Scholarly article on topic 'Translation and cross-cultural adaptation of FFI to Brazilian Portuguese version: FFI – Brazil'

Translation and cross-cultural adaptation of FFI to Brazilian Portuguese version: FFI – Brazil Academic research paper on "Educational sciences"

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{Function / Questionnaire / Translation / Foot / Função / Questionário / Tradução / Pé}

Abstract of research paper on Educational sciences, author of scientific article — Liu Chiao Yi, Isabela Maschk Staboli, Danilo Harudy Kamonseki, Elly Budiman-Mak, Eduardo Kenzo Arie

Abstract Objective Perform the translation and cultural adaptation of the questionnaire Foot Functional Index (FFI), which assesses the functionality of the foot, to the Brazilian Portuguese version. Method The Brazilian version development of FFI questionnaire was based on the guideline proposed by Guillemin. The applied process consisted of: (1) translation; (2) back-translation; (3) committee review; (4) pretesting. The Portuguese version was applied to 40 patients, both genders, aged over 18 years old, with plantar fasciitis and metatarsalgia to verify the level of the instrument comprehension. The final Brazilian version of the FFI was set after getting less than 15% of “not understanding” on each item. Results Some terms and expressions were changed to obtain cultural equivalence for FFI. The terms that were incomprehensible were changed in accordance of patient suggestions. Conclusion After the translation and cultural adaptation of the questionnaire, the final Portuguese version of FFI was concluded.

Academic research paper on topic "Translation and cross-cultural adaptation of FFI to Brazilian Portuguese version: FFI – Brazil"

REVISTA BRASILEIRA DE REUMATOLOGIA

www.reumatologia.com.br

Original article

Translation and cross-cultural adaptation of FFI to Brazilian Portuguese version: FFI - Brazil^

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Liu Chiao Yia'*, Isabela Maschk Stabolib, Danilo Harudy Kamonsekia, Elly Budiman-Makc, Eduardo Kenzo Aried

a Interdisciplinary Post-Graduation Program in Health Sciences, Universidade Federal de Sao Paulo, Santos, SP, Brazil b Physiotherapy Course, Universidade Federal de Sao Paulo, Santos, SP, Brazil c Medicine Department, Loyola University of Chicago, Chicago, United States d Santa Casa de Santos, Santos, SP, Brazil

article info abstract

Article history: Objective: Perform the translation and cultural adaptation of the questionnaire Foot Func-

Received 17 May 2014 tional Index (FFI), which assesses the functionality of the foot, to the Brazilian Portuguese

Accepted 9 November 2014 version.

Available online 18 March 2015 Method:The Brazilian version development of FFI questionnaire was based on the guideline

proposed by Guillemin. The applied process consisted of: (1) translation; (2) back-translation; (3) committee review; (4) pretesting. The Portuguese version was applied to 40 patients, both genders, aged over 18 years old, with plantar fasciitis and metatarsalgia to verify the level of the instrument comprehension. The final Brazilian version of the FFI was set after getting less than 15% of "not understanding" on each item.

Results:Some terms and expressions were changed to obtain cultural equivalence for FFI. The terms that were incomprehensible were changed in accordance of patient suggestions. ConcIusion:After the translation and cultural adaptation of the questionnaire, the final Portuguese version of FFI was concluded.

© 2015 Elsevier Editora Ltda. All rights reserved.

Keywords:

Function

Questionnaire

Translation

Traducao e adaptacao cultural do Foot Function Index para a lingua portuguesa: FFI - Brasil

r e s u m o

Palavras-chave Funcpao Questionario Traducao Pe

Objetivo: Fazer a traducao e a adaptacao cultural do questionário Foot Functional Index (FFI), que avalia a funcionalidade do pé, para a versao em lingua portuguesa do Brasil. Métodos: A versao brasileira do FFI foi baseada no protocolo proposto por Guillemin.8 O processo aplicado consistiu em: (1) traducao; (2) retrotraducao; (3) análise do comité de especialistas; (4) pré-teste. A versao brasileira foi aplicada em 40 pessoas, homens e

* Work conducted with the help of the institutional Program of Scientific Initiation scholarships (PIBIC/CNPq).

* Corresponding author.

E-mail: liuchiaoyi@yahoo.com.br (L.C. Yi). http://dx.doi.org/10.1016/j.rbre.2014.11.005 2255-5021/© 2015 Elsevier Editora Ltda. All rights reserved.

mulheres com idade superior a 18 anos, com fasciíte plantar e metatarsalgia, para verificar o nível de compreensao do instrumento. A versao final foi definida após se obter menos de 15% de "nao compreensao" em cada item.

ResuItados:Foram alterados termos e expressoes para obter equivalencia cultural do FFI. As alterares feitas foram baseadas nas sugestoes dos pacientes.

ConcIusao:Após a traducao e adaptacao cultural do questionário, foi concluida a versao da língua portuguesa do Brasil do FFI.

© 2015 Elsevier Editora Ltda. Todos os direitos reservados.

Introduction

In recent years there have been changes in the approach of musculoskeletal disorders. In the past, clinical changes were assessed by physical examination and laboratory tests. Currently, outcomes such as functionality have been emphasized as they allow for an analysis of the health situation, the impact of diseases on patient's life, and provide the necessary information to evaluate the effectiveness of different treatments.

Thus, evaluation measures that measure functional, social and emotional aspects have been proposed, which can be used both in clinical practice and in research.1-4

In order to apply health evaluation measures, developed and used in another language, a cross-cultural equivalence is necessary. This process consists on the translation, cultural adaptation and evaluation of the psychometric properties of the instrument. The translation and cultural adaptation phase allows the adjustment of the instrument to the new language, population, environment and culture. Psychometric properties assessment phases (validity, reproducibility and sensitivity to changes) consists on checking whether the new version retained the features of the original design.5-9

Musculoskeletal injuries in distal lower limbs causes several complications such as functional limitations and impaired quality of life. Approximately 4% of the world population between 25 and 74 years are likely to develop diseases in the ankle and foot.2 Therefore, instruments have been proposed to assess the impact on quality of life and effectiveness of different treatments.1

Evaluation instruments of ankle and foot disorders are mainly available in English language. Among them, the FFI (Foot Function Index), AO FAS (American Orthopaedic Foot and Ankle Society), FAOS (Foot and Ankle Outcome Score), WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index), LFIS (Leeds Foot Impact Scale) and MFPDQ (Manchester Foot Pain and Disability Questionnaire).

FFI (Foot Function Index) is a questionnaire developed in English to evaluate foot function in patients who have muscu-loskeletal injuries. Since evaluation is focused on the foot, the questionnaire has greater accuracy and sensitivity for identifying changes in this area, when compared to other available instruments.2 In assessing the reproducibility of the original FFI, the intraclass correlation coefficient was considered excellent.2

FFI translations and validations have already been done into Chinese,4 German,5 French6 an Italian.7 This study aimed

at translating and making the cultural adaptation of the FFI questionnaire to Brazilian Portuguese.

Materials and methods

Participants

Forty patients participated in the study, with clinical diagnosis of plantar fasciitis and metatarsalgia. The mean age was 33 years and 78% were female. Regarding the level of education, 42% had not completed tertiary education, 32% completed tertiary education, 24% completed secondary education, and 2% did not complete secondary education.

The study was approved by the Research Ethics Committee n. 226.521 and an authorization from the author of the FFI was obtained via electronic mail for its use.

Procedures

The Brazilian version of FFI was obtained according to the guideline proposed by Guillemin8 (Fig. 1).

FFI was initially translated by two independent translators who had Portuguese as a native language. Thus two independent versions, V1 and V2, were obtained. Then, the two translations were compared and discussed by the translators and members of the committee consisting of three physiotherapists specialized in traumatology and orthopedics, and an orthopedist specialized on ankle and foot research. This meeting resulted in a consensus version, V3, which maintained the fundamental characteristics of the original questionnaire.

V3 version was translated back into English by two native English-speaking translators, forming two independent versions (V4 and V5), and the translators did not have access to the original questionnaire. Then, the members of the committee met again, to discuss the differences between versions (V1, V2, V3, V4 and V5) and the original questionnaire. Sentences that required modifications had been rewritten in order to improve the semantic, idiomatic, cultural and conceptual equivalence, and the V6 version was obtained.

The V6 questionnaire was administered to 40 patients with clinical diagnosis of plantar fasciitis and metatarsalgia. Initially, the questionnaire was administered to 20 patients to check understanding and acceptability of questions and answers. This phase was called the first phase of the Cognitive Interviews.

First version in Portuguese V3

Committee analysis

Committee analysis original version +V1+V2+V3+V4+V5

Fig. 1 - Study flowchart.

Each item of the questionnaire was read aloud for the participants, who had to: (1) answer if they understood (yes or no); (2) comment what they understood of each item read; and (3) suggest changes if there were any items that were "not understood". According to the results of this stage, some terms had been adapted and modified. After this step, the questionnaire was administered to 20 patients in a second phase of Cognitive Interviews to refine clarity and understanding of the instrument, and items with more than 15% of "no understanding" were reformulated by the committee.

Again, this version was analyzed by the committee and sent to the author of FFI for approval, resulting in the final version V7 (Fig. 2).

Score calculation

For the total score of each domain, the following formula was applied: sum of the score obtained from all items answered by the patient/total score possible of the domain x 100, in order to get the value in percent. If the patient does not perform an activity mentioned in one of the items (e.g. no use of assistive devices), this is considered not applicable. Thus, the score of these items are not considered in the total sum of that domain.

The final percentage of all domains shall be summed and divided by three (total number of domains) thus obtaining the final result of the questionnaire. The results may vary from 0 to 100% and are directly proportional to the limb functional impairment, and the higher the percentage, the greater the functional change presented by the patient.2

Results

At the translation phase, some changes took place during the committee meeting, when all items of V1 and V2 versions were discussed for the formulation of consensus version V3 (Table 1).

After back-translation the committee met again to discuss the differences between all versions (V1, V2, V3, V4 and V5) and the original questionnaire. At this stage, changes were made in grammatical structures of some items for equivalence of words, languages, and adaptation of cultural context (Table 2).

Regarding the pre-test, the items "not understood" and changed during the phases of cognitive interview are included in Table 3.

In the first phase of the Cognitive Interviews two items of the FFI questionnaire, the numerical scale of 10 scores and item C1 in the worst pain crisis were reformulated, due to "no understanding" by more than 15% of patients. In the second stage of cognitive examination, patients did not show difficulties in understanding the items. So there was no changes.

With the pre-test performed and the necessary changes made, the final version of Portuguese FFI was defined (V7). This version was sent to the author of the original version of FFI, who did not suggest any changes.

Discussion

The process of translation and cultural adaptation of FFI to the Portuguese language was performed and the Brazilian Portuguese version was obtained.

Nome: Identifícalo do paciente: Data:

Patologia do pé: Idade: Nível de escolaridade:

Escala numérica de dor: 0 1 2 3 4 5 6 7 8 9 10

Dor no pé e índice de incapacidade:

Incapacidade

Pontuagao

A escala numérica de cada item abaixo representa com que frequéncia vocé fez cada atividade na última semana. A extremidade esquerda dos números representa nunca e a direita sempre. Faga uma marca no número que indica com que frequéncia vocé conseguiu realizar as atividades na última semana por causa de seus pés. Caso vocé nao tenha realizado a atividade na última semana marque NA (nao se aplica) aextrema direita do item.

Exemplo: Por quanto tempo vocé:

0. Anada pela casa de sapatos: Nunca 0 1 2 3 4 5 6 7 8 9 Sempre /

A. Por quanto tempo vocé: Pontuaçâo/ NA

1. Usa bengala, muletas ou andador dentro de casa? Nunca 0 1 2 3 4 5 6 7 8 9 Sempre /

2. Usa bengala, muletas ou andador fora de casa? Nunca 0 1 2 3 4 5 6 7 8 9 Sempre /

3. Fica em casa a maior parte do dia devido a problemas no pé? Nunca 0 1 2 3 4 5 6 7 8 9 Sempre /

4. Fica na cama a maior parte do dia devido a problemas no pé? Nunca 0 1 2 3 4 5 6 7 8 9 Sempre /

5. Limita suas atividades devido a problemas no pé? Nunca 0 1 2 3 4 5 6 7 8 9 Sempre /

/Possível

Fig. 2 - Brazilian version of FFI questionnaire.

Dificuldade Pontuagao

A escala numérica de cada item abaixo representa quanta dificuldade voce teve quando realizou estas atividades na última. A extremidade esquerda dos números representa nenhuma dificuldade e a direita tanta dificuldade que nao foi possível realizar. Faga uma marca no número que indica a dificuldade que voce teve para realizar as atividades na última semana por causa de seus pés. Caso voce nao tenha realizado a atividade na última semana marque NA (nao se aplica) ä extrema direita do item.

B. Quanta dificuldade você teve para:

Pontuaçâo/

1. Andar pela casa? Nenuma dificuldade О 2 3 4 5 6 7 8 9 Muita dificuldade/

ImpossÍvel

2. Andar fora de casa no solo irregular? Nenuma dificuldade О 2 3 4 5 6 7 8 9 Muita dificuldade/

ImpossÍvel

3. Andar quarto quarteiroes ou mais? Nenuma dificuldade О 2 3 4 5 6 7 8 9 Muita dificuldade/

ImpossÍvel

4. Subir escadas? Nenuma dificuldade О 2 3 4 5 6 7 8 9 Muita dificuldade/

ImpossÍvel

5. Descer escadas? Nenuma dificuldade О 2 3 4 5 6 7 8 9 Muita dificuldade/

ImpossÍvel

6. Ficar na ponta dos pés? Nenuma dificuldade О 2 3 4 5 6 7 8 9 Muita dificuldade/

ImpossÍvel

7. Levantar da cadeira? Nenuma dificuldade О 2 3 4 5 6 7 8 9 Muita dificuldade/

ImpossÍvel

8. Subir ou descer calçadas? Nenuma dificuldade О 2 3 4 5 6 7 8 9 Muita dificuldade/

ImpossÍvel

9. Andar rápida ou correr? Nenuma dificuldade О 12 3 4 5 6 7 8 9 Muita dificuldade/

ImpossÍvel

/PossÍvel

Fig. 2 - (Continued )

Pontuagao

A escala numérica de cada item abaixo representa o nível de dor que vocé sentiu em cada situagao. A extremidade esquerda dos números represnta sem dor e a direita a pior dor imaginável. Faga uma marca no número que indica a intensidade da dor nos seus pés quando realizou essas atividades na última semana. Caso vocé tenha realizado a atividade na última semana marque NA (nao se aplica) a extrema direita do item.

B. Quanta dificuldade vocé teve para:

Pontuagao/

1. Na pior crise de dor? Sem dir 0 2 3 4 5 6 7 8 9 A pior dor imaginável

2. Antes de se levantar pela manha? Sem dir 0 2 3 4 5 6 7 8 9 A pior dor imaginável

3. Quando anda descalgo? Sem dir 0 2 3 4 5 6 7 8 9 A pior dor imaginável

4. Quando fica em pé descalgo? Sem dir 0 2 3 4 5 6 7 8 9 A pior dor imaginável

5. Quando anda calgado? Sem dir 0 2 3 4 5 6 7 8 9 A pior dor imaginável

6. Quando fica em pé calgado? Sem dir 0 2 3 4 5 6 7 8 9 A pior dor imaginável

7. Quando anda usando aparelho ortopédico? Sem dir 0 2 3 4 5 6 7 8 9 A pior dor imaginável

8. Quando fica em pé usando aparelho ortopédico? Sem dir 0 2 3 4 5 6 7 8 9 A pior dor imaginável

9. Ao final do dia? Sem dir 0 2 3 4 5 6 7 8 9 A pior dor imaginável

Total_/Possível_=_%

Fig. 2 - (Continued).

Table 1 - Modification on the initial phase of translation.

Questionnaire Item V1 and V2 Modification for consensual version V3

A. Foot pain and disability index V1 Índice de dor no pé e incapacidade Dor no pé e índice de incapacidade

V2 Dor no pé e índice de imobilidade

A. None of time V1 Nenhuma parte do tempo Nunca

V2 Nunca

A. Disability V1 Imobilidade Incapacidade

V2 Incapacidade

A3. Stay V1 Fica Fica

V2 Permanece

B2. Uneven ground V1 Piso irregular Solo irregular

V2 Solo irregular

B9. Walk fast V1 Andar depressa Andar rápido

V2 Andar rápido

C1. At its worst V1 Quando dói mais Na pior dor

V2 Na pior das hipóteses

C5. Wearing shoes V1 Calcando sapatos Calcado

V2 Usando sapatos

C7. Wearing orthotics V1 Usando aparelho ortopédico Usando aparelho ortopédico

V2 Usando palmilha ortopédica

C. Worst pain imaginable V1 A pior dor imaginável A pior dor imaginável

V2 Pior dor que sentiu

V1, version in Portuguese by the first translator; V2, version in Portuguese by the second translator; V3, consensual version in Portuguese defined at the end of the initial phase of translation.

Table 2 - Phase of back-translation. Modifications in "V4" and "V5" for definition of "V6".

V4 and V5. Questionnaire Item - Term V6. Questionnaire Item - Term

B8. V4 Subir ou descer na calçada? V5 Subir ou descer calçadas? C1. V4 Quando dói mais? V5 Quando dói mais? C5. V4 Quando anda com calcado? V5 Quando você anda com calcado? C6: V4 Quando você está parada em pé com calcado? V5 Quando você está em pé com calcado? B8. Subir ou descer calçadas? C1. Na pior dor? C5. Quando anda calcado? C6. Quando fica em pé calcado?

V4 and V5, versions in Portuguese of the back-translation phase; V6, version defined in Portuguese after a original version of the questionnaire. nalysis of all translated versions and

The procedure of translation and cultural adaptation of instruments proposed by Guillemin8 has been followed and cited in several studies, due to international recognizement criteria. There are several questionnaires already translated and validated in the literature that followed this procedure, as WOMAC (Western Ontario and McMaster Universities)9 and FAOS (Foot and Ankle Outcome Score).10 Thus, the same procedure was followed for the FFI questionnaire.

In the initial phase of FFI translation into Portuguese, some expressions were changed by the committee. Among them, the question A. ("Disability") was the most distinct expression among translators, in which one of the translators interpreted as immobility (Imobilidade) and the other as lack of capacity (Incapacidade). At consensus, the committee decided that the most appropriate term would be Incapacidade. In backtranslation, the questions that were most discussed with the

Table 3 - Pretest: cognitive interviews.

Not understood items Patients (%) Suggestions

1st phase of the Cognitive Interviews (n = 20) Visual Analog Scale C1. At worst pain? C7. When wear orthotics? 14 (70%) 11 (55%) 1 (5%) Numeral Scale of 10 points C1. At worst pain crisis? C7. In case you wear orthotics, when you walk wearing orthotics?

2nd phase of the Cognitive Interviews (n = 20) No items "not understood" No changes

Items with more than 15% of "no comprehension" in the first phase were reformulated for the second phase of the Cognitive Interviews.

committee members in order to reach a consensus were questions C1. "Quando doi mais (When is your pain more severe)?" and C5. "Quando anda com calcado (When you walk with shoes)?", which were modified to "Na pior dor (At the worst pain)?" and "Quando anda calcado (When you walked wearing shoes)?", respectively.

At pretest phase (Cognitive Interviews phase), changes in some items were suggested for the better understanding of the patients. The changes made in the first phase were related to the Visual Analog Scale (a line of 10 cm is arranged between the numbers of the two extremes 0 and10) and the item C1. "At worst pain?", which were suggested by more than 15% of patients, being modified to: interspersed Numerical Scales from 1 to 10 points and "Na pior crise de dor (At the worst pain crisis)?". Item C7 "Quando anda usando aparelho ortopédico (When you walk wearing orthotics)?" was suggested to be changed by only 5% of patients, not reaching 15% to be rewritten. After the changes, there was no need to change anything in the second phase of Cognitive Interviews.

In the present study, plantar fasciitis and metatarsalgia were selected because they are chronic diseases that affect mostly the feet. As they affect mainly women, this gender prevailed in the study. All applications of FFI were conducted through interviews, based on previous studies with the same purpose.9,10

Although there are methodological variations of the process of translation and cultural adaptation of questionnaires about quality of life and functionality, the standard process must be maintained, including the phases of translation, back translation and cultural adaptation.11-13 The Brazilian version of FFI is in process of psychometrics properties evaluation. After the end of the process it will be available for use in Brazil.

Conclusion

The process of translation and cultural adaptation of the FFI was carried out and the version to Brazilian Portuguese was obtained.

Conflicts of interest

The authors declare no conflicts of interest.

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