The MPOC-20 is a self-administered questionnaire with internal consistency of 0.83 to 0.90 (Cronbach's alpha) and test–retest reliability of 0.78 to 0.86 (Intraclass Correlation Coefficient – ICC).2,18 All the 20 questions start with the expression: “In the past year, to what extent do the people who work with your child...” which is followed with, for example: “...help you to feel competent as a parent” or “...provide you with written information about what your child is doing in therapy”. Responses vary from 0 to 7 in a Likert-type scale as follows: 7 – to a very great extent, 6 – to a great extent; 5 – to a fairly great extent; 4 – to a moderate extent; 3 – to a small extent; 2 – to a very small extent; 1 – not at all. Option zero (0) refers to ‘not applicable’.18 The questions are divided into five domains corresponding to key aspects of FCP: Enabling and Partnership, Providing General Information, Providing Specific Information about the Child, Coordinated and Comprehensive Care for Child and Family, Respectful and Supportive Care.6,18,19 Item scores are averaged to compose the final score of each domain.19 High domain scores indicate perception of frequent family-centered behaviors.8

The MPOC-SP is a self-administered questionnaire for professionals with internal consistency of 0.76 to 0.88 and test–retest reliability of 0.79 to 0.99.11 The 27 questions of the MPOC-SP begin with the expression: “In the past year, to what extent did you...”, which is followed with, for example: “...take the time to establish rapport with parents and children?” or “...discuss expectations for each child with other service providers, to ensure consistency of thoughts and action?”. Response options are the same as MPOC-20. The questions are divided into four domains: Showing Interpersonal Sensitivity, Treating People Respectfully, Communicating Specific Information About the Child and Providing General Information.11,13,19 Each domain has its own average score. Higher scores reflect greater focus of the service on the patient and family.8

The process included six stages after authorization from the CanChild Centre for Childhood Disability Research at McMaster University, Canada.20 This study was approved by the Research Ethics Committee of Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil (CAAE: 74097417.7.1001.5149). All participants signed the Informed Consent Term

In the first stage, two Brazilian translators with different backgrounds (a university professor and a clinician) who were proficient in English and experienced in rehabilitation (both were physical therapists) independently translated the original instruments from English to Portuguese. Then an Expert Committee with three university professors from physical and occupational therapy departments (two who were experienced with translation and cultural adaptation of standardized instruments, one who was certified and experienced as an English teacher and had performed the translation) and two physical therapists (one who was the second translator) compared the two translations and produced a unified version. In the third stage, this version was sent to two professional translators. They were native English speakers who were also fluent in Portuguese; they worked independently of each other and did not know or consulted the original versions of the instruments. They translated the unified Brazilian version back into English (back-translation).15,16 In the fourth stage, two professors (from the physical therapy department) and a physical therapist from the Expert Committee worked with the back-translators and compared the back-translations with the Brazilian and the original version. The Committee also discussed conceptual, idiomatic, semantic and cultural correspondence for each item. The panel worked on best solutions to solve the discrepancies between the Portuguese and English versions of the MPOC-20 and MPOC-SP and produced a unified back-translated version of each. The resulting Brazilian versions as well as the unified back-translations were sent to and approved by CanChild. The Brazilian versions were tested at the fifth stage to ensure that users understood the contents of the MPOC-20 and MPOC-SP.

The fifth stage involved cognitive interviews, which consisted of two techniques. In the ‘think aloud’ technique, the participant is asked to describe what he/she thought when reading the item.21,22 Direct probing’ was used to identify items that were difficult to understand. In this technique, the interviewer asked: “Can you tell me in your words what this question was asking?”.21,22

A physical therapist and two students interviewed parents or family members about their understanding of the MPOC-20, and rehabilitation professionals about the MPOC-SP. After a round of three interviews for each instrument, the interviewers and a university professor analyzed the responses, adjusted the wording and added examples as necessary. To guarantee that meaning was not altered, all changes were submitted to and vetted by the Expert Committee and CanChild. Procedures are detailed in a recent publication.23 Three rounds of interviews were necessary to fully eliminate comprehension problems for each instrument.21,22 All 18 respondents were selected by convenience at the General Hospital of UFMG.

The MPOC-20 and MPOC-SP adjusted Brazilian versions were then tested as recommended internationally.15 Participants were 30 parents and 30 rehabilitation professionals from the SARAH Network in Belo Horizonte. They were interviewed about their understanding of each item and the reason for their response choice. Only if 15% or more of the respondents had any doubts in any of the items, would it be rewritten and a new round of testing carried out.15 At this phase, we noted that some parents felt more comfortable being orally interviewed rather than filling in the self-administered questionnaire. For the next phase, each parent chose his or her preferred format. All professionals used the self-administered format.

At the final sixth stage, the internal consistency was determined with 107 and 92 respondents for the MPOC-20 and MPOC-SP, respectively. To determine test–retest reliability and the standard error of measurement, the questionnaires were applied twice to a subset of 50 and 62 parents and professionals, respectively, 7 to 14 days apart to avoid memory bias. The Brazil-ABEP Economic Classification Criteria were used to describe their socioeconomic level.24

For this phase of the study, parents or caretakers of children under 12 years of age were selected by convenience. The children were in treatment for at least one year (as outpatient or inpatient) in one of the hospitals of the Sarah Network. Professionals working with children's rehabilitation for at least one year were also selected, including 3 physical therapists from the Associação Mineira de Reabilitação in Belo Horizonte and other professionals (physical therapists, pediatricians, occupational therapists, pedagogues, nurses, physical educators, speech therapists, psychologists, social workers and dietitians) from the Sarah Hospitals in Rio de Janeiro, Belo Horizonte, Salvador and São Luís.

Reliability indices were determined using intra-class correlation coefficients (ICC3,1) with the ICCagreement model. Reliability values were classified as poor (<0.4), moderate (0.4–0.75) or excellent (>0.75).25 For each domain of each instrument, the Cronbach's alpha as used as an index of internal consistency. The Cronbach's alpha is a measure of how closely related a set of items are as a group. Values between 0.70 and 0.90 indicate a good correlation between items.26 The standard error of measurement was calculated for the total score of each domain, for each instrument. The Statistical Package for Social Sciences version 18.0 (2011) was used for all analyses.

Some wording was adapted by the Expert Committee to reflect terms commonly used in Brazilian Portuguese. The response options for both instruments in the original version included options ranging from 7 (to a very great extent) to 1 (not at all). Because the direct translation would involve unusual wording (e.g. ‘em bastante grande medida’), the options were translated as follows: 7 (totally), 6 (very much); 5 (plenty); 4 (more or less); 3 (little); 2 (very little), 1 (not at all). ‘Parents’ was changed to the more inclusive expression ‘mothers and fathers’ in the MPOC-20. ‘Circling’ was changed to ‘Marking’, which is the most commonly used action to indicate answers in a form. In question 20 of the MPOC-20, “organization's parent resource library” was replaced by “web pages and parent associations” because resource libraries are uncommon in Brazil. In the description of the type of services evaluated by the MPOC-SP, the expression “community care facility” was replaced by a list of Brazilian institutions that usually provide care to children: rehabilitation clinics and hospitals, primary health care units and rehabilitation centers. ‘Disability’ was translated to ‘Deficiência’, in line with previous Brazilian translations of the International Classification of Functioning, Disability and Health.27 Finally, in the absence of a literal translation for “nonjudgmental way”, the expression “without any judgment of values” was used. These amendments were approved by CanChild.

Cognitive interviews indicated the need to change wording and give examples to avoid difficulties in understanding the questions. Eight questions were modified in each instrument. A detailed report of the interview procedures and all ensuing changes is available in Vaz et al.23 To guarantee that the changes in wording and addition of examples did not affect original content, all modifications were analyzed and vetted by CanChild. For example, question 11 of the MPOC-20 asked: “In the past year, to what extent do the people who work with your child treat you as an equal rather than just as the parent of a patient (e.g., by not referring to you as “mom” or “dad”)?”. In the Brazilian version, the example was changed to “(e.g., by calling you and your child by the name)?”

The translated and cross-culturally adapted versions of the instruments were then tested with 30 caretakers and 30 rehabilitation professionals to detect doubts. Caretakers included 28 mothers, one grandmother and one aunt with age varying between 17 and 57 (33.7±9.36). Their socioeconomic status varied from A to D/E. Professionals included 15 nurses, 6 physicians, 5 physical therapists, 1 speech therapist, 1 clinical psychologist, 1 nursing assistant and 1 orthopedic workshop technician aged between 35 and 56 years (44.4, ±6.70) with socioeconomic status varying between A and B2. Because less than 15% of the interviewees had doubts in any specific item, none of the items had to be rewritten and re-tested.15 Please refer to Appendices I and II for the final translation of the questions of each instrument to Brazilian Portuguese (approved by CanChild).

Table 1 contains characteristics of the 107 caretakers and 92 professionals whose resposnses were used to determine measurement properties of the MPOC-20 and MPOC-SP, respectively. Internal consistency of the MPOC-20 varied between 0.61 and 0.91. Test–retest reliability (ICC3,1) varied between 0.44 and 0.84 for the five domains. The standard error of measurement varied between 0.66 and 0.85 (Table 2). Internal consistency of the MPOC-SP varied between 0.52 and 0.83. Test–retest reliability (ICC3,1) varied between 0.83 and 0.97 for the four domains. The standard error of measurement varied between 0.34 and 0.46 (Table 2).

The lowest internal consistency value was observed for the domain “Providing Specific Information” of the MPOC-SP”, which is formed by questions 14, 15 and 16. Further analysis indicated that origin of the low internal consistency was the fact that the responses to question 15 had a wider dispersion (were more varied between respondents) than questions 14 and 16. In Fig. 1, histograms show the frequency distribution for responses of each question.

Figure 1.

Histograms with the frequency of each answer option, for each of the three questions of the of the MPOC-SP domain “Providing Specific Information (PIE)”.

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