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Department of Medicine and Public Health, Section of Psychiatry, University of Verona, Italy
Department of Psychiatry, Academic Medical Centre, Amsterdam, The Netherlands
Institute of Preventive Medicine, Copenhagen University Hospital, Denmark
Section of Community Psychiatry (PRiSM), Institute of Psychiatry, King's College, London, UK
Clinical and Social Psychiatry Research Unit, University of Cantabria, Santander, Spain
Correspondence: Dr Mirella Ruggeri, Dipartimento di Medicina e Sanità Pubblica, Sezione di Psichiatria, Università di Verona, Ospedale Policlinico, via delle Menegone, 10, 37134 Verona, Italy. Tel: + 39 045 8074441; fax: +39 045 585871; e-mail: mruggeri {at}borgoroma.univr.it
Declaration of interest No conflict of interest. Funding detailed in Acknowledgements.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODRESULTSDISCUSSIONAPPENDIXACKNOWLEDGMENTSREFERENCES |
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Aim To report the development and reliability study of the European Version of the VSSS (VSSS-EU).
Method A sample of people with schizophrenia on the case-load of local mental health services in the five European participating countries was assessed. The VSSS-EU was administered at one site in each country at two points in time. Internal consistency and test-retest reliability were assessed and compared between the five sites.
Results The 
coefficient for the VSSS-EU total score in the
pooled sample was 0.96 (95% CI0.94-0.97) and ranged from 0.92 (95%
CI0.60-1.00) to 0.96 (95% CI 0.93-0.98) across the sites. Test-retest
reliability for VSSS-EU total score, pooled over sites, was 0.82 (95%
CI0.78-0.85) and ranged from 0.73 (95% CI0.6-0.86) to 0.93 (95% CI0.89-0.97)
across the sites.
Conclusion VSSS-EU is a reliable instrument for measuring service satisfaction in people with schizophrenia, for usein comparative cross-national research projects and in routine clinical practice in mental health services across Europe.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONAPPENDIXACKNOWLEDGMENTSREFERENCES |
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Unfortunately, there is a lack of knowledge about the extent to which patients with psychosis are satisfied with services. This seems to be due both to prejudice against such patients, believing them to be incapable of meaningfully judging the care they receive, and to methodological problems of measurement, mainly related to the difficulty of providing instruments which are acceptable to these patients.
Research in the area of satisfaction with psychiatric services has been hampered by the widespread use of many non-standardised methods, so that direct comparison between studies is usually impossible. Most studies have used instruments with few or no data regarding their validity or reliability, and investigators have frequently designed their own instruments for specific studies. As a result, findings are not generalisable (Ruggeri, 1994). In addition, although satisfaction has been demonstrated to be a multi-dimensional concept (Ware et al, 1978), instruments have often been limited to a few broad items which only enquire about one or two dimensions of mental health care. Thus not only may they fail to detect any dissatisfaction - they are inherently unable to detect the reasons for dissatisfaction.
The Verona Service Satisfaction Scale (VSSS) (Ruggeri & Dall'Agnola, 1993) is a questionnaire meant to fill this gap: it is a validated, multi-dimensional scale which measures the satisfaction of patients with mental health services. First, an 82-item version was developed: it consisted of a set of 37 items cross-setting for health services and a set of 45 items specific for mental health services. The former group of items involves aspects meant a priori to be relevant across a broad array of both medical and psychiatric settings, and was derived from the Service Satisfaction Scale (SSS-30) (Greenfield & Attkinson, 1989; Attkinson & Greenfield, 1994; Ruggeri & Greenfield, 1995). The latter group of items involves aspects which are specifically relevant in mental health settings, particularly in community-based services, such as social skills and types of intervention (e.g. admissions, psychotherapy, rehabilitation) and has been developed for the purpose by the authors of the VSSS. VSSS-82, in its versions for patients and relatives, has then been tested for acceptability, content validity, sensitivity and test-retest reliability (Ruggeri & Dall'Agnola, 1993; Ruggeri et al, 1994) in 75 patients and 75 relatives. Finally, a factor analysis was performed (Ruggeri et al, 1996). The combination of results obtained in the validation study and factor analysis gave rise to the Intermediate (VSSS-54) and the Short (VSSS-32) versions, two reliable instruments that can be easily used in everyday clinical settings. So far, the VSSS has been translated into various languages and used in studies performed in many sites in the world (Cozza et al, 1997; Parkman et al, 1997; Leese et al, 1998; Boardman et al, 1999; Clarkson et al, 1999; Henderson et al, 1999 ; Merinder et al, 1999).
The aim of this paper is to describe the development, translation, cultural validation and reliability of a new European Version of the VSSS (VSSS-EU), for use in multi-site international comparative studies.
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METHOD |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONAPPENDIXACKNOWLEDGMENTSREFERENCES |
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Five instruments were converted for use from their original language into the other study languages by: (a) accurate translation and back-translation into/from the other languages, (b) checks of cross-cultural applicability using focus groups, and (c) assessment of instrument reliability. Fuller details on the translation and cross-cultural adaptation process are given in this supplement by Knudsen et al (2000). The five instruments were the Camberwell Assessment of Need (CAN) (Phelan et al, 1995), Client Service Receipt Inventory (CSRI) (Beecham & Knapp, 1992), Involvement Evaluation Questionnaire (IEQ) (Schene et al, 1998), Lancashire Quality of Life Profile (LQoLP) (Oliver, 1991; Oliver et al, 1996) and Verona Service Satisfaction Scale (VSSS) (Ruggeri & Dall'Agnola, 1993).
The VSSS reliability results are presented in this paper, while the results for the other scales are given in other papers in this supplement (Chisholm et al, 2000 ; Gaite et al, 2000; McCrone et al, 2000; van Wijngaarden et al, 2000).
Study sites
Six partners in five European countries (The Netherlands, Denmark, England,
Spain and Italy) joined forces. The teams are located in Amsterdam,
Copenhagen, London (Centre for Economics in Mental Health, and Section of
Community Psychiatry), Santander and Verona. The criteria used to identify
study centres and the key summary characteristics of each study site are given
in Becker et al
(1999).
Case identification
Cases included in the study were adults aged 18-65 inclusive with an ICD-10
diagnosis of any of F20 to F25. Administrative prevalence samples of people
with these diagnoses were identified either from Psychiatric Case Registers
(in Copenhagen and in Verona) or from the case-loads of local specialist
mental health services (in-patients, out-patients and community). Patients
needed to have been in contact with mental health services during the 3-month
period preceding the start of the study. Thus, an administrative prevalence
sample of people with schizophrenia in contact with mental health services was
used in each site as the sampling frame. Cases identified were diagnosed using
the item group checklist (IGC) of the Schedule for Clinical Assessment in
Neuropsychiatry (SCAN) (World Health
Organization, 1992). Only patients with an ICD-10 F20 research
diagnosis were included in the study.
The exclusion criteria were: current residence in prison, secure residential services or hostels for long-term patients; co-existing learning disability (mental retardation), primary dementia or other severe organic disorder; and extended in-patient treatment episodes longer than one year. The numbers of patients finally included in the study varied from 52 to 107 between the five sites, with a total of 404.
Verona Service Satisfaction Scale - European Version (VSSS-EU)
The VSSS-EU was developed from the Italian VSSS-54 version, which was first
translated into Danish, Dutch, English and Spanish by professional
translators. The resulting four translations were then backtranslated into
Italian. The back-translations were checked by the authors of the VSSS and
compared with the original Italian version. Small discrepancies were examined
and alterations made to the Italian version in order to preserve the precise
meaning of each question, while still producing an understandable and
acceptable translation into the various languages. Specific items were changed
to adapt them to the context of each country's mental health system. When
those changes occurred, the local researchers made a list of modifications.
The next step was the focus group process, which discussed the content and the
language of the translated instruments. In the light of the comments and
recommendations, the instrument was then revised both in its original Italian
version and in each of the four translations. On the basis of the focus
groups' discussions, minor changes were made to the wording of the items, and
a further change was made by deciding to assess separately the skills and
behaviour of psychiatrists, psychologists, nurses and social workers, who in
the previous version had been assessed in pairs (psychiatrists/psychologists,
nurses/social workers) (see Appendix).
Conceptually, the items in the VSSS-EU cover seven dimensions: Overall Satisfaction, Professionals' Skills and Behaviour, Information, Access, Efficacy, Types of Intervention and Relative's Involvement. Items in the first five dimensions cover all areas belonging to Ware's taxonomy of satisfaction (Ware et al, 1983). The last two dimensions, on the other hand, examine domains that have not been assessed systematically in previous studies and have been specifically developed for the VSSS.
Each conceptual dimension of the VSSS-EU consists of a certain number of items that cover various aspects of satisfaction with services (see Appendix for a detailed description of each item) :
The VSSS-EU is designed for self-administration and can be completed without prior training. In cases of cognitive deficit, severe psychopathology or low level of literacy, a research worker may assist the patient and/or the relative by reading through the items with them. Special care must be taken to guarantee confidentiality and anonymity and, in the case of assisted administration, to stress the independence of the research worker from the clinical team. Administering the questionnaire takes 20-30 minutes.
In the VSSS-EU, subjects are asked to express their overall feeling about their experience of the mental health service they have been using in the past year.
For items 1-40, satisfaction ratings are on a 5-point Likert scale (1=terrible, 2=mostly dissatisfactory, 3=mixed, 4=mostly satisfactory, 5=excellent), presented with alternate directionality to reduce stereotypic response. Items 41-54 consist of three questions: first, the subject is asked if he/she has received the specific intervention (Question A: "Did you receive the intervention x in the last year?"). If the answer is ‘yes’, he/she is asked his/her satisfaction on a 5-point Likert scale (Question B). If the answer is ‘no’, he/she is asked Question C: "Do you think you would have liked to receive intervention x?" (6=no, 7=don't know, 8=yes). These questions permit the estimation of the subject's degree of satisfaction both with the interventions provided and with the professional's decision not to provide an intervention (if that was the case). The latter may be considered a measure of underprovision of care, from the patient's point of view.
Data management
SPSS (Version 6.1 and above) was used for data entry. Data consistency and
homogeneity were ensured by the coordinating centre (London) preparing the
SPSS templates for use at all participating sites; this ensured consistent
data structures across sites. Subsequent cross-instrument merging and analysis
was possible as the same patient/carer identifiers were used throughout the
study.
Reliability assessment procedures
Reliability testing in the EPSILON project has been conducted on several
levels, depending on the nature of the instruments involved and the way they
were administered (interviews v. questionnaires). Details on the general
methodology of the reliability study are given elsewhere in this supplement
(Schene et al,
2000).
As far as the VSSS-EU is concerned, the reliability tests have been
performed: (a) on the VSSS-EU total mean score; (b) on the mean scores of
each dimension; and (c) item by item, both for the pooled sample and across
the five sites. Three kinds of reliability tests have been used: Cronbach's
(Cronbach, 1951), to
check the internal consistency of the whole questionnaire and the different
dimensions; the intraclass correlation coefficient (ICC)
(Bartko & Carpenter, 1976),
to evaluate test-retest reliability of the VSSS-EU total mean score and
dimension mean scores; and Cohen's weighted 
(Cohen, 1968), to evaluate
test-retest reliability of single VSSS-EU items. Additional statistics
estimated were the standard errors of measurement, which were obtained from
the analysis of variance used to estimate the intraclass correlations.
Statistical analysis was performed using SPSS for Windows, release 7.5
(Norusis, 1997), the Amsterdam
-testing program, ALPHA.EXE based on Feldt et al
(1987) and EXCEL for tests of
the homogeneity of ICCs.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONAPPENDIXACKNOWLEDGMENTSREFERENCES |
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Internal consistency
Table 1 shows the mean
scores for each VSSS-EU dimension in the various EPSILON sites and the tests
of homogeneity of variance (Levene test) and of means. The latter tests are
not discussed in the present study, but will be investigated in a future
paper. Assuming that the standard error of measurement is the same in all
countries, the reliability coefficient depends on the variance in each sample.
Conversely, where standard errors of measurement do differ, sample variables
will be affected, since they are composed both of variance in true scores and
variation due to measurement error. Therefore, when computing reliability
coefficients and testing differences between samples, differences between
sites in terms of both sample variance and standard errors of measurement
should be considered.
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The variability of the scores differed across the sites, both in the VSSS-EU total mean score and in all VSSS-EU dimensions, with the exception of Overall Satisfaction and Access; therefore the lack of homogeneity across the sites for the total mean scores and most of the dimension scores may account to some extent for the degree of variability in the reliability coefficients across the sites.
Table 2 shows the
coefficients and the test for the equality of across the sites. Alpha
coefficients indicate the degree to which items exhibit a positive correlation
(internal consistency above 0.7 is considered adequate;
Bech et al, 1993).
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It should first be noted that the high degree of variability in the number
of cases is usually not due to missing values but to the fact that some items
(i.e. items on the performances of the different professionals assessed in the
VSSS, items on the relatives, items on response of the service to emergencies
during the night or at weekends) are not applicable to all patients. For this
reason, values in the VSSS-EU total mean scores have been computed for
a small number of cases only. However, they were always over 0.90 and were
similar across the sites, with the exception of Relative's Involvement. In the
VSSS-EU dimensions, coefficients ranged from 0.60 (Information
dimension, in Copenhagen) to 0.93 (Relative's Involvement dimension, in
Copenhagen) and did not differ significantly across the sites. The dimension
Access, which consists of just two items (Costs of Service and Physical
Layout) measuring different constructs, is a special case. In this dimension,
varied greatly, ranging from 0.08 (London) to 0.96 (Copenhagen), and
differed significantly across the sites. Dimensions constituted by a higher
number of items are expected to have higher values. This was true for
the dimension Professionals' Skills and Behaviour, but not for the dimension
Types of Intervention, which is not expected to have high internal
consistency, due to the wide range of different interventions explored by the
questionnaire.
On the whole, values of the pooled sample were good, with the
above-mentioned exception of the Access dimension, and ranged from 0.72
(Information) to 0.91 (Professionals' Skills and Behaviour).
Stability
The test-retest reliability was studied by considering the ratings both in
each dimension (ICC) and item by item (weighted ).
Table 3 shows the test-retest reliability for the VSSS-EU total mean score and VSSS-EU dimension scores, both in the pooled sample and at each EPSILON site. ICCs and the standard errors of measurements are reported.
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The VSSS-EU total mean score in the pooled sample shows a high degreee of reliability (0.82; 95% CI 0.78-0.85), although there are some differences between the sites, with all sites above 0.70 and three sites (Copenhagen, London and Santander) above 0.80. Each of the VSSS-EU dimension mean scores in the pooled sample had a degree of reliability ranging from 0.56 to 0.78. The reliability of the VSSS-EU dimension mean scores across the sites was over 0.50 in all cases, with the exception of the Access dimension in Santander (0.43) and the Information dimension in Amsterdam (0.49). Overall, there was some degree of variability in the ICC coefficients across the sites. This could be due either to differences in measurement errors between different sites, or to lack of homogeneity in the samples. The lower reliabilities tend to be associated with higher standard errors of measurement, and therefore lack of homogeneity in the samples is unlikely to be the explanation for differences in reliability; rather, the performance of the instrument itself differs.
Table 4 shows Cohen's
weighted for both the pooled sample and the five EPSILON sites,
calculated in each VSSS-EU item by taking the disagreements' weight to be
equal to the square of the distances. According to Landis & Koch
(1977), a coefficient
of 0.2-0.4 indicates fair agreement, 0.4-0.6 indicates moderate agreement,
0.6-0.8 indicates a substantial agreement and 0.8-1.0 indicates almost perfect
agreement, although alternative schemes are possible (see
Schene et al, 2000,
this supplement).
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In the pooled sample, all items generated coefficients from 0.4 to
0.8, indicating a moderate-substantial agreement. In the various EPSILON sites
the percentage of items with coefficients exceeding 0.4 (generally
accepted as the minimum value) ranged from 54% (Verona) to 97% (London).
A paired sample t-test on the difference between test and retest for the VSSS-EU total mean scores and dimension sub-scores revealed no significant differences, both pooled across sites and at individual sites (with the exception of Access in London and Santander, where the retest values were respectively higher and lower than the time 1 values, P <0.001), thus showing no overall tendency for patients to respond more or less favourably after an interval of time ranging from 1 to 2 weeks.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONAPPENDIXACKNOWLEDGMENTSREFERENCES |
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In the past few years, the need for a measure which could assess satisfaction with mental health services in a manner which would be correct from a methodological point of view led to the development of the VSSS (Ruggeri & Dall'Agnola, 1993). One of the most important aims during the development of the original version of the VSSS was the avoidance of methodological biases: data previously obtained on content validity, test-retest reliability and factor analysis showed that the original version measures satisfaction in a sensitive, valid and reliable way (Ruggeri & Dall'Agnola, 1993; Ruggeri et al, 1994, 1996). The present paper demonstrates that the newly developed VSSS-EU also has good psychometric properties.
The scale has an excellent overall Cronbach's (0.96), which
confirms its adequacy from the standpoint of internal consistency if it is
used as a global satisfaction measure. All dimensions except one (Access)
showed good internal consistency, as indicated by coefficients of Cronbach's
ranging from 0.72 for Information to 0.91 for Professionals' Skills
and Behaviour. The dimension with the lowest consistency (Access), made up of
two items (Cost of Service and Physical Layout), was not expected to show high
interrelatedness, because theoretically these two items are quite independent
of one another.
The test-retest data provided encouraging results. The stability of the scale was satisfactory both at dimensional level and item by item. Although there was some evidence of differing reliability between sites, which was associated with differing standard errors of measurement rather than differing homogeneity of the samples, all the individual site reliability coefficients for the total score were above 0.7. Interestingly, the lowest test-retest reliability was found in Verona, thus indicating that the translation of the scale did not affect its acceptability to patients. The overall pooled test-retest reliability for the total score was excellent at 0.82 (95% CI 0.78-0.85). Furthermore, there was no evidence of any tendency for the measurements to change systematically over time, either in the pooled sample or across the sites (with the above-mentioned exception of Access).
In conclusion, the analysis of the data presented here demonstrates that the VSSS-EU has good psychometric properties and suggests that it is a reliable instrument for measuring satisfaction with mental health services in people with schizophrenia, for use in comparative cross-national research projects and in routine clinical practice in mental health services across Europe.
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APPENDIX |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONAPPENDIXACKNOWLEDGMENTSREFERENCES |
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Overall Satisfaction (3)
Professionals' Skills and Behaviour (16)
Information (3)
Access (2)
Efficacy (8)
Types of Intervention (17)
Relative's Involvement (5)
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ACKNOWLEDGMENTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONAPPENDIXACKNOWLEDGMENTSREFERENCES |
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This study was supported by the European Commission BIOMED-2 Programme (Contract BMH4-CT95-1151). We would also like to acknowledge the sustained and valuable assistance of the users, carers and the clinical staff of the services in the five study sites. In Amsterdam, the EPSILON Study was partly supported by a grant from the National Fonds Geestelijke Volksgezondheid and a grant from the Netherlands Organization for Scientific Research (940-32-007). In Santander the EPSILON Study was partially supported by the Spanish Institute of Health (FIS) (FIS Exp. No. 97/1240). In Verona additional funding for studying patterns of care and costs of a cohort of patients with schizophrenia were provided by the Regione del Veneto, Giunta Regionale, Ricerca Sanitaria Finalizzata, Venezia, Italia (Grant No. 723/01/96 to Professor M. Tansella).
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  T. BECKER, M. KNAPP, G. THORNICROFT, H. C. KNUDSEN, A. H. SCHENE, M. TANSELLA, and J. L. VAZQUEZ-BARQUERO Aims, outcome measures, study sites and patient sample: EPSILON Study I The British Journal of Psychiatry, July 1, 2000; 177 (39): s1 - s7. [Abstract] [Full Text] [PDF]
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H. C. KNUDSEN, J. L. VAZQUEZ-BARQUERO, B. WELCHER, L. GAITE, T. BECKER, D. CHISHOLM, M. RUGGERI, A. H. SCHENE, and G. THORNICROFT Translation and cross-cultural adaptation of outcome measurements for schizophrenia: EPSILON Study 2 The British Journal of Psychiatry, July 1, 2000; 177 (39): s8 - s14. [Abstract] [Full Text] [PDF]
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A. H. SCHENE, M. KOETER, B. VAN WIJNGAARDEN, H. C. KNUDSEN, M. LEESE, M. RUGGERI, I. R. WHITE, and J. L. VAZQUEZ-BARQUERO Methodology of a multi-site reliability study: EPSILON Study 3 The British Journal of Psychiatry, July 1, 2000; 177 (39): s15 - s20. [Abstract] [Full Text] [PDF]
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P. McCRONE, M. LEESE, G. THORNICROFT, G. GRIFFITHS, S. PADFIELD, A. H. SCHENE, H. CHARLOTTE KNUDSEN, J. L. VAZQUEZ-BARQUERO, A. LASALVIA, and I. R. WHITE Reliability of the Camberwell Assessment of Need - European Version: EPSILON Study 6 The British Journal of Psychiatry, July 1, 2000; 177 (39): s34 - s40. [Abstract] [Full Text] [PDF]
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L. GAITE, J. L. VAZQUEZ-BARQUERO, A. A. ARRIZABALAGA, E. VAZQUEZ-BOURGON, M. P. RETUERTO, A. H. SCHENE, B. WELCHER, G. THORNICROFT, M. LEESE, and M. RUGGERI Quality of life in schizophrenia: development, reliability and internal consistency of the Lancashire Quality of Life Profile - European Version: EPSILON Study 8 The British Journal of Psychiatry, July 1, 2000; 177 (39): s49 - s54. [Abstract] [Full Text] [PDF]
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