The revised Patient Perception of Patient‐Centeredness Questionnaire: Exploring the factor structure in French‐speaking patients with multimorbidity

Abstract Background The Patient Perception of Patient‐Centeredness (PPPC) questionnaire was revised, and there is a need for the questionnaire to be tested in diverse primary care populations. Objectives This study aimed to examine the factor structure of the Revised PPPC questionnaire (PPPC‐R) in French‐speaking patients with multimorbidity. Design Secondary analysis from baseline data of the French arm of Patient‐Centered Innovations for Persons with Multimorbidity Study (PACEinMM Study). Setting and participants Participants were adult patients with multimorbidity attending primary health‐care settings. Outcome measures Exploratory factor analyses were applied to examine the factor structure of the PPPC‐R. Cronbach's alpha values were calculated to assess the internal consistency of the whole questionnaire and of each factor explored. Results There were 301 participants, mean age 61.0, 53.2% female. The PPPC‐R showed very good internal consistency, with three factors: Patient‐Centered Clinical Method (PCCM) Component 1‐Exploring the health, disease and illness experience + PCCM Component 4‐Enhancing the patient–clinician relationship (Factor 1); PCCM Component 2‐Understanding the whole person (Factor 2); and PCCM Component 3‐Finding common ground (Factor 3). There was a good internal consistency within each factor (Cronbach's α = 0.87 for 8 items in Factor 1, 0.77 for 5 items in Factor 2 and 0.87 for 5 items in Factor 3). Discussion and conclusions The French PPPC‐R factor structure was in accordance with the underpinning conceptual model and presented with three factors. Further assessment of its validity and reproducibility are needed to allow its use as a measure of patient's perception of patient‐centeredness.


| INTRODUC TI ON
There have been many innovations to improve quality of care and health-related outcomes for patients in primary health care in Canada. 1,2 Patient-centred care, a model of care that enables patients to be co-producers or co-creators of their care, is among these innovations. [3][4][5] Researchers and policymakers worldwide are working to improve patient-centred care across health-care systems. [6][7][8] Patient-centred care has been shown to enhance patient satisfaction, patient adherence and improve patient health outcomes. [9][10][11][12][13] It is essential to understand patients' perceptions and experiences with patient-centred care so that health-care providers can tailor and improve the care for these patients. Among the measures available, the Patient Perception of Patient-Centeredness (PPPC) questionnaire has been widely applied in primary care research in Canada and many other countries. [14][15][16][17][18][19][20] The original PPPC questionnaire consisted of 14 items and covered 3 interactive components of the Patient-Centered Clinical Method (PCCM) (exploring health, disease and the illness experience; understanding the whole person; finding common ground). [16][17][18][19] Recently, the PPPC questionnaire was revised, so that the revised PPPC now contains 18 items (PPPC-R), intended to map to the current Patient-Centered Clinical Method which contains four components (the original three and enhancing the patient-clinician relationship). 21 In Quebec, Canada, the French version of the PPPC questionnaire is currently used but little was known about the measure's psychometric properties. There is a need for the PPPC-R to be tested in diverse primary care populations. In this study, our focus was patients with multimorbidity who constitute a major proportion of the primary health-care patients. Multimorbidity, defined as having multiple chronic conditions, has become a primary health-care concern. 22 A systematic review on 45 studies conducted from 2007 to 2017 showed that the overall prevalence of multimorbidity was 66.1% (with multimorbidity defined as having ≥2 chronic conditions), and 44.2% (with multimorbidity defined as having ≥3 chronic conditions) in older adults in high-income countries. 23 In the United States, the number of Americans with multimorbidity is estimated to be around 81 million by 2020. 24 In Canada, it was reported that the prevalence of multimorbidity was also significant, from around 30% to 70% in primary care settings and around 17% to 59% in the general population. 25 The prevalence of multimorbidity was also quite high in French-speaking communities. In 2016, more than 1.1 million people aged 25 or older in Quebec were having multimorbidity. 26 According to the French National Surveys, around 25% of the French population over 55 had multimorbidity (2008)(2009)(2010)(2011)(2012). 27 In a population-based trial of 5647 participants aged 55 years or older in France (2007-2009), more than 63% of the participants reported having two or more chronic conditions. 28  Therefore, this study aimed to examine the factor structure of the French revised version of the PPPC, the internal consistency of the whole questionnaire and of its factors in a context of primary care in French-speaking patients with multimorbidity.

| ME THODS
This study was a secondary analysis from the baseline data of the French arm of Patient-Centered Innovations for Persons with Multimorbidity Study (PACE in MM Study). 30 The PACE in MM study encompassed two randomized controlled trials, one in Quebec and one in Ontario, Canada, that evaluated complex interventions to improve patient-centred outcomes for patients with multimorbidity. 30 In the PACE in MM study, multimorbidity was defined as having ≥3 chronic diseases from a list of 19 self-reported chronic conditions, including hypertension, hyperlipidaemia, obesity, diabetes, chronic musculoskeletal conditions causing pain or limitation, arthritis and/or rheumatoid arthritis, osteoporosis, stomach problem (reflux, heartburn or gastric ulcer), chronic lung disease (asthma, chronic obstructive pulmonary disease, chronic bronchitis), depression/anxiety, cardiovascular disease (angina, myocardial infarction, atrial fibrillation, poor circulation in the lower limbs), heart failure (including valve problems or replacement), colon problem (irritable bowel, Crohn's disease, ulcerative colitis, diverticulosis), thyroid disorder, any cancer in the previous 5 years (including melanoma, but excluding other skin cancer), kidney disease or failure, stroke/transient ischemic attack, chronic urinary problem and chronic hepatitis.
In this study, only data from participants from Quebec, the French-speaking province of Canada, were utilized. The recruitment period for this study was from July 2016 to July 2017. Studied participants were adult patients with multimorbidity attending primary health-care settings. Exclusion criteria included severe cognitive impairment and being unable to read or write. At baseline, all participants were required to provide demographic information such as age, gender, height, weight, socio-economic status and answer questionnaires about chronic health conditions, 31 and patient-cen-

| Statistical analysis
Analysis of the data was performed using SPSS for Windows 24.0 (IBM Corp.). Continuous variables are presented as mean ± standard K E Y W O R D S factor analysis, French-speaking, multimorbidity, patient-centred, primary care, questionnaires deviation or median (range), and categorical variables as frequencies and percentages.
While the questionnaire is intended to measure patient-centeredness, there has been no previous work conducted on the factor structure of the revised measure in French-speaking patients.
Therefore, we conducted an exploratory factor analyses to explore the initial factor structure of the PPPC-R in French-speaking patients with multimorbidity in primary care in Quebec. More precisely, we carried out a principal components factor analysis of the 18 items. The number of components to be extracted was decided based on eigenvalues greater than 1 (The Scree Plot, Figure S1). As the factors were expected to be correlated, Oblimin rotation was applied. However, we also performed Varimax, which is one of the most widely used rotation methods, for comparison. 32 The minimum loading for an item to be linked to a factor was 0.30. 33,34 In case, one item was loaded into two factors, the one with higher loading value will be chosen. We calculated Cronbach's alpha values to assess the internal consistency of each factor explored through the first step.
The acceptable value for Cronbach's alpha was recommended to be at least 0.70. 35 Correlation between factors was assessed with Spearman correlation, and two-sided P values < .05 were considered significant.

| RE SULTS
There were 301 participants in this study. The mean age of the participants was 61.0 ± 10.5, 53.2% were female, 65.4% were married, and 22.6% had lower education level. (Table 1).

| The PPPC-R characteristics
Based on the Scree Plot ( Figure S1), three factors were extracted.
The 18 items were loaded into 3 factors. The factor loading matrix obtained through Oblimin rotation is presented in Table 2, and the results obtained through Varimax rotation are presented in Appendix S1 (Table S1). The number of items loaded into each factor was similar between the two rotation methods, although there were some minor differences in the loading values. Among the 18 questions, cross-loadings happened in 3 questions ( Table 2). All items in this analysis had primary loadings over 0.3.
Upon examination, the items within each of these three factors corresponded to the four components of the PCCM as follows:

| D ISCUSS I ON
In this study of 301 participants with multimorbidity, the French version of the PPPC-R showed three distinct factors with good internal Heart failure (including valve problems or replacement)
consistency. The consistency value found in this study was similar to previous studies using the previous 14-item version of this questionnaire in evaluating patient's perception of patient-centred care. 18,19,36 In this study in French-speaking patients with multimorbidity,

| CON CLUS ION
In this study in French-speaking patients with multimorbidity, the PPPC-R factor structure was in accordance with the underpinning conceptual model and presented with three factors. Further assessment of its validity, reproducibility and responsiveness is needed to allow its use as a measure of patient's perception of patient-centeredness in research and clinical care for patients with multimorbidity.

CO N FLI C T O F I NTE R E S T
All authors have no conflict of interests to declare.

E TH I C A L A PPROVA L
The PACE in MM study was approved by the Comité d'éthique de la recherche du Centre intégré universitaire de santé et de services sociaux du Saguenay-Lac-St-Jean.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available upon request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.