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Introduction
By assessing the user's experience, women's perception of quality of this mass examination may be
measured. Such quality measurement is the driving force
behind any improvement effort.4"6
Based on relevant theory and psychometric
criteria7-' a multidimensional questionnaire MGQ for
measuring patient satisfaction with mammography was
developed and described in detail.9 In terms of content, items were selected and categorized in order to
cover women's mammographic experience on the
following four dimensions; the structural settings; the
process (patient-provider interaction); discomfort; and
general satisfaction.
67
Loeken K, Steine S, Sandvik l_ Laerum E and Finset A. A new measure of patient satisfaction with mammography. Validation by factor analytic technique. Family Practice 1996;
13: 67-74.
Background and objectives. The success of national breast screening programmes hinges
on women's adherence. By monitoring patients' perceptions, potential barriers to attendance may be detected, measured and possibly alleviated. Consequently a new questionnaire MGQ, measuring patients' experience of and satisfaction with mammography, has
been developed. As discomfort is a predictor of non-attendance, a dimension measuring
physical and psychological discomfort was included.
Methods. The internal structure of observed variables was tested using factor analysis as
part of the validation process. The study was conducted in six radiological departments
in Norway including 550 patients presenting for mammography. The analysis suggested
eight factors explaining 56.7% of the variance.
Results. Construct validity was supported since the factor scales covered all hypothesized
dimensions and all but one subdimension. The factors were internally consistent and externally independent, indicating that distinct aspects of patients' experience with mammography may be assessed and thus possibly improved.
Conclusions. A relationship between pain and re-attendance was suggested as pain and
worries about the next mammography belonged to the same factor. This underlines the
importance of including a discomfort dimension when monitoring patient satisfaction with
mammography.
Keywords. Mammography, patient satisfaction, quality control, questionnaires, pain.
68
The validation process in relation to a theoretical construct requires three steps.10 Two of these, describing
the domain of variables, i.e. the content validity, and
verifying the relationship between external, clinical
criteria and scales scores, were described earlier.9
With factor analysis, the third step of establishing the
internal structure of the observed variables by identifying underlying dimensions is evaluated.11 Factor
analysis may also point to the possibility of reducing
a large set of variables to a more compact set with
minimum loss of information.11
The purpose of the study was to compare the
theoretical construct with the empirical scales emerging from factor analysis. Reliability and convergent and
discriminant validity of the factor analytic scales were
estimated.
Results
With both methods of extraction, before rotation, the
items describing pain, discomfort and awkwardness
Methods
Data analysis
showed high loadings on the first two unrotated factors which covered 26% of total measured variance.
Extraction with maximum likelihood factoring and
orthogonal rotation resulted in eight factors, in which
19 of the original items were included. This accounted
for 56.7% of total measured variance.
The factor structure was confirmed, since both
estimates and rotations resulted in a similar structure
with eight factors. The factors are presented in Table
1, including items which did not load clearly on any
factor. All items except item 24 loaded on one factor
only. The eight factors shown in Table 1 corresponded with the postulated dimensions as follows.
Process dimension
Three factors, all made up of items from the proposed
process dimension, emerged and were interpreted as
representing this dimension.
Factor m represented 6.1% of explained variance and
was based on two related, but still different items, one
measuring 'subjective' waiting time, the other measuring time in minutes. Factor three was labelled' 'waiting
time".
Factor IV was composed of three items and conformed to the subdimension "information transfer between staff and patient". This was labelled "information
transfer", and accounted for 3.1% of explained
variance.
Factor VIII included a single item explaining 1.7%
of the variance. The factor corresponded to the
hypothesized subdimension "staffs technical skills"
and was labelled "staffs technical skills".
Structure dimension
Factor V was interpreted as representing the proposed
structure dimension and labelled "physical surroundings". This was made up of two items describing the
waiting and examination rooms, it represented 3.5%
of explained variance and was identical to the hypothesized subdimension "physical surroundings".
Items from the proposed "convenience and accessibility" subdimension had loadings less than 0.40.
and accordingly not included in the factor structure.
General satisfaction dimension
Factor VI contained three items and accounted for 2.3%
of explained variance. In one item surprise at having
to undress before mammography was described.
Another item referred to how rough the technician was
perceived as being, while the third item related to
whether the service could be recommended to friends.
Since all items expressed dissatisfaction and one item
indicated future mammographic behaviour, the factor
was labelled "future satisfaction".
Factor VII was based on two items derived from the
hypothesized subdimension named "satisfaction now",
and covered 2.4% of explained variance. This factor
was labelled "satisfaction now".
Discriminant validity was mostly supported by correlation analysis (Table 2). Correlation coefficients corrected for overlap were higher between own than
between other dimensions for all but two items.
The interfactor correlations were less than 0.60 and
acceptable according to accepted guidelines. In fact,
only factor II and factor VII, i.e. psychological discomfort and satisfaction now, had a correlation mat exceeded
0.40 (Table 3).
Thus the eight-factor solution provides evidence for
scoring and interpreting distinct scales that differentiate
various aspects of womens' subjective mammographic
experiences.
The reliability estimates of internal consistency
measured as Cronbach's alpha were all except one above
0.50; they ranged from 0.49-0.75 (Table 3). Reliability
measured as Cronbach's alpha of the 19-item scale was
0.77.
Scree plot analysis indicated the inclusion of eight
factors, and the factor model was appropriate according to the Kaiser-Meyer-Olkin measure (0.78), and
Bartlett's test of sphericity (0.00000). The 27 items were
weakly to moderately intercorrelated; the correlation
coefficients ranged from 0.08-0.55 (complete results
not presented), suggesting that orthogonal rotation was
acceptable.
Discussion
Evidence of construct validity of the new questionnaire
MGQ was supported since the factor analysis resulted
in eight internally consistent factors covering all proposed dimensions. The factor structure was considered
robust because it was highly similar in two different
analyses. The amount of total variance accounted for
was satisfactory compared with other questionnaires.14"17 Analysis of discriminant validity of the factors demonstrated a solid psychometric basis for
Discomfort dimension
Two factors corresponded to the proposed discomfort
dimension since each was made up of two items from
this dimension. In addition both factors included one
item from the proposed general satisfaction dimension.
Factor I accounted for 11.4 % of explained variance
and covered physical pain and discomfort together with
worry about the next mammographic examination. This
factor was labelled "discomfort, physical".
Factor II explained 9.9% of the variance. This scale
was made up of two items describing negative
psychological experiences such as feeling awkward and
embarrassed, and a third item worded towards altering the service. Factor II was labelled "discomfort,
psychological".
69
70
TABLE
Factors
Item no.
I.
Loading
on factor
11.4
12.
0.86
22.
0.82
23.
0.44
II.
Discomfort, psychological
9.9
8.
0.70
4.
0.62
HI.
0.43
6.1
19.
0.94
20.
0.66
IV.
Information transfer
3.1
7.
0.75
3.
0.49
The staff did not explain what was to be done with me.
0.46.
11.
V.
Physical surroundings
3.5
16.
0.54
18.
0.51
VI.
2.3
1.
0.54
2.
0.50
0.48
26.
VTI.
2.4
24.
0.52
25.
0.65
VHI.
6.
1.7
0.62
27
% Variance
explained by factor
71
1 (com.)
The staff used words that were easy to understand.
9.
10.
13.
14.
15.
17.
21.
I
Discomfort
(physical)
IV
Discomfort
(psychol.)
Process
(staffs
interpers.
skills)
Process
(information
transfer)
Structure
Satisfaction
(physical
(now)
(future)
surroundings)
12
ILfifi
0.14
0.02
0.09
0.11
0.28
0.15
0.10
22
070
0.24
0.09
0.08
0.16
0.23
0.19
0.11
23
(LM
0.29
0.03
0.14
0.11
0.28
0.35
0.20
0.24
049
0.09
0.28
0.08
0.23
0.33
0.14
0.23
(LSI
0.00
0.28
0.19
0.14
0.33
0.12
27
0.27
042*
0.12
0.26
0.26
0.15
0.45
0.25
19
0.08
0.09
QJS1
0.09
0.15
0.10
0.23
0.06
20
0.02
0.05
OM
0.09
0.09
0.07
0.12
0.05
0.13
0.30
0.11
<L51
0.20
0.11
0.34
0.30
0.13
0.25
0.01
040
0.17
0.11
0.31
0.26
11
0.02
0.15
0.13
DJU
0.07
0.00
0.26
0.13
18
0.13
0.11
0.12
0.11
L3ft
0.07
0.26
0.04
16
0.13
0.21
0.09
0.21
03Q
0.11
0.29
0.18
0.06
0.05
0.03
0.11
0.07
QJi
0.04
0.00
0.41
0.16
0.09
0.13
0.12
QJ2*
0.18
0.19
26
0.15
0.17
0.06
0.05
0.02
QJ2
0.04
0.07
24
0.22
0.34
0.17
0.38
0.36
0.18
QJ2
0.23
25
0.25
0.41
0.16
0.26
0.17
0.13
0 52
0.27
0.16
0.18
0.06
0.26
0.19
0.07
0.33
1.00
scales
VI
vm
vn
i
Process
(staffs tech.
skills)
Item no.
Factor
2 Item-factor scale correlations (corrected for overlap) for summated rating scales
Scales
number
No. of
items
Discomfort
(physical)
(0.75)
D.
0.27
(0.66)
m.
0.06
0.07
(0.76)
IV.
0.13
0.31
0.10
(0.6 0)
0.15
0.20
0.13
0.20
(0.59)
VI.
0.32
0.17
0.08
0.15
0.05
(0.49)
VII.
0.27
0.43
0.18
0.37
0.31
0.17
(0.69)
0.16
0.17
0.06
0.26
0.19
0.07
0.29
I.
V.
Factor scales
Discomfort
(psychol.)
Diagonal entries in parentheses are reliability estimates of internal consistency (Cronbach's alpha).
Process
(staffs
interpers.
skills)
Process
(information
transfer)
Structure
(physical
surroundings)
Satisfaction
(future)
Satisfaction Process
(now)
(staffs tech.
skills)
73
Acknowledgement
This study was supported by the Norwegian Medical
Association's Quality Assurance Fund.
References
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