Research Article | Open Access
Cross-Cultural Adaptation and Face Validity of the Functional Mobility Assessment into Brazilian Portuguese
Introduction. The Functional Mobility Assessment (FMA) measures satisfaction with mobility devices in daily life. However, in Brazil, there is a lack of instruments which measure functional mobility. Objective. We aim to report the cross-cultural adaptation process and face validity of the FMA for use in Brazil. Methods. Two international guidelines were used in the cross-cultural adaptation process. Two independent translators translated the instrument from English to Brazilian Portuguese, and the two versions were reconciled. Two different translators back translated this reconciled version, and an expert committee analysed the resulting synthesis. For face validity, the FMA was applied with 24 participants, divided into two groups, users with disabilities () and occupational therapy students (), to verify their understanding of each item of the instrument. Results. The cross-cultural adaptation of the FMA was concluded, and its face validity presented that both groups understood most or completely all instrument items. Conclusion. The Brazilian version of FMA is now available in Brazilian Portuguese and has face validation. Further studies should test its psychometric properties.
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 . However, countries in which English is not the primary language usually use standardized instruments developed internationally. Because these instruments are created originally in a different context, they need to be adapted to the culture of the country in which they are intended to be used . Studies on cross-cultural adaptation of instruments are an international issue for occupational therapy because they can allow different countries to discuss about the same measurement and to compare their results, once they are using an instrument applied internationally . Cross-cultural adaptation studies are also fundamental due to instruments in the native language of the target population, which present more reliable results. Moreover, only the translation, instead of a cross-cultural adaptation, may present mistakes related to the meaning of items because concepts are deeply influenced by the local culture of a country .
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 [5–9].
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 Functional Mobility Assessment (FMA) was developed at the University of Pittsburgh in the United States and measures levels of satisfaction of mobility device users in regard to the performance of ten daily living tasks while using the device [10, 11]. The FMA fills a gap of tools which assess mobility, as it is applicable to the entire range of mobility devices, such as wheelchairs, crutches, walkers, canes, scooters, and prosthetic limbs . This instrument has been used in both research and clinical practice. The FMA is easy to use; for instance, it is short enough to be applied by practitioners, does not take long to complete, and can be administered by telephone [10–13].
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 [10, 11].
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.
2. Materials and Methods
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 [14, 15]. Each stage is described in Table 1.
According to Pasquali , the purpose of performing a pretest is to ensure, even if theoretically, the instrument’s face validity. This theoretical analysis is performed by a group of judges, which should include the lowest stratum of the instrument’s potential users and a more sophisticated stratum. To select who would respond to the FMA, we adopted the same criteria as in the study where the lowest stratum was represented by undergraduate students of an occupational therapy program and by users of mobility aids, who would possibly face difficulties understanding some items and also provide suggestions to facilitate understanding; the highest stratum was represented by the expert committee .
The participants of this research were divided into two groups: Group 1: twelve () people with disabilities and Group 2: twelve occupational therapy students () for the pretest and face validation.
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) [19–21]. The MMSE examines the following items: temporal orientation, spatial orientation, registration, attention and calculation, evocation memory, language, and visual constructive capacity . The maximum possible score is 30, while a was adopted in this study, as recommended [19–22]. Face validity is important because it refers to the transparency or relevance of an instrument for both respondents and examiners . In this case, participants with different diagnoses using various types of mobility aids were considered for the face validity process, comprising of the assessment of not only manual and powered wheelchairs but also canes, walkers, and lower limb prostheses. In Group 2, the inclusion criteria consisted of undergraduate students from an occupational therapy program in their 4th semester or higher. Undergraduate students were included because the instrument can be used as an interview, so both professionals and users needed to understand its use and objectives .
2.2. Instruments and Procedures
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 (1)form to characterize participants addressing sociodemographic data(2)Mini-Mental State Examination (MMSE)(3)Functional Mobility Assessment (version translated into Brazilian Portuguese)(4)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)I understood completely(ii)I understood a lot(iii)I understood a little(iv)I did not understand
2.3. Data Analysis and Procedures
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 , obtained by the formula , was the criterion adopted to reformulate the FMA’s items during the cross-cultural adaptation .
2.4. Ethical Considerations
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.
3.2. Back translation
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 . The first two authors of this research analysed both back translations to create a single version in English. This consensus was made together with the two translators (B12). In this stage, we identified that the title of the instrument was back translated into “Functional Mobility Evaluation (FME)” by translator B1 and “Functional Mobility Assessment” by translator B2,” where the consensus was always to be approximate of the original version; in this case, the second option was accepted.
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.
3.3. Expert Committee
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 2 presents qualitative data from the cross-cultural adaptation where each sentence with a low level of agreement among the experts was analysed by the two first authors of this study.
3.4. Face Validity
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 3 illustrates the characterization of the participants of Group 1 users of mobility devices, where it can be observed that ten were wheelchair users.
Table 4 presents data about Group 2: occupational therapy undergraduate students, where it can be identified that they knew previous knowledge about mobility.
Table 5 show that in the total of eighteen sentences of the FMA, both groups presented good levels of understanding where it can be seen that the majority of respondents of both groups understood completely or most statements of the instrument.
The frequency distribution was based on the analysis of the instrument’s 18 sentences by 24 participants in each group.
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 . Moreover, standardized instruments, sensitive to the needs of clients, should be used to ensure the process of prescribing an assistive technology product [10, 25, 26]. In Brazil, cross-cultural adaptation of instruments is growing partly related to a need for standardization and systematization of research procedures and interventions focused on assistive technology .
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 [1, 3, 8, 9]. We also observed that the single version of back translation, when compared to the original version of FMA, was very similar, which could be a result of the work on Stages 2, 3, and 4.
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 . Fifty-eight changes were suggested by five experts for the instrument adapted to Spanish, which shows the relevance of Stage 5—expert committee—in the adaptation process of an instrument to a given language and context .
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 [14, 15].
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 [15, 28].
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.
Conflicts of Interest
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).
- D. M. C. Cruz, S. Parkinson, D. S. Rodrigues et al., “Cross-cultural adaptation, face validity and reliability of the model of human occupation screening tool to Brazilian Portuguese,” Cadernos Brasileiros de Terapia Ocupacional, vol. 27, no. 4, pp. 691–702, 2019.
- D. Castro, S. Dahlin-Ivanoff, and L. Mårtensson, “Cultural awareness scale for occupational therapy students in Latin America,” Cadernos de Terapia Ocupacional da UFSCar, vol. 25, no. 1, pp. 3–20, 2017.
- L. C. B. Campos, V. A. Y. Ossada, V. S. P. Costa, and D. M. C. Cruz, “Adaptação transcultural e validade face do Wheelchair Skills Test Questionnaire (versão 4.3) para cuidadores,” Cadernos Brasileiros de Terapia Ocupacional, vol. 27, no. 1, pp. 17–26, 2019.
- D. Peres, F. Romaguera, J. M. Garcia, L. C. Rodrigues, R. J. Knabben, and S. M. Michaelsen, “Cross-cultural adaptation of the Chedoke Arm and Hand Activity Inventory (CAHAI),” Cadernos Brasileiros de Terapia Ocupacional, vol. 25, no. 3, pp. 595–605, 2017.
- K. E. C. Carvalho, B. G. J. Miburge, and K. N. Sá, “Translation and validation of the Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST 2.0) into Portuguese,” Revista Brasileira de Reumatologia, vol. 54, no. 4, pp. 260–267, 2014.
- R. L. Kirby, J. Swuste, D. J. Dupuis, D. A. MacLeod, and R. Monroe, “The Wheelchair Skills Test: a pilot study of a new outcome measure,” Archives of Physical Medicine and Rehabilitation, vol. 83, no. 1, pp. 10–18, 2002.
- A. C. J. Alves, T. S. Matsukura, and M. J. Scherer, “Cross-cultural adaptation of the assistive technology device – predisposition assessment (ATD PA) for use in Brazil (ATD PA Br),” Disability and Rehabilitation: Assistive Technology, vol. 12, no. 2, pp. 160–164, 2017.
- V. Ossada, L. C. B. Campos, V. Costa, D. M. C. Cruz, J. Garcia, and F. Orsi, “Cross-cultural adaptation of wheelchair skills test (version 4.3) for wheelchair users and caregivers to the Portuguese language (Brazil),” Disability and Rehabilitation: Assistive Technology, vol. 14, pp. 1–8, 2019.
- L. C. B. Campos, C. C. Caro, E. Fachin-Martins, and D. M. C. Cruz, “Cross-cultural adaptation and reliability of the Brazilian version of the Wheelchair Skills Test-Questionnaire 4.3 for manual wheelchair users,” Assistive Technology, pp. 1–7, 2019.
- A. Kumar, M. R. Schmeler, A. M. Karmarkar et al., “Test-retest reliability of the functional mobility assessment (FMA): a pilot study,” Disability and Rehabilitation: Assistive Technology, vol. 8, no. 3, pp. 213–219, 2013.
- D. C. Paulisso, M. R. Schmeler, R. M. Schein et al., “Functional mobility assessment is reliable and correlated with satisfaction, independence and skills,” Assistive Technology, pp. 1–7, 2019.
- A. Howell, C. Hughes, D. Morris et al., Changes in Functioning of People with Progressive and Non-Progressive Disorders with Prescribed Seating and Mobility Devices, Vanderbilt University, 2014.
- E. Halkiotis and J. Minkel, “Integrating outcome assessments into practice: the functional mobility assessment,” in International Seating Symposium: Building the Future. N° 29, pp. 103-104, Nashville, March 2013.
- D. E. Beaton, C. Bombardier, F. Guillemin, and M. B. Ferraz, “Guidelines for the process of cross-cultural adaptation of self-report measures,” Spine, vol. 25, no. 24, pp. 3186–3191, 2000.
- D. Wild, A. Grove, M. Martin et al., “Principles of good practice for the translation and cultural adaptation process for patient-reported outcomes (PRO) measures: report of the ISPOR task force for translation and cultural adaptation,” Value in Health, vol. 8, no. 2, article S1098301510602525, pp. 94–104, 2005.
- F. Guillemin, C. Bombardier, and D. E. Beaton, “Cross-cultural adaptation of health-related quality of life measures: Literature review and proposed guidelines,” Journal of Clinical Epidemiology, vol. 46, no. 12, pp. 1417–1432, 1993.
- L. Pasquali, “Princípios de elaboração de escalas psicológicas,” Revista de psiquiatria clínica, vol. 25, no. 5, pp. 27–36, 1998.
- E. Hiratuka, T. S. Matsukura, and L. I. Pfeifer, “Cross-cultural adaptation of the gross motor function classification system into Brazilian-Portuguese (GMFCS),” Brazilian Journal of Physical Therapy, vol. 14, no. 6, pp. 537–544, 2010.
- C. C. Caro, P. V. B. Mendes, J. D. Costa, L. J. Nock, and D. M. C. Cruz, “Independence and cognition post-stroke and its relationship to burden and quality of life of family caregivers,” Topics in Stroke Rehabilitation, vol. 24, no. 3, pp. 194–199, 2016.
- P. H. F. Bertolucci, S. M. D. Brucki, S. R. Campacci, and Y. Juliano, “The Mini-Mental State Examination in an outpatient population: influence of literacy,” Arquivos de Neuro-Psiquiatria, vol. 52, no. 1, 1994.
- M. F. Folstein, S. E. Folstein, and P. R. Mchugh, “"Mini-mental state": A practical method for grading the cognitive state of patients for the clinician,” Journal of Psychiatric Research, vol. 12, no. 3, pp. 189–198, 1975.
- R. A. Lourenço and R. P. Veras, “Mini-Mental State Examination: psychometric characteristics in elderly outpatients,” Revista de Saúde Pública, vol. 40, no. 4, pp. 712–719, 2006, Epub 2006 Aug 8.
- F. J. Gravetter and L. B. Forzano, Research Methods for the Behavioral Sciences, CENGAGE, Belmont, CA: Wadsworth, 4th edition, 2012.
- J. A. Lenker, M. J. Scherer, M. J. Fuhrer, J. W. Jutai, and F. DeRuyter, “Psychometric and administrative properties of measures used in assistive technology device outcomes research,” Assistive Technology, vol. 17, no. 1, pp. 7–22, 2005.
- M. R. Schmeler, M. Holm, and T. L. Mills, “Wheelchairs functional outcome measures and functioning everyday with wheelchair,” in Canadian Seating and Mobility Conference, Canada, 2006.
- M. R. Schmeler, Development and testing of a clinical outcome measurement tool to assess wheeled mobility and seating intervention., [Ph.D. thesis], 2005, http://d-scholarship.pitt.edu/9562/.
- E. M. Orellano and J. W. Jutai, “Cross-cultural adaptation of the psychosocial impact of assistive device scale (PIADS) for Puerto Rican assistive technology users,” Technology, vol. 25, no. 4, pp. 194–203, 2013.
- J. Epstein, R. M. Santo, and F. Guillemin, “A review of guidelines for cross-cultural adaptation of questionnaires could not bring out a consensus,” Journal of Clinical Epidemiology, vol. 68, no. 4, pp. 435–441, 2015.
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