This study aimed to validate the English version of the Dutch Satisfaction with Stroke Care Questionnaire (SASC-19) outpatient subscale among Malaysian post stroke patients receiving longer-term stroke care at ten public primary healthcare facilities, in a trial- within-a- trial.
Pound et al first developed the Satisfaction with Stroke Care (SASC) questionnaire, a 13-item questionnaire to measure satisfaction with inpatient (Hospsat) and outpatient (Homesat) stroke care services in United Kingdom (6). The questionnaire was then expanded to include a further 7 items to gather more details on satisfaction with stroke care after discharge (7). This expanded version has been used in several studies and translated into Dutch as well (SASC19). The SASC was found to have good reliability for both scales, and demonstrated concurrent validity with the General Satisfaction Questionnaire, Barthel Index, Hospital Anxiety-Depression Scale and the SF-16 (8).
Patients were asked to indicate their agreement on each item using a 4-point Likert scale which ranges from 0 (strongly disagree) to 3 (strongly agree). The items can be analysed descriptively i.e. individually or summed up to produce a total score for all subscales. The higher the sum score indicated greater satisfaction (9,10). Based on the Dutch version, a patient who scores 22 or higher on the Homesat, indicates satisfaction with the care received after discharge from hospital (8).
As the focus of our study is on satisfaction with post-discharge care services, we aimed to produce a Malay language version of the SASC19 Homesat subscale, which measures patients’ satisfaction with outpatient stroke care services.
Two bilingual FMS were enlisted to translate the English version of the Homesat component of SASC19 into Malay language. Differences in the terms were reconciled through discussions and final consensus. This harmonized version was subsequently sent to another two different FMS who translated it back into English. Both FMS’ involved were competent users of both Malay and English language, and were native Malay speakers.
All language versions were then compared by the researcher with the original version to ensure conceptual and semantic equivalence. Modifications were made to provide local examples of healthcare services available in the community. In item number 3 of SASC19– ‘meals-on-wheels’ was removed as this service is not available for patients residing at home in the community.
The harmonized version was then pretested on 5 post-stroke patients and 5 caregivers of stroke patients (ages 20 - 62 years old). This was done to determine its comprehensibility, clarity as well as determine ease of use among local respondents. No further modifications were required after pre-testing was complete. The final version was then used for the validation and to determine the satisfaction with the current outpatient services provided at ten public primary care health centres representing different zones in Peninsular Malaysia.
This study was part of a larger trial to evaluate the profile and outcomes of longer-term stroke care provision for patients residing at home in the community and receiving longer term stroke care from public primary care health centres in Peninsular Malaysia. The study was conducted between July 2012 till June 2013. Multistage sampling methods were used to recruit patients or caregivers of stroke from ten public primary care health centres across Peninsular Malaysia, for this phase of the study.
The inclusion criteria were (1) patients aged 18 years and above, (2) clinically diagnosed with stroke due to any cause by the treating physician, with or without radiological confirmation. (3) Patients must have completed acute stroke treatment, discharged from hospital and referred or receiving treatment for long term stroke care at community health centres. Patients who were diagnosed with Transient Ischaemic Attack (TIA), or presented with isolated nerve palsy or those who were depressed were excluded from the study. The methodology is described in detail in another publication (11). The validation of SASC19 was conducted during recruitment stage of the trial, and the respondents were asked to recall their satisfaction with public outpatient healthcare services received after discharge from a tertiary hospital i.e. mainly at the public primary care health centres. Subsequently, the scores for satisfaction with outpatient stroke care services were then calculated using the finalized, validated version of the SASC10-MyTM questionnaire.
Descriptive statistics was used to analyse patients’ characteristics.
Missing responses in the questionnaire were not replaced. The sum scores for satisfaction were not calculated if the respondents had invalid responses for more than half (i.e. 6) of the SASC10-MyTM.
The feasibility of the questionnaire was determined by the response rate, the time taken to fill the questionnaire and percentage of missing values per item.
Internal consistency reliability of the scale was determined using Cronbach alpha coefficient. An alpha coefficient value of 0.7 and above indicated good internal consistency reliability.
Construct validity was determined using the exploratory factor analysis. Suitability of the data for exploratory factor analysis was determined using the Kaiser-Meyer-Olkin coefficient and the Bartlett’s test of sphericity. The number of factors to extract was determined using both the Scree plot and Monte Carlo Parallel Analysis. We postulated that domains from satisfaction with post-stroke care services would be partly related and thus used Oblimin rotation in exploratory factor analysis. Items with factor loading above 0.40 would be retained. The internal consistency reliability for identified factors would be determined individually.