Available via license: CC BY 4.0
Content may be subject to copyright.
RESEARCH ARTICLE
Transcultural adaptation and validation of the
Serbian version of Functional Assessment of
Chronic Illness Therapy—Treatment
Satisfaction—Patient Satisfaction (FACIT-TS-
PS) questionnaire
Ivana RadovicID
1
*, Igor Krdzic
2
, Ana Jovanovic
3
, Danka VukasinovicID
3
, Ivan Soldatovic
4
,
Masa PetrovicID
5,6
, Ana Tomic
5
, Tanja Jesic-Petrovic
7
, Aleksandar Matejic
8
,
Bojana Salovic
5
, Ilic-Zivojinovic JelenaID
3
1Department of Pretransfusion Testing, Blood and Blood Products Issuing and Heamovigilance, Institute for
Blood Transfusion of Serbia, Belgrade, Serbia, 2Department of Colorectal Surgery, University Clinical
Hospital Center Zvezdara, Surgery Clinic “Nikola Spasić”, Belgrade, Serbia, 3Faculty of Medicine, Institute of
Hygiene and Medical Ecology, University of Belgrade, Belgrade, Serbia, 4Faculty of Medicine, Institute of
Medical Statistics and Informatic, University of Belgrade, Belgrade, Serbia, 5Faculty of Medicine, University
of Belgrade, Belgrade, Serbia, 6Center of Excellence, Institute for cardiovascular diseases “Dedinje”,
Belgrade, Serbia, 7Public Health Care Center Doboj, Doboj, Bosnia and Herzegovina, 8Department of
plastic and reconstructive surgery, Institute for Orthopedic Surgery “Banjica”, Belgrade, Serbia
*ivanaradovic2@gmail.com
Abstract
Objective
Transcultural adaptation and validation of FACIT-TS-PS questionnaire to Serbian language.
Methods
Standard forward and backward translation from English to Serbian language was per-
formed. Pilot testing of FACIT-TS-PS was conducted on 12 patients with a confirmed diag-
nosis of malignant tumor. The study included 154 patients with malignant disease. The
Questionnaire of Patient Satisfaction was used as a validated tool to evaluate concurrent
validity of FACIT-TS-PS questionnaire. Reproducibility was tested on 30 subjects who
answered the questionnaire for the second time two weeks later.
Results
Three FACIT-TS-PS subscales (Physician Communication, Treatment Staff Communica-
tion and Nurse Communication) demonstrated satisfactory construct validity using Cron-
bach’s alpha, the remaining two subscales (Technical Competence and Confidence &
Trust) showed high ceiling effect. Treatment Staff Communication subscale showed large
floor effect. Concurrent validity was demonstrated by correlation with the two dimensions of
the Questionnaire of Patient Satisfaction. Satisfactory reproducibility was demonstrated on
30 patients who filled the questionnaire for the second time two weeks after initial interview.
PLOS ONE
PLOS ONE | https://doi.org/10.1371/journal.pone.0294339 November 15, 2023 1 / 11
a1111111111
a1111111111
a1111111111
a1111111111
a1111111111
OPEN ACCESS
Citation: Radovic I, Krdzic I, Jovanovic A,
Vukasinovic D, Soldatovic I, Petrovic M, et al.
(2023) Transcultural adaptation and validation of
the Serbian version of Functional Assessment of
Chronic Illness Therapy—Treatment Satisfaction—
Patient Satisfaction (FACIT-TS-PS) questionnaire.
PLoS ONE 18(11): e0294339. https://doi.org/
10.1371/journal.pone.0294339
Editor: Mohammad Nusair, Nova Southeastern
University / Yarmouk University, UNITED STATES
Received: July 24, 2023
Accepted: October 30, 2023
Published: November 15, 2023
Copyright: ©2023 Radovic et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the paper and its Supporting information
files.
Funding: The authors received no specific funding
for this work.
Competing interests: The authors have declared
that no competing interests exist.
Conclusion
The Serbian version of FACIT-TS-PS with the omission of Treatment Staff Communication
subscale could be used as a valid instrument to assess patient and treatment satisfaction in
chronically ill patients in the Serbian population. Omission of Treatment Staff Communica-
tion subscale is necessary because it contains questions not relevant for patients in Serbian
healthcare system.
Introduction
Patient ratings of health care are an integral component of patient-centered care [1]. There are
two major types of patient-reported health care ratings: patient satisfaction and patient reports
of their actual experiences. Patient satisfaction includes patient concerns about their disease
and its treatment, issues of treatment affordability and financial burden for the patient, com-
munication with health care providers, access to services, satisfaction with treatment explana-
tions, and confidence in their physician. Patient reports of their actual experiences with health
care services are often regarded as more specific, actionable, understandable, and objective
compared to general ratings alone [2].
It is often very difficult to completely understand a patient satisfaction regarding health ser-
vices. Both care-related and non-service factors play a significant role in users’ health care per-
ception. Elements linked to care itself combined with those unrelated to the provision of
services can have a substantial impact on how people perceive their overall experience of
receiving medical care, even when the treatment’s outcome is sufficient [3,4].
The most extensively studied possible indicators of patient satisfaction are healthcare ser-
vice-quality factors like medical practitioner’s competence, their experience and education,
and treatment outcomes, which have a significant and mostly beneficial effect [5–7]. Non-ser-
vice factors, such as political support and cultural change, can play into patient satisfaction
with changes to improve the quality of medical services [8].
Patient-related factors like education and overall health status can also have an impact on
patient satisfaction scores, [9] but even the influence of these variables can be modified with
certain medical practice determinants, such as good physician-patient communication, inter-
personal skills and meeting the patient’s pre-visit expectations [10,11].
The assessment of satisfaction has evolved into a continuous process that periodically
informs physicians and hospital management how health service is being delivered and if
patient expectations are being met and fulfilled [12]. This highlights the importance of
research on which aspects and determinants of health care have the greatest impact on patient
satisfaction that can potentially contribute to public health policymaking [13].
From a clinician’s perspective, evaluating what makes patients satisfied with health institu-
tions and services is very important as well, as it is also relates to the extent to which patients
comply with the recommended medical intervention or treatment [14]. Furthermore, satisfied
patients tend to take a more active role in their treatment and are more likely to continue treat-
ment in a certain institution, keep the same health insurance provider, and are more accepting
of the healthcare system in general [14–16]. In this way, patient satisfaction could increase sur-
vival rates in certain groups of patients, primarily those suffering from cancer, but also other
chronic diseases that require long-term treatment [17].
The aim of this study is to validate Functional Assessment of Chronic Illness Therapy—
Treatment satisfaction—Patient satisfaction (FACIT-TS-PS) measure [18,19]. This
PLOS ONE
Transcultural adaptation and validation of the Serbian version of FACIT-TS-PS questionnaire
PLOS ONE | https://doi.org/10.1371/journal.pone.0294339 November 15, 2023 2 / 11
questionnaire is a part of the FACIT system, a collection of measures and symptom indicators
primarily focused on cancer and other chronic diseases. The FACIT system initially began
measuring the Functional Assessment of Cancer Treatment (FACT-G) and since then, addi-
tional scales and indicators to cover other conditions and treatment-related aspects have been
added. Each FACIT scale or index is specific enough for clinically relevant issues but still
allows comparisons between patients with different chronic illnesses if needed (available at
www.facit.org).
Method
Questionnaires
FACIT-TS-PS is a self-administered questionnaire developed and validated by Peipert et al.
[18] which measures multiple aspects of patient satisfaction including communication, trust
and overall ratings. It is currently available in 7 different languages and validated in the US
and Mexican patient population [18,19]. Both countries have very distinct healthcare systems.
The Mexican public healthcare system is fully or partially subsidized by the federal govern-
ment, bearing a strong resemblance to the Serbian healthcare system [20]. Contrarily, the US
healthcare is mainly provided by private sector healthcare facilities and paid for by a combina-
tion of public programs, private insurance and out-of-pocket payments [21]. In addition, both
Mexico and Serbia are considered as upper-middle-income economies, contrary to the US
[22]. The FACIT-TS-PS consists of 26 items organized in 5 domains: Physician Communica-
tion PC (12 items), Treatment Staff Communication TSC (4 items), Technical Competence
TC (3 items), Nurse Communication NC (3 items), Confidence & Trust CT (4 items), and 3
questions treated as individual items which are not included in any summary scores. The ques-
tionnaire is designed to be completed by patients 18 years and older with a chronic illness who
are currently undergoing treatment. The questionnaire aims to evaluate their satisfaction in
the last seven days. The 26 items are scored on a 4 point Likert scale (0 = No, not at all, 1 = Yes,
but not as much as I wanted, 2 = Yes, almost as much as I wanted, 3 = Yes, and as much as I
wanted). Of the three individual items, two items are scored on 3 point Likert scale (0 = No,
1 = Maybe, 2 = Yes) and the third individual item is scored on 5 point Likert scale 5 (0 = Poor,
1 = Fair, 3 = Good, 4 = Very Good, 5 = Excellent). Domain scores are calculated as the sum of
all individual items’ scores, multiplied by the number of items in the domain, and divided by
the number of the items answered [23].
For an assessment of patients’ satisfaction the Questionnaire of Patient Satisfaction (QPS) is
widely used in Serbia. QPS is a 20 item questionnaire that was designed by the Institute of Pub-
lic Health of Republic of Serbia “Dr Milan Jovanovic Batut” and validated by Vukovićet al.
[16]. The questionnaire is composed of 5 items assessing demographic and socio-economic
indicators, 3 items regarding information on whether the patient has a personal GP, the fre-
quency of visits to a GP, and the place where the patient receives advice from nurses regarding
healthy lifestyles, and 12 items that aim to evaluate patient satisfaction. Ten of the items are
scored on a 3 point Likert scales, and two items on a 5-point Likert scale. The QPS evaluates
two domains: patient satisfaction with medical staff and contextual patient dissatisfaction. The
scores for each domain is calculated as the sum of the number of points for each individual
item multiplied by the given component loading for that item [16].
Translation and cultural adaptation
The translation of FACIT-TS-PS was conducted following the standard FACIT translation
methodology and internationally accepted methodology for cross-cultural adaptation and vali-
dation of questionnaires. The forward translation from English into Serbian was performed by
PLOS ONE
Transcultural adaptation and validation of the Serbian version of FACIT-TS-PS questionnaire
PLOS ONE | https://doi.org/10.1371/journal.pone.0294339 November 15, 2023 3 / 11
two translators, working independently from one another. The third translator reviewed the
English version and two translations into the Serbian language. A fourth translator performed
a back translation from Serbian into English. Then, the back translation was reviewed by the
translation project team. A team of clinical experts provided feedback on the acceptability of
the forward and back translation. All versions of the questionnaire were submitted to the
licence holder.
Pilot testing
Pilot testing of the pre-final Serbian version of the questionnaire was performed in February
2019 on 12 randomly selected patients with a confirmed diagnosis of malignant disease, who
were Serbian native speakers, able to read and write and give verbally informed consent.
Patients completed the FACIT-TS-PS and the Patient Interview form prepared by FACIT
organization. Patients were asked to read all of the questions, even those that did not seem rele-
vant, in order to evaluate the wording of the questions and statements. None of the patients
found the questions difficult to understand, offensive, irrelevant, disturbing or upsetting. No
major challenges occurred during the pilot testing. The data from pilot testing were submitted
and approval was obtained from FACIT-TS-PS questionnaire licence holder.
Study subjects
The study was conducted from September 1
st
2019 until Jun 30
th
2020 at the University Clinic
for Surgery “Nikola Spasić” of Clinical Center Zvezdara, in Belgrade, Serbia. During the period
from April 1st to May 29th 2020 the Clinical Center Zvezdara functioned as a COVID hospital,
and did not accept any other patients. During this period patient recruitment and data collec-
tion were temporally suspended. It included 154 patients, recruited by availability that were
hospitalized or were treated in the outpatient setting. Inclusion criteria were age between 18
and 70, diagnosis of any type of cancer regardless of a stage and previous or current treatment
modality, and more than 6 months of life expectancy. All subjects were Serbian native speakers
and were able to communicate. Exclusion criteria were presence of cognitive impairment or
psychosis. The patients completed the questionnaires by themselves and for those who had
visual, literal, or some other impairment, a trained interviewer was provided.
All the patients signed a written consent form. The study was approved by the Ethics Com-
mittee of the Medical Faculty University of Belgrade (No 2650/X-16).
Construct validity
Internal consistency, measured by Cronbach’s alpha coefficient [24], evaluates if all domains
of an instrument measure the same construct. Values above 0.60 were considered satisfactory,
and above 0.70 ideal.
Concurrent validity was tested by correlating the FACIT-TS-PS subscales and total score
with both dimensions of the QPS. Spearman correlation coefficient was used.
Reliability
Thirty subjects filled the FACIT-TS-PS questionnaire for a second time two weeks after the ini-
tial interview. We explored test-retest reliability by Related-Samples Wilcoxon Signed Rank
Test and Pearson correlation coefficient. Interpretation of values were as follows: 0.90–1.00 a
very strong correlation, 0.70–0.89 a strong correlation, 0.40–0.69 a moderate correlation, 0.10–
0.39 a weak correlation and <0.10 a negligible correlation, p<0.05 was considered statistically
significant [25].
PLOS ONE
Transcultural adaptation and validation of the Serbian version of FACIT-TS-PS questionnaire
PLOS ONE | https://doi.org/10.1371/journal.pone.0294339 November 15, 2023 4 / 11
Data analysis
Results are presented as count (%), means±standard deviation or median (25
th
Percentile-75
th
Percentile) depending upon data type and distribution. Normality of distribution was assessed
by Kolmogorov–Smirnov test and by visual analysis of histogram of frequencies and Q-Q plot.
Data were analysed using the statistical package SPSS (Statistical Package for the Social Sci-
ences) v.29.0 (IBM Corp., Armonk, USA).
Results
Socio-demographic and clinical characteristics of subjects
The main characteristics of the study sample are presented in Table 1. Approximately half of
the subjects were male. On average, patients included were elderly (�65 years old) and slightly
overweight (BMI�25). The majority of subjects were married and had completed primary or
secondary school. Colorectal cancer was the most prevalent diagnosis and patients in all stages
of disease were included. From the study population, more than half of patients had previously
undergone a classic surgery and nearly a quarter had previously undergone laparoscopic sur-
gery. Around 17% received radio and chemotherapy. Complications were rare. The majority
of patients were hospitalized for more than 10 days, and a quarter was hospitalized during the
study.
Descriptive statistics of FACIT-TS-PS
Measures of central tendency and dispersion, internal consistency, floor and ceiling effects for
subscales of FACIT-TS-PS are displayed in Table 2. Internal consistency expressed by Cron-
bach’s Alpha is high in subscales PC and TSC and adequate in subscale NC. Internal consis-
tency for TC and CT subscales is low. High ceiling effect is present in this two scales, also.
High floor effect is observed in TSC subscale. Three items, which are not included in any sum-
mary scores, had the following median, 25
th
percentile and 75
th
percentile: TS38 Would you
recommend this clinic or office to others? 2 (2–2), TS39 Would you choose this clinic or office
again? 2 (2–2) TS40 How do you rate the care you received? 4 (4–4). No subject had minimum
score for aforementioned questions, and percentages of subjects with maximum score were
98.7%, 98.1% and 74.7% respectively.
Construct validity
We examined the influence of item deletion on internal consistency (Table 2). In the PC sub-
scale, if items “TS11 Did your doctor(s) explain the possible side effects or risks of your treat-
ment?” and “TS28 Did you have enough time to make decisions about your health care?” are
omitted higher internal consistency can be achieved (0.864 and 0.870). Similar results were
observed in the NC subscale, if item “TS32 Did your nurse(s) show genuine concern for you?”
was deleted Cronbach’s alpha would rise to 0.780. In contrast, the deletion of items would not
raise internal consistency of the TC and CT subscales.
Concurrent validity
Concurrent validity was tested by Spearman correlation coefficient between subscales and
total score of FACIT-TS-PS and two dimensions of the QPS (Table 3.). Scores obtained in the
PC and CT subscales as well as the FACIT-TS-PS total score correlated positively, weakly with
dimension 1, patient satisfaction with medical staff and negatively with dimension 2, contex-
tual patient dissatisfaction. No correlation between TSC, TC and NC sub scores and the QPS
were observed.
PLOS ONE
Transcultural adaptation and validation of the Serbian version of FACIT-TS-PS questionnaire
PLOS ONE | https://doi.org/10.1371/journal.pone.0294339 November 15, 2023 5 / 11
Reproducibility
Reproducibility of the FACIT-TS-PS questionnaire was tested on 30 subjects who answered
the questionnaire for the second time two weeks later. Median, 25
th
percentile and 75
th
percen-
tile of subscales’ and total score for test and retest are presented in Table 4. No significant dif-
ference between scores was confirmed by Related-Samples Wilcoxon Signed Rank Test. The
reproducibility was high for PC, TSC, TC subscale and total score, which showed strong (TSC
Table 1. Socio-demographic and clinical characteristics of study subjects.
N (%)/ mean±sd
Male gender 85 (55.2)
Age (yrs.) 67.8±10.0
Body height (cm) 171.1±9.2
Body mass (kg) 74.9±14.9
BMI (kg/m2) 25.5±4.4
Marital status
single 7 (4.5)
married 104 (67.5)
divorced 14 (9.1)
widowed 29 (18.8)
Education level
primary 27 (17.5)
secondary 84 (54.5)
high/university 39 (25.3)
no formal education 4 (2.6)
Type of cancer
duodenal cancer 1 (0.6)
hepatic cancer 3 (1.9)
colorectal cancer 131 (85.1)
pancreatic cancer 5 (3.2)
gastric cancer 11 (7.1)
gallbladder cancer 3 (1.9)
Stage of cancer
I 18 (32.1)
II 16 (28.6)
III 14 (25)
IV 8 (14.3)
Type of treatment
classic surgery 85 (55.2)
laparoscopic surgery 36 (23.4)
no surgery 33 (21.4)
Radiotherapy and chemotherapy before 3 (1.9)
Radiotherapy and chemotherapy after 23 (14.9)
Complication 13 (8.4)
Hospitalization 38 (24.7)
Duration of hospitalization
<5 days 25 (16.2)
5–10 days 60 (39)
>10 days 69 (44.8)
https://doi.org/10.1371/journal.pone.0294339.t001
PLOS ONE
Transcultural adaptation and validation of the Serbian version of FACIT-TS-PS questionnaire
PLOS ONE | https://doi.org/10.1371/journal.pone.0294339 November 15, 2023 6 / 11
and total score) and moderate (PC and TC) highly statistically important linear correlation of
test-retest results and good for NC subscale (moderate statistically important linear correla-
tion). Only CT subscale presented with below expected reproducibility (r = 0.124, p = 0.515).
Discussion
According to the data published by the Institute of Public Health of Serbia “Dr Milan Jovano-
vic Batut”, malignant diseases were the second leading cause of death before the start of the
COVID-19 pandemic [26]. The annual number of newly diagnosed malignant cases was 41419
Table 2. Descripitve statistics, celling and floor effects of FACIT-TS-PS.
Median (25
th
Perc-75
th
Perc)
item average, min,
max
Cronbach’s Alpha Cronbach’s Alpha del
interval
Floor effect
(%)
Ceiling effect
(%)
PC 31 (26–34) 28.76 (6–36) 0.860 0.835–0.870 0 19.5
TSC 0 (0–4) 2.58 (0–12) 0.921 0.885–0.906 62.3 9.1
TC 9 (9–9) 8.78 (6–9) 0.230 0.146–0.211 0 87.7
NC 9 (7–9) 7.61 (0–9) 0.728 0.568–0.780 3.2 55.8
CT 12 (12–12) 11.63 (7–12) 0.372 0.224–0.348 0 78.6
FACIT-TS-PS total
score
61 (54–66) 59.36 (29–78) 0 2.6
PC- Physician Communication, TSC- Treatment Staff Communication, TC- Technical Competence, NC- Nurse Communication, CT- Confidence and Trust
https://doi.org/10.1371/journal.pone.0294339.t002
Table 3. Concurrent validity (Spearman correlation coefficient) of FACIT-TS-PS.
PC TSC TC NC CT FACIT-TS-PS total score
Dimension 1, patient satisfaction with medical staff .167*
0.041
0.020 0.132 0.133 .196*
0.016
.161*
0.048
Dimension 2, contextual patient dissatisfaction -.170*
0.038
-0.019 -0.139 -0.095 -.198*
0.015
-.164*
0.045
PC- Physician Communication, TSC- Treatment Staff Communication, TC- Technical Competence, NC- Nurse Communication, CT- Confidence and Trust
*p<0.05
https://doi.org/10.1371/journal.pone.0294339.t003
Table 4. Reproducibility of FACIT-TS-PS subscales.
FACIT-TS-PS subscales test score retest score p
a
r
b
PC 33 (31–36) 33 (29–36) 0.755 0.637**
TSC 1 (0–7) 2 (0–10) 0.721 0.806**
TC 9 (9–9) 9 (9–9) 0.317 0.695**
NC 9 (7–9) 9 (7–9) 0.552 0.406*
CT 12 (12–12) 12 (12–12) 0.589 0.124
FACIT-TS-PS total score 63 (57–72) 66 (57–72) 0.684 0.799**
a
Related-Samples Wilcoxon Signed Rank Test
b
Pearson correlation coefficient
** p<0.01
*p<0.05
PC- Physician Communication, TSC- Treatment Staff Communication, TC- Technical Competence, NC- Nurse Communication, CT- Confidence and Trust
https://doi.org/10.1371/journal.pone.0294339.t004
PLOS ONE
Transcultural adaptation and validation of the Serbian version of FACIT-TS-PS questionnaire
PLOS ONE | https://doi.org/10.1371/journal.pone.0294339 November 15, 2023 7 / 11
for 2020, 22110 (53.4%) of whom were male. The majority of newly diagnosed cases belonged
to the elderly group, 63.3% and 54.7%, males and females above the age of 65, respectively
[27]. Our study sample had similar gender and age distribution; however there is a bias toward
colorectal cancer in our sample. In the Serbian population, the colon and rectum are the sec-
ond leading site of the newly diagnosed cancer cases [27].
Internal consistency of the FACIT-TS-PS was good for PC and TSC subscales and accept-
able for NC subscale. On the other hand, TC and CT subscales had very low internal consis-
tency. The English version of FACIT-TS-PS showed adequate internal consistency between
0.72–0.95 [18]. The Arabic version of FACIT-TS-PS had high internal consistency for all sub-
scales (0.854–0.966), except TSC (0.499) [28]. TC and CT subscales in our study had a very
prominent ceiling effect, and both had a floor effect of zero. This may be a consequence of cul-
tural influence. Our subjects were elderly and three quarters of them had completed secondary
education or less. This population group, in Serbian society, usually has absolute trust in their
physician and seldom questions physician’s decisions. Better adherence to prescribed therapy
among older patients was documented in culturally very similar neighbouring population
[29], as well as in other populations [30]. On the contrary, almost half of the subjects in US-
based study obtained a college degree or higher [18] and they were more likely to manifest crit-
ical thinking. Therefore, the small number of subjects achieving a less than maximum score,
coupled with the small number of items (3 for TC and 4 for CT subscale), ultimately led to a
poor internal consistency for two subscales in this study.
Furthermore, a small increase in the Cronbach’s alpha coefficients can be achieved for PC
subscale if items TS11 and TS28 are deleted. The same is observed for the NC subscale if item
TS32 is deleted, but we believe that the increase is not significant enough to validate the omis-
sion of these items.
Exploration of the floor and ceiling effect showed that high ceiling effect was present in the
TC, NC and CT subscales, while the PC subscale had ceiling effect only slightly above the
desired value. In a previous study, conducted by Peipert et al. similar high ceiling effects (rang-
ing from 31.6 to 75.9) were observed [18]. This might suggest that the questionnaire is not able
to distinguish between those at the higher end of the satisfaction spectrum.
TSC was the only subscale with a very prominent floor effect (62.3%). We believe that that a
cause lies in the nature of questions as they estimate satisfaction with explanation how patient’s
health and treatment may affect his/her normal work, normal daily activities, personal rela-
tionships and emotions. These topics are seldom, if ever discussed in Serbian health care sys-
tem. Furthermore these questions relate to the communication with treatment staff. In the
Serbian health care system, patients interact with only physicians and nurses, therefore, the
questions could cause confusion to whom the questions are referring to. In addition, the over-
all structure of the Serbian healthcare system, along with existing allied healthcare professions
differs compared to other healthcare systems, like in the United States. For example, in Serbia
treatment staff refers solely to the nurses and physicians involved in patient care, while in the
US this may refer to physician assistants, nurse practitioners, medical assistants, pharmacists,
and other allied healthcare professionals alongside the patient’s assigned nurse and physician.
All of these factors could explain the exceptionally high percentage of subjects that reported a
minimal score.
To examine concurrent validity, we used QPS, which is the official questionnaire currently
used in Serbia that has also been previously validated [16]. This questionnaire gives two scores
which represent patient satisfaction with medical staff and contextual patient dissatisfaction.
Given the fact that QPS examines patient satisfaction within a primary health care environ-
ment, we believe that it is not the most optimal tool to assess patient satisfaction and treatment
satisfaction in chronic diseases, but rather it was the only questionnaire that we had at our
PLOS ONE
Transcultural adaptation and validation of the Serbian version of FACIT-TS-PS questionnaire
PLOS ONE | https://doi.org/10.1371/journal.pone.0294339 November 15, 2023 8 / 11
disposal. Nevertheless, the FACIT-TS-PS total score, showed a positive correlation with patient
satisfaction with medical staff and a negative correlation with contextual patient dissatisfac-
tion. Similar correlations were also observed for the PC and CT subscales.
We found no statistically significant difference between all the subscales and the total score
in the test-retest setting, and results correlated well for all subscales except CT. It should be
noted; however, that the majority of patients scored maximum points in test and retest for this
subscale, without any scores below 10, so therefore there was a small variability in scores and
no linear correlation could be observed.
Limitation
This study was conducted in a single hospital and all subjects were patients with malignant dis-
ease. This led to an elderly age of subjects. Furthermore, the study was conducted in a large
hospital centre to whom patients of various socio-economic status from the Belgrade area and
beyond gravitate to; however, the inclusion of patients with other chronic diseases would have
made the study stronger and contributed to less bias.
Conclusion
This study showed that the Serbian version of FACIT-TS-PS could be used as an instrument to
assess patient and treatment satisfaction in chronically ill patients in the Serbian population.
We believe that the TSC subscale should be omitted from the questionnaire because it contains
questions that are not relevant for patients in Serbia.
Supporting information
S1 Data.
(XLSX)
Acknowledgments
Great thanks are due to Jason Bradle from the FACIT organization on great help during the
translation process.
Author Contributions
Conceptualization: Igor Krdzic, Ana Jovanovic, Danka Vukasinovic, Masa Petrovic, Ilic-Zivo-
jinovic Jelena.
Formal analysis: Ivana Radovic.
Investigation: Igor Krdzic, Danka Vukasinovic.
Methodology: Ana Jovanovic, Ilic-Zivojinovic Jelena.
Project administration: Ivan Soldatovic, Ilic-Zivojinovic Jelena.
Validation: Ivan Soldatovic.
Writing – original draft: Ivana Radovic, Masa Petrovic, Ana Tomic, Tanja Jesic-Petrovic,
Aleksandar Matejic, Bojana Salovic.
Writing – review & editing: Ivana Radovic, Ivan Soldatovic, Masa Petrovic, Ana Tomic, Tanja
Jesic-Petrovic, Aleksandar Matejic, Bojana Salovic.
PLOS ONE
Transcultural adaptation and validation of the Serbian version of FACIT-TS-PS questionnaire
PLOS ONE | https://doi.org/10.1371/journal.pone.0294339 November 15, 2023 9 / 11
References
1. Rao JK, Weinberger M, Kroenke K. Visit-specific expectations and patient-centered outcomes: a litera-
ture review. Arch Fam Med. 2000; 9: 1148–1155. https://doi.org/10.1001/archfami.9.10.1148 PMID:
11115222
2. Ware JJ, Davies-Avery A, Stewart AL. The measurement and meaning of patient satisfaction. Heal
Med Care Serv Rev. 1978; 1: 3–15. PMID: 10297474
3. Joseph K, Udogwu UN, Manson TT, Ludwig SC, Banagan KE, Baker M, et al. Patient Satisfaction After
Discharge Is Discordant With Reported Inpatient Experience. Orthopedics. 2021; 44: e427–e433.
https://doi.org/10.3928/01477447-20210415-01 PMID: 34039209
4. Murasko MJ, Ivanov D V, Roe AK, Kamal RN, Amanatullah DF. Patient Satisfaction Scores Are a Poor
Metric of Orthopedic Care. Orthopedics. 2022; 45: e127–e133. https://doi.org/10.3928/01477447-
20220217-06 PMID: 35201936
5. Hemadeh R, Hammoud R, Kdouh O, Jaber T, Ammar L. Patient satisfaction with primary healthcare
services in Lebanon. Int J Health Plann Manage. 2019; 34: e423–e435. https://doi.org/10.1002/hpm.
2659 PMID: 30259563
6. Bergmann K, Kugler J, Klewer J, Schoenfelder T. Predictors of patient satisfaction after cardiac pace-
maker implantation or ICD implantation. J Card Surg. 2020; 35: 140–145. https://doi.org/10.1111/jocs.
14333 PMID: 31705826
7. Abidova A, da Silva P Alca
ˆntara, Moreira S. Predictors of Patient Satisfaction and the Perceived Quality
of Healthcare in an Emergency Department in Portugal. West J Emerg Med. 2020; 21: 391–403. https://
doi.org/10.5811/westjem.2019.9.44667 PMID: 31999247
8. Aharony L, Strasser S. Patient satisfaction: what we know about and what we still need to explore. Med-
ical Care Review. 1992. pp. 49–79.
9. Secle
´n-Palacin J, Darras C. Satisfaccio
´n de usuarios de los servicios de salud: factores sociodemogra
´-
ficos y de accesibilidad asociados: Peru
´. An Fac med. 2005; 66: 127141.
10. Trant AA, Szekely B, Mougalian SS, DiGiovanna MP, Sanft T, Hofstatter E, et al. The impact of commu-
nication style on patient satisfaction. Breast Cancer Res Treat. 2019; 176: 349–356. https://doi.org/10.
1007/s10549-019-05232-w PMID: 31025271
11. Shirley ED, Sanders DO. The orthopaedic forum:Patient satisfaction: Implications and predictors of suc-
cess. J Bone Jt Surg. 2013; 95: 1–4. https://doi.org/10.2106/JBJS.L.01048 PMID: 23677370
12. Cella D, Yount S, Sorensen M, Chartash E, Sengupta N, Grober J. Validation of the Functional Assess-
ment of Chronic Illness Therapy Fatigue Scale relative to other instrumentation in patients with rheuma-
toid arthritis. J Rheumatol. 2005; 32: 811–819. PMID: 15868614
13. Kippenbrock T, Emory J, Lee P, Odell E, Buron B, Morrison B. A national survey of nurse practitioners’
patient satisfaction outcomes. Nurs Outlook. 2019; 67: 707–712. https://doi.org/10.1016/j.outlook.2019.
04.010 PMID: 31607371
14. Marquis MS, Davies AR, Ware JEJ. Patient satisfaction and change in medical care provider: a longitu-
dinal study. Med Care. 1983; 21: 821–829. https://doi.org/10.1097/00005650-198308000-00006 PMID:
6888031
15. Donabedian A. Evaluation the quality of medical care. Milbank Mem Quart. 166AD; 44: 166–249.
16. VukovićM, GvozdenovićBS, GajićT, StamatovićGajićB, JakovljevićM, McCormick BP. Validation of
a patient satisfaction questionnaire in primary health care. Public Health. 2012; 126: 710–718. https://
doi.org/10.1016/j.puhe.2012.03.008 PMID: 22831911
17. Gupta D, Rodeghier M, Lis CG. Patient satisfaction with service quality in an oncology setting: Implica-
tions for prognosis in non-small cell lung cancer. Int J Qual Heal Care. 2013; 25: 696–703. https://doi.
org/10.1093/intqhc/mzt070 PMID: 24123242
18. Peipert JD, Beaumont JL, Bode R, Cella D, Garcia SF, Hahn EA. Development and validation of the
functional assessment of chronic illness therapy treatment satisfaction (FACIT TS) measures. Qual Life
Res. 2014; 23: 815–824. https://doi.org/10.1007/s11136-013-0520-8 PMID: 24062239
19. Herna
´ndez-Marı
´n JE, Galindo-Va
´zquez O, Costas-Muñı
´z R, Cabrera-Galeana P, Del Rosario Cabal-
lero-Tinoco M, Aguilar-Ponce JL, et al. Validation of an instrument to assess health care quality (FACIT-
TS-PS) in cancer patients. Gac Med Mex. 2020; 156: 405–412. https://doi.org/10.24875/GMM.
20005441
20. Fro
¨de CG. El Sistema De Salud En Me
´xico. El derecho a una Asist Sanit para todos. 2018; 2: 271–288.
https://doi.org/10.2307/j.ctt22p7hcq.12
21. Vladeck B. Universal health insurance in the United States: Reflections on the past, the present, and
the future. Am J Public Health. 2003; 93: 16–19. https://doi.org/10.2105/ajph.93.1.16 PMID:
12511377
PLOS ONE
Transcultural adaptation and validation of the Serbian version of FACIT-TS-PS questionnaire
PLOS ONE | https://doi.org/10.1371/journal.pone.0294339 November 15, 2023 10 / 11
22. The World Bank. World Bank Country and Lending Groups. [cited 30 Sep 2023]. https://datahelpdesk.
worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups
23. FACIT group. FACIT-TS-PS Scoring Guidelines (Version 4). 2013. https://www.facit.org/measures-
scoring-downloads/facit-ts-ps-scoring-downloads
24. Cronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrika. 1951; 16: 297–334.
https://doi.org/10.1007/BF02310555
25. Schober P, Schwarte LA. Correlation coefficients: Appropriate use and interpretation. Anesth Analg.
2018; 126: 1763–1768. https://doi.org/10.1213/ANE.0000000000002864 PMID: 29481436
26. Institute of Public Health of Serbia "Dr Milan Jovanovic. Health Statistical Yearbook of Republic Of Ser-
bia 2019. Belgrade; 2021.
27. Institute of Public Health of Serbia "Dr Milan Jovanovic. Malignant tumors in Republic of Serbia 2020.
Belgrade; 2022.
28. Bitar Z, Haddad C, Obeid S, Hallit S. Treatment satisfaction and its association with anxiety, depression
and fear of covid-19 among lebanese inpatients with schizophrenia. Pharm Pract (Granada). 2021; 19:
3–8. https://doi.org/10.18549/PharmPract.2021.3.2364 PMID: 34621448
29. Horvat O, Poprz
ˇen J, Tomas A, Paut Kusturica M, TomićZ, Sabo A. Factors associated with non-adher-
ence among type 2 diabetic patients in primary care setting in eastern Bosnia and Herzegovina. Prim
Care Diabetes. 2018; 12: 147–154. https://doi.org/10.1016/j.pcd.2017.10.002 PMID: 29089247
30. Rolnick SJ, Pawloski PA, Hedblom BD, Asche SE, Bruzek RJ. Patient characteristics associated with
medication adherence. Clin Med Res. 2013; 11: 54–65. https://doi.org/10.3121/cmr.2013.1113 PMID:
23580788
PLOS ONE
Transcultural adaptation and validation of the Serbian version of FACIT-TS-PS questionnaire
PLOS ONE | https://doi.org/10.1371/journal.pone.0294339 November 15, 2023 11 / 11
