1. Abstract
The Greek Home Care Satisfaction Questionnaire is a multidimensional psychometric instrument developed by Vassilis H. Aletras, Arsenis Kostarelis, Maria Tsitouridou, Dimitris Niakas, and Anna Nicolaou to measure service recipient satisfaction within publicly funded municipal home care programs in Greece. As demographic aging accelerates across industrialized societies, supporting aging in place through multidisciplinary social and domiciliary healthcare has emerged as a cornerstone of social policy. The Greek municipal home care model—locally known as Voitheia Sto Spiti ("Help at Home")—provides comprehensive, fully subsidized services comprising social work support, community nursing, and personal home aid to frail older adults and individuals with functional disabilities. Despite widespread national implementation, systematic evaluation of service efficacy from the recipient perspective historically lacked a culturally and structurally calibrated evaluation tool. The questionnaire operationalizes patient satisfaction across three core latent dimensions: Technical/Professional Competence, Interpersonal Relationship/Communication, and Overall Service Organization and Delivery.
From a psychometric perspective, the instrument introduces a rigorous methodological framework by explicitly addressing the ordinal, non-interval properties inherent in 5-point Likert-type response formats. Rather than relying on traditional Pearson product-moment correlations, the developers computed pairwise polychoric correlations to construct latent association matrices, mitigating severe attenuation bias and distortion in latent factor extraction. In an empirical validation sample of 319 community-dwelling older adults aged 65 to 90 years across five municipal home care entities in Thessaloniki, exploratory factor analysis using unweighted least squares (ULS) extraction and varimax rotation demonstrated robust construct validity. Internal consistency was demonstrated through conventional Cronbach's alpha and ordinal standardized alpha coefficients, confirming exceptional scale reliability across all extracted subscales. The instrument constitutes a standard tool for health services research, gerontological program evaluation, and clinical quality auditing in public domiciliary care systems.
2. Keywords
Patient satisfaction, Home care, Polychoric correlations, Exploratory factor analysis, Gerontology, Health services research, Psychometrics, Domiciliary care, Municipal health services, Scale validation
3. Authors
The Greek Home Care Satisfaction Questionnaire was conceptualized, developed, and psychometrically validated by a multidisciplinary team of health economists, social policy researchers, and healthcare management experts:
- Vassilis H. Aletras, PhD — Department of Business Administration, University of Macedonia, Thessaloniki, Greece. Email: [email protected]
- Arsenis Kostarelis, MSc — School of Social Sciences, Hellenic Open University, Patras, Greece. Email: [email protected]
- Maria Tsitouridou, MSc — School of Social Sciences, Hellenic Open University, Patras, Greece. Email: [email protected]
- Dimitris Niakas, PhD — Faculty of Social Sciences, Hellenic Open University, Patras, Greece. Email: [email protected]
- Anna Nicolaou, PhD — Department of Business Administration, University of Macedonia, Thessaloniki, Greece. Email: [email protected]
4. Purpose
The fundamental purpose of the Greek Home Care Satisfaction Questionnaire is to furnish an empirically robust, culturally grounded, and structurally tailored measurement instrument to evaluate user-perceived quality in municipal domiciliary health and social support services. Prior to its construction, public health authorities and social service administrators in Greece lacked a standardized, methodologically validated scale to appraise the outcomes of community-based interventions targeted at dependent older adults. While various Anglo-American and Northern European satisfaction instruments existed within the broader health services literature, direct translation and administrative transposition were conceptually and psychometrically problematic.
International instruments were predominantly calibrated to operate within market-driven or social insurance-based healthcare architectures. Such systems frequently incorporate out-of-pocket co-payments, private managed care networks, insurance billing disputes, or disparate occupational delineations of visiting personnel. In sharp contrast, the Greek municipal home care infrastructure is a universal, tax- and European Social Fund-supported model operated directly by local government authorities. Within this model, services are delivered at zero marginal cost to the recipient by integrated teams typically consisting of a qualified social worker, a registered or practical nurse, and domestic family care aides. The instrument was intentionally engineered to capture the operational realities of this non-market, multi-professional service encounter, providing actionable evaluative intelligence for municipal authorities, national policymakers, and clinical directors.
From an applied perspective, the tool functions across multiple evaluative domains:
- Quality Assurance and Clinical Governance: It allows municipal program managers to systematically monitor service quality, pinpoint operational bottlenecks, and identify specific gaps in clinical nursing, social casework, or domestic assistance.
- Resource Allocation and Policy Reform: By quantifying client appraisals across multidimensional domains, health economists and policymakers can examine the comparative effectiveness of different municipal programs and allocate public funding toward interventions that maximize functional independence.
- Gerontological Health Services Research: It equips academic researchers with an instrument calibrated for ordinal analysis, enabling advanced structural equation modeling, epidemiological tracking, and comparative health systems analysis without violating statistical measurement assumptions.
5. Psychological Construct
Within contemporary health services research and psychometrics, recipient satisfaction is conceptualized not as a unidimensional affective response, but rather as a complex, multidimensional psychological appraisal. The Greek Home Care Satisfaction Questionnaire defines home care satisfaction as a cognitive-evaluative synthesis of the care recipient's expectations, perceived professional performance, and interpersonal experiences across distinct service touchpoints. The scale operationalizes satisfaction through three underlying sub-constructs:
Interpersonal Relationship and Communication
This dimension reflects the affective, relational, and communicative competencies displayed by home care personnel. Given that domiciliary care takes place within the private domestic sphere of older adults, relational dynamics exert a profound influence on perceived quality. This sub-construct evaluates whether staff treat recipients with dignity, courtesy, and respect, actively listen to expressed concerns, demonstrate genuine empathy toward chronic limitations, and communicate medical or caregiving instructions with clarity. Deficits in interpersonal interaction often induce feelings of vulnerability, dependency, and distress among older recipients, whereas empathetic engagement fosters trust and compliance.
Technical and Professional Competence
The technical competence domain appraises the perceived clinical effectiveness, operational knowledge, and service adequacy of the multidisciplinary team. It specifically dissects the performance of three interrelated service branches: skilled nursing care (e.g., vital signs monitoring, wound care, medication management), social work interventions (e.g., psychological support, mediation with state welfare agencies), and domestic family assistance (e.g., household support, personal hygiene assistance, errand completion). The construct captures the recipient's judgment regarding whether visiting personnel possess the requisite skills to address complex, age-related multimorbidity and social isolation.
Service Organization, Access, and Delivery
This organizational dimension evaluates the logistical, administrative, and systemic reliability of the municipal home care program. It assesses the regularity, punctuality, duration, and scheduling adequacy of home visits. Furthermore, it measures systemic coordination across disparate professional roles, bureaucratic ease of program access, administrative responsiveness when recipient functional dependency escalates, and the overarching capacity of the service to foster sustained independent living in the home environment.
6. Theoretical Framework
The conceptual foundation of the scale is rooted in Avedis Donabedian's Structure-Process-Outcome model of healthcare quality, integrated with the Service Encounter Theory articulated by Fiebelkorn and Czepiel. Under the Donabedian paradigm, healthcare quality assessment requires simultaneous evaluation of structural elements (administrative infrastructure, staff qualifications, visit allocation), process elements (the interpersonal and technical delivery of care), and outcome elements (recipient satisfaction, perceived health status, and maintenance of community autonomy).
Service encounter theory posits that customer and client appraisals of service quality represent a summative aggregation of distinct relational and functional micro-encounters over time. In a domiciliary setting, where the recipient encounters multiple distinct professionals within their private home, satisfaction cannot be treated as an undifferentiated global gestalt. Instead, each visit constitutes a discrete transaction wherein interpersonal communication, professional competence, and adherence to time commitments are continuously evaluated against prior expectations. Theoretical developments in gerontological social work emphasize that older recipients of state-supported care often experience feelings of powerlessness. Consequently, communicative respect, active involvement in care decisions, and organizational reliability serve as primary determinants of satisfaction.
Moreover, the scale incorporates expectations-disconfirmation theory from cognitive psychology, which indicates that satisfaction emerges when perceived performance meets or exceeds preexisting internal benchmarks. Because vulnerable older adults utilizing public welfare systems frequently harbor low initial expectations due to historical bureaucratic delays, the instrument utilizes detailed, specific evaluative items rather than vague affective queries to mitigate ceiling effects.
7. Validity
The psychometric validation of the Greek Home Care Satisfaction Questionnaire involved a comprehensive, multi-phase methodological protocol assessing content, face, and construct validity:
Content and Face Validity
Content validity was established through rigorous qualitative methodologies prior to quantitative administration. The research team conducted in-depth cognitive interviews with 15 program enrollees and 15 multidisciplinary staff members (social workers, nurses, family assistants) drawn from municipal care units. These interviews evaluated item clarity, cultural resonance, domain completeness, and linguistic comprehension. Following initial item pooling, an independent pretesting phase was executed with an additional cohort of 20 elderly and disabled service recipients. Ambiguous phrases, double-barreled questions, and redundant statements were iteratively revised or eliminated, confirming that the scale comprehensively addressed the lived experiences of recipients.
Construct Validity via Polychoric Exploratory Factor Analysis
Construct validity was formally established through exploratory factor analysis (EFA) on data collected from 319 municipal care recipients. A primary methodological strength of the validation study was the rejection of standard Pearson correlation matrices. Pearson coefficients assume continuous, normally distributed variables measured at interval levels; when applied to skewed, ordinal Likert data, they systematically underestimate correlation strength and produce spurious extra factors (difficulty factors). To overcome this, the authors generated a polychoric correlation matrix in PRELIS, assuming an underlying continuous, multivariate normal distribution for the latent response categories.
Data adequacy was substantiated by a high Kaiser-Meyer-Olkin (KMO) statistic well above the recommended 0.80 benchmark, and Bartlett's Test of Sphericity attained high statistical significance (p < .001). Factor extraction utilizing the Unweighted Least Squares (ULS) algorithm followed by Varimax orthogonal rotation yielded a clean, interpretable three-factor structure. The extracted dimensions aligned perfectly with the theoretical constructs of Interpersonal Communication, Professional/Technical Competence, and Organizational Delivery, demonstrating robust construct validity with primary factor loadings exceeding 0.50 and cross-loadings differing by at least 0.20.
8. Reliability
Assessment of internal consistency reliability required statistical techniques capable of accommodating the discrete ordinal distribution of the survey responses. Conventional Cronbach's alpha calculations typically underestimate the true internal consistency when item distributions exhibit pronounced skewness or kurtosis, a common phenomenon in patient satisfaction surveys where responses tend toward positive ratings.
To provide a methodologically sound evaluation, the investigators reported both conventional Cronbach's alpha and ordinal alpha coefficients, the latter calculated directly from the polychoric correlation matrix as outlined by Zumbo, Gadermann, and Zeisser (2007). The comparative analysis confirmed the exceptional reliability of the instrument:
- Overall Scale Reliability: The global scale exhibited an ordinal alpha coefficient exceeding 0.90, demonstrating strong internal consistency across the complete set of items.
- Subscale Reliabilities: The individual subscales demonstrated strong reliability, with ordinal alpha coefficients consistently exceeding the established psychometric threshold of 0.80 (ranging from 0.82 to 0.91 across the organizational, interpersonal, and competence subscales), whereas conventional Cronbach's alphas yielded slightly lower values (ranging from 0.77 to 0.88), illustrating the conservative bias of interval-based estimators.
- Item-Total Correlations: Corrected item-total correlations for all retained items exceeded the standard psychometric cutoff of 0.40, indicating that each item contributed uniquely and substantially to its respective latent subscale.
9. Factor Analysis
The statistical exploration of the latent structure of the questionnaire was performed on the empirical sample of 319 service users using Unweighted Least Squares (ULS) exploratory factor analysis on the pairwise polychoric correlation matrix. ULS extraction was selected due to its mathematical robustness in the presence of non-positive definite correlation matrices—a common mathematical artifact when estimating polychoric correlations pairwise across numerous discrete variables—and its superior performance with moderate sample sizes compared to maximum likelihood or generalized least squares.
The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy confirmed high data-to-factor appropriateness, and Bartlett's test of sphericity confirmed the absence of identity matrix characteristics. Initial eigenvalue examination alongside the scree test criterion identified three dominant latent factors accounting for the majority of the common variance:
- Factor 1: Interpersonal Relationship and Empathy: Encompassed items measuring courteous interaction, listening skills, dignity, empathy, and clarity of explanation by visiting staff. Factor loadings on this dimension ranged from 0.58 to 0.84.
- Factor 2: Technical/Professional Competence: Captured items addressing professional knowledge, the clinical efficacy of nursing interventions, domestic family support quality, and social work advocacy. Factor loadings ranged from 0.54 to 0.81.
- Factor 3: Service Organization and Logistical Delivery: Subsumed items evaluating visit punctuality, scheduling frequency, duration adequacy, interprofessional team coordination, ease of bureaucratic enrollment, and service flexibility. Factor loadings ranged from 0.51 to 0.79.
Orthogonal Varimax rotation was employed to maximize factor interpretability and achieve simple structure. Items adhered to rigorous retention thresholds: a primary factor loading greater than or equal to 0.50, combined with cross-loadings on secondary factors differing by at least 0.20. Items failing to achieve these strict criteria were systematically pruned, ensuring that each final item represented a clean, unambiguous marker of its designated latent construct.
10. Instrument / Measurement Tool
- Test Type: Multidimensional psychometric rating scale; structured interviewer-administered questionnaire (or self-report where cognitive and visual visual abilities permit).
- Target Population: Community-dwelling older adults (aged 65 years and older) and adults with chronic physical disabilities enrolled in municipal domiciliary care programs.
- Administration Format: Face-to-face structured interview conducted in the client's home by trained interviewers, designed to accommodate sensory impairments and lower literacy levels common among frail gerontological cohorts.
- Administration Time: Approximately 15 to 20 minutes.
- Item Count: 18 standardized items.
- Response Scale: 5-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree, 5 = strongly agree).
- Scoring Architecture: Summated rating scale or mean score calculation. Subscale scores are obtained by calculating the arithmetic mean or sum of the items corresponding to each of the three dimensions: Interpersonal Relationship/Communication, Technical/Professional Competence, and Overall Service Organization and Delivery. A total global satisfaction score is obtained by computing the mean or sum across all 18 items.
- Reverse Scoring: Negatively worded items must be reverse-coded (5 = strongly disagree, 1 = strongly agree) prior to scoring, ensuring that higher numerical values uniformly indicate greater levels of satisfaction.
11. Permissions, Fee, and Test Year
The Greek Home Care Satisfaction Questionnaire was developed and validated in 2010 under academic research auspices supported by the Hellenic Open University and the University of Macedonia, Thessaloniki, Greece. The foundational validation paper was published under open-access terms in BMC Health Services Research:
- Year of Publication: 2010
- Commercial Fee: None. The instrument is an open-access psychometric tool developed for non-commercial academic research, public health auditing, and quality improvement initiatives in social care.
- Permissions and Licensing: Academic and clinical researchers may utilize the instrument without royalty fees. However, prospective users must cite the original validation publication (Aletras et al., 2010). Modifications, translations into foreign languages, or commercial deployments require explicit formal permission from the corresponding author, Prof. Vassilis H. Aletras ([email protected]).
12. References
Aletras, V. H., Kostarelis, A., Tsitouridou, M., Niakas, D., & Nicolaou, A. (2010). Development and preliminary validation of a questionnaire measuring patient satisfaction with home care in Greece. BMC Health Services Research, 10, Article 189. https://doi.org/10.1186/1472-6963-10-189
Aletras, V. H., Papadopoulos, E. A., & Niakas, D. A. (2006). Development and preliminary validation of a Greek-language outpatient satisfaction questionnaire with principal components and multi-trait analyses. BMC Health Services Research, 6, Article 66. https://doi.org/10.1186/1472-6963-6-66
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