Measure of Processes of Care: a review of 20 years of research

Authors

  • Barbara J Cunningham,

    1. CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, ON, Canada
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  • Peter L Rosenbaum

    Corresponding author
    1. CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, ON, Canada
    • Correspondence to Peter Rosenbaum, CanChild Centre for Childhood Disability Research, Institute for Applied Health Sciences, McMaster University, 1400 Main Street West, Room 408 Hamilton, ON L8S 1C7, Canada. E-mail: rosenbau@mcmaster.ca

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Abstract

Aim

This article reviews literature on findings from the Measure of Processes of Care (MPOC) to assess family-centred services.

Method

Systematic searches for papers citing MPOC in both PubMed and Web of Science identified 107 articles. Fifty-five met the criterion for inclusion in this review in that they reported MPOC data.

Results

Over the past 20 years MPOC has been used in settings additional to the children's treatment centres for which it was designed; used in 11 countries and translated into 14 languages; and used to measure change in respondents' perceptions over time. MPOC findings have also informed our understanding of the provision of family-centred services. Overall, parents report that service providers do a good job of providing respectful, comprehensive services in partnership with families, but that there remain limitations in the provision of general information, an area for improvement. Finally, MPOC has been shown to correlate with various other measures related to the provision of family-centred services.

Interpretation

The MPOC ‘family’ of measures can be used to assess both families' and service providers' experiences and perceptions of the family-centredness of services received/provided. Opportunities abound for further research enquiries.

Abbreviations
CSQ

Client Satisfaction Questionnaire

FCS

Family-centred services

FES

Family Empowerment Scale

FSS

Family Support Scale

MPOC

Measure of Processes of Care

Once a new measure is created, validated, and published it is easy to assume that the story is complete. There is, however, an afterlife to measures with respect to the ways in which they are used, their adaptations, whether they are translated (and, if so, whether they are validated to assess if they still ‘work’), and what is learned about the issues for which the measure was developed in the first place.

The Measure of Processes of Care (MPOC) was developed as a clinical and research tool to measure parental perceptions of caregiving.[1] It provides a self-report account of parents' perceptions of the extent to which the health services they and their children receive are family centred. Several versions of MPOC are available for both parents and service providers. MPOC has been translated into 14 languages and is a trusted measure in many countries around the world.

MPOC was designed to evaluate parents' perceptions of the family-centredness of the services they and their children receive from developmental service providers and how those perceptions relate to parents' satisfaction with services.[1] The developers reasoned that parents who experienced more family-centred behaviours from their child's service provider would experience less stress and greater satisfaction with their child's services than parents who were served in a more traditional way.[1]

The original MPOC is a 56-item self-report measure that assesses ‘the extent to which’ services parents and children receive are family centred in five factorially determined domains: enabling and partnership; providing general information; providing specific information about the child; co-ordinated and comprehensive care; and respectful and supportive care.[1] Reponses on the original MPOC-56 were made using a seven-point scale, of which three of the seven points were labelled as follows: 7 (to a great extent), 4 (sometimes), and 1 (never).[2]

MPOC-56 was developed in collaboration with close to 2000 parents from numerous children's treatment centres across Ontario, Canada, in order to ensure that the concepts, content, format, and language of the measure were relevant, applicable, and accessible to potential users.[1] MPOC-56 is psychometrically sound, with good reliability and good evidence of construct validity.[1] It also correlates strongly with the Client Satisfaction Questionnaire (CSQ),[3] a standard measure of satisfaction.[1]

A shorter, 20-item version (MPOC-20) developed in 2004 to improve the utility of the measure and increase its ability to discriminate programmes with different service delivery models.[2] The psychometric properties of the shorter version were evaluated using existing data sets, and MPOC-20 was found to perform as well as MPOC-56 in terms of internal consistency, test–retest reliability, and construct validity.[2] MPOC-20 was intended for use in programme evaluation and quality assurance activities; however, the more robust MPOC-56 is still recommended for research purposes.[2]

MPOC – Service Provider (MPOC-SP) was developed as an analogue of MPOC-56 to include service providers as well as parents in the evaluation of the provision of family-centred services (FCS).[4] This measure served the important purpose of providing a self-assessment tool for professionals to evaluate their practices with respect to family-centredness, rather than their attitudes and beliefs, as could be done with other tools.[4]

Other adaptations of the original MPOC include MPOC-Adult (A),[5] MPOC-28,[6] and MPOC-8 South Africa (8 SA).[7]

The specific purposes of this review are twofold: (1) to review how MPOC tools have been used in research, and what researchers have learned about the measures, and (2) to summarize what researchers have learned and reported about FCS using this family of measures. In this paper, we discuss findings related to MPOC-56, MPOC-20, and MPOC-SP, but do not discuss findings related to MPOC-8(SA), MPOC-28, or MPOC-A as these were each used in only one study found in our search; however, detailed descriptions of all versions of MPOC are available in Appendix SI (online supporting information).

Method and summary of search findings

To retrieve articles that had used MPOC, the term MPOC in a title or abstract was searched in the PubMed database. A citation search was also carried out using the Web of Science database for the original MPOC-56 article[1] and MPOC-20 article.[2]

One hundred and seven articles were identified using the above-mentioned search criteria. Those articles were reviewed and sorted as follows: papers containing MPOC data (n=55); papers writing about FCS citing the MPOC as a way to assess but without MPOC data (n=7); papers that only referred to MPOC (n=13); papers with no reference to the MPOC, but that discussed FCS (n=21); and papers that were unrelated to FCS or MPOC, but discussed service provision in general (n=11).

Since we wanted to review all of the published experiences with MPOC, we did not complete a formal quality evaluation of the papers as we planned to include all articles that contained MPOC data. Therefore, our inclusion criterion was that an article had to contain data from one of the MPOC measures, while our exclusion criterion was papers that only discussed MPOC or FCS, but did not report actual data from an MPOC measure.

The 55 papers containing MPOC data were extracted from the original list and were further examined. Table 1 provides specific details on how those papers were sorted. Eleven countries were represented across the 55 articles (Table 2).

Table 1. Papers reporting MPOC data (n=55)
  1. MPOC, Measure of Processes of Care; SP, service provider; A, adult.

MPOC-5618
MPOC-56 + MPOC-SP5
MPOC-SP5
MPOC-2020
MPOC-20 + MPOC-SP4
MPOC-A1
MPOC-28 (modified with permission)1
MPOC-8 (SA)1
Table 2. Countries represented in articles reporting the MPOC
  1. MPOC, Measure of Processes of Care.

Canada20
United States9
The Netherlands7
Australia5
England4
Sweden3
Finland2
Singapore2
Iceland1
Norway1
South Africa1

MPOC has been used in various settings, including children's treatment or rehabilitation centres, children's hospitals, large urban hospitals, university hospitals, and one community development programme (Australia). Numerous disabilities and conditions of children were targeted, including type 1 diabetes, physical disabilities, cerebral palsy, cancer, and acquired brain injury, as well as general developmental disorders typically treated by developmental therapists. MPOC was usually used to evaluate services provided to parents of preschool or school-aged children; however, parents of children from as young as 2 months to as old as 26 years of age were included in some studies.

MPOC-SP has been completed by numerous professionals, including physiotherapists, speech–language pathologists, occupational therapists, recreation therapists, physicians, nurses, social workers, psychologists, neurosurgeons, audiologists, managers, and case managers.

In the articles examined for this project, MPOC-56 was used in English, Dutch, and Swedish; MPOC-20 was used in English, Dutch, Finnish, Norwegian, Traditional Chinese and Icelandic; and MPOC-SP was used in English, Dutch, Finnish, and Traditional Chinese. Among the adaptations of the original version of MPOC, MPOC-A was used in English; MPOC-8(SA) was used in six African languages; and MPOC-28 was translated into Swedish.

In addition to the eight languages we found that were used in MPOC research, CanChild Centre for Childhood Disability Research reports that MPOC is available in ten other languages including, for MPOC-20, Arabic, Danish, French, German, Hebrew, Italian, Japanese, Latvian, Portuguese, and Spanish[8] for MPOC-56, Hebrew and Japanese;[8] and, for MPOC-SP, Arabic, Danish, Hebrew, Italian, Japanese, and Portuguese,[9] in addition to the seven referred to above, but no published research articles were found in these languages.

Results

How research has expanded our understanding of MPOC measures

When MPOC-56, MPOC-20, and MPOC-SP were originally created, they were known to be psychometrically strong measures that were developed based on what parents felt was important in terms of service provision for their children;[1, 2] however, several questions still remained. First, the measures were developed and validated almost entirely with parents of children with long-term, mainly stable, neurodevelopmental disabilities in Canada. The parents who helped with the development of MPOC-56 were recruited from 13 of 19 ambulatory children's rehabilitation centres and participation was voluntary. It was therefore not known how MPOC would perform if it were used with children and families outside traditional children's treatment centres or with children with diagnoses other than stable neurodevelopmental disabilities.[1, 2, 4]

Second, testing was done only in English. Non-English-speaking Canadians were not sampled, and differences for ethnicity were not examined; the developers did not know how parents from cultures other than the majority English-Canadian group would respond to the measures.[1, 2, 4] Finally, the developers wondered whether the measures would stand up as tools that could be used over time.[1, 2, 4]

Use outside traditional children's treatment centres

Overall, MPOC-56 and MPOC-20 have been used to measure parents' perceptions of the provision of FCS in a variety of settings, including child development and rehabilitation centres, hospitals, children's hospitals, and a paediatric neurology clinic.[1, 10-19] These measures worked as expected for their originally intended population (children with stable neurodevelopmental disorders). They were also able to measure FCS in other populations for which they were not initially intended, including children with visual impairment,[20] children with diabetes,[21] children in complex care clinics,[22, 23] and children in paediatric oncology wards.[24, 25] MPOC-20 was used to measure provision of FCS for families in an acquired brain injury treatment clinic;[26] however, MPOC-56 was less successful in measuring the provision of FCS for children with acute mild head injury.[27] It was thought that, owing to the mild nature of the injury and intervention in that study, the parents of children with acute mild head injury had difficulty completing all items on MPOC-56.[27] The authors of that report felt that MPOC would have been more effective had it been used for children with more severe head injuries, who required longer hospital stays and more direct intervention.[27]

In our examination of the literature, MPOC-SP proved to be a useful measure in the setting of traditional children's treatment centres.[16, 17, 28-30] It was also used in other settings, including hospitals,[10, 14, 31] children's hospitals,[32] and community development programmes.[13] MPOC-SP was reported to be useful in gathering service providers' perceptions about their use of family-centred practices;[14, 28, 31] in identifying strengths and gaps in service delivery;[13, 17, 32] and in comparing parents' perceptions with service providers' perceptions.[10, 12, 29] There was some evidence to suggest that professionals rated their provision of FCS differently depending on their working environment and their past experiences. For example, Jeglinsky et al.[31] found that professionals working in multidisciplinary teams rated provision of general information higher than those who worked independently (p<0.01) and more experienced professionals rated themselves higher on providing general information than professionals with less experience (p<0.01). Social workers and rehabilitation guides rated themselves significantly higher than nurses (p=0.02), occupational therapists (p=0.01), and psychologists (p=0.04) in the domain of ‘providing general information.[31]

Use in different languages and cultures

MPOC measures were originally developed and standardized in Canada with English-speaking parent volunteers.[1, 2, 4] MPOC measures have since been used in 14 languages throughout the world. For the purposes of this paper, we were particularly interested to know whether researchers had been able to determine whether the measures were psychometrically sound if they were translated or used in different cultures. In fact, psychometric evaluations for all three original measures had been done in several countries.

Bjerre et al.[33] evaluated the Swedish version of MPOC-56 in four habilitation centres and reported that it had sufficient sensitivity to be used as an evaluation tool in those centres. In that study, MPOC was able to discriminate between differences in services. In the Netherlands, both MPOC-56 and MPOC-20 have been shown to have good psychometric properties.[34, 35] Van Schie et al.[35] conducted a psychometric evaluation of the Dutch version of MPOC-56 and found that it had good construct validity, sound confirmation of the scale structure, internal consistency, and good reliabilities. Siebes et al.[34] conducted a similar evaluation of the Dutch version of MPOC-20 and reported it to have good reliability and validity. In Norway, MPOC-20 was found to be both reliable and valid,[36] and, in England, McConachie and Logan[37] modified MPOC-56 slightly to make it more relevant to British culture. They judged MPOC-56 to be a strong outcome measure for child disability services in that country. Finally, in Singapore, 16 of the 20 MPOC-20 items were considered to be useful in evaluating FCS. In this case the ‘co-ordinated and comprehensive care’ construct was found not to be relevant to Asian culture.[38]

MPOC-SP has been used in six countries, including Australia,[13, 17, 32] Finland,[14, 31] the Netherlands,[29] and Singapore.[38] Only two of the papers reviewed[30, 39] examined the psychometric properties of a translated version. In Norway, a ‘family-specific’ version of MPOC-SP was developed and evaluated. Using this measure, service providers completed ratings of their family-centred behaviours, but, instead of considering their practice as a whole, they focused on their practice with one specific family.[30, 39] This ‘family-specific’ version was found to be valid and reliable in Norway, and the authors felt that this would be the best choice for evaluating individualized care as it was attuned to a family's specific wishes, needs, and preferences.[30, 39]

Ability to measure changes over time

MPOC-56 was used to measure change over time in four studies. LeGrow and Rossen[15] used MPOC-56 in a Canadian children's hospital to evaluate families who were being treated with a new approach, the family systems nursing approach. In that study, mean MPOC-56 scores increased significantly on four of five subscales from pre- to post-intervention. Parents reported the greatest differences in the areas of ‘co-ordinated and comprehensive care’, ‘respectful and supportive care’, and ‘enabling and partnership’. Rahi et al.[20] studied the views of families of children with visual impairment who received a new service with those who did not. Statistically significant changes in MPOC-56 scores were found for ‘providing general information’ and ‘providing specific information’. Siebes et al.[40] evaluated the 1-year stability of MPOC-56(NL) in the Netherlands. The authors found only a moderate 1-year stability as all mean scores except for ‘providing general information’ decreased after 1 year. Finally, Camden et al.[12] measured the effects of organizational change in a children's centre in Quebec, Canada. The authors wanted to determine whether service excellence was maintained over a 3-year period of organizational change. No significant differences in MPOC scores were found, suggesting that the programme changes did not affect parents' experiences of receiving FCS.

Among the studies reviewed, MPOC-20 was twice used to measure change over time. In 2010, Cohen et al.[22] evaluated the impact of a complex care clinic in a children's hospital on parents' perceptions of care at 6 and 12 months after first being introduced to the clinic. Parents reported statistically significant increases in all five domains of MPOC-20, showing that parents' perceptions of the family-centredness of their care increased over time with the new programme.[22] In a second study, Cohen et al.[23] evaluated the effectiveness of family-centred care in a community-based complex care clinic. Evaluations were done at baseline, at 6 months, and again at 12 months. MPOC-20 measured changes in parents' experience of family-centred care in those clinics, with statistically significantly higher parent ratings reported at the 12-month point for three of the five domains: enabling and partnership, co-ordinated and comprehensive care, and respectful and supportive care.[23]

Only one study examined the responsiveness of MPOC-SP. In this study, during a time when an organization was being restructured, the authors evaluated whether the overall quality of service was maintained. MPOC-SP was used to evaluate service providers' perceptions of their family-centred behaviours. Service provider ratings increased over time, but the increases were not statistically significant. This meant that, from a service provision point of view, the organizational restructuring did not affect service quality.[12]

How MPOC has informed our understanding of family-centred service

A family-centred approach is different from the traditional approach to health care service delivery in that it focuses on the whole family and engages the family actively in the development of an intervention programme. Under this approach, the family is considered to be the expert on their child.[41]

In terms of outcomes, a family-centred approach to services has been shown to be of significant benefit to both children and families.[42] Benefits for children include developmental gains and skill development, and better psychological adjustment. Parents benefit from having received FCS in terms of increased knowledge about development, increased participation in therapy home programming, better psychological well-being, feeling more competent as a parent, and experiencing increased self-efficacy and sense of control. Family-centredness has also been shown to be of benefit to service providers and organizations because parents and families are more satisfied with their care when it is provided in a family-centred way.[42]

One way to understand more about FCS is to examine the results from studies that reported MPOC data. We looked at results from studies reporting both MPOC-56 data[1, 11-13, 15, 16, 20, 27-29, 33, 35, 37, 40, 43-50] and MPOC-20 data.[2, 3, 6, 10, 14, 18, 21-26, 32, 34, 36, 38, 51-56] In all but two of those studies, ‘respectful and supportive care’ was ranked highest by parents. In those two studies, it ranked a close second. Ratings of ‘enabling and partnership’ and ‘co-ordinated and comprehensive care’ were different, depending on which version of MPOC was used. In studies that used MPOC-56,' enabling and partnership' was typically ranked second and ‘co-ordinated and comprehensive care’ was third; however, studies that used MPOC-20 most often found the reverse, and ‘co-ordinated and comprehensive care’ was most often ranked second while ‘enabling and partnership’ was ranked third. ‘Providing specific information’ was typically ranked fourth both for studies using MPOC-56 and for studies using MPOC-20, and ‘providing general information’ was always rated lowest for both measures.

Overall, it appears that parents are reporting that their service providers do a good job of providing care that is respectful and supportive, and also that service providers work in partnership with them to provide care that is co-ordinated and comprehensive. Parents have identified gaps in terms of service delivery specifically in the lack of provision of both specific and general information.

Service providers tended to agree with families on what features of FCS were most prominent in their practices. In studies that used MPOC-SP, service providers consistently rated ‘treating people respectfully’ highest. As was seen with the parent perception measures, service providers varied in how they rated ‘interpersonal sensitivity’ and ‘providing specific information about the child’. Those two domains alternated between second and third; however, overall, ‘providing specific information about the child’ was rated second highest most often.' Providing general information' was always rated lowest.

Another way to increase our understanding of FCS through MPOC is to examine MPOC's association with other measures related to FCS. Some of the studies we reviewed found that MPOC was correlated with other measures. Those included MPOC-SP,[14, 16] Client Satisfaction Questionnaire[57] Short-Form Health Survey,[48, 58] Family Support Scale,[43, 59] and Family Empowerment Scale.[43, 60] Table 3 provides more information on those correlations. The significant relationship between MPOC and the above-mentioned measures emphasizes the importance of a holistic approach to intervention that considers the whole child, but also the whole family.

Table 3. The relationship between MPOC-56 and other measures related to family-centred service
StudyRelated measureRelationship to MPOC-56
  1. MPOC, Measure of Processes of Care; SP, service provider.

O'Neil et al.[16]MPOC-SPMothers' perceptions of physiotherapist's family-centred behaviours correlated with physiotherapist's attitudes towards family-centred care only for the respectful and supportive care scale (r=0.23, p<0.05)
Mah et al.[48]Short Form Health Survey – 36 (SF-36)Parents with higher scores on the five domains of MPOC had significantly better SF-36 mental health scores (p-values all <0.05). Parental SF-36 mental scores were positively associated with MPOC domains related to partnership (odds ratio [OR] 1.13; 95% confidence interval [CI] 1.05–1.21), specific information (OR 1.11; 95% CI, 1.03–1.19), comprehensive care (OR 1.06; 95% CI 1.01–1.13), and supportive care (OR 1.07; 95% CI 1.01–1.13). This relationship was statistically significant, but small
Fordham et al.[43]The Family Empowerment Scale (FES)

There were significant positive correlations between MPOC-56 and the FES for all five subscales of MPOC-56 and two of the FES subscales (empowerment with the family and empowerment with the service system)

Enabling and partnership (r=0.32/r=0.42)

Providing general information (r=0.33/r=0.41)

Providing specific information (r=0.33/r=0.36)

Co-ordinated and comprehensive care (r=0.36/r=0.45)

Respectful and supportive care (r=0.33/r=0.41)

All correlations were significant at the p<0.01 level (two-tailed)

Fordham et al.[43]The Family Support Scale (FSS)

All subscales of MPOC-56 were significantly and positively related to the ‘professional services’ FSS subscale, indicating that families who said they experienced good care also reported good support from professionals.

Enabling and partnership (r=0.34)

Providing general information (r=0.33)

Providing specific information (r=0.33)

Co-ordinated and comprehensive care (r=0.42)

Respectful and supportive care (r=0.32)

All correlations were significant at the p<0.01 level (two-tailed)

King et al.[1]Client Satisfaction Questionnaire (CSQ)

Pearson correlation coefficients between MPOC subscales and the CSQ obtained during the development of MPOC. Correlations are reported from field testing and from a reliability study respectively:

Enabling and partnership (r=0.64**/r=0.69**)

Providing general information (r=0.40**/r=0.36*)

Providing specific information (r=0.43**/r=0.24)

Co-ordinated and comprehensive care (r=0.61**/r=0.65**)

Respectful and supportive care (r=0.52**/r=0.63**)

*p<0.05; **p<0.01

Discussion

The field of developmental disability has come a long way in the past 20 years in terms of our understanding of both the family of MPOC measures and how MPOC can be used to inform the provision and evaluation of FCS. The family of MPOC measures (MPOC 56, 20, SP) has been used to measure parents' and service providers' perceptions of FCS outside the children's treatment centre focus, showing a far-reaching use of MPOC beyond its original design. This family of measures has also been shown to be valid and reliable in numerous European languages including Swedish, Norwegian, Dutch, and Finnish. All three of the main measures have been used to measure change in people's perceptions over time. In terms of FCS, it is clear that clinicians are perceived as doing an excellent job of providing care that is respectful and supportive, co-ordinated and comprehensive, and that enables partnerships. This has been the perception of parents about their service providers as well as service providers' perceptions about themselves. It has been made clear, though, that service providers can do an even better job of considering the whole child and family when providing services.

For both parents and service providers, providing general information was always ranked lowest. Service providers are busy and have significant demands placed on them, not only to provide excellent family-centred services, but also to see large numbers of children and families. Often it takes an entire session to work on goals and discuss specific therapeutic home programming recommendations with parents. There is often little time available to discuss general information. While service providers can make every effort to take this extra step in ‘providing general information’, this will not always be possible. An information board or a website that is accessible to all families where parents can find the answers to general questions such as ‘Where can I find accessible swimming lessons for children with CP?’, ‘Is there anyone who specializes in haircuts for children with autism?’, or ‘Where can my partner and I get counselling to help us deal with our child's diagnosis?’ might help to improve service providers' provision of general information.

While a significant amount of knowledge has been gained over the past 20 years about how MPOC functions and about how MPOC informs FCS, there are still questions to be answered. Some questions of interest are: (1) How does MPOC perform in Eastern cultures? In other words, to what extent is the content of the measure rooted in specific socio-cultural assumptions? (2) How does MPOC perform in developing countries? What modifications (if any) are needed?

How does MPOC perform in Eastern cultures?

In our review of the literature, one study used MPOC-20 to evaluate FCS in an early intervention programme in Singapore.[38] In that study, the authors found that four of the five factors (enabling and partnership, provision of general information, provision of child specific information, and respectful and supportive care) and 16 of the 20 items were relevant to that Asian context. Factors in this review were ranked differently that what is typically found in North American or European studies. Provision of specific information was ranked highest, followed by respectful and supportive care, enabling and partnership, and providing general information.[38]

This review was interesting in that it also included a qualitative component. In parent discussions, it was reported that MPOC did not attend enough to ‘parent self-care’ by, for example, provision of parent-to-parent support as a way for parents to share grief, interests, information, and resources.[38] In the Asian context in this review, ‘self-care’ was considered to be an important part of the caregiving service.

Tang et al.[61] used MPOC-SP to evaluate family-centred practices in that same early intervention programme in Singapore. MPOC-SP was completed by 213 service providers including teachers, therapists, psychologists, and social workers who provided intervention to children under the age of 6 years. MPOC-SP factors were ranked similarly to what is typically observed in Western studies with treating people respectfully ranked first, followed by communicating specific information, showing interpersonal sensitivity, and providing general information; however, only 19 of the 27 items were retained following a factor analysis,[61] suggesting that some items did not apply to the Asian setting. The authors reported that MPOC-SP was an adequate cross-cultural measure of FCS in Singapore and the 19 items used were deemed universally applicable in reflecting the practice of providing FCS.[61]

Overall, findings from the above-mentioned studies suggested that MPOC-20 and MPOC-SP show promise as sound measures of FCS in an Asian setting. Parts of both MPOC-20 and MPOC-SP were different in Singapore.[38] Further exploration into how MPOC performs in both Asian and other Eastern settings would be of benefit. Pairing MPOC with a qualitative component in those studies would help to identify which, if any, components of FCS are missing from MPOC in those cultures.

How does MPOC perform in developing countries?

In the only study using MPOC to evaluate the provision of FCS in a developing country, Saloojee et al.[7] examined the extent to which MPOC-20 needed to be adapted to be relevant for disadvantaged South African settings. In rural South Africa at the time of the study, therapy was available only on a monthly basis, functional literacy of parents was low, and caregivers had little or no experience of completing questionnaires and were unfamiliar with being asked for their opinions.[7] The measure was translated into six South African languages and two items were added to include the important component of home programming used in therapy in South Africa.[7] Language was simplified and references to written information were removed in an attempt to make the measure more relevant to public hospitals in this setting.[7] The eight-item modified MPOC-8(SA) was neither reliable nor valid in the new setting, but the authors felt it was a useful starting point in the development of a new measure for use in impoverished communities.[7]

In their discussion, the authors identified several difficulties with using MPOC in a disadvantaged South African setting – issues that are relevant and important to consider in any context other than developed western countries. One such struggle was vocabulary. The African languages used did not always have the same range of vocabulary to distinguish between items (e.g. ‘to a very great extent’ and ‘to a great extent’) as are used in English. Also, some questions were difficult for respondents to understand as they were phrased in ways that were unfamiliar to them.[7] Another struggle was related to the concept of scaling. Living in impoverished communities, many of the caregivers who were interviewed for this study had little if any experience of the concept of making the discriminative distinctions that are required to complete MPOC.[7]

In addition to those difficulties, several fundamental differences between impoverished African communities and the Western settings in which MPOC is typically used were identified. For example, in Africa, a traditional approach to service delivery is typically used. Caregivers are not often asked for their opinions or given choices about their child's treatment plan.[7] Families in rural South Africa also receive services infrequently (once per month) and typically by single therapists, not in multidisciplinary teams. Thus, items relating to co-ordinated and comprehensive care and providing specific information were not relevant in this context.[7] While this was true, the authors reasoned that some of the underlying concepts of MPOC, specifically providing respectful and supportive care and providing general information and advice, were still relevant in the South African context, indicating that some interpersonal aspects of care may be universally important, regardless of the setting.[7] Finally, in the focus groups conducted in this study, caregivers identified practical factors, such as the provision of assistive devices, food supplements, and nappies, in addition to help finding schools and accessing welfare grants as being important to their care.[7] Based on the environment and culture, additional factors need to be considered when assessing the provision of FCS in disadvantaged settings.

Although the South African study by Saloojee et al.[7] does provide a good starting point for future research, we cannot reliably comment on how MPOC functions in developing countries based on this single study. Authors wishing to use MPOC in developing regions should consider all components of that region's culture, language, expectations, and practices and adapt the measure accordingly. It is important to consult with community members, including parents, in making those determinations. Focus groups or informal interviews may be of particular benefit to researchers working in this area.

Conclusions

Over the past 20 years a lot has been learned about MPOC and about FCS both nationally and internationally. We now know that MPOC is a robust measure that can be used to measure FCS in children's treatment centres, but also in various other settings. We also know that MPOC is a valid and reliable tool in several languages in addition to English. We have seen that MPOC can be used to measure change over time in various ways. In terms of FCS, we have learned more about what is important to parents (respectful and supportive care) and areas in which we can improve the family-centredness of our services (providing general information).

Most authors in the studies we reviewed felt that MPOC was a strong measure with good psychometric properties. MPOC was most often recommended as a tool for conducting programme and service provider performance evaluations, and for research initiatives. It is our hope that researchers will continue to use MPOC as a measure of FCS and that more research will be undertaken to examine the concept of FCS in Eastern cultures and in developing countries.

Ancillary