The Syrian Health Care Scale: A Novel Instrument for Assessing Physician-Delivered Care in Crisis Contexts

The Syrian Health Care Scale: A Novel Instrument for Assessing Physician-Delivered Care in Crisis Contexts | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Syrian Health Care Scale: A Novel Instrument for Assessing Physician-Delivered Care in Crisis Contexts Nawras Bassal, Jawdat Ataya, Mayssoon Dashash This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6996415/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Feb, 2026 Read the published version in BMC Medical Education → Version 1 posted 13 You are reading this latest preprint version Abstract Background The Syrian healthcare system has faced profound disruptions due to prolonged conflict, resulting in major challenges to delivering quality patient care. Recognising the need for a culturally and contextually relevant assessment tool, this study introduces the Syrian Health Care Scale (SHCS), a novel instrument designed to evaluate the quality of physician-delivered care from a multidimensional perspective. Methods A cross-sectional study was conducted in July 2024 with a sample of 103 physicians across Syria. The SHCS, a 20-item self-report instrument, encompasses affective, behavioural, and cognitive dimensions of patient-centred care, using a 7-point Likert response format with both positively and negatively worded items. Internal consistency was assessed via Cronbach’s alpha, while item validity was examined using Pearson correlation. Independent samples t-tests and ANOVA were used to explore differences by gender and years of clinical experience. Additionally, Exploratory Factor Analysis (EFA) was conducted to evaluate the scale’s dimensional structure. Results The SHCS demonstrated acceptable internal reliability (Cronbach’s alpha = 0.753). Factor analysis revealed a three-factor structure corresponding to the intended affective, behavioural, and cognitive domains, explaining 36.4% of the total variance. Several items showed strong loadings on their expected domains, supporting the scale’s conceptual validity. While male physicians scored significantly higher in the behavioural dimension (p = 0.036), no significant differences were observed in total scores based on gender or years of experience. Most participants (67.96%) scored in the “Below Standard” category, highlighting substantial gaps in healthcare delivery under crisis conditions. Conclusion The SHCS is a reliable and valid instrument for assessing physician-delivered care in conflict-affected settings. Its multidimensional design offers a nuanced evaluation of healthcare provision, making it a valuable tool for guiding policy, clinical training, and future research. The confirmed factor structure provides a foundation for subsequent confirmatory validation and broader application in resource-limited contexts. Clinical trial number : not applicable. Syrian Health Care Scale patient-centred care healthcare quality conflict-affected regions physician assessment psychometric validation Figures Figure 1 Background The delivery of healthcare transcends essential clinical interventions involving a complex interplay of emotional intelligence, empathy, and ethical responsibility—elements crucial for effective patient care ( 1 – 3 ). In Syria, where the healthcare system has been severely impacted by conflict and displacement, comprehending the subtleties of care delivery is increasingly vital ( 4 ). Healthcare professionals serve not only as medical practitioners but also as community pillars, navigating patient interactions amid societal upheaval ( 4 – 6 ). Healthcare encompasses a broad spectrum of services, including preventive measures, public health initiatives, personalised medical care, and social support systems for vulnerable populations ( 7 ). Effective delivery requires aligning patient needs with provider capabilities to ensure services are both accessible and of high quality ( 8 , 9 ). Quality healthcare fosters patient satisfaction and well-being, essential for positive health outcomes and for enhancing the overall patient experience ( 7 , 8 ). In health sciences, measurement is foundational for evaluating the efficacy of interventions and outcomes ( 10 ). Despite its importance, discussions on measurement methodologies in clinical settings, especially in patient-centred care, have been limited ( 10 ). While laboratory sciences have established rigorous assessment frameworks, clinical research often lacks standardised approaches, leading to inconsistencies in care quality evaluation ( 11 ). This gap underscores the need for robust measurement tools that accurately reflect the complexities of patient-centred care ( 10 ). The Syrian Health Care Scale (SHCS) aims to address this need by providing a comprehensive framework for assessing healthcare quality among Syrian health professionals. In a context marked by instability, the SHCS captures the multidimensional nature of care delivery, evaluating not only clinical competencies but also the emotional and interpersonal aspects of patient interactions—vital for fostering trust and rapport between providers and patients. Previous research highlights the significance of diverse measurement techniques ( 12 ), such as self-report questionnaires, observational methods, and qualitative interviews, to gain insights into patient experiences and outcomes ( 13 ). However, measuring patient-centred care is hindered by conceptual ambiguities and a lack of standardised assessment tools ( 14 ). Consequently, health systems often struggle to accurately gauge care quality, impeding efforts to implement meaningful improvements ( 15 ). In Syria, the ongoing challenges faced by healthcare professionals necessitate a tailored measurement approach reflecting their unique experiences and operating context ( 16 ). The SHCS seeks to bridge this gap by offering a psychometrically sound instrument that effectively measures patient-centred healthcare among physicians with varying experience levels, while also considering gender dynamics. Comprising 20 items on a 7-point Likert scale ( 17 ), the SHCS provides nuanced insights into healthcare providers’ attitudes and practices, ultimately contributing to enhancing care quality in the region. By focusing on the emotional and relational dimensions of healthcare, this study aims to measure healthcare among Syrian health professionals using the Syrian Health Care Scale (SHCS). Methods Methods Ethical Approval Ethical approval for the study was obtained from the Ethical Committee of the Syrian Virtual University (07-031-6678). Informed consent was secured from all participants in accordance with the principles of the Helsinki Declaration (18). Study Design and Participants This study was conducted in July 2024 among physicians in Syria. A total of 103 participants were recruited, comprising 47 females (45.6%) and 56 males (54.4%). Among these, 48 participants (46.4%) had over ten years of professional experience, while 55 participants (53.4%) had less than ten years of experience. The sample size was determined to be five to ten times the number of items on the Syrian Health Care Scale (SHCS), based on prior research recommendations (19). Instrument Development The SHCS was developed by the medical education program at the Syrian Virtual University to assess healthcare practices among health professionals. The scale includes 20 statements designed to be simple, clear, and relevant to the study's objectives. Approximately half of the items were framed negatively to encourage thoughtful responses from participants. Specifically, the scale consists of 12 negative and eight positive statements, with the scores for negative items reversed to ensure consistency with positive responses. The statements were categorised into three dimensions: Emotional Questions: 8 items Behavioural Questions: 8 items Cognitive Questions: 4 items The items of the Syrian Health Care Scale were grouped into three thematic domains: Affective , Behavioural , and Cognitive components. Each domain represents a different aspect of healthcare delivery—emotional engagement, practical behaviour, and cognitive understanding—related to interactions with patients and the clinical setting. The categorisation of items into these components is outlined below. The questionnaire used in this study was developed by the authors (see Supplementary File 1). Table 1. Questionnaire item distribution across affective, behavioural, and cognitive components Affective Behavioural Cognitive 1- A smile and a cheerful face are essential elements for treatment success. 3- Good medical equipment in clinics is essential to the quality of health care provided. 2- Listening carefully to the patient is one of the most important elements in providing treatment. 7- Most patients want to leave the clinic after receiving their prescriptions*. 4- There is a close relationship between the doctor’s experience and the response to patients’ complaints*. 9- When taking a clinical history, I only commit to filling out a pre-written card*. 11- I feel it is helpful to listen to a patient’s household problems when providing health care. 5- Newly graduated doctors are more keen on the basics of health care*. 12- The clinical examination phase should not exceed five minutes before any clinic treatment is performed*. 13- As a doctor, it is important for me to empathize with patients, feel their problems, and appreciate their condition in order to achieve successful treatment. 6- Clinics with a small number of visitors daily are better than crowded clinics in applying the concept of health care to patients. 14- I follow a single protocol when reporting bad medical news to all patients*. 15- Patients want reassurance about their health condition rather than information about their actual health status*. 8- Providing patient care is an essential component of achieving successful treatment. 16- Sensitivity to a patient’s problems may complicate my healthcare delivery to patients*. 10- Being aware of patients’ circumstances and their social lives is an interference in their personal affairs and is not beneficial to treatment*. 17- Responsiveness to a patient’s specific needs may influence the quality of clinical healthcare decisions*. 18- Patients must comply with my instructions as a doctor without asking too many questions*. 20- I feel that a good doctor is one who provides the correct diagnosis and treatment without interfering in the affairs of individual patients*. 19- I prefer for the patient to comply with my recommendations without trying to identify his own condition individually*. *Items are reverse-scored. Scores on the scale range from 20 to 140, with interpretations as follows: 20–58: Severely Deficient Indicates a critical lack of adequate health care systems, training, or support among Syrian medical staff. 58–90: Below Standard Reflects suboptimal health care with many areas in need of development and support. 90–118: Moderately Effective Demonstrates a fair level of healthcare delivery with room for strategic improvements. 118–140: Highly Proficient Represents a strong health care environment with excellent practices and outcomes. Data Collection The SHCS was distributed digitally using Google Forms privately to ensure the confidentiality and anonymity of responses. Following the initial development of the scale, it was reviewed by specialists who provided feedback for refinement to undergo validation. Modifications were made to certain phrases, while no statements were removed. Reliability testing was conducted on survey responses from a sample of 6 doctors, who were subsequently excluded from the final analysis to maintain data integrity. Statistical analysis was conducted using IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics, including means, standard deviations (SD), frequencies, and percentages, were calculated to summarise participants’ demographic characteristics, specifically focusing on gender and years of clinical experience. The mean overall score on the Syrian Health Care Scale (SHCS), as well as the mean scores for the cognitive and empathetic subscales, were computed. Scores were categorised and analysed according to participants’ gender and years of experience. An independent samples t -test was applied to compare mean health care scores between male and female physicians. Additionally, one-way analysis of variance (ANOVA) was employed to assess differences in scores between groups stratified by clinical experience (i.e., more than 10 years vs. 10 years or less). A p -value of less than 0.05 was considered indicative of statistical significance. An independent samples t-test was conducted to examine differences in SHCS scores based on gender across the three dimensions: affective, behavioural, and cognitive. Pearson correlation coefficients were calculated to assess the relationship between the total score of the scale and individual items, revealing significant correlations (P=0.05). Additionally, the correlation of each item with its respective dimension was analysed, with coefficients also indicating significance (P<0.05). The stability of scores obtained by the same individuals at different times was evaluated using Cronbach's Alpha, demonstrating high values indicative of strong reliability. The internal consistency of the Syrian Health Care Scale (SHCS) was assessed using Cronbach's Alpha. Factor Analysis Exploratory Factor Analysis (EFA) was conducted using Principal Component Analysis (PCA) with Varimax rotation to explore the underlying structure of the Syrian Health Care Scale (SHCS). The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was 0.604, and Bartlett’s Test of Sphericity was significant (χ² = 411.769, df = 190, p < 0.001), confirming the suitability of the data for factor analysis. Seven components had eigenvalues greater than 1, accounting for a cumulative variance of 61.3%. However, based on the scale’s theoretical framework, a 3-factor solution was interpreted, reflecting the Affective, Behavioural, and Cognitive dimensions of patient-centred care. Table 2 presents the rotated component matrix showing primary loadings of each item on its corresponding factor. Table 3 summarises the total variance explained by these three factors. Figure 1 presents the eigenvalues scree plot. The extracted factors align reasonably with the scale’s intended domains, though several items showed moderate cross-loadings, suggesting areas for refinement in future iterations. Overall, the factor structure supports the multidimensional nature of the SHCS and provides a foundation for future Confirmatory Factor Analysis (CFA). Table 2. Rotated Component Matrix Summary (Top Loadings by Factor) Item No. Item Summary (Shortened) Primary Factor Loading Q20 A good doctor stays out of patient affairs Behavioural 0.758 Q10 Awareness of social lives unnecessary Behavioural 0.745 Q11 Short clinical exams acceptable Behavioural -0.724 Q12 Empathising is important Affective 0.563 Q13 Appreciating patient’s condition Affective -0.594 Q5 New grads follow basics better Cognitive -0.749 Q2 Listening is important Cognitive 0.615 Q14 Follow single protocol for bad news Behavioural 0.559 Q18 Compliance over questioning Behavioural 0.778 Q19 Compliance w/ recommendations Behavioural 0.775 Q8 Household problems interfere Affective -0.668 Q15 Patients want reassurance Affective 0.538 Q16 Sensitivity complicates delivery Cognitive 0.418 Q9 Only follow pre-written card Cognitive 0.494 Q1 Smile helps treatment Behavioural 0.457 Q4 Experience matters Behavioural 0.839 Q3 Equipment matters Cognitive 0.38 Q7 Patients leave after prescription Behavioural 0.824 Q6 Small clinics are better Behavioural 0.452 Table 3. Total Variance Explained by Retained Factors Component Initial Eigenvalue % of Variance Cumulative % Factor 1 – Behavioural 3.129 15.644 15.644 Factor 2 – Affective 2.188 10.94 26.585 Factor 3 – Cognitive 1.969 9.846 36.431 Results Participants Characteristics A total of 103 physicians participated in the study. Among them, 56 (54.4%) were males and 47 (45.6%) were females. Regarding clinical experience, 55 physicians (53.4%) reported practising for fewer than ten years, whereas 48 physicians (46.6%) had over ten years of professional experience. Reliability Analysis The Cronbach's Alpha coefficient of 0.753 indicates acceptable internal reliability for the scale. Scale Score Distribution Participants' total SHCS scores ranged between 58 and 118, categorised into four levels of healthcare provision: 20–58: Severely Deficient Healthcare 58–90: Below Standard Healthcare 90–118: Moderately Effective Healthcare 118–140: Highly Proficient Healthcare The majority of participants (n = 70, 67.96%), as shown in Table 4, fell within the "Below Standard" category (58–90 points), suggesting significant areas requiring improvement in healthcare delivery. Meanwhile, 33 participants (32.02%) scored within the "Moderately Effective" range (90–118 points), reflecting a generally positive but still improvable quality of healthcare. Table 4: Distribution of Participant Responses to Health Care Statements (n and %) *Statements marked with an asterisk are negatively phrased and may require reverse scoring for composite scale calculation. No. Statement Strongly Disagree Disagree Partially Disagree Not Decided Partially Agree Agree Strongly Agree 1 A smile and a cheerful face are essential elements for treatment success. 1 (1%) 2 (1.9%) 2 (1.9%) 1 (1%) 19 (17.1%) 39 (37.1%) 41 (39%) 2 Listening carefully to the patient is one of the most important elements in providing treatment. 1 (1%) 1 (1%) 1 (1%) 1 (1%) 7 (6.7%) 36 (34.3%) 59 (56.2%) 3 Good medical equipment in clinics is essential to the quality of health care provided. – 12 (11.5%) 19 (18.1%) 3 (2.9%) 36 (34.3%) 27 (25.7%) 8 (7.6%) 4 There is a close relationship between the doctor’s experience and the response to patients’ complaints.* 1 (1%) 2 (1.9%) 8 (7.6%) 5 (4.8%) 12 (11.4%) 50 (47.7%) 27 (25.7%) 5 Newly graduated doctors are more keen on the basics of health care.* 4 (3.8%) 27 (25.7%) 10 (9.6%) 20 (19%) 15 (14.3%) 26 (24.8%) 3 (2.9%) 6 Clinics with a small number of visitors daily are better than crowded clinics in applying the concept of health care to patients. 3 (2.9%) 12 (11.5%) 9 (8.6%) 8 (7.6%) 14 (13.3%) 31 (29.5%) 28 (26.7%) 7 Most patients want to leave the clinic after receiving their prescriptions.* 16 (15.2%) 31 (29.5%) 14 (13.3%) 14 (13.3%) 17 (16.2%) 21 (20%) 2 (1.9%) 8 Providing patient care is an essential component of achieving successful treatment. – 4 (3.8%) 5 (4.8%) 5 (4.8%) 5 (4.8%) 66 (62.9%) 20 (19%) 9 When taking a clinical history, I only commit to filling out a pre-written card.* 5 (4.8%) 20 (19%) 10 (9.5%) 9 (8.6%) 14 (13.3%) 31 (29.5%) 16 (15.2%) 10 Being aware of patients’ circumstances and their social lives is an interference in their personal affairs and is not beneficial to treatment.* 4 (3.8%) 19 (18.1%) 18 (17.1%) 5 (4.8%) 25 (23.8%) 31 (29.5%) 3 (2.9%) 11 I feel it is helpful to listen to a patient’s household problems when providing health care. 1 (1%) 2 (1.9%) 2 (1.9%) 1 (1%) 19 (17.1%) 39 (37.1%) 41 (39%) 12 The clinical examination phase should not exceed five minutes before any clinic treatment is performed.* 22 (21%) 38 (36.2%) 9 (8.6%) 6 (5.7%) 12 (11.4%) 17 (16.2%) 1 (1%) 13 As a doctor, it is important for me to empathise with patients, feel their problems, and appreciate their condition in order to achieve successful treatment. 4 (3.8%) 5 (4.8%) 11 (10.5%) 2 (1.9%) 23 (21.9%) 47 (44.8%) 13 (12.4%) 14 I follow a single protocol when reporting bad medical news to all patients.* 16 (15.2%) 45 (42.9%) 17 (16.2%) 7 (6.7%) 13 (12.4%) 6 (5.7%) 1 (1%) 15 Patients want reassurance about their health condition rather than information about their actual health status.* 9 (8.6%) 22 (21%) 14 (13.3%) 12 (11.4%) 19 (18.1%) 29 (27.6%) – 16 Sensitivity to a patient’s problems may complicate my healthcare delivery to patients.* 6 (5.8%) 28 (26.9%) 18 (17.3%) 14 (13.5%) 21 (20.2%) 16 (15.4%) 1 (1%) 17 Responsiveness to a patient’s specific needs may influence the quality of clinical healthcare decisions.* 9 (8.6%) 16 (15.2%) 4 (3.8%) 17 (16.2%) 27 (25.7%) 31 (29.5%) 1 (1%) 18 Patients must comply with my instructions as a doctor without asking too many questions.* 12 (11.4%) 30 (28.6%) 21 (20%) – 23 (21.9%) 17 (16.2%) 2 (1.9%) 19 I prefer for the patient to comply with my recommendations without trying to identify his own condition individually.* 31 (29.8%) 40 (38.5%) 9 (8.7%) 3 (2.9%) 6 (5.8%) 14 (13.5%) 1 (1%) 20 I feel that a good doctor is one who provides the correct diagnosis and treatment without interfering in the affairs of individual patients.* 6 (5.7%) 19 (18.1%) 14 (12.4%) 5 (4.8%) 22 (21%) 26 (24.8%) 13 (12.4%) Gender Differences The comparison between males and females in the mean scores of the SHCS is presented in Table 5. Table 5: Independent Samples t-Test Results Comparing Syrian Health Care Scale (SHCS) Scores by Gender Dimension Gender Mean Score Standard Deviation t-value p-value Decision Affective Male 35.71 5.18 0.326 0.745 No significant difference Female 35.39 4.71 Behavioural Male 33.80 3.96 2.125 0.036 Significant difference Female 31.96 4.82 Cognitive Male 16.50 3.22 -1.160 0.249 No significant difference Female 17.28 3.57 Total SHCS Score Male 86.02 8.95 0.815 0.417 No significant difference Female 84.62 8.02 A statistically significant difference was identified in the behavioural dimension (p = 0.036), where male physicians scored higher than their female counterparts. However, no significant differences were observed in the affective or cognitive dimensions, nor in the overall SHCS scores. Differences Based on Years of Clinical Experience Further analysis using an independent samples t-test was performed to compare SHCS scores based on physicians' years of experience (<10 years vs ≥10 years), as presented in Table 6. Table 6: Independent Samples t-Test Results Comparing Syrian Health Care Scale (SHCS) Scores by Years of Clinical Experience Dimension Years of Practice Mean Score Standard Deviation t-value p-value Decision Affective <10 years 35.57 4.89 0.012 0.991 No significant difference ≥10 years 35.56 5.07 Behavioural <10 years 32.74 4.58 -0.552 0.582 No significant difference ≥10 years 33.23 4.32 Cognitive <10 years 16.51 3.23 -1.107 0.271 No significant difference ≥10 years 17.25 3.56 Total SHCS Score <10 years 84.81 8.02 -0.722 0.472 No significant difference ≥10 years — — There were no statistically significant differences in any dimension or the overall SHCS scores between physicians with fewer than ten years and those with more than ten years of experience. Discussion This study presents the development and validation of the Syrian Health Care Scale (SHCS), a novel instrument designed to assess the quality of healthcare provided by medical professionals in Syria. The SHCS uniquely integrates cognitive, affective, and behavioural dimensions, reflecting the multifaceted nature of healthcare delivery, particularly within the context of Syria’s protracted conflict. Over the past decade, Syria’s healthcare system has faced unprecedented challenges due to ongoing conflict, infrastructural damage, and resource constraints (4). Reports indicate that up to 50% of health facilities have been destroyed, and approximately 70% of healthcare providers have fled the country, leading to a significant strain on the remaining medical staff (20). Traditional metrics, such as mortality rates and hospital admissions, often fail to capture the nuanced experiences of healthcare providers and patients in such settings (21). The SHCS addresses this gap by offering a culturally sensitive tool that evaluates healthcare quality from the perspective of medical practitioners. The study’s findings indicate no statistically significant differences in SHCS scores between male and female physicians. This aligns with previous research suggesting that, despite societal and systemic challenges, female healthcare providers in Syria have demonstrated resilience and commitment to patient care (16). However, it’s essential to acknowledge that gender dynamics in healthcare are complex and influenced by various socio-cultural factors, which may not be fully captured by quantitative measures alone. Interestingly, the SHCS scores did not significantly differ between physicians with more than ten years of experience and those with less. This suggests that, in the Syrian context, factors such as ongoing professional development, adaptability, and commitment to patient care may play more pivotal roles than years of experience alone. It also underscores the importance of continuous training and support for healthcare providers, regardless of their tenure. This finding diverges from previous studies (16) that reported a decline in empathy among more experienced practitioners. While empathy may fluctuate with time, the core quality of healthcare, at least as measured by this scale, remains unaffected by length of service. This reinforces the notion that professional care should remain consistent regardless of years in practice. The SHCS demonstrated strong psychometric properties, indicating its reliability and validity as a tool for assessing healthcare quality. The balanced inclusion of positively and negatively worded items, along with the use of a 7-point Likert scale (22), enhances its sensitivity and reduces response bias. Such methodological rigour ensures that the SHCS can serve as a valuable instrument for both research and practical applications in healthcare settings. The SHCS offers significant potential for informing healthcare policy and practice in Syria. By providing insights into the perceptions and experiences of medical professionals, it can guide targeted interventions aimed at improving healthcare delivery. Moreover, its adaptability allows for potential application in other conflict-affected or resource-limited settings, facilitating comparative studies and broader healthcare improvements. Limitations While the SHCS provides valuable insights, certain limitations must be acknowledged. The study’s sample size, though adequate for initial validation, may not fully represent the diverse experiences of all Syrian healthcare providers. Future research should aim to include a broader range of participants, including those from various specialities and regions. Additionally, integrating patient perspectives could offer a more comprehensive understanding of healthcare quality. Conclusion The SHCS stands as a valid and reliable measure for assessing physician-delivered care in crisis contexts. Its adoption can facilitate the monitoring and enhancement of healthcare quality, ultimately contributing to improved patient outcomes in regions grappling with the challenges of conflict and resource constraints. Abbreviations Syrian Health Care Scale (SHCS) Principal Component Analysis (PCA) Confirmatory Factor Analysis (CFA) Exploratory Factor Analysis (EFA) Declarations Ethics approval and consent to participate: Ethical approval for the study was obtained from the Ethical Committee of the Syrian Virtual University (07-031-6678). Consent for publication: No applicable Availability of data and materials The datasets generated and analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: The authors received no specific funding for this work. It is supported by the Syrian Virtual University. Authors' contributions NB and MD conceived and designed the study and collected the data, JA conducted the statistical analysis and drafted the manuscript. NB, JA and MD reviewed the manuscript and provided critical revisions. 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Supplementary Files TheQuestionnaireSHCS.docx Cite Share Download PDF Status: Published Journal Publication published 20 Feb, 2026 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 18 Sep, 2025 Reviews received at journal 27 Aug, 2025 Reviews received at journal 19 Aug, 2025 Reviewers agreed at journal 15 Aug, 2025 Reviewers agreed at journal 11 Aug, 2025 Reviewers agreed at journal 10 Aug, 2025 Reviews received at journal 08 Aug, 2025 Reviewers agreed at journal 05 Aug, 2025 Reviewers invited by journal 05 Aug, 2025 Editor assigned by journal 30 Jul, 2025 Editor invited by journal 11 Jul, 2025 Submission checks completed at journal 10 Jul, 2025 First submitted to journal 10 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6996415","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":497362016,"identity":"5b0f17fa-c571-44f9-a813-a8a1ace45e8a","order_by":0,"name":"Nawras Bassal","email":"","orcid":"","institution":"Syrian Virtual University","correspondingAuthor":false,"prefix":"","firstName":"Nawras","middleName":"","lastName":"Bassal","suffix":""},{"id":497362017,"identity":"bce66b18-f5f5-4b16-b908-4d7b75bf51c3","order_by":1,"name":"Jawdat Ataya","email":"data:image/png;base64,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","orcid":"","institution":"Syrian Virtual University","correspondingAuthor":true,"prefix":"","firstName":"Jawdat","middleName":"","lastName":"Ataya","suffix":""},{"id":497362018,"identity":"9ea65016-4d5a-472e-8aaf-31ccbbfd2df5","order_by":2,"name":"Mayssoon Dashash","email":"","orcid":"","institution":"Syrian Virtual University","correspondingAuthor":false,"prefix":"","firstName":"Mayssoon","middleName":"","lastName":"Dashash","suffix":""}],"badges":[],"createdAt":"2025-06-28 08:08:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6996415/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6996415/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-026-08839-y","type":"published","date":"2026-02-20T15:56:59+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88774477,"identity":"b14ce9c5-ef5e-4c7a-ba28-dab6aefdafb1","added_by":"auto","created_at":"2025-08-11 10:01:34","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":26124,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ethe eigenvalues scree plot.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6996415/v1/82de327266912caec6e07d19.jpg"},{"id":103251062,"identity":"04c4ef3b-0562-4fe1-939e-8be99b58349e","added_by":"auto","created_at":"2026-02-23 16:03:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1279023,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6996415/v1/e0291ab6-b078-4a1c-a4b9-3a718c0dd235.pdf"},{"id":88776816,"identity":"cd3bd694-521f-495b-b4bb-c1081ca9866d","added_by":"auto","created_at":"2025-08-11 10:09:34","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":22536,"visible":true,"origin":"","legend":"","description":"","filename":"TheQuestionnaireSHCS.docx","url":"https://assets-eu.researchsquare.com/files/rs-6996415/v1/95059bf37426f5f88d551234.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Syrian Health Care Scale: A Novel Instrument for Assessing Physician-Delivered Care in Crisis Contexts","fulltext":[{"header":"Background","content":"\u003cp\u003eThe delivery of healthcare transcends essential clinical interventions involving a complex interplay of emotional intelligence, empathy, and ethical responsibility\u0026mdash;elements crucial for effective patient care (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In Syria, where the healthcare system has been severely impacted by conflict and displacement, comprehending the subtleties of care delivery is increasingly vital (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Healthcare professionals serve not only as medical practitioners but also as community pillars, navigating patient interactions amid societal upheaval (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHealthcare encompasses a broad spectrum of services, including preventive measures, public health initiatives, personalised medical care, and social support systems for vulnerable populations (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Effective delivery requires aligning patient needs with provider capabilities to ensure services are both accessible and of high quality (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Quality healthcare fosters patient satisfaction and well-being, essential for positive health outcomes and for enhancing the overall patient experience (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn health sciences, measurement is foundational for evaluating the efficacy of interventions and outcomes (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Despite its importance, discussions on measurement methodologies in clinical settings, especially in patient-centred care, have been limited (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). While laboratory sciences have established rigorous assessment frameworks, clinical research often lacks standardised approaches, leading to inconsistencies in care quality evaluation (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This gap underscores the need for robust measurement tools that accurately reflect the complexities of patient-centred care (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe Syrian Health Care Scale (SHCS) aims to address this need by providing a comprehensive framework for assessing healthcare quality among Syrian health professionals. In a context marked by instability, the SHCS captures the multidimensional nature of care delivery, evaluating not only clinical competencies but also the emotional and interpersonal aspects of patient interactions\u0026mdash;vital for fostering trust and rapport between providers and patients.\u003c/p\u003e\u003cp\u003ePrevious research highlights the significance of diverse measurement techniques (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), such as self-report questionnaires, observational methods, and qualitative interviews, to gain insights into patient experiences and outcomes (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, measuring patient-centred care is hindered by conceptual ambiguities and a lack of standardised assessment tools (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Consequently, health systems often struggle to accurately gauge care quality, impeding efforts to implement meaningful improvements (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn Syria, the ongoing challenges faced by healthcare professionals necessitate a tailored measurement approach reflecting their unique experiences and operating context (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The SHCS seeks to bridge this gap by offering a psychometrically sound instrument that effectively measures patient-centred healthcare among physicians with varying experience levels, while also considering gender dynamics. Comprising 20 items on a 7-point Likert scale (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), the SHCS provides nuanced insights into healthcare providers\u0026rsquo; attitudes and practices, ultimately contributing to enhancing care quality in the region.\u003c/p\u003e\u003cp\u003eBy focusing on the emotional and relational dimensions of healthcare, this study aims to measure healthcare among Syrian health professionals using the Syrian Health Care Scale (SHCS).\u003c/p\u003e\u003cp\u003eMethods\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eEthical Approval\u003c/h2\u003e\n\u003cp\u003eEthical approval for the study was obtained from the Ethical Committee of the Syrian Virtual University (07-031-6678). Informed consent was secured from all participants in accordance with the principles of the Helsinki Declaration (18).\u003c/p\u003e\n\u003ch2\u003eStudy Design and Participants\u003c/h2\u003e\n\u003cp\u003eThis study was conducted in July 2024 among physicians in Syria. A total of 103 participants were recruited, comprising 47 females (45.6%) and 56 males (54.4%). Among these, 48 participants (46.4%) had over ten years of professional experience, while 55 participants (53.4%) had less than ten years of experience. The sample size was determined to be five to ten times the number of items on the Syrian Health Care Scale (SHCS), based on prior research recommendations (19).\u003c/p\u003e\n\u003ch2\u003eInstrument Development\u003c/h2\u003e\n\u003cp\u003eThe SHCS was developed by the medical education program at the Syrian Virtual University to assess healthcare practices among health professionals. The scale includes 20 statements designed to be simple, clear, and relevant to the study\u0026apos;s objectives. Approximately half of the items were framed negatively to encourage thoughtful responses from participants. Specifically, the scale consists of 12 negative and eight positive statements, with the scores for negative items reversed to ensure consistency with positive responses.\u003c/p\u003e\n\u003cp\u003eThe statements were categorised into three dimensions:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eEmotional Questions:\u003c/strong\u003e 8 items\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eBehavioural Questions:\u003c/strong\u003e 8 items\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCognitive Questions:\u003c/strong\u003e 4 items\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe items of the Syrian Health Care Scale were grouped into three thematic domains: \u003cstrong\u003eAffective\u003c/strong\u003e, \u003cstrong\u003eBehavioural\u003c/strong\u003e, and \u003cstrong\u003eCognitive\u003c/strong\u003e components. Each domain represents a different aspect of healthcare delivery\u0026mdash;emotional engagement, practical behaviour, and cognitive understanding\u0026mdash;related to interactions with patients and the clinical setting. The categorisation of items into these components is outlined below.\u0026nbsp;The questionnaire used in this study was developed by the authors (see Supplementary File 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Questionnaire item distribution across affective, behavioural, and cognitive components\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAffective\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBehavioural\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCognitive\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1- A smile and a cheerful face are essential elements for treatment success.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3- Good medical equipment in clinics is essential to the quality of health care provided.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2- Listening carefully to the patient is one of the most important elements in providing treatment.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7- Most patients want to leave the clinic after receiving their prescriptions*.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4- There is a close relationship between the doctor\u0026rsquo;s experience and the response to patients\u0026rsquo; complaints*.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9- When taking a clinical history, I only commit to filling out a pre-written card*.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11- I feel it is helpful to listen to a patient\u0026rsquo;s household problems when providing health care.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5- Newly graduated doctors are more keen on the basics of health care*.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12- The clinical examination phase should not exceed five minutes before any clinic treatment is performed*.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13- As a doctor, it is important for me to empathize with patients, feel their problems, and appreciate their condition in order to achieve successful treatment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6- Clinics with a small number of visitors daily are better than crowded clinics in applying the concept of health care to patients.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14- I follow a single protocol when reporting bad medical news to all patients*.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15- Patients want reassurance about their health condition rather than information about their actual health status*.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8- Providing patient care is an essential component of achieving successful treatment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16- Sensitivity to a patient\u0026rsquo;s problems may complicate my healthcare delivery to patients*.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10- Being aware of patients\u0026rsquo; circumstances and their social lives is an interference in their personal affairs and is not beneficial to treatment*.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17- Responsiveness to a patient\u0026rsquo;s specific needs may influence the quality of clinical healthcare decisions*.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18- Patients must comply with my instructions as a doctor without asking too many questions*.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20- I feel that a good doctor is one who provides the correct diagnosis and treatment without interfering in the affairs of individual patients*.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19- I prefer for the patient to comply with my recommendations without trying to identify his own condition individually*.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cul\u003e\n \u003cli\u003e*Items are reverse-scored.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eScores on the scale range from 20 to 140, with interpretations as follows:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003e20\u0026ndash;58: Severely Deficient\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eIndicates a critical lack of adequate health care systems, training, or support among Syrian medical staff.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003e58\u0026ndash;90: Below Standard\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eReflects suboptimal health care with many areas in need of development and support.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003e90\u0026ndash;118: Moderately Effective\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eDemonstrates a fair level of healthcare delivery with room for strategic improvements.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003e118\u0026ndash;140: Highly Proficient\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eRepresents a strong health care environment with excellent practices and outcomes.\u003c/p\u003e\n\u003ch2\u003eData Collection\u003c/h2\u003e\n\u003cp\u003eThe SHCS was distributed digitally using Google Forms privately to ensure the confidentiality and anonymity of responses.\u003c/p\u003e\n\u003cp\u003eFollowing the initial development of the scale, it was reviewed by specialists who provided feedback for refinement to undergo validation. Modifications were made to certain phrases, while no statements were removed. Reliability testing was conducted on survey responses from a sample of 6 doctors, who were subsequently excluded from the final analysis to maintain data integrity.\u003c/p\u003e\n\u003cp\u003eStatistical analysis was conducted using IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics, including means, standard deviations (SD), frequencies, and percentages, were calculated to summarise participants\u0026rsquo; demographic characteristics, specifically focusing on gender and years of clinical experience.\u003c/p\u003e\n\u003cp\u003eThe mean overall score on the Syrian Health Care Scale (SHCS), as well as the mean scores for the cognitive and empathetic subscales, were computed. Scores were categorised and analysed according to participants\u0026rsquo; gender and years of experience. An independent samples \u003cem\u003et\u003c/em\u003e-test was applied to compare mean health care scores between male and female physicians. Additionally, one-way analysis of variance (ANOVA) was employed to assess differences in scores between groups stratified by clinical experience (i.e., more than 10 years vs. 10 years or less). A \u003cem\u003ep\u003c/em\u003e-value of less than 0.05 was considered indicative of statistical significance. An independent samples t-test was conducted to examine differences in SHCS scores based on gender across the three dimensions: affective, behavioural, and cognitive.\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003ePearson correlation coefficients were calculated to assess the relationship between the total score of the scale and individual items, revealing significant correlations (P=0.05). Additionally, the correlation of each item with its respective dimension was analysed, with coefficients also indicating significance (P\u0026lt;0.05). The stability of scores obtained by the same individuals at different times was evaluated using Cronbach\u0026apos;s Alpha, demonstrating high values indicative of strong reliability.\u0026nbsp;The internal consistency of the Syrian Health Care Scale (SHCS) was assessed using Cronbach\u0026apos;s Alpha.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eFactor Analysis\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eExploratory Factor Analysis (EFA) was conducted using Principal Component Analysis (PCA) with Varimax rotation to explore the underlying structure of the Syrian Health Care Scale (SHCS).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was 0.604, and Bartlett\u0026rsquo;s Test of Sphericity was significant (\u0026chi;\u0026sup2; = 411.769, df = 190, p \u0026lt; 0.001), confirming the suitability of the data for factor analysis. Seven components had eigenvalues greater than 1, accounting for a cumulative variance of 61.3%. However, based on the scale\u0026rsquo;s theoretical framework, a 3-factor solution was interpreted, reflecting the Affective, Behavioural, and Cognitive dimensions of patient-centred care. Table 2 presents the rotated component matrix showing primary loadings of each item on its corresponding factor. Table 3 summarises the total variance explained by these three factors. Figure 1 presents the eigenvalues scree plot. The extracted factors align reasonably with the scale\u0026rsquo;s intended domains, though several items showed moderate cross-loadings, suggesting areas for refinement in future iterations. Overall, the factor structure supports the multidimensional nature of the SHCS and provides a foundation for future Confirmatory Factor Analysis (CFA).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Rotated Component Matrix Summary (Top Loadings by Factor)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItem No.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItem Summary (Shortened)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary Factor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLoading\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eQ20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eA good doctor stays out of patient affairs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eBehavioural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.758\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eQ10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eAwareness of social lives unnecessary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eBehavioural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.745\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eQ11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eShort clinical exams acceptable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eBehavioural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e-0.724\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eQ12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eEmpathising is important\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eAffective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.563\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eQ13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eAppreciating patient\u0026rsquo;s condition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eAffective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e-0.594\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eQ5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eNew grads follow basics better\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eCognitive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e-0.749\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eQ2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eListening is important\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eCognitive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.615\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eQ14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eFollow single protocol for bad news\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eBehavioural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.559\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eQ18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eCompliance over questioning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eBehavioural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.778\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eQ19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eCompliance w/ recommendations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eBehavioural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.775\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eQ8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eHousehold problems interfere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eAffective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e-0.668\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eQ15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ePatients want reassurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eAffective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.538\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eQ16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eSensitivity complicates delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eCognitive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.418\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eQ9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eOnly follow pre-written card\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eCognitive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.494\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eQ1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eSmile helps treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eBehavioural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.457\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eQ4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eExperience matters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eBehavioural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.839\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eQ3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eEquipment matters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eCognitive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eQ7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ePatients leave after prescription\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eBehavioural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.824\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eQ6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eSmall clinics are better\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eBehavioural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.452\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Total Variance Explained by Retained Factors\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eComponent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003eInitial Eigenvalue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e% of Variance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eCumulative %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eFactor 1 \u0026ndash; Behavioural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e3.129\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e15.644\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e15.644\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eFactor 2 \u0026ndash; Affective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e2.188\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e10.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e26.585\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eFactor 3 \u0026ndash; Cognitive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e1.969\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e9.846\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e36.431\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Results","content":"\u003ch2\u003eParticipants Characteristics\u003c/h2\u003e\n\u003cp\u003eA total of 103 physicians participated in the study. Among them, 56 (54.4%) were males and 47 (45.6%) were females. Regarding clinical experience, 55 physicians (53.4%) reported practising for fewer than ten years, whereas 48 physicians (46.6%) had over ten years of professional experience.\u003c/p\u003e\n\u003ch2\u003eReliability Analysis\u003c/h2\u003e\n\u003cp\u003eThe Cronbach\u0026apos;s Alpha coefficient of \u003cstrong\u003e0.753\u003c/strong\u003e indicates acceptable internal reliability for the scale.\u003c/p\u003e\n\u003ch2\u003eScale Score Distribution\u003c/h2\u003e\n\u003cp\u003eParticipants\u0026apos; total SHCS scores ranged between 58 and 118, categorised into four levels of healthcare provision:\u003c/p\u003e\n\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003e20\u0026ndash;58: Severely Deficient Healthcare\u003c/li\u003e\n \u003cli\u003e58\u0026ndash;90: Below Standard Healthcare\u003c/li\u003e\n \u003cli\u003e90\u0026ndash;118: Moderately Effective Healthcare\u003c/li\u003e\n \u003cli\u003e118\u0026ndash;140: Highly Proficient Healthcare\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe majority of participants (n = 70, 67.96%), as shown in Table 4, fell within the \u0026quot;Below Standard\u0026quot; category (58\u0026ndash;90 points), suggesting significant areas requiring improvement in healthcare delivery. Meanwhile, 33 participants (32.02%) scored within the \u0026quot;Moderately Effective\u0026quot; range (90\u0026ndash;118 points), reflecting a generally positive but still improvable quality of healthcare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Distribution of Participant Responses to Health Care Statements (n and %)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e*Statements marked with an asterisk are negatively phrased and may require reverse scoring for composite scale calculation.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"640\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eStatement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eStrongly Disagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDisagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePartially Disagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNot Decided\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePartially Agree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAgree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eStrongly Agree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eA smile and a cheerful face are essential elements for treatment success.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19 (17.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e39 (37.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e41 (39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eListening carefully to the patient is one of the most important elements in providing treatment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36 (34.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e59 (56.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eGood medical equipment in clinics is essential to the quality of health care provided.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12 (11.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19 (18.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36 (34.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27 (25.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8 (7.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eThere is a close relationship between the doctor\u0026rsquo;s experience and the response to patients\u0026rsquo; complaints.*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8 (7.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (4.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12 (11.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50 (47.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27 (25.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNewly graduated doctors are more keen on the basics of health care.*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27 (25.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10 (9.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20 (19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26 (24.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eClinics with a small number of visitors daily are better than crowded clinics in applying the concept of health care to patients.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12 (11.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 (8.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8 (7.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14 (13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31 (29.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28 (26.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMost patients want to leave the clinic after receiving their prescriptions.*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16 (15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31 (29.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14 (13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14 (13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17 (16.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eProviding patient care is an essential component of achieving successful treatment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (4.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (4.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (4.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e66 (62.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20 (19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eWhen taking a clinical history, I only commit to filling out a pre-written card.*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (4.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20 (19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10 (9.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 (8.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14 (13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31 (29.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16 (15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eBeing aware of patients\u0026rsquo; circumstances and their social lives is an interference in their personal affairs and is not beneficial to treatment.*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19 (18.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18 (17.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (4.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25 (23.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31 (29.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eI feel it is helpful to listen to a patient\u0026rsquo;s household problems when providing health care.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19 (17.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e39 (37.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e41 (39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eThe clinical examination phase should not exceed five minutes before any clinic treatment is performed.*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22 (21%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38 (36.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 (8.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (5.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12 (11.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17 (16.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAs a doctor, it is important for me to empathise with patients, feel their problems, and appreciate their condition in order to achieve successful treatment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (4.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (10.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23 (21.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e47 (44.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13 (12.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eI follow a single protocol when reporting bad medical news to all patients.*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16 (15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e45 (42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17 (16.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13 (12.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (5.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePatients want reassurance about their health condition rather than information about their actual health status.*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 (8.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22 (21%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14 (13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12 (11.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19 (18.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29 (27.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSensitivity to a patient\u0026rsquo;s problems may complicate my healthcare delivery to patients.*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (5.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28 (26.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18 (17.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14 (13.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21 (20.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eResponsiveness to a patient\u0026rsquo;s specific needs may influence the quality of clinical healthcare decisions.*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 (8.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16 (15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17 (16.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27 (25.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31 (29.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePatients must comply with my instructions as a doctor without asking too many questions.*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12 (11.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30 (28.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23 (21.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17 (16.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eI prefer for the patient to comply with my recommendations without trying to identify his own condition individually.*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31 (29.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40 (38.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 (8.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (5.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14 (13.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eI feel that a good doctor is one who provides the correct diagnosis and treatment without interfering in the affairs of individual patients.*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (5.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19 (18.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14 (12.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (4.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22 (21%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26 (24.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13 (12.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n\u003c/table\u003e\n\u003ch2\u003eGender Differences\u003c/h2\u003e\n\u003cp\u003eThe comparison between males and females in the mean scores of the SHCS is presented in Table 5.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5:\u003c/strong\u003e \u003cstrong\u003eIndependent Samples t-Test Results Comparing Syrian Health Care Scale (SHCS) Scores by Gender\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDimension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMean Score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eStandard Deviation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003et-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDecision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eAffective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e35.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e0.326\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e0.745\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eNo significant difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e35.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.71\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eBehavioural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e33.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e2.125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e0.036\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eSignificant difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.82\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eCognitive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-1.160\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.249\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eNo significant difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eTotal SHCS Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e86.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e0.815\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e0.417\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eNo significant difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e84.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eA statistically significant difference was identified in the behavioural dimension (p = 0.036), where male physicians scored higher than their female counterparts. However, no significant differences were observed in the affective or cognitive dimensions, nor in the overall SHCS scores.\u003c/p\u003e\n\u003ch2\u003eDifferences Based on Years of Clinical Experience\u003c/h2\u003e\n\u003cp\u003eFurther analysis using an independent samples t-test was performed to compare SHCS scores based on physicians\u0026apos; years of experience (\u0026lt;10 years vs \u0026ge;10 years), as presented in Table 6.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6: Independent Samples t-Test Results Comparing Syrian Health Care Scale (SHCS) Scores by Years of Clinical Experience\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDimension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eYears of Practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMean Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eStandard Deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003et-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eDecision\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eAffective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e35.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e0.991\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eNo significant difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ge;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e35.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eBehavioural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e32.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e-0.552\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e0.582\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eNo significant difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ge;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e33.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eCognitive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e-1.107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e0.271\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eNo significant difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ge;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eTotal SHCS Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e84.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e-0.722\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e0.472\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eNo significant difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ge;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThere were no statistically significant differences in any dimension or the overall SHCS scores between physicians with fewer than ten years and those with more than ten years of experience.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study presents the development and validation of the Syrian Health Care Scale (SHCS), a novel instrument designed to assess the quality of healthcare provided by medical professionals in Syria. The SHCS uniquely integrates cognitive, affective, and behavioural dimensions, reflecting the multifaceted nature of healthcare delivery, particularly within the context of Syria’s protracted conflict.\u003c/p\u003e\n\u003cp\u003eOver the past decade, Syria’s healthcare system has faced unprecedented challenges due to ongoing conflict, infrastructural damage, and resource constraints (4). Reports indicate that up to 50% of health facilities have been destroyed, and approximately 70% of healthcare providers have fled the country, leading to a significant strain on the remaining medical staff (20). Traditional metrics, such as mortality rates and hospital admissions, often fail to capture the nuanced experiences of healthcare providers and patients in such settings (21). The SHCS addresses this gap by offering a culturally sensitive tool that evaluates healthcare quality from the perspective of medical practitioners.\u003c/p\u003e\n\u003cp\u003eThe study’s findings indicate no statistically significant differences in SHCS scores between male and female physicians. This aligns with previous research suggesting that, despite societal and systemic challenges, female healthcare providers in Syria have demonstrated resilience and commitment to patient care (16). However, it’s essential to acknowledge that gender dynamics in healthcare are complex and influenced by various socio-cultural factors, which may not be fully captured by quantitative measures alone.\u003c/p\u003e\n\u003cp\u003eInterestingly, the SHCS scores did not significantly differ between physicians with more than ten years of experience and those with less. This suggests that, in the Syrian context, factors such as ongoing professional development, adaptability, and commitment to patient care may play more pivotal roles than years of experience alone. It also underscores the importance of continuous training and support for healthcare providers, regardless of their tenure. This finding diverges from previous studies (16) that reported a decline in empathy among more experienced practitioners. While empathy may fluctuate with time, the core quality of healthcare, at least as measured by this scale, remains unaffected by length of service. This reinforces the notion that professional care should remain consistent regardless of years in practice.\u003c/p\u003e\n\u003cp\u003eThe SHCS demonstrated strong psychometric properties, indicating its reliability and validity as a tool for assessing healthcare quality. The balanced inclusion of positively and negatively worded items, along with the use of a 7-point Likert scale (22), enhances its sensitivity and reduces response bias. Such methodological rigour ensures that the SHCS can serve as a valuable instrument for both research and practical applications in healthcare settings.\u003c/p\u003e\n\u003cp\u003eThe SHCS offers significant potential for informing healthcare policy and practice in Syria. By providing insights into the perceptions and experiences of medical professionals, it can guide targeted interventions aimed at improving healthcare delivery. Moreover, its adaptability allows for potential application in other conflict-affected or resource-limited settings, facilitating comparative studies and broader healthcare improvements.\u003c/p\u003e\n\u003ch2\u003eLimitations\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eWhile the SHCS provides valuable insights, certain limitations must be acknowledged. The study’s sample size, though adequate for initial validation, may not fully represent the diverse experiences of all Syrian healthcare providers. Future research should aim to include a broader range of participants, including those from various specialities and regions. Additionally, integrating patient perspectives could offer a more comprehensive understanding of healthcare quality.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe SHCS stands as a valid and reliable measure for assessing physician-delivered care in crisis contexts. Its adoption can facilitate the monitoring and enhancement of healthcare quality, ultimately contributing to improved patient outcomes in regions grappling with the challenges of conflict and resource constraints.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSyrian Health Care Scale (SHCS)\u003c/p\u003e\n\u003cp\u003ePrincipal Component Analysis (PCA)\u003c/p\u003e\n\u003cp\u003eConfirmatory Factor Analysis (CFA)\u003c/p\u003e\n\u003cp\u003eExploratory Factor Analysis (EFA)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate: \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the study was obtained from the Ethical Committee of the Syrian Virtual University (07-031-6678).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication: \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no specific funding for this work. It is supported by the Syrian Virtual University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNB and MD conceived and designed the study and collected the data, JA conducted the statistical analysis and drafted the manuscript. NB, JA and MD reviewed the manuscript and provided critical revisions. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSpecial thanks to Prof. Monzer Boubou for his assistance and the Syrian Virtual University for the support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBirks YF, Watt IS. Emotional intelligence and patient-centred care. 100, J R Soc Med. 2007.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcNulty JP, Politis Y. Empathy, emotional intelligence and interprofessional skills in healthcare education. J Med Imaging Radiat Sci. 2023;54(2):238\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTurjuman F, Alilyyani B. Emotional Intelligence among Nurses and Its Relationship with Their Performance and Work Engagement: A Cross-Sectional Study. J Nurs Manag. 2023;2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKherallah M, Alahfez T, Sahloul Z, Eddin KD, Jamil G. Health care in Syria before and during the crisis. Avicenna J Med. 2012;2(03):51\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWHOLE OF SYRIA OPERATIONS. People targeted 1 13 million.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbbara A, Rayes D, Ekzayez A, Jabbour S, Marzouk M, Alnahhas H et al. The health of internally displaced people in Syria: are current systems fit for purpose? J Migr Heal. 2022;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNembhard IM, David G, Ezzeddine I, Betts D, Radin J. A systematic review of research on empathy in health care. Health Serv Res. 2023;58(2):250\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHaar R, Rayes D, Tappis H, Rubenstein L, Rihawi A, Hamze M et al. The cascading impacts of attacks on health in Syria: A qualitative study of health system and community impacts. PLOS Glob Public Heal. 2024;4(6).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAudi MN, Mwenda KM, Wei G, Lurie MN. Healthcare accessibility in preconflict Syria: A comparative spatial analysis. BMJ Open. 2022;12(5).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eClarke GM, Conti S, Wolters AT, Steventon A. Evaluating the impact of healthcare interventions using routine data. BMJ. 2019;365.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFlegar-Meštrić Z, Perkov S, Radeljak A. Standardization in laboratory medicine: Adoption of common reference intervals to the Croatian population. World J Methodol. 2016;6(1):93.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAtaya J, Jamous I, Dashash M. Measurement of Humanity among Health Professionals: Development and Validation of the Medical Humanity Scale Using the Delphi Method. JMIR Form Res. 2023;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBeattie M, Murphy DJ, Atherton I, Lauder W. Instruments to measure patient experience of healthcare quality in hospitals: A systematic review. Syst Rev. 2015;4(1).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHarding E, Wait S, Scrutton from The Health Policy Partnership. J. The state of play in person-centred care: A pragamatic review of how person-centred care is defined, applied and measured.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEpstein RM, Fiscella K, Lesser CS, Stange KC. Analysis \u0026amp; commentary: Why the nation needs a policy push on patient-centered health care. Vol. 29, Health Affairs. 2010. pp. 1489\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDashash M, Boubou M. Measurement of empathy among health professionals during Syrian crisis using the Syrian empathy scale. BMC Med Educ. 2021;21(1):1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSullivan GM, Artino AR. Analyzing and Interpreting Data From Likert-Type Scales. J Grad Med Educ. 2013;5(4):541\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Medical Association Declaration. of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAli Memon M, Ting H, Cheah JH, Thurasamy R, Chuah F, Huei Cham T. Journal of Applied Structural Equation Modeling SAMPLE SIZE FOR SURVEY RESEARCH: REVIEW AND RECOMMENDATIONS. 4, J Appl Struct Equation Model. 2020.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePhysicians for Human Rights. Destruction, Obstruction, and Inaction The Makings of a Health Crisis in Northern Syria. 2021.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHanefeld J, Powell-Jackson T, Balabanova D. Understanding and measuring quality of care: dealing with complexity. Bull World Health Organ. 2017;95(5):368\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eALTUNA OK, m\u0026uuml;ge ARSLAN F. Impact of the number of scale points on data characteristics and respondents\u0026rsquo; evaluations: An experimental design approach using 5-point and 7-point likert-type scales. İstanbul \u0026Uuml;niversitesi Siyasal Bilgiler Fak\u0026uuml;ltesi Derg. 2016;(55):1\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Syrian Health Care Scale, patient-centred care, healthcare quality, conflict-affected regions, physician assessment, psychometric validation","lastPublishedDoi":"10.21203/rs.3.rs-6996415/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6996415/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Syrian healthcare system has faced profound disruptions due to prolonged conflict, resulting in major challenges to delivering quality patient care. Recognising the need for a culturally and contextually relevant assessment tool, this study introduces the Syrian Health Care Scale (SHCS), a novel instrument designed to evaluate the quality of physician-delivered care from a multidimensional perspective.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA cross-sectional study was conducted in July 2024 with a sample of 103 physicians across Syria. The SHCS, a 20-item self-report instrument, encompasses affective, behavioural, and cognitive dimensions of patient-centred care, using a 7-point Likert response format with both positively and negatively worded items. Internal consistency was assessed via Cronbach’s alpha, while item validity was examined using Pearson correlation. Independent samples t-tests and ANOVA were used to explore differences by gender and years of clinical experience. Additionally, Exploratory Factor Analysis (EFA) was conducted to evaluate the scale’s dimensional structure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe SHCS demonstrated acceptable internal reliability (Cronbach’s alpha = 0.753). Factor analysis revealed a three-factor structure corresponding to the intended affective, behavioural, and cognitive domains, explaining 36.4% of the total variance. Several items showed strong loadings on their expected domains, supporting the scale’s conceptual validity. While male physicians scored significantly higher in the behavioural dimension (p = 0.036), no significant differences were observed in total scores based on gender or years of experience. Most participants (67.96%) scored in the “Below Standard” category, highlighting substantial gaps in healthcare delivery under crisis conditions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe SHCS is a reliable and valid instrument for assessing physician-delivered care in conflict-affected settings. Its multidimensional design offers a nuanced evaluation of healthcare provision, making it a valuable tool for guiding policy, clinical training, and future research. The confirmed factor structure provides a foundation for subsequent confirmatory validation and broader application in resource-limited contexts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: not applicable.\u003c/p\u003e","manuscriptTitle":"The Syrian Health Care Scale: A Novel Instrument for Assessing Physician-Delivered Care in Crisis Contexts","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-11 10:01:29","doi":"10.21203/rs.3.rs-6996415/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-18T14:26:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-27T12:10:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-19T12:32:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"173840933220156265644572744755656596662","date":"2025-08-15T14:55:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"108287031075521228830204614891006861625","date":"2025-08-11T10:20:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"158867964319542245340802866762278362842","date":"2025-08-10T19:13:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-08T08:58:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"292162921111843065677832397195307946241","date":"2025-08-05T20:10:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-05T18:41:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-30T12:35:27+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-11T04:55:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-11T01:53:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-07-11T01:50:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6c7bcc72-2036-427f-ad4f-6fa086baefbd","owner":[],"postedDate":"August 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-23T16:00:55+00:00","versionOfRecord":{"articleIdentity":"rs-6996415","link":"https://doi.org/10.1186/s12909-026-08839-y","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2026-02-20 15:56:59","publishedOnDateReadable":"February 20th, 2026"},"versionCreatedAt":"2025-08-11 10:01:29","video":"","vorDoi":"10.1186/s12909-026-08839-y","vorDoiUrl":"https://doi.org/10.1186/s12909-026-08839-y","workflowStages":[]},"version":"v1","identity":"rs-6996415","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6996415","identity":"rs-6996415","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}