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Translation and transcultural adaptation of the Hip Fracture Recovery Score assessment tool☆

Objective The Hip Function Recovery Score questionnaire is an instrument that was developed for evaluating the functional recovery of patients over 60 years of age who undergo surgical treatment due to hip fractures. The objective of this study was to make a thorough transcultural translation of this questionnaire, with adaptation to the individual and cultural traits of the Brazilian population. Method This translation method consisted of initial translation, back translation, drafting of a consensual version and pretesting with comments invited. Subsequently, a final version was drawn up after making the necessary adjustments, without altering the semantics of the questions in the original text. Results The consensual version was applied to thirty patients over the age of 60 years who had undergone surgical treatment due to hip fractures. However, some difficulties in understanding some words and expressions were observed, and these were then replaced with terms that were more easily understood. After the final version had been drawn up, this was applied to the same patients and full understanding was achieved among some of them, without altering the semantics of the questions of the original text. Conclusion The transcultural translation of the Hip Function Recovery Score will have an immediate impact on functional evaluations on patients over 60 years of age who underwent surgery due to hip fracture. It will subsequently be possible for other Brazilian scientific studies to use this questionnaire, which has been standardized and adapted to Brazilian culture, in order to make comparisons between results, thereby enriching Brazilian scientific production.


Introduction
Hip fractures include transtrochanteric, femoral head/neck and acetabulum fractures. This group of fractures occurs in all age groups and is a major problem for the Brazilian public health system. The most affected population is the geriatric group, as the incidence of hip fractures increases with age and doubles every 10 years after age 50. 1 The increasing life expectancy of the population in recent decades, associated with a more active lifestyle of the elderly and comorbidities found in this population, such as the reduced lean mass, balance, reflexes and bone mineral density results in osteopenia and osteoporosis and has led to an increase in fractures in the geriatric population. 2 Mortality after hip fractures is close to 10% in the first month and approximately 30% in one year. Among patients who survive, many develop a reduction in mobility and degree of independence. 3 Most studies have focused primarily on the mortality caused by these traumas. However, studies assessing morbidity, or loss of function post-fracture, are less common. 4 Surgical treatment of hip fractures is considered the gold standard, as it reduces some complications related to prolonged immobilization, such as thromboembolic events and pressure ulcers. 5 Due to the increasing incidence of hip fractures, and, consequently, a higher number of surgical procedures for this type of trauma, it becomes necessary to evaluate the degree of independence and quality of life of patients after they have undergone surgery. One way to evaluate the functional results after surgical treatment of hip fractures is through questionnaires, aiming to follow the improvement or not of daily functions in patients' life.
A study applied a questionnaire to 537 elderly patients with hip fracture with three parameters, self-care, transfers and locomotion, to measure the degree of patients' independence after the surgical repair. 6 Subsequently, another study involved 154 fractures of the proximal third of the femur treated surgically and used the Hip Function Recovery Score questionnaire (Appendix A) created by Zuckerman et al. [7][8][9] It consists of 11 questions related to the activities of daily living: four related to independence in basic activities, six to instrumental activities and one to mobility. 10 However, this questionnaire was used in its original version, in the English language, after its literal translation. 10 We know the importance of the translation into Portuguese of questionnaires originally written in English and also the adaptation of these questionnaires to individual and cultural characteristics of the local population to make them appropriate to the cultural context of the target population. 11,12 Therefore, a standardized translation of English language questionnaires into Portuguese is fundamental for an accurate assessment of the information extracted from these translated questionnaires, which allows a better comparison of scientific studies covering different surgical techniques and different rehabilitation programs in patients that suffered fractures involving the hip and submitted to surgical treatments.
Therefore, we aim to carry out the accurate cross-cultural translation of the Hip Function Recovery Score questionnaire

Material and methods
The present is a cohort, qualitative, observational study, considering that no interventions were performed while patients were followed by the hospital trauma team. Thus, we provide only an evaluation of the questionnaires and assess the possible difficulties in understanding by those participating in the research. The method of translation and cultural adaptation of the Hip Function Recovery Score questionnaire (Table 1) into Brazilian Portuguese used the criteria described by Guillemin et al. 13 and Heruti et al. 14 and reviewed by Beaton et al., 15 which consists in a standardized set of instructions for cultural adaptation of quality of life tools, which briefly include four steps: initial translation, back translation, consensus translation and pretest.
This standardization aims to achieve a cultural adaptation of expressions so there is no loss of semantics during the translation process. 16 This method of translation consists of an initial translation, followed by a back translation and then an assessment of the versions followed by the development of a consensus version and commented pretest, followed by the creation of the final version.
Initially, the Hip Functional Recovery Score questionnaire, in its original version in English, was translated into Portuguese by two certified, independent and bilingual translators, whose native language is Portuguese and who are fluent in English (Table 1). Subsequently, both versions were compared and a consensus version was created. This version was then back-translated into English by two bilingual translators, whose native language is English and who are fluent in Portuguese and reside in Brazil ( Table 2).
The translators responsible for the back-translation had no knowledge of the original version of the questionnaire in English.
Both obtained translated versions were assessed by a panel consisting of translators, medical researchers and a teacher of Portuguese, so that, by comparing it with the original text, discrepancies could be corrected and a consensus version created ( Table 2).
The consensus version was used as pre-test and applied to 30 patients and caregivers of patients that suffered hip fractures older than 60 years, who underwent surgical treatment in a referral hospital in traumatology, to assess the understanding and acceptability of the tool and to estimate possible necessary changes due to difficulties found by researchers and patients when the questionnaire was applied. The questionnaire was not applied to patients or caregivers who did not have a reasonable degree of orientation and/or satisfactory cognition in response to the questionnaires, so that there was no interference on the results regarding the understanding of the questions.
All patients invited to participate in the study were instructed on the study principles and signed an informed consent form. The present study was assessed and approved by an Institutional Review Board and is in accordance with Resolution 466/12.
After a consensus version was applied, meetings were held with a hip surgeon, also a member of the team involved with the research, to assess the difficulties encountered by patients and those applying the consensus version. Based on the suggestions, the final Portuguese version of the Hip Function Recovery Score questionnaire (Appendix A) was created, including some explanations in brackets for those expressions considered difficult to understand.
Subsequently, the new questionnaire, after the necessary changes were made, was reapplied to the same patients.  (3) b. You need assistance to go to the Laundry; OR c. You need assistance to hang clothes (unable to reach the clothesline); OR d. The patient could do the laundry if he/she had a washing machine at home; OR e. The patient is able to do this, but someone else does; (2) f. You can wash delicate and personal clothing by hand; OR g. You Need assistance for loading and unloading the washing machine; (1) h. You can go to the laundry but you need others to do all the rest; (0) i. All the laundry must be done by others.

Results
A great similarity was observed between the two translators' versions (T1 and T2). When the terms were not identical, we chose the translation we thought was easier to understand by the assessed individuals. Table 1 shows the original version together with the two translations made by certified translators. Among the differences found in the translations, we chose the version of translator 1 for the item 'bath', as we realized that the bathtub is not present in the daily lives of most of the population. We chose the translation of "capacity to shower". For the item 'feeding', we choose translation 2, as we considered it easier to understand the expression "to handle food" instead of "food manipulation", in addition to choosing the term "enteral feeding" instead of "feeding tube", as it best characterizes the use of the tool that aids nutrition. We also realized that there were differences in the translation of the word bedpan and obtained as translations the words "aparador" and "comadre". We selected "aparador", as initially translated by translator 1. Another topic that generated discussion was the translation of the word "bending" in the item "housework", shown as "flexion" (T1) and "bow" (T2). In this case we chose the expression used by translator 1. Another important disparity occurred in the component "mobility", for which we chose translation 2, as it refers to walking outdoors, does not use the expression walking in the external environment.
After drafting the consensus version, we applied this version to 30 patients in order to assess comprehension, semantic equivalence, possible cultural discrepancies and analyzed the concept of the proposed translation. From the point of view of understanding the questionnaire, there was no difficulty in understanding the translated words. However, there was difficulty regarding some habits of the Brazilian population. Analyzing items that refer to "doing laundry", "housework" and "food preparation", we observed that elderly men are not used to doing domestic chores and have difficulty answering these items. In the item "buying food", we expanded the possibilities of shopping in stores to include shopping at the supermarket, bakery and grocery store because culturally, women in Brazil do more shopping in supermarkets, while men do the usual everyday shopping in bakeries and grocery stores (e.g., to buy bread).
In the item "domestic work", we chose to put between parentheses the words "lifting" and "bending" when referring to the words elevation and flexion, respectively, with the use of such words to increase understanding by the respondents.
After the suggested modifications were made in agreement with the authors during the application of the consensus version, the final version of the Hip Function Recovery Score questionnaire was drawn up. This version can be seen in Appendix A and was applied to the 30 previously assessed patients. At the reapplication, full understanding was achieved by the patients with respect to the semantics.

Discussion
Orthopedists usually evaluate their surgical results based on parameters such as positioning of the synthesis material, bone healing rate, percentage of infection and range of motion. However, particularly in the elderly, a satisfactory surgical procedure, from the technical point of view, does not necessarily result in good functional results. Based on that fact, we aimed to bring to the Brazilian medical community the transcultural standardized translation of a globally well-known functional assessment questionnaire, which had several citations in national medical literature, previously used in its literal translation version, but without the concern to adapt it to the cultural reality of our country, which prevents the comparison between national articles.
Among the factors that most often influence the loss of functional capacity are: functional dependence prior to the fracture, number of comorbidities, advanced age, loss of cognitive ability and low functional capacity at the time of hospital discharge. 17 Factors such as female gender, absence of diabetes mellitus, capacity of independent ambulation and not living alone before the fracture can be factors of better prognosis. 18 Associated comorbidities have been recorded as precursors of mortality after hip fractures. The effect of comorbidity on mortality has been measured both by the number and the type of coexisting diseases. Patients with more coexisting diseases have a higher chance of dying. 19 In this type study, we decided to alter the structure of the original tool as little as possible, by not including or excluding items of the questionnaire, so as not to promote major changes of the psychometric properties and allow the comparison of versions.
We sought to ensure homogeneity between the versions, changing only minor differences in cultural habits of life, which are relevant for the local population. Certified translators who participated in the work were interpreters/translators from different health areas, in order to minimize technical terms that could hinder the understanding by the general population.
In the pre-test, there were some difficulties in understanding some terms, which after further discussion and creation of the final version, showed easy reproducibility and understanding among patients after the new application.

Conclusion
The process of translation and cultural adaptation of questionnaires created in a foreign language must be carried out very carefully, as was done with the Hip Fracture Recovery Score questionnaire. We obtained an excellent understanding by the respondents of the questions after the preparation of the final Brazilian version. Subsequent scientific manuscripts will be able to use this standardized questionnaire, which can be used to compare the results in the assessment of several treatments and rehabilitation programs of elderly patients submitted to surgeries due to hip fractures and improve the national scientific production.

Conflicts of interest
The authors declare no conflicts of interest.