Programmatic situation from the perspective of health vulnerability: Item database validation

Azevedo, Samir Gabriel Vasconcelos; Florêncio, Raquel Sampaio; Cestari, Virna Ribeiro Feitosa; Moreira, Thereza Maria Magalhães

doi:10.1590/2177-9465-EAN-2021-0347en

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RESEARCH • Esc. Anna. Nery 26 • 2022 • https://doi.org/10.1590/2177-9465-EAN-2021-0347en copy

Programmatic situation from the perspective of health vulnerability: Item database validation

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective

To validate an item database to assess the programmatic situation of health vulnerability.

Method

A validation study carried out in 2021. Two scoping reviews were elaborated to identify operational definitions and, afterwards, meetings were held with the authors to formulate items. As a follow-up, the items were sent via Google Forms to specialists with expertise in the areas of health vulnerability or construction and validation of instruments. To validate the items, we used the content validity coefficient and binomial test, in addition to the intraclass correlation coefficient to verify reliability, all via SPSS® version 25.

Results

Seven experts answered with item evaluations in the language clarity, practical relevance and theoretical relevance criteria. Of the 88 items organized in the infrastructure and work process sub-concepts, most were modified following the experts' suggestions and had content validity coefficients greater than 0.80. The intraclass correlation coefficient was 0.80 for clarity, 0.94 for relevance, and 0.92 for relevance (p < 0.05). Two items were excluded after the authors' meeting for consensus on the final item database and ten were merged.

Conclusion and implications for the practice

The items were internally validated and there was good reliability among the judges, enabling their use by health professionals to investigate vulnerability.

Keywords:
Validation study; Workflow; Health infrastructure; Public health; Health vulnerability

E	Category/Degree	Level of expertise	Evaluation of the items
E1	Nurse. Master and PhD student in Nursing. Member of the Brazilian Association of Gerontological Nursing (CE)	Junior	Agreed with 97% (86) of the items. Suggested changing and removing terms to improve the reader's understanding of the items, standardizing between being the “service used” or the “most used service”.
E2	Speech therapist. Specialist, Master and PhD student in Collective Health.	Senior	Agreed with 75% (63) of the items. Mostly reported that the items would be difficult for the reader to understand, and that it is necessary to qualify the term “not applicable”.
E3	Nurse. Master in Collective Health. PhD in Public Health.	Senior	Agreed with 84% (74) of the items. Suggested involving aeration in some infrastructure conditions, making clear what “specific”, “regular”, “periodic form” and “routine” are in the items, and suggested removing item 26.
E4	Nurse. Master and PhD student in Nursing.	Junior	Agreed with 95% (84) of the items. Suggested replacing some terms for the reader's understanding. And criticized item 26, for considering that it did not portray a situation of vulnerability.
E5	Nurse. Master and PhD student in Clinical Health Care.	Junior	Agreed with 99% (87) of the items. Suggested standardizing terms such as “health service” or “health unit”. Gave examples to be included in the items for the subject to better understand and replace other terms.
E6	Nurse. Master in Family Health.	Junior	Agreed with 96% (85) of the items. Redrafted a few items. Suggested specifying some terms for the subject to understand what is being evaluated.
E7	Physical Education Professional. Master and PhD student in Collective Health.	Senior	Agreed with 98% (86) of the items. Suggested changing the order of some items, reformulating and changing terms and clarifying some items so that the subject understands.

Item	Clarity	Pertinence	Relevance	Mean CVCi	p-value*	Item	Clarity	Pertinence	Relevance	Mean CVCi	p-value^*	Item	Clarity	Pertinence	Relevance	Mean CVCi	p-value*
1	0.89	0.91	0.91	0.90	0.51	31	0.71	0.77	0.94	0.81	0.10^a	61	0.83	0.91	0.91	0.89	0.51
2	0.94	0.86	0.89	0.90	0.51	32	0.80	0.80	0.91	0.84	0.51	62	0.91	0.97	0.94	0.94	0.51
3	0.94	0.97	0.97	0.96	0.51	33	0.97	0.86	0.83	0.89	0.51	63	0.97	0.97	0.97	0.97	0.51
4	0.77	0.80	0.80	0.79	0.48^a	34	0.97	0.97	0.97	0.97	0.51	64	0.97	0.97	0.97	0.97	0.51
5	0.91	0.91	0.91	0.91	0.51	35	0.89	0.83	0.91	0.88	0.51	65	0.91	0.97	0.97	0.95	0.51
6	0.91	0.94	0.94	0.93	0.51	36	0.97	0.94	0.94	0.95	0.51	66	0.97	0.97	0.97	0.97	0.51
7	0.91	0.91	0.91	0.91	0.51	37	0.97	0.91	0.91	0.93	0.51	67	0.94	0.94	0.94	0.94	0.51
8	0.86	0.91	0.91	0.90	0.51	38	0.80	0.83	0.80	0.81	0.51	68	0.94	0.91	0.94	0.93	0.51
9	0.71	0.83	0.89	0.81	0.48^a	39	0.94	0.86	0.89	0.90	0.51	69	0.97	0.94	0.94	0.95	0.51
10	0.83	0.83	0.89	0.85	0.51	40	0.89	0.97	0.97	0.94	0.51	70	0.94	0.97	0.97	0.96	0.51
11	0.83	0.91	0.91	0.89	0.51	41	0.97	0.94	0.97	0.96	0.51	71	0.91	0.97	0.97	0.95	0.51
12	0.89	0.94	0.94	0.92	0.51	42	0.94	0.97	0.97	0.96	0.51	72	0.97	0.97	0.97	0.97	0.51
13	0.86	0.91	0.94	0.90	0.51	43	0.89	0.94	0.97	0.93	0.51	73	0.97	0.97	1.00	0.98	0.51
14	0.86	0.97	0.97	0.93	0.51	44	0.77	0.83	0.86	0.82	0.48^a	74	0.80	0.97	0.97	0.91	0.51
15	0.91	0.94	0.94	0.93	0.51	45	0.94	0.97	0.97	0.96	0.51	75	0.97	0.97	0.97	0.97	0.51
16	0.83	0.83	0.86	0.84	0.51	46	0.91	0.91	0.91	0.91	0.51	76	0.86	0.97	0.97	0.93	0.51
17	0.89	0.89	0.94	0.90	0.51	47	0.97	0.97	0.97	0.97	0.51	77	0.94	0.86	0.89	0.90	0.51
18	0.91	0.97	0.97	0.95	0.51	48	0.94	0.97	0.97	0.96	0.51	78	0.86	0.86	0.86	0.86	0.51
19	0.86	0.89	0.89	0.88	0.51	49	0.97	0.97	0.97	0.97	0.51	79	0.97	0.86	0.89	0.90	0.51
20	0.71	0.89	0.89	0.83	0.48^a	50	0.91	0.86	0.94	0.90	0.51	80	0.97	0.86	0.89	0.90	0.51
21	0.91	0.86	0.94	0.90	0.51	51	0.94	0.97	0.97	0.96	0.51	81	0.97	0.86	0.89	0.90	0.51
22	0.94	0.97	0.97	0.96	0.51	52	0.86	0.94	0.97	0.92	0.51	82	0.97	0.86	0.89	0.90	0.51
23	0.91	0.94	0.94	0.93	0.51	53	0.97	0.97	0.97	0.97	0.51	83	0.97	0.86	0.89	0.90	0.51
24	0.94	0.94	0.94	0.94	0.51	54	0.89	0.97	0.97	0.94	0.51	84	0.97	0.86	0.89	0.90	0.51
25	0.91	0.91	0.94	0.92	0.51	55	0.86	0.97	0.97	0.93	0.51	85	0.97	0.86	0.89	0.90	0.51
26	0.74	0.77	0.77	0.76	0.008^a	56	0.74	0.94	0.94	0.88	0.48^a	86	0.97	0.86	0.89	0.90	0.51
27	0.86	0.94	0.94	0.91	0.51	57	0.80	0.91	0.91	0.88	0.51	87	0.86	0.86	0.89	0.87	0.51
28	0.91	0.97	0.97	0.95	0.51	58	0.94	0.97	0.97	0.96	0.51	88	0.97	0.97	0.97	0.97	0.51
29	0.69	0.80	0.83	0.77	0.48^a	59	0.80	0.89	0.89	0.86	0.51
30	0.89	0.91	0.97	0.92	0.51	60	0.91	0.97	0.97	0.95	0.51

Item database to assess the programmatic situation of the concept of health Vulnerability
Infrastructure
According to the service you use the most, please answer:

1 - Is there any area with compromised infrastructure (broken chairs, aeration conditions, rooms with mold, cracks, leaks, lack of water, etc.)?	41 - In the health service, are the care routines frequently modified?
1) None; 2) At least one area; 3) Few areas; 4) Some areas; 5) The vast majority of the areas; 6) All areas; 7) Not applicable.	1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.

2 - In your consultations or appointments, do the professionals provide materials that explain health topics (pamphlets, booklets, educational folders, applications, etc.)?	42 - Have you ever been mechanically treated (which procedure, what it is for, etc.) by the professional during the consultation or appointment?
1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.	1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.

3 - Have you ever lacked medication?	43 - Do the health professionals record your appointments in any medical chart?
1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.	1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.

4 – Do you have a room with ample space that can be used for collective/educational activities?	44 - Have you had access to the health bulletin of the city or neighborhood in which you live (publications of the health department or similar bodies)?
1) Yes, very wide; 2) Yes, wide; 3) Yes, wide enough; 4) Yes, little wide; 5) Has room, but very small; 6) No space for activities; 7) Not applicable.	1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.

5 - Have you ever failed to undergo examinations/procedures due to absence of materials/equipment?	45 - In the health service, is there a responsible and active group that discusses the organization of the health service (health council)?
1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.	1) Yes; 2) Probably; 3) I can't say; 4) At least once; 5) Probably not; 6) No; 7) Not applicable.

6- Have you ever failed to undergo exams due to absence of personal protective equipment for the health professionals (glove, hat, mask, etc.)?	46 - When you are referred to another service, do you take the referral paper?
1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.	1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.

7 - Is there equipment to perform the expected diagnostic tests (mammography, tomography, ultrasound, blood collection, etc.)?	47 - When returning to the original service where you were treated, do you bring with you the document that explains how the consultation went and your health condition?
1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.	1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.

8 - Are there specific exams for your health condition (e.g., routine exams)?	48 - Did you have difficulty being referred to a specialized service?
1) Always; 2) Most of the the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) I don't know how to answer.	1) Never; 2) I had difficulty at least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.

9 - Have you ever not been treated due to problems with the online medical records system (slow system, system down, etc.)?	49 - Have you been referred to a specialized service and been waiting a long time to be called for this consultation/exam?
1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) I don't know how to answer/There is no medical record	1) No; 2) Yes, at least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.

10 - Is rapid testing available for diagnosis (HIV, syphilis, Diabetes, Hepatitis C, etc.)?	50 - When you need to use other services, is your unit of origin informed by this other service?
1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.	1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never, it is generally me that reports; 7) Not applicable.

11 - Is there privacy in the appointment rooms (without interruptions, one person at a time)?	51 - Do the health professionals who assist you report that they are following pre-established routines (flows established by the health department or similar bodies)?
1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.	1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.

12 – Are disposable materials available for personal use (syringes, needles, condoms, etc.)?	52 - Were you offered any health education activities, such as groups, conversation circles, etc.?
1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.	1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.

13 - Did the health professional ever ask about your social condition (work and salary, housing, government benefits, etc.)?	53 - Are there many people waiting for care/long queues in the health service?
1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.	1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.

14 - Do you usually have quick consultations or appointments?	54 - Do you take a long time to receive the results of the exams performed?
1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.	1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.

15 - In the medical consultations or appointments, do the health professionals usually make a more detailed evaluation/examination (did they search for antecedents and talk about what can happen, did they search for the probable cause)?	55 - Do you receive the result of your health exams at the time it was agreed upon?
1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable	1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.

16 - Have you ever not performed a procedure that you needed due to lack of trained health professionals in the service?	56 – Do health professionals request your exams periodically (once a year)?
1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.	1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.

17 - Was there any difficulty or delay in your appointment or consultation with a health professional due to your disability?	57 - Have you ever received exams with results that were not in accordance with your diagnosis?
1) Never; 2) I had difficulty at least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.	1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.

18 - Did the health professional ever not know how to interpret your exams (gynecological prevention, laboratory exams, imaging exams, etc.)?	58 - Do you attend routine consultations to assess your health (once a year)?
1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.	1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.

19 - Has the health professional ever focused only on filling out papers and making the referral without giving further explanations about your health status during your consultation or appointment?	59 - Have you ever been mistreated in the health service?
1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.	1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.

20 - Did you have any health conditions that took a long time to be diagnosed?	60 - In the health service, are there people who advise you to go to the right places/rooms?
1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.	1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.

21 - Have you ever had complications in your health condition due to a delay in diagnosis (delay in test results, lack of vacancies, difficulty scheduling returns)?	61 - Do you feel safe being treated at the nearest health service?
1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.	1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.

22 - When you arrived at the health service to be assisted, did you return due to the reduction of the service hours?	62 - Did you feel unsafe with any guidance during a consultation or appointments by a health professional?
1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.	1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.

	63 - Do you perform any activities related to your health outside the health service that you use the most?
Work processes	1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.
According to the service you use the most, please answer:
	64 - Have you ever had confidential information about your health shared with third parties without your permission?
23 - Are there teams responsible for care planning (e.g., is there a team responsible for you)?	1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.
1) Always; 2) Most of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) I don't know how to answer.
	65 - Do the health technologies (app, websites, crime reporting service) provided by the health services work when you need them?
24 - Do you believe that there are few health professionals working in the service you use the most?	1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.
1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.
	66 - In the health service you use, are there specific consultations/appointments for various health conditions (hypertension, diabetes, leprosy, tuberculosis, respiratory diseases, etc.)?
25 - Do you usually see health professionals of the service in courses, case discussion, staff training, etc.?	1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.
1) Always; 2) Most of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) I don't know how to answer.
	67 - When you attend a consultation, is it usual to be assisted by a multidisciplinary team (several professionals)?
26 - Is there a good relationship between professionals in the service?	1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.
1) Always; 2) Most of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) I don't know how to answer.
	68 - In the health service that you use the most, are there appointments/consultations with nurses available?
27 - Is alternate consultation offered between nurse and physician in the service?	1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.
1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.
	69 - In the health service that you use the most, are there appointments/consultations with a physician available?
28 - Have you stopped being assisted due to the limited number of forms/passwords for consultations with health professionals?	1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.
1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.
	70 - In the health service that you use the most, are there appointments/consultations with a physiotherapist available?
29 - Do you wait more than two hours to be served?	1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.
1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.
	71 - In the health service that you use the most, are there appointments/consultations with a physical education professional available?
30 - During your consultations or appointments, do the health professionals pay more attention to your disease, leaving aside other aspects of your life that you wanted to share?	1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.
1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.
	72 - In the health service that you use the most, are there appointments/consultations with a dentist available?
31 - Do you receive guidance on all the procedures and exams you need to undergo (objective of the exam, risks, benefits, what is used, how long it will take etc.)?	1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.
1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.
	73 - In the health service that you use the most, are there appointments/consultations with a social worker available?
32 - Do you receive regular (1x/month) visits from health professionals at your home to address issues related to your health?	1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.
1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.
	74 - In the health service you use the most, are there appointments/consultations with a psychologist available?
33 - Do the home visits you receive from health professionals meet your needs?	1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.
1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.
	75 - In the health service you use the most, are there appointments/consultations with a nutritionist available?
34 - Has the health professional ever informed you that you have a disease that needs to be notified (informed to the health department)?	1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.
1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.
	76 - In the health service you use the most, are there complementary health practices (dance groups, physical exercise groups, yoga, acupuncture, auriculotherapy, flower therapy, etc.)?
35 - Is there a space for reception in the health service (private space that allows you to have an initial conversation with a health professional)?	1) Always; 2) Most of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) I don't know how to answer.
1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.

36 - Do health professionals pay attention when you talk about your health condition?
1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.

37 - Do health professionals give excessive personal opinions* related to their health condition?
1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.
*Note: Based on quick information and without a more extended elaboration on important issues

38 - Have you ever felt dissatisfied with the care you received when using the health service?
1) Never; 2) At least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.

39 - Do you have difficulty interacting with the health professional during your consultation/appointment?
1) Never; 2) I had difficulty at least once; 3) Few times; 4) Sometimes; 5) The vast majority of the times; 6) Always; 7) Not applicable.

40 - In your perception, do the professionals put themselves in your shoes when dealing with your health condition (welcoming, understanding, patient)?
1) Always; 2) The vast majority of the times; 3) Sometimes; 4) Few times; 5) At least once; 6) Never; 7) Not applicable.

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[1] Corresponding Author: Samir Gabriel Vasconcelos Azevedo. E-mail: samirueva@gmail.com