A strong primary care (PC) with a high capacity for resolving problems can modulate the use of the rest of the health system, making the system more efficient.1,2 Until now, few studies have attempted to assess the strength of PC because of an unclear conceptualization and specification of its component attributes.3 Moreover, very little use is made of tools that are able to measure the multiple functions of PC or which allow comparison between countries or systems. Although some instruments are already available to measure core attributes of PC4, they are not widely disseminated, nor have they been adapted and validated to obtain equivalent measures in distinct countries.

Starfield's theoretical model defines a number of core and ancillary domains that PC should accomplish.5 For the core domains, PC should be the point of entry into the health system (except for emergency situations); provide care focused on the person, which is longitudinal (based on a long-term personal relationship), and should be comprehensive, and coordinated with other levels of care. For the ancillary domains, PC should focus on the health of individuals in the context of their family and community and be able to adapt and develop a relationship with the various social groups present in the community, demonstrating cultural competence.

The Primary Care Assessment Tools (PCAT) was developed to address that assessment model for PC domains.6,7 Three versions were developed to allow evaluation from the points of view of the population (consumer version), managers (facility version) and health professionals (provider version). The consumer version has been applied in the USA,6,8,9 Brazil,10 Canada,11 Korea,12 Hong Kong,13 and Taiwan,14 and several other countries are currently working on it (Uruguay, Argentina, China, etc.).15,16. In Spain, a brief version of the PCAT-consumer version was included in the 2006 Catalan Health Interview Survey.17–19

The Spanish General Health Service Act (1986) establishes a national health system composed of 17 regional health services. The Spanish health system is financed mainly by taxes and provides universal and free health coverage, including primary, specialized and hospital care.20 Catalonia is one of the regions with transferred health responsibilities within Spain and has two official languages, Spanish and Catalan.

For evaluation of health services, equivalent instruments are essential. Originally designed for the USA, a cross-cultural adaptation of the PCAT is needed when used in other contexts. The general objective of this study was to obtain and evaluate an instrument to assess the domains of primary care (accessibility, continuity, comprehensiveness, coordination, family-centeredness, community orientation and cultural competence) that are useful for the Spanish health system. The specific objectives were to adapt the PCAT to the Spanish health system and culture and to analyze its feasibility, reliability and validity. This article describes the adaptation process that may be useful in other contexts because it followed international recommendations for cross-cultural adaptations,21,22 adding a specific step of health system adaptation, in order to ensure the equivalence between PC measures in an international context.

A cross-cultural adaptation process was conducted to obtain versions of the PCAT - Facility questionnaire to be applied in the Spanish National health system and to test its reliability and validity. The procedure followed is represented in figure 1. Since this study was conducted in Catalonia, the Castilian (Spanish) and Catalan languages were used because they are the main official languages spoken in this autonomous region, language being the only difference between Spanish health regions relevant to the measure of PC.

Fig. 1.

Process of translation-adaptation and analysis.

(0.53MB).

Finally, a pre-test including a cognitive interview was conducted to test the feasibility and understanding of the pre-pilot version. Semi-structured individual interviews were conducted with six directors of PC teams in the public system. These directors were asked to complete the questionnaire and were later asked for their opinions on and experience of completing the questionnaire. From this phase a pilot version was obtained.

PC evaluation should involve multiple perspectives and tools.25–27 This study describes an instrument to measure whether PC provision achieves the standards of the theoretical model. A review highlighted the PCAT, as the only tool that includes psychometrically tested domains for all of the PC core domains and is available in multiple and comparable formats (for providers as well as users).4 The PCAT measures the key characteristics of PC defined by the World Health Organization-Europe,28 as well as other basic components of particular interest for Spain, such as Family-centeredness and Cultural competence.

The method used for obtaining the Spanish version ensures equivalence with the original. All the analyses conducted with the items, as well as the test-retest analysis, indicate the good reliability of the questionnaire. The PCAT-Facility has shown acceptable convergent validity (81% of items showed item-total correlation, with Pearson's correlation coefficients ≥0.30)22 and good discriminant validity (in 95% of cases, the correlation of each item with its scale was higher than with other domains), as well as good internal consistency in most of the domains (Cronbach's alpha coefficient >0.70).24 Repeatability was less good (ICC <0.70),22 which may be due to the difficulty of choosing a suitable time lapse between the two measures. When health effects are measured in people, a 2-week lapse has been reported to be advisable, but in the case of measures of the health system we have found no references on a recommended period. The period used may have been too long.

The use of the PCAT adapted to Spain allows comparison between our health system and others, which is the main reason to adhere to the original instrument. There are other tools, such as PC Monitor,29 to compare PC in distinct countries, but PCAT specifically provides assessment of the theoretical components that should be met by PC. The PCAT instrument has already been validated for assessing the theoretical model of PC,5 making it suitable for use in different contexts. In Spain, there is extensive experience of having adapted and validated instruments designed in other contexts, especially in the field of measuring health and quality of life,30–32 but there is less experience in the field of health services evaluation, specifically PC, and fewer tools for international comparability are available.

As expected, the main differences between the original instrument and its Spanish adaptation are in sections concerning aspects of organization and structure of PC teams and their assigned populations. For the sections of PC domains of the questionnaire, the Spanish version of the PCAT-Facility shows good linguistic and conceptual equivalence with the original. The low variability in some items can be explained by the homogeneity of PC teams, since many aspects of PC provision and functioning are determined by the system not by the team (e.g. items related to the services covered). We decided to maintain these items to allow international comparability.

The main weakness of the instrument obtained concerns its criterion validity; being a new instrument, there are no other good measures to obtain evidence about this feature. Even so, the result of the approximation used, consisting of correlating the score for accessibility to the fact that the center is open 24hours, suggests confidence in the measure. The results for the questionnaire's content validity are considered appropriate, firstly, because the original questionnaire was designed by one of the authors (Starfield) and the consumer version has already been validated in the English version,6 and secondly the members of the research team and expert panel that collaborated in the adaptation phases are knowledgeable about the PC model and functioning in Spain and, more specifically, in Catalonia.

In the measure of PC domains, Comprehensiveness -subdomain services provider- showed a ceiling effect; one of the reasons could be the above-mentioned homogeneity of the public healthcare system in specifying the services portfolio covered. Comparing different systems or suppliers outside the public system would probably result in less homogeneity. Continuity, Family-centeredness, Community orientation and Cultural competence had the best Cronbach's alpha results (0.82, 0.94, 0.90 and 0.80, respectively) and showed no ceiling effects. In the Spanish health system, these PC attributes are less determined by the system and depend more on the dynamics and organization of each team. The PCAT-Facility in Brazil, the only country with published results on its psychometric properties, showed that the dimensions of access, comprehensiveness and community orientation had Cronbach's alpha scores close to 0.70, but the remaining dimensions had scores below 0.60.33 Similarly, in the Spanish PCAT, coordination has a Cronbach's alpha score under 0.60, but in all the other domains, our scores are higher.

The results should be analyzed in light of the existing organizational system, given that some aspects of services provision will be determined by distinct levels: the macro-system organization, the provider, and the organization of the PC team. Finally, it is important to acknowledge that the provision of care will ultimately depend on the professionals providing the care.

Importantly, the PCAT-Facility version assumes a certain homogeneity among the distinct professionals within the PC team, and those completing the questionnaire could have been biased toward the mean or otherwise have tended to respond positively.

Given the response rate obtained, nearly 70%, and the good results (not shown) of a comparative analysis between the total sample and that finally obtained with respect to geographical area and type of healthcare provider, we are confident that the sample on which the tests were based did not show a sufficient selection bias to influence the psychometric characteristics obtained by the questionnaire.

We conclude that, even taking into account the limitations of this study, we have an instrument with which to expand the scope of PC assessment, with adequate reliability and validity. Moreover, we believe this instrument could be especially useful as it is feasible to implement (being completed by the PC team manager/coordinator), requires only about 35minutes to complete and presents low difficulty. This questionnaire also provides a measure of the domains of PC with good reliability, and their assessed validity has been partly corroborated by the analysis performed.

This instrument could be useful for national (at the regional level) and international comparisons, especially in light of the World Health Report 2008 on primary care.34 In addition, the PCAT could be used to ascertain whether the results for the PC domains are associated or not with the characteristics of the team and/or the population, and an inequality perspective can be introduced in this analysis. Furthermore, the PCAT could be useful to monitor the health system, at PC level, especially in the present context, with the current economic crisis provoking changes in the health system.

M.I. Pasarín and S. Berra conceived the project and the article. M.I. Pasarín, S. Berra, A. Segura, A. García-Altés and B. Starfield participated in the study design, in the definition of the analysis strategy and in the discussion of results. M.I. Pasarín wrote the first draft of the manuscript. All the authors critically reviewed the manuscript. A. González performed most of the fieldwork and analyzed the data, guided and supervised by M.I. Pasarín and S. Berra. M.I. Pasarín conducted the interviews in the fieldwork. A. Gonzalez, C. Tebé and I. Vallverdú participated in the definition of the analysis strategy and discussion of the results and critically reviewed the manuscript. All the authors approved the final version.

This study was partially funded by the Fondo de Investigaciones Sanitarias [proyecto FIS number 052763] and the CIBER de Epidemiología y Salud Pública (CIBERESP).

None.