Abstract

The performance evaluation of services through instruments is relevant, as it can support thoughts, actions and political approaches to meet a social need. The objective of the article was to develop and validate the Quality and Strengthening of Primary Care Questionnaire (QSPC-Q) for professionals and users based on Starfield attributes and Donabedian pillars. A mixed sequential study was performed to develop the QSPC-Q. The test was applied to 149 doctors and 795 users of basic health units. Psychometric properties was assessed by testing internal consistency using Cronbach’s alpha and exploratory factor analysis. Reproducibility od scale was assessed using intraclass cognitive and test-retest correlation. The final version of the follow-up consisted of 45 items aimed at physicians (Cronbach’s alpha = 0.921) and 33 at users (Cronbach’s alpha = 0.86); the intraclass respiratory capacity was 0.88. An exploratory factor analysis identified 13 factors associated with the pattern components. A short version with 29 items for professionals was also elaborated. Professional QSPC-Q (short and braided versions) and user QSPC-Q were valid.

Key words:
Primary care; Quality of health care; Validation studies

Resumo

A avaliação do desempenho dos serviços por meio de instrumentos é relevante, pois pode subsidiar pensamentos, ações e abordagens políticas para atender a uma necessidade social. O objetivo do artigo foi desenvolver e validar o Questionário de Qualidade e Fortalecimento da Atenção Primária (QSPC-Q) para profissionais e usuários com base nos atributos Starfield e nos pilares donabedianos. Um estudo sequencial misto foi realizado para desenvolver o QSPC-Q. O teste foi aplicado em 149 médicos e 795 usuários de unidades básicas de saúde. As propriedades psicométricas foram avaliadas testando a consistência interna usando o alfa de Cronbach e a análise fatorial exploratória. A reprodutibilidade da escala foi avaliada por meio da correlação cognitiva intraclasse e teste-reteste. A versão final do questionário foi composta por 45 itens direcionados a médicos (alfa de Cronbach = 0,921) e 33 a usuários (alfa de Cronbach = 0,86); o coeficiente de correlação intraclasse foi de 0,88. A análise fatorial exploratória identificou 13 fatores associados aos componentes do questionário. Também foi elaborada uma versão curta com 29 itens para profissionais. O QSPC-Q profissional (versões curta e estendida) e usuário foram válidos.

Palavras-chave:
Atenção primária; Qualidade da atenção à saúde; Estudos de validação

Background

Primary care in Brazil is a network of health promotion and prevention services that identifies the needs and coordinates care¹1 Ribeiro SP, Cavalcanti MLT. Primary Health Care and Coordination of Care: device toincrease access and improve quality. Cien Saude Colet 2020; 25(5):1799-1808.. It is also the first contact of the population with the health system and attends to the most frequent and less complex grievances²2 D'Avila OP, Pinto LFS, Hauser L, Gonçalves MR, Harzheim E. The use of the Primary Care Assessment Tool (PCAT): an integrative review and proposed update. Cien Saude Colet 2017; 22(3):855-865.. Considering that the evaluative process may support reflections and actions or even assume a political dimension to reach social needs, studies reinforce the need to assess the performance of health services using adequate instruments, especially because of the relevance of assessing the presence and extent of primary care attributes. However, the scope and applicability of scales are still limited to assessing the strengthening of primary care³3 Harzheim E, Oliveira MMC, Agostinho MR, Hauser L, Stein AT, Gonçalves MR, Trindade TG, Berra S, Duncan BB, Starfield B. Validação do instrumento de avaliação da atenção primária à saúde: PCATool- Brasil adultos. Rev Bras Med Fam Comunidade 2013; 8(29):274-284.^,44 Morgado FFR, Meireles JFF, Neves CM, Amaral ACS, Ferreira MEC. Scale development: ten main limitations and recommendations to improve future research practices. Psicol Reflex Crit 2017; 30(1):3..

The Primary Care Assessment Tool (PCATool), created by Barbara Starfield⁵5 Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: UNESCO/MS; 2002. between 1997 and 2001, identifies and monitors the quality of primary care services in Brazil and contributes to comparative studies between Primary Health Care Units⁶6 Prates ML, Machado JC, Silva LS, Avelar OS, Prates LL, Mendonça ET, Costa GDD, Cotta RMM. Performance of primary health care according to PCATool instrument: a systematic review. Cien Saude Colet 2017; 22(6):1881-1893.^,77 Castro RCL, Knauth DR, Harzheim E, Hauser L, Duncan BB. Avaliação da qualidade da atenção primária pelos profissionais de saúde: comparação entre diferentes tipos de serviços. Cad Saude Publica 2012; 1772-1784.. For a period, the National Program for the Improvement of Access and Quality of Primary Care (PMAQ-AB) was used to assess the quality of primary care⁸8 Figueiredo AM, Kuchenbecker RS, Harzheim E, Vigo A, Hauser L, Chomatas ERV. Análise de concordância entre instrumentos de avaliação da Atenção Primária à Saúde na cidade de Curitiba, Paraná, em 2008. Epidemiol Serv Saude 2013; 22(1):41-48.^,99 Felisberto E, Freese E, Natal S, Alves CKA. Contribuindo com a institucionalização da avaliação em saúde: uma proposta de auto-avaliação. Cad Saude Publica 2008; 24(9):2091-2102., a normative and self-assessment instrument applied to health managers and workers to improve primary care⁸8 Figueiredo AM, Kuchenbecker RS, Harzheim E, Vigo A, Hauser L, Chomatas ERV. Análise de concordância entre instrumentos de avaliação da Atenção Primária à Saúde na cidade de Curitiba, Paraná, em 2008. Epidemiol Serv Saude 2013; 22(1):41-48.^,99 Felisberto E, Freese E, Natal S, Alves CKA. Contribuindo com a institucionalização da avaliação em saúde: uma proposta de auto-avaliação. Cad Saude Publica 2008; 24(9):2091-2102.. The PMAQ-AB has also been used to encourage managers and teams to improve the quality of health services offered in primary care, ensuring the equivalence of standards at the national, regional and local levels¹⁰10 Brasil. Ministério da Saúde (MS). Manual instrutivo PMAQ: para as equipes de atenção básica (Saúde da Família, Saúde Bucal e Equipes Parametrizadas) e Nasf [Internet]. 2015. [acessada 2022 jun 13]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/manual_instrutivo_pmaq_atencao_basica.pdf.
https://bvsms.saude.gov.br/bvs/publicaco... . The Quality Assessment Questionnaire for Primary Care Services, QualiAB, also stands out for its online and self-administered usability by managers and health teams in the quest to develop mechanisms to encourage improvement in the quality of Primary Care¹¹11 Castanheira ERL, Nemes MIB, Almeida MAS, Puttini RF, Soares ID, Patrício KP, Nasser MA, Machado DF, Caldas Junior AL, Vasconcelos RDA, Pissato SB, Carrapato JFL, Bizelli SSK. QualiAB: development and validation of a methodology for the assessment of primary health care services. Saude Soc 2011; 20(4):935-947.. However, these instruments have been criticized due to their length, lack of validation or psychometric inconsistencies.

In this sense, the evaluative process must support reflections and actions and create political conditions to change the sanitary reality¹²12 De Salazar L. Feasibility for Health Promotion Under Various Decision-Making Contexts. In: McQueen DV, Jones CM, editors. Global perspectives on health promotion effectiveness. New York: Springer; 2007. p. 353-365.

13 Zhong C, Huang J, Li L, Luo Z, Liang C, Zhou M, Kuang L. Development and validation of a rapid assessment version of the assessment survey of primary care in China. Front Public Health. 2022; 10:852730.^-1414 Bara VMF, Paz EPA, Guimarães RM, Silva BF, Gama BBDM, Moratelli L. Diagnóstico de utilização do instrumento de avaliação da atenção primária à saúde - PCATool-Brasil versão adulto - para população idosa. Cad Saude Colet 2015; 23(3):330-335.. Although studies have demonstrated the need to adequately assess health services⁶6 Prates ML, Machado JC, Silva LS, Avelar OS, Prates LL, Mendonça ET, Costa GDD, Cotta RMM. Performance of primary health care according to PCATool instrument: a systematic review. Cien Saude Colet 2017; 22(6):1881-1893.^,88 Figueiredo AM, Kuchenbecker RS, Harzheim E, Vigo A, Hauser L, Chomatas ERV. Análise de concordância entre instrumentos de avaliação da Atenção Primária à Saúde na cidade de Curitiba, Paraná, em 2008. Epidemiol Serv Saude 2013; 22(1):41-48.^,1414 Bara VMF, Paz EPA, Guimarães RM, Silva BF, Gama BBDM, Moratelli L. Diagnóstico de utilização do instrumento de avaliação da atenção primária à saúde - PCATool-Brasil versão adulto - para população idosa. Cad Saude Colet 2015; 23(3):330-335.

15 Hauser L, Castro RCL, Vigo A, Trindade TG, Gonçalves MR, Stein AT. Tradução, adaptação, validade e medidas de fidedignidade do Instrumento de Avaliação da Atenção Primária à Saúde (PCATool) no Brasil: versão profissionais de saúde [Internet]. 2013. [acessado 2022 jun 13]. Disponível em https://lume.ufrgs.br/handle/10183/140059
https://lume.ufrgs.br/handle/10183/14005... ^-1616 Donabedian A. An introduction to quality assurance in health care. Oxford: Oxford University Press; 2002., some challenges remain (e.g., limitations in coverage and applicability of questionnaires to assess primary care). Therefore, we aimed to create and validate a simple instrument for physicians and users to assess the strengthening of primary care based on Donabedian’s model of quality assessment¹⁷17 Mokkink LB. COSMIN - Improving the selection of outcome measurement instruments [Internet]. [cited 2022 jul 1]. Disponível em: https://www.cosmin.nl/
https://www.cosmin.nl... and Starfield’s attributes for primary health care⁵5 Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: UNESCO/MS; 2002.. Thefore at this stage was aimed to report the quantitative phase of the validation process.

Methods

This is a mixed sequential quali-quant study of the development and validation of instruments. This study was approved by the research ethics committee of the Instituto de Medicina Integral Professor Fernando Figueira (CAAE 698495517.3.0000.5201) and conducted according to the Declaration of Helsinki. All participants (users and professionals) signed the informed consent form before data collection.

The validation process started with a qualitative phase that aimed to develop the construct discussed here, in order to do it a systematic literature review and a validation of face was made. The face validation process was carried out with professionals who are experts in the Family and Community Health Strategy (ESFC), based on the consensus of the Nominal Group Technique (TGN), proposed by Jones and Hunter¹⁸18 Perry J, Linsley S. The use of the nominal group tchnique as an evaluative tool in the teaching and summative assessment of the inter-personal skills of student mental health nurses. Nurs Educ Tod 2006; 26(4):346-353.. Based on this validated matrix (Chart 1), which left 24 indicators related to the principles and attributes of primary care and the pillars of quality, a research instrument was developed with a view to analyzing the quality and strengthening of primary care, called Quality and Strengthening of Primary Care Questionnaire (QSPC-Q). Two versions of the QSPC-Q (professionals and users) were applied to 149 physicians and 795 users of 147 BHU from 23 municipalities in the state of Pernambuco.

The validation process was conducted according to universal methodology Streiner and Norman¹⁹19 Jones J, Hunter D. Consensus methods for medical and health services research. BMJ 1995; 311(7001):376-380. and followed recommendations to the Consensus-based Standards for the selection of health Measurements Instruments to guided work (COSMIN)²⁰20 Goes PSA, Fernandes LMAG, Lucena LBS. Validação de instrumentos de coleta de dados. In: Marcos A, Peres LA, organizadores. Epidemiologia da saúde bucal. Rio de Janeiro: Guanabara Koogan; 2006. p. 390-397. to quality assurance evaluation. The use of COSMIN showed that our study use a classical theory of validation therefore not all items applied for; nonetheless regarding the box F, item 7 it should take into account that we use the strategy to apply the similar scales for different socials actors such as health service user’s and professionals as strategy to access convergent validity.

In the quantitative analysis, we validated the questionnaire using Cronbach’s alpha coefficient, item-total correlation, and intraclass correlation coefficient. The Kaiser-Meyer- Olkin index, Bartlett Sphericity Test, the Factor Exploratory analysis and the measure of sampling adequacy were also conducted.

Quantitative analysis

The responses of 149 physicians and 795 users were used in the quantitative analysis. A stratified probability sample was calculated based on the population of municipalities and health macroregions of the state of Pernambuco and the number of participants linked to BHU. The selection of professionals and users was paired in these municipalities, considering all BHUs covered or not by physicians of the More Doctors Program. BHUs composed of physicians of both profiles were also searched at the same stage.

The inclusion criteria considered physicians working at least six months in the Family Health Strategy team, whereas users should have > 18 years old and at least two appointments with the selected physicians; the questionnaire should be applied on the same day of the visit. Those who refused to sign the informed consent form or did not finish the questionnaire were excluded.

The questionnaire was validated using the following psychometric analyses²¹21 Streiner DL, Norman GR. Health Measurement Scales: a practical guide to their development and use. New York: Oxford Scholarship Online; 2015.

22 Daniel WW. Biostatistics: a foundation for analysis in the health sciences. New York: Wiley; 1999.

23 Pasquali L. Psicometria: teoria dos testes na psicologia e na educação. Petrópolis: Vozes; 2017.^-2424 Razali NM, Wah YB. Power comparisons of Shapiro-Wilk, Kolmogorov-Smirnov, Lilliefors and Anderson-Darling tests. J Stat Mod Anal 2011; 2(1):21-33.: Cronbach’s alpha, item-total correlation, and intraclass correlation coefficient. The multidimensionality of the questionnaire was verified and reduced using exploratory factor analysis (principal axis factoring method). The extraction of factors was performed using varimax orthogonal rotation, and items were included in factors if they presented a factor load > 0.300²²22 Daniel WW. Biostatistics: a foundation for analysis in the health sciences. New York: Wiley; 1999..

Construct validity

The Kaiser-Meyer-Olkin index and Bartlett’s sphericity tests were also analyzed for the factor analysis²³23 Pasquali L. Psicometria: teoria dos testes na psicologia e na educação. Petrópolis: Vozes; 2017.^,2424 Razali NM, Wah YB. Power comparisons of Shapiro-Wilk, Kolmogorov-Smirnov, Lilliefors and Anderson-Darling tests. J Stat Mod Anal 2011; 2(1):21-33.. The measure of sampling adequacy was conducted for the primary care characterization. Cronbach’s alpha assessed internal consistency; values > 0.70 (or > 0.20 for corrected item-total correlation) were considered adequate. The Kolmogorov-Smirnov test assessed data normality, and statistical significance was set at 5%²⁵25 Almeida C, Macinko J. Validação de uma metodologia de avaliação rápida das características organizacionais e do desempenho dos serviços de atenção básica do sistema de saúde (SUS) em nível local. Brasília: OPAS; 2006..

Convergent validity

It was calculated cores - QSPC-Q professional and user versions. Responses to the QSPC-Q items ranged between 1 and 5 (1 considered the worst situation and 5 the best situation). Scores were transformed to a scale ranging from 0 to 10 to facilitate comparisons²¹21 Streiner DL, Norman GR. Health Measurement Scales: a practical guide to their development and use. New York: Oxford Scholarship Online; 2015..

The Bland-Altman plot analyzed the concordance²¹21 Streiner DL, Norman GR. Health Measurement Scales: a practical guide to their development and use. New York: Oxford Scholarship Online; 2015., and Pearson’s correlation coefficient analyzed correlations between the short (29 items) and extended (45 items) versions of the QSPC-Q professionals. Data were analyzed using SPSS version 28.0.1.1 (IBM Corp, USA) and Rstudio version 4.0.0.

Results

The study was carried out using the classical test theory (CTT). At the stage of face validity fourteen items were excluded from the initial QSPC-Q professionals due to a lack of association with conceptual domains. In this sense, the final questionnaire comprised 45 items distributed as follows: one in first-contact care, five in longitudinality, eight in comprehensiveness, 20 in coordination, ten in family and community orientation, and one in cultural competence.

The internal consistency and convergent validitywas assessed using COSMIN recommendation and results showed satisfactory. The standardized Cronbach’s alpha was 0.943 (Table 1). The mean total score of the QSPC-Q professionals was 147.99, considering the 5-point Likert scale. The short version of the QSPC-Q professional included 29 items and presented a Cronbach’s alpha of 0.898.

Regarding the QSPC-Q for users, three items were excluded due to lack of associations with conceptual domains. Thus, the questionnaire comprised 33 questions distributed in six attributes. The standardized Cronbach’s alpha was 0.86. The mean total score of the QSPC-Q user was 105.33, considering the 5-point Likert scale. Nonetheless, the user scale will be discussed in detail in a future study due to the limited number of words requested by the journal. The respective mean scores of attributes in the extended and short versions were 7.81 and 8.37 (longitudinality), 6.21 and 6.01 (comprehensiveness), 5.54 and 4.86 (coordination), and 5.18 and 5.36 (family and community orientation). The concordance was also assessed using the Bland-Altman plot and Pearson’s correlation coefficient (Figure 1). Only one item was included in the first-contact care and cultural competence attributes of both versions.

Following the COSMIN recommendations was calculated test-retest reliability and intra-rater reliability, was observed adequate reliability (test-retest) in 88% of items using 10% of the sample. Value for the Kaiser-Meyer-Olkin index of the QSPC-Q professionals was 0.872, while Bartlett’s sphericity test was significant (p < 0.01) and communality (h²) > 0.5. In addition, was analyzed the structural validity of scale by testing its the dimensionality using explanatory factor analysis. The factor load of the QSPC-Q professionals was > 0.300 (13 factors with eigenvalues > 1 and accumulated variance of 69.53%).

We observed that nine items of the QSPC-Q professionals demonstrated a valid factor load in factor 1, six in factor 2, four in factor 3, three in factor 4, four in factor 5, three in factor 6, four in factor 7, four in factor 8, two in factor 9, one in factor 10, two in factor 11, two in factor 12, and one in factor 13 (Table 2).

Regarding the interpretability of scale it was described the percentage of items and tested to look explanatory associations and mean difference for some demographic variables such as gender, time since graduation, nature of employment and if they have a post graduate program.

Discussion

The study presented a valid and reproducible scale to assess the quality and strengthening of primary health care by professionals and users.

The instruments developed by Mackinko and Almeida²⁶26 Figueredo RC, Gonzales RIC, Signor E, Silva LS, Amorim RCC, Almeida DR. Avaliação da atenção primária em saúde no Brasil: principais características, limitações e potencialidades entre PMAQ e PCATool. Res Soc Dev 2022; 11(1):e29311124395. were used for a rapid evaluation of primary care in 2006. As of 2011, despite the wide coverage of the PMAQ-AB, the periodicity of the evaluation is criticized, in addition to the low transparency, lack of validation and inclusion of several variables for the evaluation of each team of the Family Health Strategy²⁷27 Anderson MIP, Moral M, Segura MC, Meoño T, Minué S, Donato R. Evaluación de la Calidad en Salud en la Medicina Familiar y en la Atención Primaria en Iberoamérica. Rev Bras Med Fam Comunidade 2016; 11(Supl. 2):26-36..

The PCATool is the most used instrument, valid in many countries, sensitive to the structure and processes of primary care services, and has adequate and recognized psychometric properties. However, some difficulties were observed in the PCATool version for Brazilian adults¹⁴14 Bara VMF, Paz EPA, Guimarães RM, Silva BF, Gama BBDM, Moratelli L. Diagnóstico de utilização do instrumento de avaliação da atenção primária à saúde - PCATool-Brasil versão adulto - para população idosa. Cad Saude Colet 2015; 23(3):330-335.

15 Hauser L, Castro RCL, Vigo A, Trindade TG, Gonçalves MR, Stein AT. Tradução, adaptação, validade e medidas de fidedignidade do Instrumento de Avaliação da Atenção Primária à Saúde (PCATool) no Brasil: versão profissionais de saúde [Internet]. 2013. [acessado 2022 jun 13]. Disponível em https://lume.ufrgs.br/handle/10183/140059
https://lume.ufrgs.br/handle/10183/14005... ^-1616 Donabedian A. An introduction to quality assurance in health care. Oxford: Oxford University Press; 2002.^,2828 Tabachnick BG, Fidell LS. Using multivariate statistics. New York: Harper Collins College Publishers; 1996.. For example, although some items did not reach the minimal factor load and the item-total correlation was below the recommended value to be included in the instrument, they were maintained due to their “extreme conceptual relevance” and concordance with the original instrument¹⁵15 Hauser L, Castro RCL, Vigo A, Trindade TG, Gonçalves MR, Stein AT. Tradução, adaptação, validade e medidas de fidedignidade do Instrumento de Avaliação da Atenção Primária à Saúde (PCATool) no Brasil: versão profissionais de saúde [Internet]. 2013. [acessado 2022 jun 13]. Disponível em https://lume.ufrgs.br/handle/10183/140059
https://lume.ufrgs.br/handle/10183/14005... .

The idea to develop and validate another instrument to assess the quality and strengthening of primary care was reinforced by gaps and inadequate aspects of the instruments already in use. Therefore, we created the QSPC-Q with reliable psychometric measures for adult users and professionals.

The lowest number of items in the QSPC-Q professionals was observed in the cultural competence attribute one item), whereas the coordination attribute presented 20 validated items. The former aspect must be further explored since the professional and adult versions of the PCATool-Brazil were not translated and cross-culturally adapted; therefore, it does not present an item referring to the cultural competence attribute. Moreover, the presence of 20 items in the coordination attribute demonstrated the strengthening of the coordination of care in the questionnaire since this attribute expresses the involvement of activities and guarantees the offer of individualized and comprehensive care¹1 Ribeiro SP, Cavalcanti MLT. Primary Health Care and Coordination of Care: device toincrease access and improve quality. Cien Saude Colet 2020; 25(5):1799-1808.. The great challenges of coordination include network fragmentation, low availability of specialists, lack of qualified professionals, communication between services, interoperability, and electronic medical history. In this sense, an instrument that assesses the coordination of care may establish conditions to measure primary care from the perspective of a network, which is essential to establish lines of care integrated into health attention networks.

The structure of primary care in the reorientation of the assistance model finds support in the QSPC-Q, an instrument for vigilance and monitoring that consolidates the coordination of care as an organizational attribute to overcome iniquities and guarantee the comprehensiveness between services, levels of assistance, and continuity of care. The QSPC-Q was reliable, balanced, easy to comprehend by the studied population, and used expressions consistent with attributes of the theoretical framework of Starfield⁵5 Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: UNESCO/MS; 2002. and Donabedian¹⁶16 Donabedian A. An introduction to quality assurance in health care. Oxford: Oxford University Press; 2002..

The internal consistency and reliability suggested a balanced questionnaire with interrelated items. The exploratory factor analysis indicated 45 items extracted in 13 factors with a total accumulated variance of 69.53% and eigenvalue > 1 (Kaiser criterion). Tabachinik and Fidell²⁹29 Batista VCL, Ribeiro LCC, Ribeiro CDAL, Paula FA, Araújo A. Avaliação dos atributos da atenção primária à saúde segundo os profissionais de saúde da família. SANARE 2016; 15(3):87-93. observed that the Kaiser criterion was better applied when the number of items was between 20 and 50, such as in the QSPC-Q professionals. As the PCATool is available only in the extended version (111 items)³⁰30 Field A, Miles J, Field Z. Discovering statistics using R. Washington: SAGE; 2012., we developed a short version of the QSPC-Q professionals.

The factor analysis²³23 Pasquali L. Psicometria: teoria dos testes na psicologia e na educação. Petrópolis: Vozes; 2017.^,2929 Batista VCL, Ribeiro LCC, Ribeiro CDAL, Paula FA, Araújo A. Avaliação dos atributos da atenção primária à saúde segundo os profissionais de saúde da família. SANARE 2016; 15(3):87-93. represents the constructs²⁴24 Razali NM, Wah YB. Power comparisons of Shapiro-Wilk, Kolmogorov-Smirnov, Lilliefors and Anderson-Darling tests. J Stat Mod Anal 2011; 2(1):21-33. that describe the initial set of variables and maintain the representative characteristics of the original variables. In the short version, we maintained only those items related to the six attributes of the original version. The concordance between mean scores of attributes after conversion of the Likert to a nominal scale (i.e., range between 0 and 10)²⁷27 Anderson MIP, Moral M, Segura MC, Meoño T, Minué S, Donato R. Evaluación de la Calidad en Salud en la Medicina Familiar y en la Atención Primaria en Iberoamérica. Rev Bras Med Fam Comunidade 2016; 11(Supl. 2):26-36. was also used to assess the concordance between the extended and short versions.

This study is not free of limitations. First, the conceptual complexity of grouping theories to create a construct regarding primary care may not have been sufficiently contemplated since only one question related to first-contact care was included. Additionally, some questions or items from the initial version of the QSPC-Q could have been used to reinforce this attribute and strengthen the conceptual model. However, we focused on validating and assessing the internal consistency and reliability of the extended version.

Another relevant aspect is the ideal sample size for the exploratory factor analysis, which should comprise at least 5 to 10 participants per item or question¹⁹19 Jones J, Hunter D. Consensus methods for medical and health services research. BMJ 1995; 311(7001):376-380.^,2222 Daniel WW. Biostatistics: a foundation for analysis in the health sciences. New York: Wiley; 1999.. However, the literature is contradictory, suggesting a minimal number of participants per item or minimal sample size²¹21 Streiner DL, Norman GR. Health Measurement Scales: a practical guide to their development and use. New York: Oxford Scholarship Online; 2015.. In this sense, we applied at least 100 questionnaires, sufficient for the factor analysis²⁴24 Razali NM, Wah YB. Power comparisons of Shapiro-Wilk, Kolmogorov-Smirnov, Lilliefors and Anderson-Darling tests. J Stat Mod Anal 2011; 2(1):21-33.^,2929 Batista VCL, Ribeiro LCC, Ribeiro CDAL, Paula FA, Araújo A. Avaliação dos atributos da atenção primária à saúde segundo os profissionais de saúde da família. SANARE 2016; 15(3):87-93.. Moreover,the results regarding communality also indicated that a sample between 100 and 200 was adequate²²22 Daniel WW. Biostatistics: a foundation for analysis in the health sciences. New York: Wiley; 1999.; an adequate number of individuals participated in the QSPC-Q professional.

We highlight that the QSPC-Q user must be applied with the QSPC-Q professional in BHU to prevent intention bias³⁰30 Field A, Miles J, Field Z. Discovering statistics using R. Washington: SAGE; 2012.. Further studies are needed to investigate the validity of the QSPC-Q and its impact on health quality and strengthening of primary care.

A strong correlation coefficient was found between the results of the short and extended versions (r = 0.98, p < 0.001) (Figure 1). The attributes of longitudinality and cultural competence were the most relevant in both versions. Moreover, family and community orientation presented a higher mean value in the short (5.36) than in the extended (5.18) version (Figure 2).

Conclusions

The QSPC-Q developed for professionals and users was valid and presented internal consistency even after adjusting items, thus attending to the psychometric criteria for the development and validation of instruments. Additionally, the short version is novel in the current Brazilian context.

We believe this questionnaire will facilitate the continuing assessment and strengthen primary care based on a qualified perception of users and professionals.

References

Publication Dates

History