Translation, transcultural adaptation, and validation of the role-modeling cost-conscious behaviors scale

Menezes et al. BMC Medical Education (2019) 19:151 https://doi.org/10.1186/s12909-019-1587-x RESEARCH ARTICLE Open Access Translation, transcultural adaptation, and validation of the role-modeling costconscious behaviors scale Marta Silva Menezes1, Marília Menezes Gusmão1, Rui Nei de Araújo Santana1, Carolina Villa Nova Aguiar2, Dilton Rodrigues Mendonça1, Rinaldo Antunes Barros1, Mary Gomes Silva3 and Liliane Lins-Kusterer4* Abstract Background: Training in the use of cost-conscious strategies for medical students may prepare new physicians to deliver health care in a more sustainable way. Recently, a role-modeling cost-conscious behaviors scale (RMCCBS) was developed for assessing students’ perceptions of their teachers’ attitudes to cost consciousness. We aimed to translate the RMCCBS into Brazilian Portuguese, adapt the scale, transculturally, and validate it. Methods: We adopted rigorous methodological approaches for translating, transculturally adapting and validating the original scale English version into Brazilian Portuguese. We invited all 400 undergraduate medical students enrolled in the 5th and 6th years of a medical course in Northeast Brazil between January and March 2017 to participate. Of the 400 students, 281 accepted to take part in the study. We analyzed the collected data using the SPSS software version 21 and structural equation modeling (SEM) was performed using AMOS SPSS version 18. We conducted exploratory factor analysis (EFA), varimax rotation, with Kaiser Normalization and Principal Axis Factoring extraction method. We conducted confirmatory factor analysis (CFA), using the SEM. We used the following indexes of adherence of the model: Comparative fit index (CFI), Goodness-of-fit index (GFI) and Tucker-Lewis Index (TLI). We considered the Bayesian Information Criterion (BIC) for Sample-size adjusted. The root mean square error of approximation was calculated. Values below 0.08 were considered acceptable. Composite reliability analyzes were performed to evaluate the accuracy of the instrument. Values above 0.70 were considered satisfactory. Results: Of the 281 undergraduate medical students, 195 (69.3%) were female. Mean age of participants was 25.0 ± 2.6 years. In the EFA, the KMO was 0.720 and the Bartlett sphericity test was significant (p < 0.001). We conducted the EFA into two factors: role-modeling cost-conscious behaviors in health (seven items) and health waste behaviors (six items). The 13 item-scale was submitted to composite reliability analyzes, obtaining values of 0.813 and 0.761 for the rolemodeling cost-conscious behaviors and the health waste behaviors factors, respectively. Conclusions: We concluded that the cost-conscious behaviors scale has good psychometric properties and is a valid and reliable instrument for evaluating medical students’ perception of their teachers’ cost-conscious behaviors. Keywords: Medical professionalism, Costs, health care, Education, medical, Rating scale, behavioral, Students, medical * Correspondence: 4 School of Medicine, Federal University of Bahia, Praça XV de Novembro, Largo do Terreiro de Jesus s/n, Salvador, Bahia CEP 400260-10, Brazil Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Menezes et al. BMC Medical Education (2019) 19:151 Background The exponential increase in health costs should be a priority concern for governments, health professionals, healthcare companies, physicians, and patients [1]. Not only demographic and socioeconomic factors such as age, health status, and income increase public healthcare expenditure each year [1], but also preventable hospital admissions, inappropriate treatment and misuse of diagnostic testing. Exercising cost-consciousness always represents a challenge for Physicians. Besides dealing with private gain, personal advantages and other potential conflicts of interests, their responsibilities include the wisely use of health care resources, as well as the duty to guarantee the patients’ best interests [2, 3]. In a situation of pressure from patients to order more tests, it is also difficult for the physician to maintain the right cost-conscious behavior [4–6]. To maintain the base of medicine’s social contract, in times of conflict of interests, physicians need continuous education, exercising the principles of professionalism, enhancing their personal commitment to patients’ welfare and collectivity. Undergraduate and post-undergraduate medical education may help future physicians to address health care costs [7–10]. A randomized study in the USA included 2556 physicians, representing many medical specialties and all currently practicing, showed that only 36% believed that practicing physicians had major responsibility for reducing health care costs. Most of them reported lawyers (60%), health insurance companies (59%), health systems (56%), pharmaceutical industries (56%) and patients (52%) as having the main responsibility to reduce costs in health care [11]. Another representative study with resident doctors suggests that the training environment may have a later influence on the physicians’ cost-consciousness [12]. Authors suggest the improvement of medical education training in order to promote cost-conscious behaviors. Approaches using cost-conscious strategies during the training of medical students and residents may be effective, and medical students seem to be more accepting of cost-conscious care than physicians [10]. In Brazil, it is also important to implement institutional measures to allow the continued development of medical teachers in terms of knowledge, skills, and innovation in medical education, since the Brazilian system of medical education adopted physicians as medical student preceptors, mainly in public health services for both private and public medical schools [13]. The improvement and development of formal and informal curricula is a fundamental basis of teaching cost-consciousness preparing new physicians to deliver health care in a sustainable way for the future [14]. Recent studies have pointed out that training measures of high-value cost-conscious care, during the medical learning phases, influence physicians’ practice behaviors Page 2 of 8 during their career. Medical school and residency programs should continue to collaborate in the development of curricula promoting the early exposur (...truncated)