Validation of an instrument for evaluating health care services to ostomized people 1

ABSTRACT Objectives: to develop and validate an array of analysis and judgment for the evaluation of Health Care Services of people with stomas. Methods: cross-sectional study in 28 health facilities in the state of Minas Gerais. A descriptive analysis of the instrument and a study of its psychometric properties were performed. We used the Delphi technique for the validation of content and appearance. A psychometric analysis was carried out through the study of the reliability and validity of the measures obtained with the instrument. Results: it was possible to construct an array analysis and judgment with 16 components (with scores from zero to five) grouped according to size and structure and process considered essential to evaluate the service. The results achieved in the reliability for structure and process, through the Cronbach alpha coefficient (α = 0.771 and α = 0.809, respectively), and the validity of content and construct demonstrated good internal consistency and satisfactory validity. An exploratory factor analysis indicated the item "main activity performed in the unit" as a limitation of the scale. Conclusion: the study provides a new tool for the evaluation of structure and process of Health Care Services of a Person with a stoma.

nd consensus among experts, the terminology stoma and ostomized (estomia/estoma, and estomizado) was adopted.The term ostomy/ostomized is still maintained only when it references names linked to government p blications (2) .

Since the National Guidelines for the Health Care for Persons with Stoma were established, the Health Care


Services of Persons with Stoma (SASPO in Portuguese)

seek to incorporate this policy in an attempt to create conditions and possibilities to provide an efficient service in an organized context network.This guideline extends car

beyond providing collectors and adjuvants devices.
lthough the distribution of these materials is also essential for the quality of care, the services will perform a set of actions developed in primary care and specialized services of level I or II (3)(4) .

The SAS/MS ordinance n. 400 of November 16   2009 further provides that SASPO must be given in a structure with material and human resources, in order to develop individual care and group activities; families guidelines; quantitative and qualitat ve planning collectors equipment and protection and safety aids; orientation and training of professionals in primary and hospital care for the establishment of reference flows and counter reference (3) .Despite the establishment of these guidelines, the lit rature does not present validated instruments that can measure the organization of SASPOs regarding structure, dimensions and processes.Instruments of such kind may make it possible to evaluate these services and su port the decision-making process of managers to improve care and reorganization of services.

It is known that the evaluation of services through the adoption of instruments with the potential for the recognition of needs can also contribute to the reorganization of health practices, in a way t better implement them (5) .This assessment, when carried out through indicators, allows to define quantitative measures of variables, characteristics or attributes of the process or system (6) .

The construction of indicators to assess SASPO, was originated from the need to critically a alyze numerical data through the degree of implementation of the Ordinance, which is this work's object of study.

The objective of this study is to describe the construction criteria, content validation, appearance and to build an assessment tool of structure and process of the Health Care Services of a Person with a stoma.So far, the Brazilian literature does not show an instrument to assess SASPO and for that reason, the construction and validation of a tool may help to evaluate the organization of these services and the quality of care.


Method

We conducted a cross-sectional methodological The study consisted of two phases.The first, organized by the researcher,

here two questionnaires were prepared in order to
collect data on the structure and process of SASPO in MG enabling a diagnostic analysis of services (7) .The second step consisted of the preparation of the analysis matrix and judgment, which allowed the definition of indicators.

The analysis' matrix and judgment are used as a way to express the causal logic of an intervention in part and in its entirety, translating how their components contribute to the production of effects, favoring synthesis i the form of value judgments (8) .

After the construction of the first version of the instrument t at originated the matrix analysis and judgment, it was submitted to validation of the contents and appearance, processes that will be described below.

For the validation of content and appearance we used the Delphi technique (9)(10) .This technique allows professionals with diverse experience, experts in a given subject, to contribute to th construction of opinions on the subject studied, fostering the discussion of relevant aspects (11) .

This method is especially recommended in situations of lack of historical data or when it is pursued to st mulate the creation of new ideas, making it very useful for conducting qualitative analysis allowing a forecast by searching a consensus of opinions by a group of specialists (11) .
To assess the construct validity of the scale a descriptive analysis of all items was carried out.The Cronbach's alpha coefficient was used to assess the internal consistency of the itens

n the sc
les proposed, proceeding later to the exploratory factor analysis with estimation of indexes "KMO test" and "Bartlett

est or sphe
icity".The total percentage of variance explained by the model was also evaluated, in addition to the eigenvalues and scree-plot to determine the number of factors to be considered.The factorial matrix was made using the varima rotation excluding items with lower factor loadings of 0.40 or higher loadings on two simultaneous factors (12) .

The KMO test (Kaiser-Meyer-Olkin) is a statistic that indicates the ratio of the data variance that can be considered common to all variables, i.e., it can be assigned to a common factor.Therefore, the closer to 1 (unit) the better the result, that is, the more appropriate is the sample to the application of factor a alysis.High values (between 0.5 to 1.0) indicate that the factor analysis is appropriate, meanwhile low values (below 0.5) indicate that the factor analysis may be inadequate (15) .

Finally, the Bartlett's test was also performed to test if the samples have homogeneous variances.

When test P-value is greater than the significance level of 5%, it does not reject the hypothesis of equality of variances (12) .

Through th s analysis, we sought to develop a model with factors purporting good features of both internal consistency (alpha Cronbach values> 0.70), and validity (with good properties in factor analysis) (13) .

Therefore, several models were tested with different numb rs of factors and items in order to make the most appropriate factor model and therefore it was decided to exclude some items from the original scale.

After defining the final model, through the factor analysis, the ronbach's alpha coefficient was recalculated to assess the final internal consistency of the selected factors set.

The correlation between each item that makes up a particular factor of the scale with its overall score was also evaluated.In all the analyses a 5% level of Rev. Latino-Am.Enfermagem2016;24:e2825 these percentages, the categories were defined for the classification of SASPO, adopting the following criteria:

structure and process with full deployment when the score compared to the parameters defined for each issue reached percen