This scholarly article has been a fine example of what a fresh
approach and interdisciplinary overview can do.
We work with illness explanatory models of patients from various
outpatient clinics who suffer from biomedically unexplained fatigue and
weakness for six months or more. Also, in private practice of clinical
psychiatry compliance is the pivotal issue. We find that cultural
epide...
This scholarly article has been a fine example of what a fresh
approach and interdisciplinary overview can do.
We work with illness explanatory models of patients from various
outpatient clinics who suffer from biomedically unexplained fatigue and
weakness for six months or more. Also, in private practice of clinical
psychiatry compliance is the pivotal issue. We find that cultural
epidemiology plays a significant role in understanding and managing
patients' compliance and outcome. Either intentional error or violation,
or unintentional slip or lapse, patients do always have subjective
explanation for their behaviour. The antecedents of compliance or non-
compliance can be found:
(1)in patient's illness experience, different
variables of which include stigma of illness or treatment, anticipated
outcome, perceived seriousness of the symptoms, and many other
sociocultural contextual factors;
(2)in subjective meaning of the illness
as exemplified by the perceived causes of the illness and their linkages
among each other; and
(3)his experiences with the help seeking behaviour
and the agencies of help, with their meeting patient's perceived needs.
Patient's explanatory models (emic) and its match or otherwise with
the explanatory models of the professional care giving agencies (etic) is
an important determinant of the patient's compliance toward the prescribed
treatment. Careful attention to the patient's emic is facilitated by
cultural epidemiological approach with the use of Explanatory Model
Interview Catalogue(EMIC), a tool that can be used in research as well as
in clinical practice. It focuses on patient's experience, meaning, and
behaviour while retaining the qualitative as well as the quantitative
aspects. Ratings on predetermined codes facilitate comparison and analysis
apart from crystallizing the salient features of the explanatory model.
Reliability of this effective tool has been documented in studies on
leprosy and depression.
The provision of free access to the electronic versions of journals to
the users in the developing world deserves lots of praise, indeed. Coming
from such a background, I cannot over emphasize the long felt need for the
same.
Internet use, especially for medical education and training in India,
has increased by leaps and bounds over the last five years. In spite of
that, institutional subscr...
The provision of free access to the electronic versions of journals to
the users in the developing world deserves lots of praise, indeed. Coming
from such a background, I cannot over emphasize the long felt need for the
same.
Internet use, especially for medical education and training in India,
has increased by leaps and bounds over the last five years. In spite of
that, institutional subscriptions for journals are poor due to funding
restrictions.
Free access is helping many medical students and trainees far more
than it is probably appreciated. The approach and awareness of doctors in
training has changed in a better direction, in the light of such quick and
comprehensive access to all the recent developments in the medical world.
From my personal experience, the idea has changed medical education in a
very positive way.
It is too good to get this facility free of cost. It could be a bit better
if many of the other publishing houses (both from the United Kingdom and
United States of America) follow the example set by the BMJ group.
Yours sincerely
Dr S Chakrabarti
Senior House Officer
Roberts et al[1] provide a commentary on the Patient Satisfaction
Questionnaire (PSQ) that we have developed and validated.[2][3] Whilst
they accept that the PSQ is a valid and internally reliable tool for
assessing patient satisfaction with primary care services, they suggest
that further work is required before the measure is adopted. In
particular they point to the need to assess the acceptabi...
Roberts et al[1] provide a commentary on the Patient Satisfaction
Questionnaire (PSQ) that we have developed and validated.[2][3] Whilst
they accept that the PSQ is a valid and internally reliable tool for
assessing patient satisfaction with primary care services, they suggest
that further work is required before the measure is adopted. In
particular they point to the need to assess the acceptability of the items
to different patient groups.
In the development of a measure such as the PSQ, continuing
assessment of reliability, validity and acceptability is clearly
worthwhile. Nevertheless we would argue that there already exists
sufficient data on the reliability and validity of the scale[2][3] to
warrant its adoption as means of assessing patient satisfaction with
primary care services.
In relation to the specific points raised by Roberts et al[1]:
First, in relation to the issue that certain items may be
unacceptable and produce low response rates. Analysis of items included in
both the original study where the questionnaire was developed[2] and the
validation study[3] has failed to show any differences in response rates
on individual items. Also, all items originated in interviews and open-ended questionnaires with patients, and we have no reason to believe that
they would be unacceptable to other patients.
Second, in relation to whether particular items may distress or
offend respondents. As all items were originally derived from interviews
with patients, the wording reflects the way in which patients talk about
these services. In reproducing the questionnaire we allow practitioners
the opportunity to judge the potential offensiveness of the items. We have
not received any negative feedback about items from practitioners or
respondents to the questionnaires used in our validation study in terms of
their distressing nature or offensiveness. There is no evidence to
support the suggestion that any of the items in the PSQ will distress or
offend respondents.
Third, in relation to the suggestion that the PSQ as a whole may not
be completed by particular groups: This is not an issue we have
specifically addressed in our research. To do so would require the
assessment of response rates in different groups where we might expect
differences. A further analysis might then compare the numbers of fully
versus partially completed PSQs. In relation to this latter point, from
the data reported in Grogan et al,[3] we were able to make a comparison
of questionnaires that were fully completed versus those that were only
partially completed. This indicated no significant impact of various
demographic groups (eg, age, gender) on completion rates.
In summary, whilst we accept that further work to assess the
reliability, validity, and acceptability of the PSQ is warranted, we
believe that the measure has been sufficiently tested to make it suitable
for adoption by those wishing to assess patient's satisfaction with
primary care services.
Sarah Grogan, PhD (Address for correspondence)
Senior Lecturer
Department of Psychology and Speech Pathology
Manchester Metropolitan University
Elizabeth Gaskell Building
Manchester M13 OJA, UK
Mark Conner, PhD
Senior Lecturer
School of Psychology
University of Leeds
Leeds LS2 9JT, UK
References
(1) Roberts L, Roalfe A, Wilson S. Patient Satisfaction Questionnaire
- Further validation required [Rapid Response]. Qual Health Care 22
December 2000. http://www.qualityhealthcare.com/cgi/eletters/9/4/210#EL1
(2) Grogan S, Conner M, Willits D, Norman P. Development of a
questionnaire to measure patients' satisfaction with general
practitioners' services. British Journal of General Practice 1995;45:525-
29.
(3) Grogan S, Conner M, Norman P, Willits, Porter I. Validation of a
questionnaire measuring patient satisfaction with general practitioner
services. Qual Health Care 2000;9:210-15.
Grogan et al[1] report that their Patient Satisfaction Questionnaire
(PSQ) is a valid and internally reliable tool for assessing patient
satisfaction with primary care services despite the acknowledgement in
their discussion that further research is required to confirm other
aspects of reliability and validity. We feel that their conclusion is
premature.
Grogan et al[1] report that their Patient Satisfaction Questionnaire
(PSQ) is a valid and internally reliable tool for assessing patient
satisfaction with primary care services despite the acknowledgement in
their discussion that further research is required to confirm other
aspects of reliability and validity. We feel that their conclusion is
premature.
Having recently been involved in the validation of a postal
questionnaire to assess quality of life in dyspeptic patients we are aware
of the importance of a full evaluation. Our principal concerns with the
published study[1] relate to the lack of information relating to
representativeness and acceptability. The need to demonstrate
acceptability is heightened when questionnaires are to be self-completed.
Response rate data were not provided because of the study design. Response
rates give not only an indication of the acceptability of the questions
used, but also provide information about the acceptability of the concept,
e.g. will patients answer questions about their doctor? Full data sets
were available for 1151/1390 returned questionnaires; 17% of patients
chose not to complete all questions, which may indicate lack of
acceptability of certain items. Acceptability is important for several
reasons:
1) ethically we should not be utilising tools which may
distress/offend
2) financially we should not use a tool which will not be
returned or where intense effort is required to generate responses
3) in the interests of quality we should not use a tool where differential
acceptability may cause bias.
Before recommending the PSQ as a tool we
would like to see some evidence that acceptability has been demonstrated
in different patient groups.
Other evidence that would be useful before concluding that the
questionnaire should be adopted includes data on reproducibility
(consistency of response) and responsiveness over time. Before using the
questionnaire for repeated audit or to evaluate change in practice, it is
important to confirm that the questionnaire is able to reflect changes in
satisfaction over time.
Whilst the data provided indicates the PSQ to be valid and reliable,
these data must be interpreted with some caution given the lack of
information about sample selection and representativeness. Other issues
pertinent to questionnaire evaluation have not been fully explored and,
given that this is designed to be a self-completion questionnaire for use
in an area in which traditionally patients have not been consulted,
acceptability of the questionnaire and individual questions should be
assessed before concluding that the tool be adopted.
Reference
(1) Grogan S, Conner M, Norman P, Willits, Porter I. Validation of a
questionnaire measuring patient satisfaction with general practitioner
services. Quality in Health Care 2000;9:210-15
I agree that every opportunity should be taken to discuss with
patients with diabetes how they can reduce the risk of complications, and
that screening can present one such opportunity. However, because the
effectiveness of this approach has not been tested in an RCT, it was not
included in the review on which this Effective Health Care Bulletin was
based.
The authors point out the effectiveness and need for retinopathy screening and foot care in diabetes. However, as in much of the "screening" literature, the opportunity for intervention during the screening visit is not ephasised.
We know that by achieving an HbA1c of 6% and blood pressure of 130/80 or below, not smoking, and having a hyperlipidaemia treated, most retinopathy could be avoided or delayed (U...
The authors point out the effectiveness and need for retinopathy screening and foot care in diabetes. However, as in much of the "screening" literature, the opportunity for intervention during the screening visit is not ephasised.
We know that by achieving an HbA1c of 6% and blood pressure of 130/80 or below, not smoking, and having a hyperlipidaemia treated, most retinopathy could be avoided or delayed (UKPDS and DCCT studies).[1][2][3] But few patients are aware of this information, fewer still know their own levels, and fewer still know how to achieve such levels. By providing such information, regarding the importance of the levels and finding them out and the need for medical care to reach the required targets, patients would not only be screened but an intervention would have been carried out that would enable many patients to avoid retinopathy and other complications.
Surely it is time to consider that retinopathy screening visits provide the opportunity for vastly improved quality of care, not simply a check up. Indeed, the authors note the success of foot intervention programs in preventing amputations, whilst it is only a very small further step to prevent many diabetic complications by informing patients of the need for good control of their diabetes, and the need to check control with HbA1c and blood pressure checks.
References
(1) Diabetes Control and Complications Trial (DCCT) Research Group. The Effect of Intensive Treatment of Diabetes on the Development and Progression of Long Term Complication in Insulin-Dependant Diabetes Mellitus. N Engl J Med 1993;329:977-86.
(2) Adler, AI, et al, on behalf of the UK Prospective Diabetes Study Group. Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36). BMJ 2000;321:412-19.
(3) Stratton, IM, et al, on behalf of the UK Prospective Diabetes Study Group. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35). BMJ 2000;321:405-12.
Dear Editor
This scholarly article has been a fine example of what a fresh approach and interdisciplinary overview can do.
We work with illness explanatory models of patients from various outpatient clinics who suffer from biomedically unexplained fatigue and weakness for six months or more. Also, in private practice of clinical psychiatry compliance is the pivotal issue. We find that cultural epide...
Dear Editor
The provision of free access to the electronic versions of journals to the users in the developing world deserves lots of praise, indeed. Coming from such a background, I cannot over emphasize the long felt need for the same.
Internet use, especially for medical education and training in India, has increased by leaps and bounds over the last five years. In spite of that, institutional subscr...
Dear Editor,
Roberts et al[1] provide a commentary on the Patient Satisfaction Questionnaire (PSQ) that we have developed and validated.[2][3] Whilst they accept that the PSQ is a valid and internally reliable tool for assessing patient satisfaction with primary care services, they suggest that further work is required before the measure is adopted. In particular they point to the need to assess the acceptabi...
Grogan et al[1] report that their Patient Satisfaction Questionnaire (PSQ) is a valid and internally reliable tool for assessing patient satisfaction with primary care services despite the acknowledgement in their discussion that further research is required to confirm other aspects of reliability and validity. We feel that their conclusion is premature.
Having recently been involved in the valida...
Dear Editor:
I agree that every opportunity should be taken to discuss with patients with diabetes how they can reduce the risk of complications, and that screening can present one such opportunity. However, because the effectiveness of this approach has not been tested in an RCT, it was not included in the review on which this Effective Health Care Bulletin was based.
The authors point out the effectiveness and need for retinopathy screening and foot care in diabetes. However, as in much of the "screening" literature, the opportunity for intervention during the screening visit is not ephasised.
We know that by achieving an HbA1c of 6% and blood pressure of 130/80 or below, not smoking, and having a hyperlipidaemia treated, most retinopathy could be avoided or delayed (U...
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