THESIS PROPOSAL

ON

Psychometric validation of the Bangla version of the Patient-Doctor

Relationship Questionnaire (PDRQ-9)

This thesis proposal is prepared for the partial fulfillment of the requirements of the

Master of Public Health (MPH) Degree of ASA University Bangladesh

Submitted by

S.M. Yasir Arafat

ID: 14-2-42-0004

Department of Public Health

Faculty of Science & Engineering

ASA University Bangladesh

Mirpur Road, Dhaka-1207

March, 2015

The Thesis Proposal Entitled

Psychometric validation of the Bangla version of the Patient-Doctor

Relationship Questionnaire (PDRQ-9)

Is submitted to the Department of Public Health, ASA University Bangladesh for the

partial fulfillment of the requirements of the Master of Public Health (MPH) degree

Dated …………………… ……………………………………….

S.M. Yasir Arafat

i

EXECUTIVE SUMMARY

This study will be undertaken for partial fulfillment of the requirements for the degree

of Master of Public Health (MPH) of ASA University Bangladesh. The main purpose

of the study is to develop a culturally adapted and validated Bangla version of Patient-

Doctor Relationship Questionnaire (PDRQ-9) for use in assessing the relationship

between the physician and the patient.

This will be a descriptive, cross sectional & analytical study. The study populations

will be the patients attending for long time medical care at Dhaka Medical College

and Hospital (DMCH) preferably at Psychiatry department during data collection

period. The study will be conducted within the time period of May 2015 to July 2015.

The sample size will be at least 50. Non probability purposive sampling will be used

to collect data. Data will be collected through face to face interview with Bangla

version of PDRQ-9 questionnaire. All data will be entered into SPSS 16.0 software

and will be analyzed. Socio-demographic and economic characteristics of the

respondents will be assessed. Internal consistency will be measured by Cronbach’s

alpha, test-retest reliability will also be measured as well as the validity of the Bangla

version of PDRQ-9 will also be seen.

Bangla version of PDRQ-9 will be valid, widely accepted, brief, less time consuming,

cost effective, widely applicable in measuring patient-doctor relationship in clinical

practice, research, public health & primary health care in Bangladesh.

ii

TABLE OF CONTENTS

Contents Page No.

Title Page

Submission Page

Executive Summary i

Table of Content ii

Abbreviations iv

CHAPTER I: INTRODUCTION

1.1 Introduction 1

1.2 Justification of the Study 3

1.3 Research Question 4

1.4 Objectives 5

1.5 Operational Definition 6

CHAPTER II: LITERATURE REVIEW 9

CHAPTER III: RESEACH METHODOLOGY

3.1 Study Design 15

3.2 Study Place 15

3.3 Study Period 15

3.4 Study Population 15

3.5 Inclusion Criteria 15

3.6 Exclusion Criteria 15

3.7 Sample Size 16

3.8 Sampling Technique 16

3.9 Demographic Variables 16

3.10 Data Collection Technique 18

3.11 Research Instruments 18

3.12 Data Management &Analysis Plan 18

iii

ContentsPage No.

3.13 Theoretical Framework 19

3.14 Ethical Consideration 25

3.15 Action Plan 26

3.16 Limitations 26

REFERENCES 27

APPENDICES

APPENDIX – A: Consent Form 31

iv

List of Abbreviations

DMCH- Dhaka Medical College Hospital

BSMMU- Bangabadhu Sheikh Mujib Medical University

ASAUB- ASA University Bangladesh

PHC- Primary Health Care

MPH- Master of Public Health

PDRQ- Patient-Doctor Relationship Questionnaire

SPSS- Statistical Package of Social Science

PCP- Primary Care Physician

PDR- Patient-Doctor Relationship

1

CHAPTER-1

1.1Introduction

The patient-doctor relationship (PDR) is an important concept in health care (Zenger et

al, 2014). Many publications in the field of primary care mention the importance of the

patient-doctor relationship (C.M. Van der Feltz-Cornelis et al, 2004). Throughout the

history of medicine, patients and doctors have scrutinized and debated their relationship,

which is undoubtedly one of the most difficult among interpersonal relations, for a

variety of reasons (Koutsosimou et al, 2013). It has been linked to patient satisfaction,

treatment adherence, and treatment outcome. In primary care, ‘‘knowing the patient is at

least as important as knowing the disease’’, and physicians with a warm and friendly

style are more effective than physicians with a more formal style (R.M. Eveleigh et al,

2012). It was found that patients search out a Primary Care Practitioner (PCP) who

matches their own representation of an ideal and validate their choice in a dynamic

communicative process (C.M. Van der Feltz-Cornelis et al, 2004).

Patient satisfaction with the care is a concept that reflects the patient's perception

regarding the care quality and treatment received. Generally evaluated by self-report,

several questionnaires focused on decision making, access and use of the different health

services, or on the treatment satisfaction. Therapeutic alliance is crucial for the evaluation

of patient- doctor satisfaction related with the development of an empathic understanding,

interpersonal opening, and climate of authenticity, confidence and acceptance.

The measurement instruments of the patient-doctor relationship make it possible to

quantify the patient's opinion regarding communication, satisfaction and accessibility in

the dealing with the doctor and the treatment followed. However, in practice, there is a

2

lack of reliable and sensitive measurement instruments focused on the patient that

evaluate the quality of the patient-doctor relationship (Adán, et al, 2009).

Both the patient’s and the physician’s perspectives must be considered to understand

the PDR . Substantial efforts have been made to develop instruments & to assess the

PDR from the patient’s point of view. A systematic review found 19 instruments that

assess the PDR. These instruments assessed a variety of dimensions and used diverse

conceptual models for the PDR. The authors stated that in the primary care setting, a

research instrument is preferably concise and easy to use. They suggested the use of the

Patient-Doctor Relationship Questionnaire (PRDQ-9) as a brief (9 items) questionnaire

with excellent overall internal consistency (Zenger et al, 2014).

3

1.2Justification of the Study

Bangladesh is the sixth most densely populated country in the world. Majority of the

population lives in the rural part of the country. Bangladesh developed multilevel health

care service system. The ratio of doctor to patient is 1: 4000. As a result work load of

clinician become immense (Chowdhury, 2014). Desired quality of service delivery

becomes questionable. The quality of patient-doctor relationship is less considered. But

Koutsosimou et al stated that, “the quality of their relation determines not only the

patient’s and doctor’s satisfaction but also the patient’s compliance/adherence, ability of

coping, relapse rate, quality of life and, to some extent, his state of health.”

The PDRQ-9 was first developed in Dutch (C.M. Van der Feltz-Cornelis et al, 2004). As

performed in the Spanish (Adán, et al, 2009) and Turkish (Mergen et al, 2012) validation

studies, the PDRQ-9 was adapted to German by translating it from its primarily published

and used English version (Zenger et al, 2014).

Bengali is one of the sixth most widely spoken languages in the world with nearly 300

million users. In 2050 estimated Bengali speaking population will be nearly 400 million

(Chowdhury, 2014). R.M. Eveleigh et al reviewed the patient-doctor relationship

measuring 19 instruments and concluded that, “In the primary care setting, a research

instrument is preferably concise and easy to use. The PDRQ is brief (nine items) and has

an excellent overall internal consistency.” It is an internationally validated instrument

that will permit us to make the comparison between different countries and makes

international research possible (Adán, et al, 2009).

In Bangladesh, Psychometrics applied to clinical practice is of recent origin. On

researcher’s present knowledge there is no culturally adapted scale to measure the patient

doctor relationship. PDRQ-9 is brief short easily applicable tool. So, the researcher think

about a scale which is widely accepted, brief, less time consuming, cost effective and

widely applicable.

4

1.3 Research Question

Is the PDRQ-9 is reliable and acceptable in assessing doctor patient relationship

status in Bangladesh?

5

1.4 Objectives

General Objective

To develop a culturally adapted and validated Bangla version of Patient-Doctor

Relationship Questionnaire (PDRQ-9) for use in assessing the relationship between the

physician and the patient.

Specific Objectives

1. To assess the internal consistency of Bangla PDRQ-9 measured by Cronbach’s

alpha and inter-rater reliability.

2. To assess the face validity, content validity & construct validity of Bangla PDRQ-9.

6

1.5 Operational Definitions

Age:

Reported completed years of the respondent according to their statement at the time of

interview.

Educational Status:

The status of literacy of the respondent.

Content validity:

The ability of an instrument to reflect the domain of interest and the conceptual

definition of a construct. In order to claim content validity, there is no formal statistical

testing, but item generation process should include a review of published data and

literature, interviews from targeted patients and an expert panel to approach item

relevance (Beaton et al, 2000).

Face validity:

The ability of an instrument to be understandable and relevant for the targeted

population. It concerns the critical review of an instrument after it has been constructed

and generally includes a pilot testing (Beaton et al, 2000).

Construct validity:

The ability of an instrument to measure the construct that it was designed to measure. A

hypothetical model has to be formed, the constructs to be assessed have to be described

and their relationships have to be postulated. If the results confirm prior expectations

about the constructs, the instrument may be valid (Beaton et al, 2000).

7

Criterion validity:

The assessment of an instrument against the true value, or a standard accepted as the

true value. It can be divided into concurrent validity and predictive validity (Beaton et al,

2000).

Concurrent validity:

The association of an instrument with accepted standards (Beaton et al, 2000).

Predictive validity:

The ability of an instrument to predict future health status or test results. Future health

status is considered as a better indicator than the true value or a standard (Beaton et al,

2000).

Reliability:

Determining that a measurement yields reproducible and consistent results (Beaton et al,

2000).

Internal consistency:

The ability of an instrument to have interrelated items (Beaton et al, 2000).

Repeatability (Test-retest reliability):

The ability of the scores of an instrument to be reproducible if it is used on the same

patient while the patient’s condition has not changed i.e. measurements repeated over

time (Beaton et al, 2000).

8

Responsiveness:

The ability of an instrument to detect change when a patient’s health status improves or

deteriorates (Beaton et al, 2000).

Floor and ceiling effects:

The number of respondents who achieved the lowest or highest possible score (Terwee et

al, 2007).

Interpretatability:

The degree to which one can assign qualitative meaning to quantitative scores (Terwee

et al, 2007).

Occupation: Main source of earning money.

Monthly family income: The socio-economic classification in this study was made

according to 2006 Gross National Income (GNI) per capita and using the calculation of

World Bank (WB) ((Haque ANMN 2007, p.18). The groups were: low-income $75.41 or

less (BDT ≤ 5360), lower middle-income $75.5 - $299.58 (BDT 5361-21270), upper

middle-income $299.68 - $926.25 (BDT 21271-65761) and high-income $926.33 or

more (BDT ≥ 65762).

9

CHAPTER 2

2. Literature Review

Possible literature search was done by library work, internet search and personal

communication. Library work was done in ASA University Bangladesh, Bangabandhu

Sheikh Mujib Medical University with the light of objectives of the study. Google &

Google Scholar search engine was extensively used to find out literatures from internet.

Researcher also used HINARI (Health Inter Network Access to Research Initiative),

PubMed and Medline for online literature. Personal communication with teachers,

researchers and colleagues especially who are expert in the relevant was done in some

circumstances.

The patient-doctor relationship is an important concept in health care (Zenger et al,

2014). It has been linked to patient satisfaction, treatment adherence, and treatment

outcome. Patient satisfaction has been considered important for many years.

As early as 1968, Kersch conducted interviews with the parents of pediatric

patients in order to measure their satisfaction. A patient who is satisfied is thought

to be more likely to comply with treatment and/or experience a more

favorable outcome. But instruments of measuring the indicator had less validity &

reliability. In 1978, Ware reviewed more than one hundred articles on patient

satisfaction that had been published within the preceding 35 years. He

pointed out that underlying the use of satisfaction data is the assumption that

"satisfaction" questionnaires measure patient satisfaction reliably and

validly . Yet he found that only 11 of 81 empirical studies reported reliability

10

estimates for patient satisfaction measures, and those that did so report suggest

poor reliability for single-item measures. Ware also noted that the validity of

satisfaction scores as dependent variables in relation to specific characteristics of health-

care providers are strictly limited. In 1984, Feletti constructed a scale, the items of

which were chosen by the researchers. No explanation was given for the choice of

those particular items, which are descriptive of physician conduct without reference to

the importance of this conduct to the patient. In 1979, Biehn published a scale, the

items of which, once again, were chosen by the researchers and not by patients.

Moreover no evaluation of reliability or validity was included. In 1978, Wolf developed

a scale of a higher quality as reflected by it's use by other researchers. Fifty patients

critically assessed the appropriateness of each item in the scale. Internal consistency

was demonstrated, as was reliability, by means of Cronbach's coefficient alpha. Fully

realizing that there is no perfect satisfaction scale, Falvo & Smith in 1983 developed the

scale after interviewing patients from a family practice, generating 1540 descriptions

of patient-preferred and not preferred physician behaviours. Reliability was assessed by

the test- retest method, and internal reliability was measured by Cronbach's alpha;

Concurrent validity was assessed by correlating the scale's scores with the patient's

reported intention to return to the physician for further health care. Lehman et al.

assessed the Petient-Doctor Interaction with Smith-Falvo Patient-Doctor Interaction

Scale at 1988 and stated as above (Lehman et al, 1988).

Little et al. assessed patient centredness in general practice and described five distinct

components of patients’ perceptions that can be measured reliably: communication and

partnership, personal relationship, health promotion, positive approach to diagnosis and

11

prognosis, and interest in the effect on life. It was concluded at that study that each

component predicts different consultation outcomes in Patient-Doctor interaction (Little

et al, 2001).

Thom et al. studied patient trust in patient-physician relationship. It was mentioned that

patient trust is a key component of the patient–physician relationship & concluded that

patients with a lower level of trust in their physician are more likely to report that

requested or needed services are not provided. Understanding this relationship may

lead to better ways of responding to patient requests that preserve or enhance patient

trust, leading to better outcomes (Thom et al, 2002).

Lings et al. studied doctor–patient relationship in U S primary care and focus on three

major aspects: communication, personal impact and professionalism (Lings et al, 2003).

In 2004, C.M. Van der Feltz-Cornelis et al. developed a patient-doctor relationship

questionnaire (PDRQ-9) in primary care based on Alexander and Lu- borsky developed

the Helping Alliance Questionnaire (HAQ) and Van der Linden validated Dutch version.

Several issues were considered. First, there is a tendency to link difficult patient-

doctor relationships to difficult patients on basis of Hahn et al. developed “Difficult

Doctor-Patient Relationship Questionnaire”. The second issue was the communicative

aspect of the patient-doctor relationship, which was studied by qualitative designs that

describe the positive role of affective behavior of physicians and communication models.

Third issue was patient satisfaction with the primary care practice, the PCP, the

community nurse, or community care in general.

12

The satisfaction with consultations in primary care, reflecting the multidisciplinary nature

of primary health care, was measured by the Consultation Satisfaction Questionnaire. The

Patient Satisfaction Questionnaire measures not only interaction but also technical and

accessibility of services items. It was concluded that, “The PDRQ-9 provides researchers

a brief measure of the therapeutic aspects of the patient-doctor relationship in the primary

care setting. It is a valuable tool for scientific and practical purposes involving the

monitoring of the patient-doctor relationship.”

Adán, et al. validated the Spanish version of PDRQ-9. Among the different aspects

characterizing the patient- doctor relationship, communication levels are one of those

studied. The patients, regardless of their social-economic status or ethnic group,

generally want to know the full details of their diagnosis and its possibility of cure.

However, several studies indicate that the information provided by the doctors is

partial. Communication and honesty between doctors and patients are extremely

important. Another one of the principal aspects in the patient-doctor relationship refers to

satisfaction levels. Patient satisfaction with the care is a concept that reflects the

patient's perception regarding the care quality and treatment received. Therapeutic

alliance is crucial for the evaluation of patient- doctor satisfaction related with the

development of an empathic understanding, interpersonal opening, and climate of

authenticity, confidence and acceptance.

The measurement instruments of the patient-doctor relationship make it possible to

quantify the patient's opinion regarding communication, satisfaction and accessibility in

the dealing with the doctor and the treatment followed. The adaptation of the PDRQ-9

is, in this sense, very appropriate, as it is an internationally validated instrument that

13

permits us to make the comparison between different countries and makes international

research possible(Adán, et al, 2009).

R.M. Eveleigh et al. reviewed the doctor-patient relationship assessment instruments. It

was opined that, “it has been linked to patient satisfaction, treatment adherence, and

treatment outcome.” In primary care, ‘‘knowing the patient is at least as important as

knowing the disease’’, and physicians with a warm and friendly style are more effective

than physicians with a more formal style. In that review it was not sought to find the best

instrument but to provide an overview giving relevant information to researchers to

decide on the best instrument for the specific aim of their study. The growing interest in

this field has resulted in a large number of doctor-patient relationship assessment

instruments. The selection of an instrument should be based on the model or conceptual

basis of the doctor-patient relationship that is most applicable to the study objectives and

the health care field in which it will be applied.

It was found 19 instruments assessing the doctor-patient relationship. The instruments

assess a variety of dimensions and use diverse conceptual models for the doctor-patient

relationship. The instruments found also vary in terms to which they have been psycho-

metrically tested. Most commonly assessed dimensions were relationship,

communication, satisfaction & miscellaneous. It was suggested that the use of the

Patient-Doctor Relationship Questionnaire (PRDQ-9) as a brief (9 items) questionnaire

with excellent overall internal consistency (R.M. Eveleigh et al, 2011).

Koutsosimou et al. developed an instrument for the assessment of doctor-patient

14

Relationship and mentioned that, the doctor-patient relationship is complex. If we

compare doctors’ and patients’ points of view for the therapeutic relationship, significant

differences emerge. It appears important to work towards the development of a common

language for doctors and patients to understand, discuss and evaluate the doctor-

patient relationship (Koutsosimou et al, 2013).

Zenger et al validated the German version of PDRQ-9 and also opined that, both the

patient’s and the physician’s perspectives must be considered to understand the PDR.

Substantial efforts have been made to develop instruments to assess the PDR from the

patient’s point of view. It is concluded that the German version of the PDRQ-9 is a brief

and useful measure of the doctor-patient relationship from the patient’s perspective. It has

good psychometric properties and can be used for research in primary care, public

health research and population surveys (Zenger et al, 2014).

15

CHAPTER-3

3. Methodology of the Study

3.1 Study design

This will be a descriptive, cross sectional & analytical study.

3.2 Study place

Data will be collected from Dhaka Medical College Hospital (preferably at Psychiatry

and other departments, where patients seek long care.

3.3 Study period

This study will be conducted for a period of 3 month started from May 2015 to July 2015.

3.4 Study population

Study will be conducted among patients attending for follow up / treatment in Dhaka

Medical College Hospital.

3.5 Inclusion criteria

All patients willing to participate above 14 years old and can read Bangla as guided by

German version validation (Zenger et al, 2014).

3.6 Exclusion criteria

Not willing to participate in the study.

First visit to the respective physician.

16

3.7 Sample size

There is no general agreement about the size of sample required for factor analysis. Some

authors recommend rules of thumb regarding the minimum ratio of participants to

variables 2:1 or extracted factors 20:1 (Ridd et al, 2011).

Approximately 92% of the articles reported a subject to item ratio greater than or equal

to 2, whereas 25% had a ratio greater than or equal to 20. About 90% of articles had a

sample size greater than or equal to 100, whereas 7% had a sample size greater than or

equal to 1000 (Anthoine et al, 2014).

Some authors decided the best method for standardizing our sample size data was subject

to item ratio. A surprisingly high proportion (almost one-sixth) reported factor analyses

based on subject to item ratios of only 2:1 or less (Costello and Osborne, 2005).

Minimum sample size will be 50 as needed for factor analysis on basis Confirmatory

Factor Analysis.

3.8 Sampling technique

Non probability purposive sampling method will be used to select sample population.

3.9 Demographic variables

As used in different literature (Zenger et al, 2014; Thom et al, 2002) researcher is willing

consider the following variables with consideration of Bangladesh context.

1. Age

i. 14-30 years

ii. 31-40 years

iii. 41-50 years

iv. Above 50 years

17

2. Gender

i. Male

ii. Female

3. Marital status

i. Unmarried

ii. Married

iii. Divorced

iv. Widow

4. Education

i. Literate & below SSC

ii. SSC

iii. HSC

iv. Graduate

v. Masters & above

5. Employment status

i. Unemployed

ii. Self employed

iii. Service holder

iv. Housewife

v. Others

18

6. Monthly income

i. Around 5000 BDT

ii. 5000-20000 BDT

iii. 20000- 70000 BDT

iv. Above

7. Length of time being treated

i. <6 month

ii. 6 months- 1 year

iii. 1 year- 3 years

iv. > 3 years

3.10 Data collection technique

Data will be collected from the respondents through face-to-face interview. The

questionnaire will be used after verbal consent of the respondents. Socio-demographic

characteristics will be also obtained.

3.11 Data collection Instrument:

Self Reporting Translated Bangla version of PDRQ-9

3.12 Data analysis:

Data will be analyzed in SPSS 16 version

19

3.13 Theoretical framework:

Stage I: Initial Translation

The first stage in adaptation is the forward translation. At least two forward

translations will be made of the instrument from Enhlish to Bangla. O n e w i l l

b e n o n m e d i c a l b a c k g r o u n d p e r s o n & a n o t h e r w i l l b e p r e f e r a b l y

P s y c h o l o g i s t . The translators each will produce a written report of the

translation that they will complete. Additional comments will be made to highlight

challenging phrases or uncertainties. Their rationale for their choices will also

summarized in the written report.

Translator 1. One of the translators will be aware of the concepts being examined in

the questionnaire being translated.

Translator 2. The other translator will neither be aware nor informed of the concepts

being quantified and preferably should have no medical or clinical back- ground. This

is called a naive translator, and he or she is more likely to detect different meaning

of the original than the first translator. This translator will be less influenced by an

academic goal and will offer a translation that reflects the language used by that

population.

Stage II: Synthesis of The Translations

The two translators will sit down to synthesize the results of the translations.

Working from the original questionnaire as well as the first translator’s (T1) and the

second translator’s (T2) versions, a synthesis of these translations will first conducted

(producing one common translation T-12), with a written report care- fully

20

documenting the synthesis process, each of the issues addressed, and how they were

resolved. The next stage is completed with this T-12 version of the questionnaire.

Stage III: Back Translation

Working from the T-12 version of the questionnaire and totally blind to the

original version, a translator then will translate the questionnaire back into the

original language. This is a process of validity checking to make sure that the

translated version is reflecting the same item content as the original versions. This

step will magnify unclear wording in the translations. However, agreement between

the back translation and the original source version does not guarantee a

satisfactory forward translation, because it could be incorrect; it simply assures a

consistent translation. Back translation is only one type of validity check,

highlighting gross inconsistencies or conceptual errors in the translation.

Once again, two of these back-translations are considered a minimum. The

back-translations (BT1 and BT2) are produced by two persons. The two

translators will neither be aware nor be informed of the concepts explored, and

should preferably be without medical background. The main reasons are to avoid

in- formation bias and to elicit unexpected meanings of the items in the translated

questionnaire (T-12), thus increasing the likelihood of “highlighting the

imperfections.”

Stage IV: Expert Committee

The composition of this committee is crucial to achievement of cross-cultural

equivalence. The minimum composition comprises methodologists, health

21

professionals, language professionals, and the translators (forward and back

translators) will be involved in the process up to this point. The researcher of the

questionnaire will in close contact with the expert committee during this part of the

process. The expert committee’s role is to consolidate all the versions of the

questionnaire and develop what would be considered the prefinal version of the

questionnaire for field testing. The committee will therefore review all the

translations and reach a consensus on any discrepancy. The material at the disposal

of the committee includes the original questionnaire, and each translation (T1, T2,

T12, BT1, BT2) together with corresponding written reports (which explain the

rationale of each decision at earlier stages). The expert committee will make

critical decisions so, again, full written documentation should be made of the issues

and the rationale for coming to a decision about them.

Stage V: Test of the Prefinal Version

The final stage of adaptation process is the pretest. This field test of the new

questionnaire seeks to use the prefinal version in subjects or patients from the target

setting. About 10 persons will be tested. Each subject will complete the

questionnaire, and will be interviewed to probe about what he or she thought was

meant by each questionnaire item and the chosen response. Both the meaning of

the items and responses would be explored. This ensures that the adapted version is

still retaining its equivalence in an applied situation. The distribution of responses

is examined to look for a high proportion of missing items or single responses.

It should be noted that although this stage wi l l provide some useful insight into

22

how the person interprets the items on the questionnaire, it does not address the

construct validity, reliability, or item response patterns that are also critical to

describing a successful cross-cultural adaptation. The described process provides

for some measure of quality in the content validity.

Stage VI: Submission of Documentation to the Developers or Coordinating

Committee for Appraisal of the Adaptation Process

The final stage in the adaptation process is a submission of all the reports and

forms to the developer of the instrument or the committee keeping track of the

translated version. They in turn probably have a means to verify that the

recommended stages were followed, and the reports seem to be reflecting this

process well. In effect it is a process audit, with all the steps followed and necessary

reports followed. It is not up to this body or committee to alter the content, it is

assumed that by following this process a reasonable translation has been

achieved.

Further Testing of the Adapted Version Cross-cultural adaptation tries to ensure a

consistency in the content and face validity between source and target versions of a

questionnaire. It should therefore follow that the resultant version has sound

reliability and validity if the original version did. However, this is not always the

case, perhaps because of subtle differences in the living habits in different cultures

that render that item more or less difficult than other items in the questionnaire.

Such changes could alter the statistical or psychometric properties of an instrument.

23

24

25

3.14 Ethical consideration

The researcher will be duly concern about the ethical issues relate to the study. In this

study the following criteria will be followed to ensure maintaining the ethical values.

A. Formal ethical clearance will be taken from the ethical review committee of the

ASA University Bangladesh for conducting the study.

B. Confidentiality of the person and the information will be maintained, observed

and unauthorized persons will not access to the data.

C. Informed written consent will be taken from the subject.

D. The content of the consent requirements will be as such:

i. Explanation of the nature & purpose of the study.

ii. Explanation of the procedure of study.

iii. Explanation that they have the right to refuse or accept to

participate the study.

E. The participants will not gain financial benefit from this study.

26

3.15 Work Plan

3.16 Limitations: Although it will be a very good scale to measure the patient doctor

relationship in a very short time as well as in public heath, health research and primary

health care, but with this minimum sample generalization may be difficult. This

instrument also bears only the patient direction, doctor direction will not be evaluated.

ActivitiesMonth

Year

Month

Year

Month

Year

Month

Year

Month

Year

Month

Year

Month

Year

Month

Year

Designing the

Study

Review of

Literature

Development &

approval of

proposal

Development of

Data Collection

Tools

Pre testing

Questionnaire

Data Collection,

Entry & Analysis

Report Writing

Submission &

Approval of Thesis

Printing, Binding

and Submission

27

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Anthoine, E., Moret, L., Regnault, A., Sbille, V., & Hardouin, J. (2014). Sample size

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APPENDICES

APPENDIX-A

PDRQ-9 English Version

1. My doctor helps me

2. My doctor has enough time for me

3. I trust my doctor

4. My doctor understands me

5. My doctor is dedicated to help me

6. My doctor and I agree on the nature of my medical symptoms

7. I can talk to my doctor

8. I feel content with my doctor’s treatment

9. I find my doctor easily accessible

5 point Likert Scale response

1 not at all appropriate

2 somewhat appropriate

3 appropriate

4 mostly appropriate

5 totally appropriate