Validation of the Brazilian version of Primary Care Assessment Tool (PCAT) for Oral Health-PCATool Brazil Oral Health for Professionals Validação da versão brasileira do Primary Care Assessment Tool (PCAT) para Saúde Bucal-PCATool Brasil Saúde Bucal para Profissionais

Resumo Este estudo verificou a consistência interna e a confiabilidade de um instrumento para avaliar os serviços odontológicos na Atenção Primária à Saúde (APS). Para verificar a validade dos fatores, foi utilizada uma análise fatorial com extração de componentes principais e método de rotação ortogonal varimax. Foram selecionados fatores com três ou mais itens com cargas fatoriais maiores que 0,35. A confiabilidade deste instrumento foi verificada usando consistência interna (correlação total de itens >0,30 e alfa de Cronbach = ou >0,70). 562 dentistas participaram do estudo. Na análise fatorial, foram mantidos dez fatores, o que explica 40,95% da variação total. Quanto à consistência interna, apenas 3 itens apresentaram correlação insuficiente. Ainda na consistência interna, utilizando o alfa de Cronbach, foram identificados os seguintes valores dos coeficientes: Acesso (0,55), Continuidade (0,74), Coordenação de Atenção (0,55), Coordenação Sistema de Informação (0,21), Abrangência dos Serviços Disponíveis (0,91), Abrangência dos serviços prestados (0,79), Orientação familiar (0,66), Orientação comunitária (0,87), Competência cultural (0,81). Para a taxa de sucesso da escala, todos os resultados foram superiores a 88%, menos o componente “Sistemas de Informação” (21%). Palavras-chave Atenção Primária à Saúde, Saúde Bucal, Avaliação de Serviços de Saúde, Monitoramento Abstract This study verified the internal consistency and reliability of an instrument to evaluate dental services in Primary Health Care (PHC). In order to verify the factor validity, a factor analysis with principal component extraction and varimax orthogonal rotation method was used. Factors with three or more items with factor loadings greater than 0,35 were selected. This instrument’s reliability was verified using internal consistency (total item correlation >0,30 and Cronbach alpha = or >0,70)). 562 dentists participated in the study. In the factor analysis, ten factors were kept, which explain 40,95% of the total variation. Regarding the internal consistency, only 3 items presented insufficient correlation. Also on internal consistency, using Cronbach’s alpha, the following values of the coefficients were identified: Access (0.55), Continuity (0,74), Care Coordination (0,55), Coordination Information System (0.21), Comprehensiveness of Services Available (0,91), Comprehensiveness of Services Provided (0,79), Family Orientation (0.66), Community Orientation (0,87), Cultural Competence (0,81). For the success ratio of the scale, all results were higher than 88%, less the “Information Systems” component (21%).

introduction Primary Health Care (PHC) has established it self as one of the most equitable and efficient ways of organizing a health system 1 . It can be defined by its essential attributes: 1) first-contact accessibility, 2) continuity, 3) comprehensiveness, 4) care coordination; and derived attributes, 5) family and community-centered attention, and 6) cultural competence [2][3][4] .
In Brazil, the Family Health Strategy (FHS) is an effort conducted by the Ministry of Health (MOH) to develop a public health policy able to establish a sturdy PHC model. In April 2003, 19,068 FHS teams, or 62,339,523 million of individuals, were covered by the FHS. In April 2020, 44,716 FHS teams or 137,360,577 million of individuals, started to be covered 5 . Oral health in Brazil started to be supported by the PHC model in 2003, with the launch of the National Oral Health Program, also known as Brasil Sorridente. Initially, the program expanded the coverage of oral health services in PHC, with the objective of expanding access and establishing guidelines to reorient oral health services, taking as a central axis the offer of services and actions associated with the attributes of PHC 6 .
Different conceptual models and instruments have been unfurled in recent years to evaluate the quality of health care, some of which include the PHC2 attributes 2,7,8 . The Primary Care Assessment (PCATool) was one of those, a set of instruments capable of measuring the presence and extension of PHC attributes, developed by Starfield and collaborators at The Johns Hopkins Populations Care Policy Center for the Underserved Populations, in Baltimore (USA) 2,9-11 . PCATool is an instrument able to assess the quality of primary care provided, based on the measurement of the extent of PHC attributes, producing a score for each attribute, an essential score and an overall score on the quality of care. It allows an opportunity to comparatively assess the degree of success of services when it comes to achieving excellence in PHC practice 11,12 . In Brazil, the versions for adult users 13 , children 14 , health professionals 15,16 and also oral health version from the perspective of the adult user have already been translated, adapted and validated 17 . It is one of the most frequently used PHC assessment instruments in the country 18 . It has recently been cited as one of the instruments that will compose the National Home-based Health Research that will enable the collection of relevant information about the health of the pop-ulation and the capacity of the Unified Health System (SUS), focusing on Primary Health Care (PHC). It encompasses the National Continuous Household Sample Survey (Continuous PNAD), the National Demographic and Health Survey (PNDS), and the Health-Medical Assistance Survey (AMS) 19 . In addition, PCATool Brazil started to compose an extension of payment for performance of the new financing model for APS do Brazil 20 and a new PCATool Brazil manual was released by the Ministry of Health, with guidance on its use in estimates 21 .
Within the scope of evaluation of oral health services in PHC from the user's perspective, in addition to the PCATool Brazil -Oral Health Adult User, there is also the QASSAB instrument (Questionnaire for Evaluation of Quality of Oral Health Services) and the instrument of External Evaluation of the National Program for Improving Access and Quality of Basic Care (PMAQ -AB) 22 . The evaluation from the user's perspective is important because they are the target audience of the services and the opportunity to know their satisfaction in terms of structures, processes and results presented by the health service that they use is important information for improving the actions and services provided.
On the other hand, the assessment of health services encompasses both those who use and those who provide and produce the services. Therefore, it is necessary to acknowledge that users and professionals have different and complementary positions within the evaluative context, and both are important for the analysis of the services researched. The PMAQ-AB presented an evaluation instrument from the perspective of the professional, whose main objective is to provide management subsidies. Nevertheless, no instruments were found to assess oral health services in PHC from a professional perspective that had validated its psychometric characteristics.
PCATool is a set of instruments developed from PHC's sturdy theoretical framework 2,9,10 and has been used in different countries, not only for academic research purposes but also for decision making of managers 23 . Given the breakthroughs registered by PHC and the expansion of oral health in the FHS in Brazil, it is relevant, at this point, to assess the results achieved in relation to the organization and provision of oral health services in the health care network. Therefore, it is essential to provide instruments for assessing oral health services in PHC that allow for international comparisons, capable of reflecting instruments that assess PHC attributes from the medical-nursing work. Therefore, the objective of this study was to adapt the instrument and verify the reliability of the PCATool Brazil Oral Health -Professional.

Outlining
Cross-sectional validation study of PCATool Brazil Oral Health -Professional.

Sample
This instrument has presented 98 evaluation items after its adaptation. In order to meet the study's objectives, data were collected using a convenience sample composed of 562 participants, complying with the minimum threshold of 5 interviews for each item of the instrument necessary for the application of factor analysis, a methodology used to assess the validity of the instrument 23  All dental surgeons who were working in the same Basic Health Unit for at least six months before the date of the interview were included in the study.

Adaptation
PCATool Brazil Oral Health -Professional is a "mirror" questionnaire for PCATool Brasil -Professional 16 and PCATool Brasil Oral Health -Adult User 17 . Therefore, to adapt the professional version to an oral health approach, the instrument was adapted from PCATool Brazil Oral Health -Adult User. The adaptation consisted of replacing the expression "your health service" with "your oral health service", except for the dimension "Comprehensiveness". For this dimension in specific, the instrument PCATool Brasil Oral Health -Adult User 17 was used as a mirror.
A previous validation study identified that among, the seven attributes that make up the questionnaire, only the comprehensiveness dimension (services available/services provided) did not properly assess this dimension in relation to oral health. To develop the "comprehensiveness" dimension, this study used the Delphi Technique to build a consensus among experts (university professors and dentists with extensive experience in PHC) for the instrument PCATool Brasil Oral Health -Adult User 24 . Therefore, the comprehensiveness dimension, developed and validated for oral health services of PHC in Brazil, was used for the instrument PCATool Brazil Oral Health -Professional.

PCATool Brazil Oral Health -Professional
The PCATool Brazil Oral Health -Professional version instrument encompasses 98 items distributed among the essential attributes -access, continuity, comprehensiveness and coordination -and their derivatives -family and community orientation and cultural competence. It was originally developed to assess the presence and extent of PHC attributes in health services. The item's responses are presented in Likert-type scales, with values ranging from 1= "certainly not" to 4= "certainly yes", with the additional option 9= "don't know/can't remember". From the answers, it is possible to calculate a score for each PHC attribute and also an essential score and an overall score. At least 50% of valid answers (4= "certainly yes", 3= "probably yes", 2= "probably not" or 1= "certainly not") is a condition to calculate the score. If the condition is met, the code responses 9= "I don't know/can't remember" should be transformed to code 2= "probably not" according to guidelines in the Instrument Manual 21 , as statistically demonstrated by Hauser 25 .
The essential score is obtained by averaging the scores of the essential attributes -first contact, continuity, comprehensiveness and coordination. In addition to these, the overall score includes the derived attributes -family orientation, community orientation and cultural competence. The score values are turned into a scale ranging from 0 to 10. A value equal to or greater than 6,6 is considered a high score.

Data collection
The professionals were identified, contacted and invited to participate in the study by telephone. The contacts were passed on by the Municipal Health Departments. Prior consent was requested from the departments in order to carry out the research and provide the contact data of the Basic Health Units (BHU). The professionals who did not agree to participate were regarded as refusals.
The research instrument was used during the oral health coordination meetings of the municipalities. Also, information was collected on sex, postgraduate education and the BHU model in which the DSs worked. A researcher, previously trained, presented the research project and each item of the instrument PCATool Brasil SB -Professional. The doubts were clarified and the instrument was handed to the professionals for them to answer. The interviews were conducted between March 2014 and December 2015 and the researcher stayed in the room to address any doubts that might arise. The average time to complete the research instrument was 25 minutes.

Statistical Analysis
In order to verify the factor validity, a factor analysis with principal component extraction and varimax orthogonal rotation method was used. Factors with three or more items with factor loadings greater than 0,35 26 were selected. This instrument's reliability was verified using the internal consistency, the success ratio of the scale and the stability over time. Regarding the assessment of internal consistency, the item-total correlation was used, taking into consideration appropriate items with a value higher than 0,30 26 and the Cronbach's alpha coefficient ideally equal or higher than 0,70 26 . For the scale's success ratio, it was verified the quotient between the number of times that correlations between the items of an attribute were higher than the correlations of each of these items with other attributes and the total number of correlations found in that attribute. High values of that measure suggest greater attribute discrimination.
The instrument's stability over time was assessed by comparing the scores of PHC attributes in ten-day intervals between test and retest. We randomly selected 10% of the sample for a new phone interview.
Wilcoxon's statistical test was applied to two paired samples. All analyses were conducted us-ing the SAS (Statistical Analysis Software) version 9.4 and the 5% significance level was considered.

ethical Aspects
The research project "Evaluation of Oral Health Services in Primary Health Care -A conceptual, psychometric, exploratory and structural analysis" was submitted to and approved by the Research Ethics Committees of the Municipal Administration of Porto Alegre and the Federal University of Rio Grande do Sul. The interviews with service professionals were carried out after reading and signing the Informed Consent Form (ICF), in tune with the ethical precepts established in the Declaration of Helsinki.

Results
The sample consisted of 562 dental surgeons interviewed. During the data collection period, there was an attempt to contact 613 DSs. Among them, 24 were not found, 15 refused to participate in the survey and 12 had less than six months of experience in the current BHU. Therefore, the loss of the original sample was 9%.
Of the interviewees, 76,7% were women, 81,2% had some specialty and for, 44,29%, the declared specialty was family health/public health/collective health. The family health strategy was the PHC model declared by 81,5% of professionals.

Factorial Analysis
The exploratory factor analysis kept 10 factors that explain 40,95% of the total variation. These factors represented, in a more homogeneous manner, the attributes that allow measuring the presence and extension of PHC and its essential and derived attributes. Regarding the distribution of the items in the factors, the First-Contact Access -Accessibility was captured by factor 5. Continuity was kept in factor 4 ( Table  1). The care coordination was captured by factor 8 ( Table 2).
The Comprehensiveness of services available presented items in factor 1, and the same is true for the Comprehensiveness of services provided ( Table 3). The attributes derived from family orientation, community orientation and cultural competence were captured by factors 3, 2 and 2, respectively ( Table 4). The coordination of Information Systems was the only dimension that did not present a factor load greater than 0,35 in the items assessed (Table 2). This dimension was kept due to its conceptual importance.
The instrument PCATool Brazil Oral Health -Professional adapted for primary health care services in Brazil was initially formed by 98 items. After validation, 85 items were kept in the final instrument.

Reliability
Regarding the internal consistency, taking into account the item-total correlation, for access (Table 1), items A3 (When the patient has a mouth issue, does someone in the service see that person the same day?), A7 (When the patient has a mouth issue at night, does someone at the service Table 1. Factorial loadings for factor validity and item-total correlation of attributes First-contact accessaccessibility and continuity. Also on internal consistency, using Cronbach's alpha, the following coefficient values were observed (Table 5) For the scale's success ratio (SSR), all results were higher than 88%, except for the "Information Systems" component (SSR=21%), (Table 5).

Discussion
This study adapted and assessed the validity and reliability of the PCATool Brazil Oral Health -Professional version in the public PHC services, indicating that the instrument is valid and reliable for the measurement of the quality of PHC health services based on the experience of the interviewed Dental Surgeons. In the factor analysis, the ten-factor model was capable of capturing the four essential attributes and three attributes derived from the PHC, according to the Starfield proposition 1 , therefore identifying the construct's multidimensional nature. This phenomenon is also found in the adult user, child user and health professional versions of PCATool validated in Brazil 13,14,16 . The first-contact access attribute was captured by factors 5 and 9. The continuity attribute had its items kept in factor 4. Family orientation was captured by factor 3, which, in turn, kept items of Community Orientation. The interrelation of items of different attributes kept by common factors indicates that the complex dynamic nature of PHC services is represented by  the instrument, since, according to the concept of PHC, the attributes can be didactically divided, but are closely related in the practice of services 16 .
The instrument PCATool Brazil Oral Health -Professional comprised 98 items. After an exploratory analysis, 13 of these items were excluded for not presenting sufficient factor loading or because they assessed the same domain. The items suggested for evaluating the information system did not have sufficient factor loadings. We may speculate that this is a limitation related to the precariousness of information systems in Brazil, and also due to the fact that the national e-SUS Basic Attention system was only implemented in 2016. Nevertheless, due to its relevance in terms of planning, organization and evaluation of services 27 , and to establish a comparison with other PCATool versions validated in Brazil, the authors decided to maintain it in the final version of the instrument. The excluded access items are related to the provision of OH services in PHC on weekends or after 8 p.m. This practice is not common in the country and no reports were found in other studies regarding the availability of dental care in PHC after 8 p.m. The removed Care Coordination items are related to the delivery of exams in PHC and the provision of different specialized consultation services. Nonetheless, the Oral Health Team does not have the habit to request laboratory tests for PHC patients and more complex situations are referred to reference services, which are still insufficient in the country, not allowing the choice between different services 28 .
For the comprehensiveness attribute, the items related to the use of fluoride "Application of fluoride on teeth and guidance for its use" and fluorosis-related orientation "Guidance on excess fluoride on teeth/fluorosis" were also excluded from the final instrument. It may be pondered that this practice is not part of the routine of the professional who, given the high demand repressed, has its focus on recovery actions such as fillings and exodontia or pain relief measures. In addition, this study was conducted in urban areas with access to running water, which restricts the recommendations for fluoride use. Another important aspect is that access to fluoridated toothpaste is widespread in the country. On the other hand, identifying and monitoring the occurrence, distribution and aggravation of fluorosis is an epidemiological surveillance action, which is part of the tasks of PHC oral health teams and, still, they were not perceived by dentists as available services.
Regarding family orientation, the excluded items are related to the use of genograms and risk factor analysis. The use of genograms is an uncommon practice in PHC by oral health teams 29 . The items regarding the discussion of family risk factors, social risk factors and living conditions were represented by three different questions. According to the authors, all of them explain the same evaluative dimension and, therefore, the option made was to maintain the highest loading in terms of discussions on social risk factors.
The results of the reliability analysis point out the consistency of all attributes, except for Care Coordination -Information Systems, which was assessed as insufficient. Nevertheless, the option was to maintain the items because they represent Starfield's concept of PHC 1 and to maintain comparability with other PCATool versions validated in Brazil. The results of the scale success ratio show that each item is allocated in its conceptual attribute, because they are more strongly related to the items of its source component than to those of the other attributes, therefore consubstantiating the reliability of the instrument.
The use of service valuation instruments is an important resource, which is nowadays used in many countries. To avoid measurement bias in these instruments, it is extremely important that the process of factor validation is performed for each one. Stein 30 points out that it is also necessary to take into account the concepts established in the literature, as well as cultural factors, particularly in epidemiological and clinical studies, and methodological rigor in the execution of the process.
The comparison between the test and the retest identified the stability of the scale over time. The comprehensiveness attribute -Services Available -showed low agreement on retesting and it is possible the rotativity of professionals in services may have influenced these results. Another possible limitation of the instrument is its large number of items (85), which may result in the interviewee not having the same willingness to answer all items. The possibility of having a reduced version of this instrument is suggested, which was already developed for another version of PCATool Brazil, one that presented reliable psychometric properties for the instrument 31 .
PCATool Brazil Oral Health -Professional captured the main attributes of PHC and generally presented acceptable measures of validity and reliability. The use of scale may account for a valuable instrument for evaluative research efforts and for the organization of oral health services in PHC in the different management areas, since it allows the analysis of the effect of interventions, policies and programs. According to a survey carried out by the authors, this is the only PCATool Brazil Oral Health -Professional described in the international literature with the derived attribute Cultural Competence validated. Moreover, the instrument has essential features for comparability, since it was designed as a mirror version of PCATool Brazil Oral Health -Professional for doctors/nurses -and is also used in other countries [32][33][34][35] .

Collaborations
OP D'Avila, FN Hugo and E Harzheim contributed to the design, execution, development and final review of the study. L Hauser, LFS Pinto were responsible for the execution and review of the data analysis as well as the final review of the results. ED Castilhos contributes to the final revision of the article, textual adjustments and improvement of the data discussion.