In occupational therapy, the use of assessments is essential for practice and research. Most of the tools available were previously developed in countries where English is the first language [
Regarding the field of assistive technology, few standardized assessments have been translated to Brazil Portuguese. Even though it is recognized that standardized assessments are essential to measure effectiveness of an intervention, today, in this country, few instruments are available for use, such as the Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST 2.0), the Assistive Technology Device Predisposition Assessment (ATD PA), the Wheelchair Skills Test Questionnaire (WSTQ version 4.3), and the Wheelchair Skills Test (WST version 4.3), for both the user and caregiver version [
Standardized instruments of functional mobility are needed in Brazil Portuguese due to the lack of instruments available. In this sense, functional mobility requires a reliable measure to assess the satisfaction of users and to document functional changes on the rehabilitation process [
The FMA adopts a Likert scale in which respondents choose from “completely agree,” “mostly agree,” “slightly agree,” “slightly disagree,” “mostly disagree,” “completely disagree,” or “does not apply” to answer each of the questions. The instrument also enables respondents to rate the priority of items, so that the first point on the scale corresponds to “minimum priority” and the tenth point corresponds to “maximum priority.” The instrument leaves blank spaces for “comments,” in which the participant is supposed to specify the reasons of disagreements with a given item, whenever that is the case [
Considering that the FMA has the potential to encourage clinical practice and research addressing functional mobility, this study’s objective was to report the cross-cultural adaptation process and face validity of the FMA Beta Version 1.0., into Brazilian Portuguese.
This is a methodological and descriptive research of a cross-cultural adaptation and face validity of an instrument. The cross-cultural adaptation was performed in seven stages, where the face validity occurred on stage 6 [
Cross-cultural adaptation procedures of Functional Mobility Assessment for Brazil.
Stages | Description |
---|---|
Preparation (stage 1) | The study was approved by the original authors of the FMA and by the Institutional Review Board at the hosting university. |
Forward translation (stage 2) | The instrument was translated from its original language (English) into the target language (Brazilian Portuguese) by two independent translators (T1 and T2). T1 was an occupational therapist, and T2 was a social scientist, both fluent in English. |
Reconciliation (stage 3) | The translated versions were reconciled (T12) using a table that listed the discrepancies, which was sent to each translator via e-mail. |
Back translation (stage 4) | The synthesis that resulted from the reconciliation of the first two first versions was back translated (from Brazilian Portuguese into English) by two translators whose native language was English but who were proficient in Brazilian Portuguese. |
Harmonization and equivalence analysis (stage 5) | An expert committee composed of eleven experts, nine occupational therapists, and two physical therapists were contacted by e-mail. Ten had a master’s degree, and four had PhDs. They filled in a form addressing professional information and analysed a table where the translated version of the FMA was divided into independent sentences. Each sentence was assessed in terms of semantic equivalence (SE), that is, whether the meanings of words were equivalent; idiomatic equivalence (IE), whether idiomatic expressions and colloquialisms were equivalent; conceptual equivalence (COE), whether the concepts are maintained in the translated version; and cultural equivalence (CUE), the cultural context must be coherent with the context of the country where the translated instrument will be used [ |
Face validity (stage 6) | The face validity of the prefinal version of the FMA corresponded to stage 6 of cross-cultural adaptation, where 24 participants were divided into two groups: Group 1 (12 clients with disabilities who used any device that aided mobility) and Group 2 (12 undergraduate students from the occupational therapy program at the Federal University of São Carlos, São Carlos, Brazil). |
Stage 7 (final report) | Finally, the cross-cultural adaptation was concluded with the final report, sent by e-mail to the authors of the original instrument, who approved all the previous stages. |
According to Pasquali [
The participants of this research were divided into two groups: Group 1: twelve (
In Group 1, the participants were selected from an association of people with disabilities. The inclusion criteria consisted of using a mobility aid and being 18 years of age or older. The exclusion criteria consisted of illiterate individuals and those who scored below 18 (among those with elementary or middle school) and below 26 (among those with higher education) in the cognitive screening instrument of the Mini-Mental State Examination (MMSE) [
For Group 1, data were gathered in the participants’ homes in a single session. For Group 2, the participants were interviewed at the Department of Occupational Therapy where the research was conducted.
The instruments applied to both groups were
form to characterize participants addressing sociodemographic data Mini-Mental State Examination (MMSE) Functional Mobility Assessment (version translated into Brazilian Portuguese) face validity questionnaire developed by the primary author
The participants were interviewed regarding their level of understanding of sentences and words contained in the FMA’s test version.
The face validity procedure included questions for each item of the FMA for the following question:
Did you understand the item?
I understood completely I understood a lot I understood a little I did not understand
Analysis of data obtained in the translation, reconciliation of versions, and verification of equivalence between versions was performed through simple descriptive statistics, presenting distribution of frequencies and percentages. An
This study was in compliance with all ethical assumptions guiding research with human subjects. The respondents signed free and informed consent forms and were ensured confidentiality of their identities and information provided. The study was approved by the Institutional Review Board (Protocol No. 939.039).
The results are presented by each stage of the cross-cultural adaptation as follows.
The versions of the two translators (T1 and T2) into Brazilian Portuguese were analysed by the two first authors of this research seeking for a consensus. We observed that both translations were very similar but differed in technical words, for instance, T2, who was a social scientist and did know about the subject “functional mobility,” translated “powered wheelchair” as “electric wheelchair” while T1 (an occupational therapist) translated correctly to “powered wheelchair.” This stage is aimed at generating a single version in Brazilian Portuguese. The other disagreements were the following: (1) translate the abbreviation of “FMA” into Brazilian Portuguese “AMF,” (2) replace the word “stage” for “step,” (3) the word “guidelines” instead of “instruction,” (4) the sentence “Answer the following ten questions” for “Answer the next ten questions,” and (5) “Fill with a “x” in the box below each answer” for “Mark with a “x” in the space below your answer.” The final decision considered the agreement of both translators who filled a form agreeing with the final decision.
The Brazilian Portuguese single version of FMA was sent by e-mail to two other independent translators (B1 and B2), who at this time were native English speakers, who were also fluent in Brazilian Portuguese. They performed the back translation of the Brazilian Portuguese into English. They were not experts in the subject of the instrument. This procedure was required to avoid the bias of translators who knew the subject of FMA and to obtain possible unexpected meanings of items translated by the first translators (T12), increasing the probability to detect imperfections [
A single version of the back translation (B12) was produced and sent to the authors of the instrument in a table where the first column had the original version of each item of FMA and the second column, the back translated version. The aim of this comparison was to check if the original and back translation version were compatible. This was confirmed by the authors who did not disagree with any items of the back translated version. These results indicate that the Brazilian Portuguese version was like the original version of FMA.
The analysis performed by the expert committee showed that 22 sentences obtained agreement below 85% regarding semantic equivalence, 23 sentences lacked idiomatic equivalence, 25 sentences lacked conceptual equivalence, and nine lacked cultural equivalence. These, therefore, needed to be rewritten. After implementing the suggestions provided by the experts, two sentences were added, and agreement improved among the committee members. In terms of semantic equivalence, 56 of the 60 sentences were approved, as well as 57, 60, and 55 statements that referred to idiomatic, conceptual, and cultural equivalences, respectively.
Table
Analysis of the suggestions made by the expert committee and the final decision (
Original items | Expert recommendations | Final decision |
---|---|---|
Step 1. Please answer the following 10 questions by placing an “X” in the box under the response | Expert 1: I suggest “the following 10 questions below.” |
Rejected. Adding more words than the original version could confuse the respondents. For example, the word “correct” answer could make the respondents think that they were being evaluated of doing something wrong or right. |
(Completely agree, mostly agree, slightly agree, etc.) | Expert 3: The item “mostly agree” could be replaced for “agree most of the time” because I believe it can facilitate the comprehension of respondents in differ from the scale “completely agree.” | Accepted. |
(i.e., walking, cane, crutch, walker, manual wheelchair, power wheelchair, or scooter) | Expert 1: The word “walking” can be clarified by “my mobility is performed without an assistive device, for example, a ‘crutch.’” |
Accepted. We changed for “I walk without an assistive device.” |
If you answer, |
Expert 3: My opinion is that “disagree a little, disagree most of the time, or disagree completely in any question.” | Accepted. |
My current means of mobility allows me to operate it as independently, safely and efficiently as possible | Expert 1: Replace the word “operate” for “use.” |
Accepted. We replaced the word “to operate” for “to use it” because in Brazilian Portuguese, “to operate” is a term more used for surgeries or industries. |
(e.g., dressing, bowel/bladder care, eating, hygiene) | Expert 1: I suggest only “dressing” rather than “dressing myself” |
Accepted the following changes: “dressing myself” for only “dressing” and “urinate and defecate” for “bowel/bladder care.” |
(e.g., uneven surfaces, dirt, grass, gravel, ramps, obstacles) | Experts 3 and 6: In any part of the original FMA is written “side walk or streets.” If you want to give examples to facilitate the comprehension, it is better to put in brackets. For instance, (i.e., irregular surfaces (side walk or streets), dirt, grass, gravel, ramps, obstacles) |
Rejected. The three suggestions did not affect the meaning of the translated version, but just suggested a style of how to present the question. Because a bracket already exists with examples, we just thought adding another one could interfere on the fluency of the reader. |
My current means of mobility allows me to use personal or public transportation | Expert 6: The emphasis “personal” is related to private means, in the opposite of public. In Brazil, expressions which indicate this notion are “private” and “particular.” | Accepted. Added “allows me to use my own transport or public transport.” |
An average score of 25.83 was obtained by the users of mobility aids on the MMSE applied in the pretest. This result indicates that the participants were cognitively able to assess the Brazilian version of the FMA.
Table
Features of participant users of mobility devices (
% | ||
---|---|---|
Age (years) | ||
20 to 29 | 5 | 41.67% |
30 to 39 | 2 | 16.67% |
40 to 49 | 2 | 16.67% |
50 or more | 3 | 25% |
Schooling | ||
Incomplete primary education | 3 | 25% |
Higher school | 7 | 58.33% |
Technical education | 1 | 8.33% |
Doctorate (in progress) | 1 | 8.33% |
Current mean of mobility | ||
Manual wheelchair | 6 | 37.50% |
Powered wheelchair | 4 | 25% |
Axillary crutch | 2 | 12.5% |
Elbow crutch | 2 | 12.5% |
Cane | 1 | 6.25% |
Walker | 1 | 6.25% |
Length of using the device (years) | ||
1 | 5 | 41.67% |
6 to 10 | 1 | 8.33% |
11 to 20 | 5 | 41.67% |
21 to 23 | 1 | 8.33% |
Device prescription | ||
Family/relatives | 3 | 25% |
Physiotherapist | 3 | 25% |
Physician | 2 | 16.67% |
Not informed | 2 | 16.67% |
Occupational therapist | 1 | 8.33% |
Bought without prescription | 1 | 8.33% |
Training with mobility device | ||
None | 7 | 58.33% |
Physiotherapist | 4 | 33.33% |
Table
Features of Group 2, occupational therapy undergraduate students (
% | ||
---|---|---|
Year of undergraduation | ||
3 | 8 | 66.67% |
4 | 4 | 33.33% |
Self-reported knowledge in mobility | ||
Very good | — | — |
Good | 7 | 58.33% |
Medium | 5 | 41.67% |
Bad | — | — |
Sources where they learned about mobility | ||
Undergraduation classes | 12 | 57.14% |
Short courses, lectures, and workshops | 4 | 19.05% |
Independent search | 4 | 19.05% |
Personal experience using mobility devices | 1 | 4.76% |
Table
Results regarding the level of understanding of Groups 1 (
Sentences | ||
---|---|---|
Frequency | Percentage | |
Options of answers | ||
I understood completely | 14 of 18 sentences | 77.78% |
I understood most statements | 4 of 18 sentences | 22.22% |
I understood a little | — | — |
I did not understand | — | — |
Total | 18 | 100% |
Options of answers | ||
I understood completely | 9 of 18 sentences | 50% |
I understood most statements | 9 of 18 sentences | 50% |
I understood a little | — | — |
I did not understand | — | — |
Total | 18 | 100% |
Our study presented the cross-cultural adaptation process of the FMA in Brazil. Particularly, studies focusing on the cross-cultural adaptation of instruments which assess the use of assistive devices are fundamental, first, because of the worldwide interest in the development of international standards and second, due to an emerging consensus on the role of technology in promoting health and well-being [
Stage 2 (translation) showed that the technical terms were important to be reviewed to address the correct meaning. For example, “electric wheelchair” was not the correct term for “powered wheelchair,” and this change was only possible when the translations were carefully compared by the two main authors of this study. We believed that these findings had influence on Stage 3 (back translation), where there was identified minimum disagreement between the two translators. This trend of having less modifications on the back translation has been observed on cross-cultural adaptation of other instruments [
However, it is important to discuss that, in our research, the cultural context was evidenced more when the expert committee suggested changes in the translation of the FMA items. These findings demonstrate the importance of the cross-cultural adaptation once the translated version from the previous stages was not enough to make the instrument precisely into Brazilian Portuguese. A similar result was found in the adaptation of the Psychosocial Impact of Assistive Device Scale (PIADS), intended for Puerto Rican assistive technology users [
These results were expected in the process of cross-cultural adaptation because the specific role of experts is to revise all the translated versions and synthesize them into a single version. We believe that the implementation of the suggestions provided by the experts and by the authors of the original version of FMA, as recommended, improved comprehension of the version into Brazilian Portuguese and enriched the process [
Such a process supports the work of researchers and practitioners, who can be able to describe the same phenomenon similarly even when applying the instrument in different cultures, ensuring that the instrument works as expected [
Face validity showed that users and undergraduate students (who will be future therapists) understood the instrument well. This is an interesting result because users and assistive technology practitioners need to understand the construct of the instrument in order to establish a relationship of cooperation, and, in this case, the FMA promotes collaboration between users and therapists, improving therapy results [
Finally, the cross-cultural adaptation was satisfactorily achieved, and the various stages, from the initial translation, synthesis and back translation, and expert committee, to face validity, enabled achieving such results, considering that these are the stages recommended to ensure the quality of the process of cross-cultural adaptations [
This study presented the process of cross-cultural adaptation of the FMA into Brazilian Portuguese. This tool is semantically, idiomatically, culturally, and conceptually adapted to the Brazilian context, while its format and content are in accordance with the FMA instrument in its original version. We identified that FMA has good face validation and allows therapists to gather relevant data related to satisfaction and priorities regarding mobility devices.
Our study has limitations as well, such as a small sample size (face validity step); however, the fact that the sample comprised of two different groups (students and users) was a positive aspect and presented satisfactory comprehension of the items for both respondents. Although given that the respondents were not blinded, this could be a bias that possibly influenced on their answers.
In conclusion, the use of the FMA can support therapists to identify problems related to the satisfaction of users of mobility devices and to guide interventions focusing on seating and positioning, in order to enable satisfaction and participation of these users indoors and outdoors. The FMA can also support rehabilitation practices, contributing to evidence-based practice. Further studies should address and test the psychometric properties of concurrent and convergent validity of this assessment once they have not been examined in previous research.
Data used to support the findings of this study are available from the corresponding author.
The authors declare that there is no conflict of interest regarding the publication of this paper.
We express thanks for the financial support provided by the Coordination for the Improvement of Higher Education Personnel (CAPES), Grant number (1726714).