Introduction
Extensive evidence shows that with aging and getting chronic diseases, the challenge of transition of care (TOC) for the elderly is an important phenomenon [1, 2, 3]. The TOC for the elderly is a process during which the elderly patient’s care is transferred from one health center to another [4]. The term “transition” is usually used interchangeably with the term “transfer”. Due to the fact that unsuccessful TOC causes problems for the elderly and their caregivers, such as falls, infections, medication errors, re-hospitalization, worsening of disease symptoms, prolongation of disease duration, and even death [5, 6, 7, 8, 9, 10], examining and measuring the quality of TOC is of particular importance. In this regard, this study aims to assess the psychometric properties of the Persian version of the care transitions measure (CTM-15) and find the structural factors of TOC concept in Iranian older people.

Methods
This methodological study was conducted during 2021-2022 in three general hospitals affiliated to Guilan University of Medical Sciences. The questionnaire was first translated into Persian based on the IQOLA protocol [11]. Then, face validity and content validity were evaluated qualitatively and quantitatively. To examine the construct validity of the Persian CTM-15, confirmatory factor analysis (CFA) and exploratory factor analysis (EFA) were used after its completion by 200 older people who were selected using a convenience sampling method based on the inclusion criteria (age≥60 years, hospitalization in the teaching hospitals of Rasht city due to internal disorders and surgery, Persian speaking, and willingness to participate in the study). Those with cognitive, hearing and vision disorders were excluded from the study. In the CFA, fit indices were used to confirm the 4-factor model of the main version. To perform EFA, first the Kaiser-Meyer-Olkin (KMO) test and Bartlett’s test of sphericity were carried out. The convergent validity was investigated in relation with the general self-efficacy scale (GSE-10), which was completed one week after discharge from the hospital. The reliability of the questionnaire was evaluated in terms of internal consistency (using Cronbach’s α) and test-retest reliability. Statistical analyses were done in SPSS software, version 26 and AMOS software, version 24.

Results
Of 200 elderly people participated in this study, 115 were female (57.5%) and 85 were male (42.5%), with a mean age of 68.9±6.68 years; 189 had chronic diseases and 160 had more than one chronic disease. In assessing qualitative face validity, modifications were made in 6 items according to their opinions. In assessing quantitative face validity, all items received an impact score higher than 1.5 and thus all items were remained. In qualitative content validity, suggestions and opinions of geriatric nursing experts were applied in terms of clarity and simplicity in 12 items. The content validity index (CVI) for the whole questionnaire was obtained as S-CVI=0.966. Therefore, all items were approved. Following CFA, the 4-factor solution was not confirmed and did not show a good fit (P<0.001, RMSEA=0.093, GFI=0.851, NFI=0.644, CFI=0.731). For performing EFA, the result of the KMO test to check the adequacy of the sampling was obtained 0.749, which was at an acceptable level, and the result of Bartlett’s sphericity test was statistically significant (P<0.001). In EFA, principal component analysis method with Promax rotation was used to obtain factors. Three factors were found and named as “patient and caregiver preferences”, “self-management and follow-up” and “medication management”. In total, they explained 58.39% of the total variance. Convergence validity of the Persian CTM-15 with GSE-10 was assessed using Pearson’s correlation test which obtained as r=0.468 (P<0.05). The internal consistency using Cronbach’s α coefficient was 0.76 and intraclass correlation coefficient was 0.85.

Conclusion
The Persian version of CTM-15 has acceptable face validity, content validity, convergence validity, internal consistency and test-retest reliability. It has three subscales of “patient and caregiver preferences”, “self-management and follow-up” and “medication management”. Due to having acceptable validity and reliability and small number of items, this questionnaire can be used as an efficient tool to evaluate the TOC in the elderly in Iran. The benefits of measuring the TOC and its impact on the promotion of discharge programs and continuity of care in various settings justify the need to pay attention to this tool.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (Code: IR.USWR.REC.1400.151).

Funding
The study is the result of Seyed Ebrahim Seyed Alavi's master's thesis, approved by Department of Nursing, University of Rehabilitation Sciences and Social Health.

Authors' contributions
All the authors participated in the implementation and writing of all parts of the research.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors thank and appreciate the support and cooperation of University of Social Welfare and Rehabilitation Sciences and Guilan University of Medical Sciences, as well as all the elderly who participated in the study.


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