.8% of variance, had satisfactory internal consistency (0.73–0.83), stability of reponses, and reading level (2nd grade, ages 7‐8).

Conclusions

The HRQoL‐IDD is a promising measure of self‐reported HRQoL for use in community‐based settings for persons requiring mild to moderate support related to intellectual and developmental disabilities.

Acceptance of ambulatory blood pressure monitoring in a semi-rural population in South Africa

Background

Ambulatory blood pressure monitoring is a valuable tool that helps in providing an insight into the diagnosis and management of hypertension; however, no evidence exists of its acceptance in the diverse South African population.

Aim

We assessed the acceptance of an ambulatory blood pressure monitor in patients attending public sector primary health care (PHC) clinics.

Setting

Five PHC clinics in the Makana subdistrict in the Eastern Cape.

Method

A cross-sectional study was conducted with 70 hypertensive patients. Eligible patients were between 40 and 75 years old, taking either enalapril and hydrochlorothiazide or enalapril, hydrochlorothiazide and amlodipine. Socio-demographic, clinical and acceptance data were collected. The monitor cuff remained in place for 24 h. Acceptance was assessed after the monitor was removed. An overall acceptance score was generated to classify acceptance as either good or poor.

Results

The mean years of schooling was 5.9 years, with 22 reporting no school attendance. Generally, acceptance was good, with 70% of the population rating the technique as ‘acceptable’ (acceptance score of > 23/30). Most participants reported minimal discomfort with only 13.3% reporting that it hindered normal daily activities. Night readings interrupted sleep in 43%, with extreme sleep disturbance (≥ 3 awakenings) reported in just over half the patients. Increased years of schooling was the only variable associated with acceptance score (r = −0.243, p = 0.042).

Conclusion

Ambulatory blood pressure monitoring was generally well-accepted, with few adverse effects being reported. Use of this technique at PHC facilities could reduce the incidence of misdiagnosis and uncontrolled hypertension.

Creation and Initial Validation of a Picture-Based Version of the Limitations of Activity Domain of the SF-36

Those with limited language comprehension or literacy face problems completing written questionnaires evaluating their health or physical status on which treatment plans are based. This brief report describes how a picture-based version of the 10 items in the limitations of activities section of the short form 36 health survey questionnaire (SF-36) was developed iteratively and then piloted. Study participants were 101 community-living volunteers (58 female and 43 male volunteers aged 18-93 yrs) educated to postsecondary level (52), high school grades 10-12 (44), and grade 9 or less (5). They first completed the picture-based SF-36 LoA and described verbally and in writing what they understood each picture to mean and then completed the English text version of the SF-36 limitations of physical activities domain for comparison assessment. Additional feedback suggested where pictures could be altered to increase information capture. Subjects rated their health as 26.7% excellent, 25.7% very good, 29.8% good, 10.9% fair, and 6.9% poor. Analysis showed strong correlation between text-based SF-36 LoA questions and the picture-based visual score-VSF-36 LoA-(intraclass correlation coefficient = 0.98) with question 10 correlating highest (intraclass correlation coefficient = 0.90) and question 2 lowest (intraclass correlation coefficient = 0.82). The VSF-36 LoA is the first picture-based version of the SF-36; good correlation with the text-based version and global need warrants further development to aid those with limited literacy or language comprehension.

Cognitive Abilities Explain Wording Effects in the Rosenberg Self-Esteem Scale

There is consensus that the 10 items of the Rosenberg Self-Esteem Scale (RSES) reflect wording effects resulting from positively and negatively keyed items. The present study examined the effects of cognitive abilities on the factor structure of the RSES with a novel, nonparametric latent variable technique called local structural equation models. In a nationally representative German large-scale assessment including 12,437 students competing measurement models for the RSES were compared: a bifactor model with a common factor and a specific factor for all negatively worded items had an optimal fit. Local structural equation models showed that the unidimensionality of the scale increased with higher levels of reading competence and reasoning, while the proportion of variance attributed to the negatively keyed items declined. Wording effects on the factor structure of the RSES seem to represent a response style artifact associated with cognitive abilities.

Perceptions of Care of Patients Undergoing Coronary Artery Bypass Surgery in Veterans Health Administration and Private Sector Hospitals

Few studies have examined differences in patient perceptions of care between health care systems. This study compared the perceptions of male patients undergoing coronary artery bypass graft surgery in 43 Veterans Health Administration (VA) hospitals (N = 808) and 102 US private sector hospitals (N = 2271) from 1995 to 1998. Patient perceptions were measured by a validated survey that was mailed to patients after discharge. For 8 of the 9 dimensions assessed by the survey, VA patients were more likely (P < .001) than private sector patients to note a problem with care (eg, Coordination, 48% versus 40%; Patient Education and Communication, 50% versus 40%; Respect for Patient Preferences, 49% versus 41%). In comparisons limited to major teaching hospitals, VA patients were more likely to note a problem for 5 dimensions. The findings indicate that patient perceptions of care may be lower in VA than in private sector hospitals. Future studies should examine whether the VA's recent focus on improving patient satisfaction has narrowed these differences.

Relationships among factors related to body mass index, healthy lifestyle beliefs and behaviors, and mental health indicators for youth in a title 1 school

INTRODUCTION

The effect of being overweight in childhood has both physical and psychological implications. The purpose of this study was to determine the relationships among body mass index (BMI), healthy lifestyle beliefs and behaviors, and mental health indicators for 5th- and 6th-grade children in a Title I school.

METHODS

This is a cross-sectional, descriptive correlational design on a convenience sample of youth in an urban school. BMI was calculated. Participants completed surveys that assessed healthy beliefs and behaviors, activity and nutrition knowledge, and mental health indicators.

RESULTS

Children with higher BMIs reported difficulty in living a healthy lifestyle. This perceived difficulty affected their ability to make healthy choices. Belief in the ability to live a healthy lifestyle resulted in reported healthier behaviors. Anxiety and depression symptomatology were not significantly related to healthy lifestyle indicators.

DISCUSSION

The results demonstrate that the proposed thinking, feeling, behavior triangle model was supported in this population.

Assessing empathy in Salvadoran high-risk and gang-involved adolescents and young adults: a Spanish validation of the basic empathy scale

Empathy is considered a key construct in the empirical study of high-risk adolescent and young adult delinquency, crime, and violence. This study examined the psychometric properties and criterion-related validity of a Spanish adaptation of the Basic Empathy Scale (BES), which is an important measure designed to capture both affective and cognitive empathy that has been validated in multiple languages but not in Spanish. The study's sample consisted of 208 high-risk and gang-involved adolescents and young adults in the Greater San Salvador Metropolitan Area. The original BES was reduced from its 20-item design to a more culturally appropriate 7-item design. The results of the confirmatory factor analysis and criterion-related validity analysis indicate that the adapted BES is a valid and reliable multidimensional measure of empathy for high-risk Salvadoran adolescents and young adults. Consistent with previous findings, females reported lower levels of empathy than males and delinquent/violent respondents reported lower levels of empathy than their nonoffender counterparts.

Innovative use of a standardized debriefing guide to assist in the development of a research questionnaire with low literacy demands

Prevalence and impact of low literacy has resulted in greater attention to developing written materials at lower reading levels for both patient education and research. The purpose of this study was to develop and evaluate how well a research questionnaire about self-management preferences, intentionally developed as a tool for individuals with low literacy skills, performed. The investigators created a standardized debriefing guide to evaluate comprehension and ease of instrument completion to accompany the administration of the Conventional and Alternative Management for Asthma (CAMA) instrument. The use of a standardized debriefing guide following cognitive interviewing techniques, allowed for the identification of problematic words, unclear meanings and confusion over scaling despite a deliberate attempt to develop a tool with low literacy demands. Such approaches might be considered critically important to insure the accuracy of patient-reported outcomes when self-administered tools are used to collect research and clinical data.

The response scale for the intellectual disability module of the WHOQOL: 5-point or 3-point?

OBJECTIVE

To deal with the question of whether a 5-point response Likert scale should be changed to a 3-point scale when used in the field testing of people with intellectual disabilities (IDs), which was raised after the pilot study of World Health Organization Quality of Life (WHOQOL)-DIS, a module being developed with the World Health Organization measure of quality of life for disabilities.

METHODS

Three possible ways were used to generate hypothetical data by merging a 5-point scale into a 3-point scale. The analyses were based on both item response theory and classical measurement theory. The partial credit model for polytomous response was performed for item evaluation; the confirmatory factor analysis was used to check construct validity, the Cronbach's alpha for domain reliability, and correlation analyses for the relationship between the 5-point scale and the generated 3-point scale.

RESULTS

Most items with a 5-point response scale had disordered response options and/or unequal-length intervals between successive response options; these deficiencies were removed or improved without decline of validity and reliability in the hypothetical data of 3-point scales.

CONCLUSION

Instead of the 5-point scale, a 3-point scale could be used for IDs in the field test of developing the module WHOQOL-DIS.

The role of helplessness, outcome expectation for exercise and literacy in predicting disability and symptoms in older adults with arthritis

OBJECTIVE

To examine the effect of outcome expectation for exercise (OEE), helplessness, and literacy on arthritis outcomes in 2 community-based lifestyle randomized controlled trials (RCTs) conducted in urban and rural communities with older adults with arthritis.

METHODS

Data from 391 participants in 2 RCTs were combined to examine associations of 2 psychosocial variables: helplessness and OEE, and literacy with arthritis outcomes. Arthritis outcomes namely, the Health Assessment Questionnaire-Disability Index (HAQ-DI) and arthritis symptoms pain, fatigue and stiffness Visual Analogue Scales (VAS), were measured at baseline and at the end of the interventions. Complete baseline and post-intervention data were analyzed using STATA version 9.

RESULTS

Disability after intervention was not predicted by helplessness, literacy, or OEE in the adjusted model. Arthritis symptoms after the intervention were all significantly predicted by helplessness at various magnitudes in adjusted models, but OEE and literacy were not significant predictors.

CONCLUSION

When literacy, helplessness, and OEE were examined as predictors of arthritis outcomes in intervention trials, they did not predict disability. However, helplessness predicted symptoms of pain, fatigue, and stiffness, but literacy did not predict symptoms.

PRACTICE IMPLICATIONS

Future sustainable interventions may include self-management components that address decreasing helplessness to improve arthritis outcomes.

Are health-care relationships important for mammography adherence in Latinas?

BACKGROUND

Latinas are the fastest growing racial ethnic group in the United States and have an incidence of breast cancer that is rising three times faster than that of non-Latino white women, yet their mammography use is lower than that of non-Latino women.

OBJECTIVES

We explored factors that predict satisfaction with health-care relationships and examined the effect of satisfaction with health-care relationships on mammography adherence in Latinas.

DESIGN AND SETTING

We conducted a cross-sectional survey of 166 Latinas who were >or=40 years old. Women were recruited from Latino-serving clinics and a Latino health radio program.

MEASUREMENTS

Mammography adherence was based on self-reported receipt of a mammogram within the past 2 years. The main independent variable was overall satisfaction with one's health-care relationship. Other variables included: self report of patient-provider communication, level of trust in providers, primary language, country of origin, discrimination experiences, and perceptions of racism.

RESULTS

Forty-three percent of women reported very high satisfaction in their health-care relationships. Women with high trust in providers and those who did not experience discrimination were more satisfied with their health-care relationships compared to women with lower trust and who experienced discrimination (p < .01). Satisfaction with the health-care relationship was, in turn, significantly associated with mammography adherence (OR: 3.34, 95% CI: 1.47-7.58), controlling for other factors.

CONCLUSIONS

Understanding the factors that impact Latinas' mammography adherence may inform intervention strategies. Efforts to improve Latina's satisfaction with physicians by building trust may lead to increased use of necessary mammography.

Literacy affected ability to adequately discriminate among categories in multipoint Likert Scales

OBJECTIVES

To assess the effect of inability to read on a five-point Likert scale, using the WHOQOL-BREF response scale. It is hypothesized that inability to read is related to loss of discriminant power among the five-category response scale.

STUDY DESIGN AND SETTING

In a cross-sectional design, nonreaders (n=141) and subjects educated at a graduate level (n-907) were assessed. Statistical analyses combined classic and modern psychometric approaches (Confirmatory factor analysis and Rasch analysis).

RESULTS

There is a remarkable difference in the psychometric performance of items across the two subgroups. Fit indexes proved to be closer to the ideal for the graduate group, but not for the nonreader group. Reducing the number of response categories improved the model exclusively for the nonreader sample. Nonreaders do not interpret the scale as a true five-category scale, but exhibit a response pattern indicative that only three categories are in fact considered.

CONCLUSION

These results confirm the hypothesis that a multiple-category response scale is not suitable for nonreaders. They suggest that a simpler response scale should be adopted to achieve a more reliable and satisfactory psychometric performance in this population. This effect seems to be stronger when more abstract and subjective constructs are involved.

Literacy and diabetes self-management

Low literacy affects outcomes; communication is key.

The Effect of a Preadmission Videotape on Patient Satisfaction

The effect of a preadmission videotape presentation on patient satisfaction in an outpatient surgery department was explored in this research study. A sample of 141 Caucasian and Hispanic patients took part in the study. Results indicated that patients who viewed the preadmission patient videotape did not differ significantly in their report of satisfaction from those who did not view the videotape. The study also found that the satisfaction of nurses in the project varied significantly during the study period.

Literacy and health outcomes: a systematic review of the literature

OBJECTIVE

To review the relationship between literacy and health outcomes.

DATA SOURCES

We searched MEDLINE, Cumulative Index to Nursing and Allied Health (CINAHL), Educational Resources Information Center (ERIC), Public Affairs Information Service (PAIS), Industrial and Labor Relations Review (ILLR), PsychInfo, and Ageline from 1980 to 2003.

STUDY SELECTION

We included observational studies that reported original data, measured literacy with any valid instrument, and measured one or more health outcomes. Two abstractors reviewed each study for inclusion and resolved disagreements by discussion.

DATA EXTRACTION

One reviewer abstracted data from each article into an evidence table; the second reviewer checked each entry. The whole study team reconciled disagreements about information in evidence tables. Both data extractors independently completed an 11-item quality scale for each article; scores were averaged to give a final measure of article quality.

DATA SYNTHESIS

We reviewed 3,015 titles and abstracts and pulled 684 articles for full review; 73 articles met inclusion criteria and, of those, 44 addressed the questions of this report. Patients with low literacy had poorer health outcomes, including knowledge, intermediate disease markers, measures of morbidity, general health status, and use of health resources. Patients with low literacy were generally 1.5 to 3 times more likely to experience a given poor outcome. The average quality of the articles was fair to good. Most studies were cross-sectional in design; many failed to address adequately confounding and the use of multiple comparisons.

CONCLUSIONS

Low literacy is associated with several adverse health outcomes. Future research, using more rigorous methods, will better define these relationships and guide developers of new interventions.

Development and pilot testing of a disease management program for low literacy patients with heart failure

Development and pilot testing of a disease management program for low literacy patients with heart failure.

BACKGROUND

Randomized trials have shown that disease management programs can reduce hospitalizations and improve symptoms for patients with congestive heart failure. We sought to create and pilot test such a program for patients with low literacy skills.

METHODS

We used focus groups and individual cognitive response interviews (CRIs) to develop an educational booklet for low literacy patients with heart failure. We incorporated the booklet into a disease management intervention that also included an initial individualized 1-h educational session and scheduled supportive phone calls that were tapered over 6 weeks. We then conducted a 3-month before-after study on patients with low literacy skills (<9th grade literacy level) in a university internal medicine clinic to test the acceptability and efficacy of our program. Outcomes of interest included heart failure-related knowledge, self-care behavior and heart failure-related symptoms measured on the Minnesota Living with Heart Failure (MLwHF) scale.

RESULTS

Twenty-five patients were enrolled and 23 (92%) completed 3-month follow-up. Mean age was 60 years (range 35-74), 60% were men, 60% were African-American, and 74% had household income under $15,000 per year. The median reading level was fifth grade with 32% reading at or below the third grade level. Mean knowledge score at baseline was 67% and did not improve after the intervention. The proportion of patients reporting weighing themselves daily increased from 32% at baseline to 100% at 12 weeks. Mean improvement on the MLwHF scale was 9.9 points over the 3-month trial (95% CI: 0.5, 19.2), which corresponds to an improvement in one class on the New York Heart Association heart failure scale.

CONCLUSION

A heart failure disease management program designed specifically for patients with low literacy skills is acceptable and is associated with improvement in self-care behavior and heart failure related symptoms.

The Influence of Nurse-Sensitive Variables on Patient Satisfaction

A DESCRIPTIVE STUDY was conducted in an ambulatory surgical unit to explore the influence of selected nurse-sensitive variables on patient satisfaction and compare the reliability and validity of existing instruments that measure patient satisfaction. STUDY RESULTS indicate that age, gender, culture, pain control, and communication affect patient satisfaction in ambulatory care. A reliable tool to measure patient satisfaction is needed to promote improvements in care.

The measurement of patient satisfaction

Patient satisfaction is an important quality outcome indicator of health care in the hospital setting. The measurement of patients' satisfaction with nursing is particularly important since nursing service is often a primary determinant of overall satisfaction during a hospital stay. This article reports on a study designed to update and revise the definition of patient satisfaction for application with ambulatory surgical patients and to develop a questionnaire that captures this definition. The Patient Satisfaction Scale, which specifically focuses on patient satisfaction with nursing care and is used extensively by nursing researchers, was selected for factor analytical examination. Psychometric testing resulted in a 15-item scale with three underlying dimensions.