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Original Articles • Rev. Saúde Pública 49 • 2015 • https://doi.org/10.1590/S0034-8910.2015049005548 copy

Validity and reliability of a health care service evaluation instrument for tuberculosis

Authorship SCIMAGO INSTITUTIONS RANKINGS

OBJECTIVE

To evaluate the validity and reliability of an instrument that evaluates the structure of primary health care units for the treatment of tuberculosis.

METHODS

This cross-sectional study used simple random sampling and evaluated 1,037 health care professionals from five Brazilian municipalities (Natal, state of Rio Grande do Norte; Cabedelo, state of Paraíba; Foz do Iguaçu, state of Parana; Sao José do Rio Preto, state of Sao Paulo, and Uberaba, state of Minas Gerais) in 2011. Structural indicators were identified and validated, considering different methods of organization of the health care system in the municipalities of different population sizes. Each structure represented the organization of health care services and contained the resources available for the execution of health care services: physical resources (equipment, consumables, and facilities); human resources (number and qualification); and resources for maintenance of the existing infrastructure and technology (deemed as the organization of health care services). The statistical analyses used in the validation process included reliability analysis, exploratory factor analysis, and confirmatory factor analysis.

RESULTS

The validation process indicated the retention of five factors, with 85.9% of the total variance explained, internal consistency between 0.6460 and 0.7802, and quality of fit of the confirmatory factor analysis of 0.995 using the goodness-of-fit index. The retained factors comprised five structural indicators: professionals involved in the care of tuberculosis patients, training, access to recording instruments, availability of supplies, and coordination of health care services with other levels of care. Availability of supplies had the best performance and the lowest coefficient of variation among the services evaluated. The indicators of assessment of human resources and coordination with other levels of care had satisfactory performance, but the latter showed the highest coefficient of variation. The performance of the indicators “training” and “access to recording instruments” was inferior to that of other indicators.

CONCLUSIONS

The instrument showed feasibility of application and potential to assess the structure of primary health care units for the treatment of tuberculosis.

Health Services Evaluation; methods; Tuberculosis; prevention & control; Quality Indicators; Health Care; Indicators of Health Services; Questionnaires; utilization; Validation Studies

Human resources	Yes (%)
1. Does this service have a nurse responsible for the care of TB patients?	99.3
2. Does this service have a nursing assistant/technician responsible for the care of TB patients?	71.4*
3. Does this service have a physician responsible for the care of TB patients?	92.6*
4. Does this service have a community health worker responsible for the care of TB patients?	88.5*
5. Are there other professionals in this service (psychologist, social worker) involved in the care of TB patients?	45.1
6. In the last three years, were nurses trained to care for TB patients?	77.1*
7. In the last three years, were nursing assistants/technicians trained to care for TB patients?	33.9*
8. In the last three years, were physicians trained to care for TB patients?	61.5*
9. In the last three years, were CHW trained to care for TB patients?	47.3*
10. In the last three years, were other professionals trained to care for TB patients?	13.0
11. In the last 12 months, did the epidemiological health surveillance agencies conduct training on TB?	60.4*
12. In the last 12 months, did the health care units train health care workers on TB?	34.9
13. Is there a professional responsible for DOT in this health care unit?	88.4
Physical resources	Yes (%)
14. In this service, are medical clinics available for the care of TB patients?	71.4
15. In this service, are nursing care rooms available to TB patients?	69.1
16. At present, are basic food staples and food vouchers available to TB patients?	51.0
17. At present, are transportation vouchers available to TB patients?	20.5
18. Do professionals have access to notification forms?	83.4*
19. Do professionals have access to medical records?	92.5*
20. Do professionals have access to monthly treatment monitoring reports?	63.4*
21. Do professionals have access to daily DOT reports?	66.5*
22. Do professionals have access to the green paper?	53.9*
23. Does the health care unit have pots for sputum examination?	89.9*
24. Has the health care unit requested sputum smear microscopy?	95.7*
25. Has the health care unit requested microbiological cultures?	90.8*
26. Has the health care unit requested HIV examination?	92.9
27. Does the health care unit have reference and counter-reference cards?	91.2
28. Did the availability (delivery) of TB drugs in this health care unit meet the demand in the last 12 months?	88.1
Service organization	Yes (%)
29. Does this HCS assist patients outside business hours (after 5 pm)?	38.3
30. Are discussions regarding cases involving TB patients who are treated in this health care unit conducted by health care professionals responsible for the treatment of this condition?	73.4
31. Can TB patients under treatment schedule a consultation within 24h in this health care unit in case they experience complications arising from TB or its treatment?	87.1
32. Are TB patients under treatment advised to seek health care units outside the scheduled date of return in case they experience any problems arising from TB or its treatment?	95.5
33. Does this health care unit have coordination with other levels of care when the patient requires consultations because of other comorbidities (diabetes, hypertension, psychiatric diseases)?	85.3*
34. Does this health care unit have coordination with other levels of care when the patient is coinfected with HIV?	87.7*
35. Does this health care unit have coordination with other levels of care when the patient experiences complications arising from treatment?	91.4*
36. Does this health care unit have coordination with other levels of care when difficulties in the realization of DOT occur?	78.6*
37. Is the frequency at which the laboratory conducts TB examination tests during treatment sufficient to meet the demand for this service?	64.5
38. Do the sputum smear microscopy results become available within 7 days?	22.6
39. In the health care unit, is there a computerized system containing information about the patients with TB (scheduled appointments, work absenteeism, problems during drug therapy)?	21.9

Questionnaire item^a	Factor loadings of the 5 validated factors

	1	2	3	4	5	Commonalities

	Access to recording instruments	Training of health professionals	Coordination with other levels of care	Professionals involved in the care of TB patients	Availability of supplies and equipment
2. Does this service have a nursing assistant/technician responsible for the care of TB patients?	0.016	-0.001	0.013	0.912^b	0.064	0.785
3. Does this service have a doctor responsible for the care of TB patients?	-0.184	0.034	0.125	0.901^b	-0.141	0.801
4. Does this service have a community health worker responsible for the care of TB patients?	0.089	0.157	-0.183	0.921^b	0.009	0.863
6. In the last three years, were nurses trained to care for TB patients?	0.194	0.973^b	0.152	0.026	0.054	0.998
7. In the last three years, were nursing assistants/technicians trained to care for TB patients?	-0.135	0.738^b	0.024	0.552	0.258	0.895
8. In the last three years, were physicians trained to care for TB patients?	0.140	0.835^b	0.262	0.150	-0.009	0.803
9. In the last three years, were CHW trained to care for TB patients?	-0.257	0.603^b	-0.104	0.428	0.365	0.714
11. In the last 12 months, did the health epidemiological surveillance agencies conduct training on TB?	0.218	0.811^b	-0.044	-0.170	0.160	0.691
18. Do professionals have access to notification forms?	0.885^b	0.248	0.144	-0.054	0.164	0.888
19. Do professionals have access to medical records?	0.941^b	0.180	0.192	-0.009	0.112	0.957
20. Do professionals have access to monthly treatment monitoring reports?	0.847^b	-0.290	0.152	-0.225	-0.015	0.818
21. Do professionals have access to daily DOT reports?	0.663^b	0.061	0.083	-0.068	0.376	0.540
22. Do professionals have access to the green paper?	0.797^b	0.161	0.134	0.126	0.108	0.648
23. Does the health care unit have pots for sputum examination?	0.096	0.043	0.004	0.031	0.898^b	0.718
24. Has the health care unit requested sputum smear microscopy?	0.399	0.302	0.254	0.126	0.791^b	0.980
25. Has the health care unit requested microbiological cultures?	0.306	0.177	0.332	-0.140	0.787^b	0.902
33. Does this health care unit have coordination with other levels of care when the patient requires consultations because of other comorbidities (diabetes, hypertension, psychiatric diseases)?	0.195	0.008	0.910^b	0.065	0.192	0.872
34. Does this health care unit have coordination with other levels of care when the patient is coinfected with HIV?	0.235	0.051	0.895^b	-0.006	-0.039	0.848
35. Does this health care unit have coordination with other levels of care when the patient experiences complications arising from treatment?	0.227	0.131	0.969^b	-0.027	-0.006	0.992
36. Does this health care unit have coordination with other levels of care when difficulties in the realization of DOT occur?	-0.050	0.126	0.804^b	-0.100	0.377	0.771
Eigenvalues	6.676	4.190	2.474	2.130	1.713	Total
Percentage of total variation	33.380	20.951	12.371	10.652	8.564	85.918
Standardized Cronbach’s α	0.7535	0.7226	0.7802	0.6460	0.6732	0.7265

Structure indicators	Mean percentage	sd	Coefficient of variation

	%	%	%
Professionals involved in the care of TB patients	84.2	3.3	3.9
Training of health care professionals	56.0	4.5	8.0
Access to recording instruments	72.0	4.1	5.7
Availability of supplies	92.2	2.4	2.6
Coordination of health care services with other levels of care	85.8	7.6	8.9

Questionnaire items
Human resources
1. Does this service have a nurse responsible for the care of TB patients?
2. Does this service have a nursing assistant/technician responsible for the care of TB patients?
3. Does this service have a physician responsible for the care of TB patients?
4. Does this service have a community health worker responsible for the care of TB patients?
5. Are there other professionals in this service (psychologist, social worker) involved in the care of TB patients?
6. In the past three years, were nursing professionals trained to care for TB patients?
7. In the past three years, were nursing assistants/technicians trained to care for TB patients?
8. In the last three years, were physicians trained to care for TB patients?
9. In the past three years, were CHW trained to care for TB patients?
10. In the past three years, were other professionals trained to care for TB patients?
11. In the last 12 months, did the epidemiological health surveillance agencies conduct training on TB?
12. In the last 12 months, did the health care units train health care workers on TB?
13. Is there a professional responsible for the realization of DOT in this health care unit?
Physical resources
14. In this service, are medical clinics available for the care of TB patients?
15. In this service, are nursing care rooms available to TB patients?
16. At present, are basic food staples and food vouchers available to TB patients?
17. At present, are transportation vouchers available to TB patients?
18. Do professionals have access to notification forms?
19. Do professionals have access to medical records?
20. Do professionals have access to monthly treatment monitoring reports?
21. Do professionals have access to daily DOT reports?
22. Do professionals have access to the green paper?
23. Does the health care unit have pots for sputum examination?
24. Has the health care unit requested sputum smear microscopy?
25. Has the health care unit requested microbiological cultures?
26. Has the health care unit requested HIV examination?
27. Does the health care unit have reference and counter-reference cards?
28. Did the availability (delivery) of TB drugs in this health care unit meet the demand in the last 12 months?
Service organization
29. Does this health care service assist patients outside business hours (after 5 pm)?
30. Are discussions regarding cases involving TB patients who are treated in this health care unit conducted by health care professionals responsible for the treatment of this condition?
31. Can TB patients under treatment schedule a consultation within 24h in this health care unit in case they experience complications arising from TB or its treatment?
32. Are TB patients under treatment advised to seek health care units outside the scheduled date of return in case they experience any complications arising from TB or its treatment?
33. Does this health care unit have coordination with other levels of care when the patient requires consultations because of other comorbidities (diabetes, hypertension, psychiatric diseases)?
34. Does this health care unit have coordination with other levels of care when the patient is coinfected with HIV?
35. Does this health care unit have coordination with other levels of care when the patient experiences complications arising from treatment?
36. Does this health care unit have coordination with other levels of care when difficulties in the realization of DOT occur?
37. Is the frequency with which the laboratory conducts TB examinations during treatment sufficient to meet the demand for this service?
38. Do the sputum smear microscopy results become available within 7 days?
39. Is there a computerized system in the health care units with information on the patients with TB (scheduled appointments, work absenteeism, issues related with drug therapy)?

Faculdade de Saúde Pública da Universidade de São Paulo Avenida Dr. Arnaldo, 715, 01246-904 São Paulo SP Brazil, Tel./Fax: +55 11 3061-7985 - São Paulo - SP - Brazil
E-mail: revsp@usp.br

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