The short form for outpatient care, translated in this study, has 18 items of Basic Mobility domain; 15 items of Daily Activity; and 19 items from the domain of Applied Cognition.

The short forms require that individuals (or proxy informants) answer questions about their difficulty to perform the activity described in the item (i.e., “How much difficulty do you currently have…”), based on an ordinal 4-point scale (Unable, A Lot, A Little, None). For the final score, the raw score must be obtained from the sum of the values of the response categories for difficulty, that is: unable=1, a lot=2, a little=3, none=4. In order to compare scores across domains, it is necessary to converted raw scores into standardized scores, using a specific conversion table for each domain, available in the short forms user's manual.8 The interpretations are provided for the final score of each domain, with ranges of functional stages.

The translation and cultural adaptation process of the AM-PAC short form started with a contact made with the Boston University group responsible for the instrument. This contact resulted in permission granted to start translating the instrument following the Guidelines for translation and cross-cultural adaptation of the AM-PAC.14 The guidelines listed the steps foreseen in the process of translation and cultural adaptation, as presented in Fig. 1.

Figure 1.

Phases of the translation and cultural adaptation of the AM-PAC – short version for outpatients in rehabilitation. Belo Horizonte, 2016.

(0.35MB).

In the first phase, both the conceptual equivalence of the AM-PAC short forms and the item equivalence were evaluated. The conceptual equivalence was carried out by a team of translators by means of reading the instrument and its manual, followed by an in-group discussion focusing on the overall AM-PAC concept of “function” – there was no in-depth discussion about the items – to guarantee that all members of the translation team agreed to the concept adopted by the AM-PAC, and it could be understood as having the same meaning in the Brazilian context.

To evaluate the item equivalence, seven rehabilitation professionals, apart from the translation team or conceptual equivalence team, were invited. They were rehabilitation professionals working in public rehabilitation services, or at the university, and did not contact any other members to discuss the items. They evaluated each item individually, and their observations were consolidated, discussed, and considered during the translation.

The second phase consisted of the translation and cultural adaptation of the instrument. Two teams with three translators each conducted the translation.15 The teams included physical therapists and occupational therapists that were fluent in English and Brazilian-Portuguese and were familiar with the ICF terminology. Among the translators, four of them had lived in English-spoken countries, one is an English teacher, and one lives in Canada. The two teams worked independently, and the members of one team could not communicate with the members of the other. Once the independent translated versions (T1 and T2) were completed, the teams met with the experts committee (which included the project and the translation coordinators) to compare the versions and reconcile the differences, resulting in a translated and common pilot version (T12).

Third step consisted of the T12 back-translation that was performed by two independent translators who were fluent in both languages and were familiar with the ICF terminology. The back-translated versions (B1 and B2) were also compared and reconciled into a common back-translated version (B12). The B12 was submitted to the evaluation of one of the authors of the AM-PAC.

Following the approval of the B12, cognitive interviews were conducted to verify whether the translated items and response categories were comprehensible by potential respondents of the instrument, as recommended by the Guidelines.14

The technique of the cognitive interview consists of administering the items from the questionnaire while collecting additional verbal information regarding the response to the items. Such information can be used to evaluate the quality of the response given by the respondent or to determine if the item is providing information according to the author's original purpose.15

Cognitive interviews were conducted with two patients from rehabilitation outpatient services, as proposed by Coster & Mancini, since the guidelines do not specify the number of interviews.15 The interviews were conducted at the most convenient time and place for each participant. Each interview lasted approximately 1h and 30min.

Different approaches can be used for cognitive interviews.16–18 In this study, the following strategies were adopted to verify the participant's comprehension of the items and the response scale: (1) verbalization of the line of thought when understanding and responding to the item; (2) explanation or exemplification of key terms present in the statement of the item; and (3) recording and quantifying the assistance provided to participant to help his/her understanding of item or response scale, during the interview.

In order to stimulate the participant's line of thought, the interviewer used commands such as: “Please tell me what were your thoughts to answer this question” or “Please give me examples of similar situations that have already happened to you.” For some specific terms, explanations or examples were requested by the respondents. The following assistances provided by the interviewer to the respondent were recorded in a field dairy: repeating the response options (RR), repeating the item statement (RI), and assistance with examples (EX).

Test-retest reliability, inter-examiner reliability, and internal consistency for the three domains of the translated version were evaluated. These measurement properties are strongly suggested by the COSMIN initiative.19 The instrument was administered to 30 individuals by two independent examiners. The test-retest reliability assess the consistency between the responses given by the individual on different occasions, and was evaluated twice by the same examiner, for the same individuals, with seven days interval between the assessments. The inter-rater reliability assessed the consistency of the responses given by the same individual when two examiners applied the instrument. The internal consistency was evaluated through the Cronbach's alpha (values above 0.70 were considered acceptable).20

Reliability analyses were conducted using Intra-class Correlation Coefficients (ICC) with 95% confidence intervals. Values of ICC>0.75 were considered as good reliability, ICC<0.75 as moderate, and ICC<0.40 as poor.21 The Statistical Package for Social Sciences software version 19.0 was used for the statistical analysis.

This study was a sub-project of a larger research project, approved by the Research Ethics Committee of Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil in 2013 (No. 414.133). All participants signed the consent form.

In the analysis of the conceptual equivalence, it was found that the concept of “functionality” adopted by the AM-PAC was understood by the team of professionals responsible for the translation and back-translation, and the instrument was considered adequate for translation into Portuguese-Brazilian.

Regarding the analysis of item equivalence, the professionals suggestions referred to the adequacy of the items to reflect the measurement units used in Brazil (i.e. to substitute “pounds” for “kilograms” and “miles” for “kilometers”). One other suggestion included changing the term “mop” to “squeegee”, most commonly used in Brazil. These suggestions were considered during the translation.

During the conciliation meeting, some divergences in the translation of the items were observed and resolved. The observed divergences and the proposed solutions are shown in Table 1.

The discussion in-group identified specific terms that needed further understanding, which was obtained in the cognitive interviews. For example, in the Daily Activity domain, item 8: “Hanging wash on a line at eye level or above?”, and item 14: “Doing 5 push-ups without stopping?”; and in the Applied Cognition domain, item 13: “Looking up a phone number or address in the phone book or in your own address book?”, the terms “at eye level”, “push-ups”, and “phone book”, respectively, were highlighted for a better understanding of its meaning during the interviews.

In the back-translation phase, the few divergences observed referred to the semantics of the terms chosen; that is, the meaning that a given word or expression would present in different contexts. These divergences were solved through discussion among the translation team and the expert committee, and the terms in the back-translation whose meaning most closely approximated the meaning in Portuguese-Brazilian language were chosen.

In the final evaluation of the back-translated version (B12) by one of the authors of the AM-PAC, a clarification for item 13 of the Applied Cognition domain “Search for a phone number or address in the phone book or in your agenda” was requested. In the discussion with the author, a second back-translation option for the item was presented. The presentation of this alternative version was sufficient to clarify the problem and the B12 was approved.

The two interviewed participants were females, active in the job market, had high-school education, and had complaints that could affect their functioning and could be approached by rehabilitation professionals. One participant had low back pain with onset less than three months ago, and the other participant had right shoulder pain and low back pain for about two years.

Table 2 presents the items that demanded the interviewer's help from at least one of the participants, as well as the detail of the identified problem, the proposed resolution, and the final writing of these items.

During the interviews, eight items demanded help to be understood: Items 1, 2, and 13 of Basic Mobility; Items 4, 5, and 6 of Daily Activity; Items 5 and 18 of Applied Cognition. During the analysis of the interviews, it was considered necessary to change the wording of only two of these items – for both, the changes were made by adding examples to facilitate the understanding of the statement of the item (Items 5 and 6 of Daily Activity). In the remaining six items, repeating the statement or the response scale was enough to clarify the item and enable the elaboration of an appropriate response by the respondent. The verbalization of the line of thought to answer the item was used to verify the understanding of the statement in the other items that demanded assistance. However, for these items, the original wording of the statement was kept:

“[Soft and low couch] is that low thing, down below. That you’re sinking in it. To get up you need to make an effort.”

Participant 2, verbalization after answering Item 2 of Basic Mobility: “Standing up from a low, soft couch?”