2.1 Study design and sample
This cross-sectional multisite design study is a part of a broad project [16, 22, 29, 49]. This project aims to strategically develop Palestinian hospital performance via the use of BSC perspectives and dimensions. This research was reported in adherence with strengthening the reporting of observational studies in epidemiology (STROBE) checklist.
2.2 Sample calculation
Since it was infeasible and geographically challenging to reach all hospitals in OPT, convenience sampling was used to choose 18 hospitals. Nevertheless, we took into consideration that our hospital sample has a variety of hospital sizes, locations, and administrative types. For that, the maximum variation sampling approach was utilized [7]. Therefore, the number of hospitals and the number of beds in each administrative category and governorate were taken into account while selecting the sample of hospitals. Patient samples were also chosen conveniently. Patients who existed in the targeted departments at the time of the visit were asked if they were willing to participate in the research.
The sample size was determined using a Steven K. Thompson sample size calculation [50]. The population volume in the Palestinian territories was considered the population size [4]. Taking 0.5 as the estimated variability in the population, the margin of error was 0.05, and the z score was 1.96 at a 95% confidence interval. Therefore, the number of patients required to conduct the study was 385. The authors were concerned about the poor survey response rate during the pandemic and opted to distribute 1000 surveys. The patients were chosen because they were willing to take part in this study.
2.3 Measures
In this research, we employed a validated survey designed to engage patients in hospital PE at the BSC implementations (BSC-PATIENT). The Arabic version was utilized. The BSC-PATIENT validation that the patient experiences loaded on seven factors: information experience (INFO EXR), price experience (PR EXR), patient experience (PT EXR), access experience (ACC EXR), service experience (SERV EXR), building environment experience (BUILENV EXR), and building capacity experience (BUILCAP EXR). The validation also revealed that all the Palestinian patients’ attitudes loaded on one factor; BSCP ATT, except the patient image toward the technology (TECH IMAGE) and complications (COMP IMAGE), which loaded separately. In this research, we analyzed the effect of experience on BSCP ATT. We were not able to assess the influence of the management experience, which is represented by the administrative type in this study. This is because eight hospitals have permission constraints that prevent us from releasing any performance evaluation results connected to the hospitals’ names or administrative types at the time being.
2.4 Data collection
The first five authors were responsible for the data collection. A three-hour training session on BSC, data collecting procedures, and ethical considerations was provided by the lead author to the other authors prior to data collection. The coauthors were assigned tasks and hospitals based on where they lived: eastern Jerusalem and the northern, middle, and southern parts of the West Bank. The exclusion of the Gaza Strip was based on political and logistical reasons. In addition, five hospitals were excluded: two military hospitals that had not yet opened, one psychiatric hospital, and two rehabilitation hospitals.
Printed surveys were given to respondents between January and October of 2021 instead of delivering the questions through email to prevent nonresponse bias [51]. To minimize the response bias [51], the “I don’t know (neutral)” answer was introduced as an option because experiences and attitudes might sometimes be ambiguous [27]. Second, the data collectors verified that the number of missing responses was reduced by examining the surveys upon recovery. In case of missing items, they drew the participant’s attention to answer them. When inserting data, if any answers were discovered to be still lacking, they were recorded as I don’t know.
A Palestinian patient who was at least 15 years old and of any gender was eligible for participation in the study. Outpatients should either have completed receiving medical care at the hospital being evaluated or should have received medical care at the evaluated hospital at least once in the past and returned there for additional treatment. Patients classified as inpatients must have been hospitalized for at least one day. The following departments were covered: pediatrics, gynecology, internal medicine, and surgery. Additionally, the emergency room was included. The patient companions were responsible for filling out the survey in the emergency room. One parent of each child was asked to complete the surveys in the pediatrics unit. The other surveys were completed by the patients themselves; in the instance that patients were unable to fill out the survey themselves, the data collector or a member of the patient's family read the survey to them and then completed the surveys based on the patient's responses. To make a distinction, a question was added that asked the responder if their answers were based on their personal experiences, the experiences of their family members, or the experiences of their friends.
2.5 Statistical analysis
The data were coded by the first author. The normality of the data was tested by employing the Shapiro–Wilk test. Additionally, frequencies were calculated for the categorical patient-sociodemographic questions. The experiences and attitudes answers were converted to scale measures. For the 3-point Likert scale, “No” answers were coded as zero, “Yes” answers were coded as 100, and “I do not know” as 50. Frequencies for each question were calculated. Then, the mean score and standard deviation (SD) of each factor in both inpatient and outpatient categories were calculated based on the average of their underlying questions [52]. Cronbach’s alpha for each factor, subscale, and the scale were calculated after piloting. Based on this, the authors decided to combine the items of BUILENV EXR and BUILCAP EXR into one factor; BSC EXR, to raise the internal consistency. The remaining factors and items were kept the same.
To perform variance analysis for the factors based on admission status, we used the Mann‒Whitney U test. Pearson correlation (r) was used to test the association strength between the independent factors or the dependent and independent factors. Then, r was described as negligible when r < 0.2, low (r = 0.2–0.49), moderate (r = 0.5–0.69), high (r = 0.7–0.85), or very high (r = 0.86–1.00). The cause-and-effect relationship was tested through a multiple linear regression. A path analysis is suggested to enhance the conceptual understanding and communication of regression results using an illustration [53]. Therefore, we performed a path analysis of the dependent and independent variables to understand the strategic map of BSC from the patients’ point of view. The residual plots were checked to test their normal distribution and linearity. Autocorrelation, which is also called serial correlation, was tested using the Durbin-Watson test [54]. A value between 1.5 and 2.5 was considered in the acceptable range, as it indicates that the residuals have relative independence and that there is no serial correlation between them. Additionally, we examined our model for multicollinearity. Multicollinearity occurs when independent factors in a regression model are correlated, which is a problem because independent factors should be independent. Multicollinearity was detected if any of the following cutoff values were crossed [55, 56]: 1- a Pearson correlation between factors was higher than 0.7, 2- a variance inflation factor (VIF) > 10, 3- a condition index > 30, 4- a variance decomposition proportion (VDP) for two or more predictors that were > 0.8. All tests were performed using the Statistical Package for Social Sciences (SPSS) software version 21.0, except for the path analysis, for which we used IBM Amos Graphics software version 23.0. Additionally, the correlogram was prepared in R version (3.1.0).
2.6 Ethical considerations
The Institutional Review Board (IRB) was issued on May 31 of 2020 by the Research and Ethics Committee at An Najah National University's Faculty of Medicine and Health Sciences with a reference code number (Mas, May/20/16). After that, we requested authorization to conduct the research at the public hospitals from the Palestinian Ministry of Health. Then, the request was submitted to every hospital individually, independent of its administrative type classification. Between June and December 2020, requests were to 15 hospitals on the West Bank and three hospitals in Jerusalem. Additionally, all of the patients provided written, informed consent to participate in the study that was in line with the Declaration of Helsinki ethical principles [57]. Patients were assured of the confidentiality and anonymity of the data. Additionally, all of the patients were informed that taking part in the study was optional, so they could refuse to take part or leave the study at any time.