Chinese Version People’s Voice Survey Instrument Development And Validation:Based On High-quality Health System Framework

Objective Based on the conceptual framework of the international High Quality Health System(HQHS)and the global version of the People’s Voice Survey(PVS)developed in collaboration with researchers at Harvard University,we constructed,validated,and optimized the Chinese Version People’s Voice Survey(PVS-CN)according to the Chinese health system context.Methods A combination of qualitative and quantitative methods was used to develop and validate the PVS-CN in phases.In the first phase,we were deeply involved in the development process of the global version of PVS.On the basis of the global version,we formed the first draft of PVS-CN through translation,and used the expert consultation method and cognitive interview method to conduct cross-cultural adaptation,language wording revision,and relevance and comprehensiveness of the first draft of PVS-CN from the perspective of experts and respondents through the expert consultation method and cognitive interviewing method,respectively,to improve the content validity of the PVS-CN,in which the Delphi method of content validity evaluation was performed using the Silent and Anonymous Feedback(SAFE).In the second phase,stratified sampling method was used to separate cities in Gansu Province into high,medium and low levels according to Gross Domestic Product(GDP)per capita ranking,and randomly selected cities of Lanzhou,Pingliang and Zhangye to conduct telephone survey by using Random Digit Dialing(RDD)method to apply PVS-CN as a research instrument to collect data to build a database.SPSS26.0 and AMOS 24.0 software were used for statistical description and statistical inference,and Consensus-based Standards for the Selection of Health Measurement Instruments(COSMIN)were followed.The critical ratio method and homogeneity test were used to select the items,content validity,exploratory factor analysis and confirmatory factor analysis of structural validity were used to initially test the validity of the items of the PVS-CN,and internal consistency and split-half reliability were used to test the reliability of the scale.Result The first draft of PVS-CN,which is based on the global version of the PVS,contained four primary indicators,including respondents’basic characteristics,health service utilization and health system capacity,care experience and health system confidence,as well as 12 secondary indicators,including health status,patient activation,usual source of care,evaluation of the public health system,overall health system assessment,including 24 scale items and 52 questionnaire items.During the cross-cultural adaptation phase,the experts suggested modifications to the population’s education level,type of health insurance and health care facility covered by the PVS global version.The results of the evaluation of the relevance and comprehensiveness of the items showed that all experts considered the included items to be relevant and comprehensive to the health system and its evaluation,and no items needed to be added or deleted.140 respondents from Lanzhou,Pingliang and Zhangye City in Gansu Province completed the pre-survey.In the item analysis,the CR values of high and low subgroups in each item score ranged from 2.814 to 10.470,and the t-test P<0.05 for24 items reached the significance level,and the items were better discriminated.The Pearson correlation coefficients between the 24 items and the total score of the scale were 0.324～0.776,and there was no significant increase in the alpha coefficient of the scale or each dimension after the deletion of all items,the commonality of all items was 0.393～0.978,all greater than 0.20,and the factor loadings were 0.472～0.985,all greater than 0.45.Finally,item 20,21,23,and 24 did not meet one or two of the six criteria(CR value,item-total score correlation,Corrected Item-Total Correlation,alpha coefficient after deletion of items,commonality,and factor loadings)each,but did not meet the deletion criteria set in this study and were temporarily retained.The final PVS scale included a total of 24 items.Content validity analysis showed that the Item-level Content Validity Index(I-CVI)was 0.71～1.00,Scale-level Content Validity Index/universal agreement(S-CVI/UA)=0.88,and the Scale-level Content Validity Index/average(S-CVI/Ave)=0.98,indicating that PVS scale has good content validity.In exploratory factor analysis,KMO=0.888,?~2/df of Bartlett’s Test of Sphericity=17.121,P<0.001,and five factors were extracted using principal component analysis and varimax rotation,named self-rated health status,last medical experience,evaluation of the public health system,confidence in the health system,and overall evaluation of the health system.The cumulative contribution of the variance of the five factors was 78.765%.In the confirmatory factor analysis,the initial structural equation model?~2/df=2.203,Comparative Fit Index(CFI)=0.948,Tucker-Lewis Index(TLI)=0.941,Root Mean Square Error of Approximation(RMSEA)=0.086,and after correction?~2/df=0.842,CFI=0.954,TLI=0.958,RMSEA=0.078(<0.08),all indicators have good fit and the structural validity was good.The AVE values of the five variables were 0.463,0.966,0.575,0.293,and 0.591,and the combined reliabilities were 0.734,0.997,0.841,0.548,and 0.809.The absolute values of the correlations among the dimensions were smaller than the square root of AVE,and the discriminant validity was good.In the reliability analysis,the Cronbach’sα=0.929 for the PVS total scale,and the Cronbach’sαcoefficients for all dimensions were 0.515～0.871,except for the dimension of confidence in the health system,which was greater than 0.70.Dividing the PVS scale questions into two parts of the questions,the front and back the alpha reliability values of the two parts were0.860 and 0.865(>0.70),and the split-half reliability value(Spearman’s correlation coefficient)was 0.990,suggesting good reliability of the PVS scale.Conclusion The PVS-CN scale has good item differentiation,reliability,and validity,and can be used as a reliable and valid instrument to assess the quality of Chinese health system from the perspective of the public,which can be further strengthened and optimized or promoted.