Portuguese Version of the PROMIS® Self‐Efficacy for Managing Daily Activities for Patients With Chronic Conditions: Translation and Cross‐Cultural Adaptation

ABSTRACT

Purpose

To translate and cross‐culturally adapt the PROMIS® Self‐Efficacy for Managing Daily Activities for Portuguese‐speaking populations, ensuring linguistic and conceptual equivalence for future validation, while considering differences between Brazil and Portugal.

Methods

The Functional Assessment of Chronic Illness Therapy (FACIT) methodology was followed, including (1) independent translations by Brazilian and Portuguese native speakers; (2) reconciliation into a single version; (3) back‐translation; (4) expert review; (5) cognitive debriefing with participants from both countries and (6) final approval by the PROMIS® Statistical Center. Ethical approval was obtained from the Federal University of Rio Grande do Norte.

Results

Minimal linguistic and cultural differences were found between Brazilian and European Portuguese. Vocabulary adjustments were made to ensure clarity (e.g., “tela” vs. “écrã,” “celular” vs. “telemóvel”). The cognitive debriefing involved seven participants (four from Brazil and three from Portugal). A new response option was added for individuals with mobility impairments. The final version preserved the scale's psychometric integrity while ensuring cultural relevance.

Conclusion

The adapted Portuguese version of the PROMIS® Self‐Efficacy for Managing Daily Activities maintains its conceptual fidelity and usability across Portuguese‐speaking populations. The item bank is ready for validation studies and clinical use in Lusophone healthcare settings.

1. Introduction

Patient‐reported outcomes (PROs) play a pivotal role in advancing patient‐centered care, as they capture an individual's own perspective on their health status, functioning, and overall well‐being [1, 2]. Growing interest in PRO assessment over recent years reflects the recognition that health is more than the absence of disease, it encompasses the subjective experience of living with a condition and undergoing treatment [3, 4]. To translate these personal perceptions into measurable data, patient‐reported outcome measures (PROMs) have become essential in both clinical practice and research [5]. These instruments enable patients to report directly on symptoms, quality of life, and other aspects of their health, without interpretation by healthcare professionals [6]. Over time, PROMs have been developed and refined into rigorously validated and standardized tools, ensuring the consistent and reliable evaluation of subjective outcomes [7].

The Patient‐Reported Outcomes Measurement Information System (PROMIS)®, developed by the National Institutes of Health (NIH, USA), offers comprehensive and reliable measures to assess physical, mental, and social health [8]. PROMIS® provides tools for efficiently and validly measuring across various health conditions, including both chronic and acute conditions [9, 10]. PROMIS® allows patients to express their perceptions of their health, providing a more patient‐centered approach. Its versatility to various clinical contexts and for different populations, ages, and health contexts, along with standardized metrics, allows for global data comparison [9]. Among the wide range of PROMIS® domains, those assessing self‐efficacy are particularly relevant for understanding patients' ability to manage their health, especially in the context of chronic conditions [11].

The Self‐Efficacy for Managing Chronic Conditions – Managing Daily Activities item bank evaluates patients' confidence in managing daily tasks and self‐care, maintaining physical activity, controlling symptoms, and performing other health‐related activities despite chronic health challenges [11]. In Bandura's social cognitive theory, self‐efficacy is defined as the belief in one's capacity to organize and execute the actions required to achieve specific goals [10]. Given its strong association with improved self‐management and quality of life, translating and culturally adapting this PROMIS® domain is essential for the precise evaluation of these competencies in individuals with chronic conditions [10].

To ensure cultural and linguistic applicability, PROMIS® item banks undergo rigorous translations and validation processes to ensure the scale's applicability across different cultural and linguistic contexts while maintaining the accuracy across diverse populations [9]. Besides the original English version [11], the Self‐Efficacy for Managing Chronic Conditions ‐ Managing Daily Activities item bank is also available in French [12]. Therefore, this study aimed to translate and linguistically validate the Portuguese version of a PROMIS® Self‐Efficacy for Managing Chronic Conditions ‐ Managing Daily Activities item bank for Portuguese‐speaking populations. This article outlines the translation and linguistic validation stages, emphasizing the cultural nuances that emerged during the process.

2. Methods

This is an exploratory methodological study conducted following the Functional Assessment of Chronic Illness Therapy (FACIT) methodology. The study assessments and data collection were conducted virtually, using an online platform for developing electronic forms. For the cognitive debriefing, FACIT methodology recommends at least five participants to verify the items after translation. Data collection began with the minimum sample and continued until response saturation was achieved, as similar feedback was repeatedly observed across items [13]. Individuals were considered eligible if they were ≥ 18 years old and self‐reported having a physician‐diagnosed chronic disease, and they were also asked additional questions during cognitive debriefing interviews about when and how they were diagnosed. Participants were excluded if they reported cognitive or memory impairments that could compromise the reliability of their responses. The presence of these impairments was assessed through self‐report in the online eligibility form, where participants indicated whether they had any conditions affecting their cognition or memory.

Participants were recruited online through dissemination on social media. As in the English validation study, virtual data collection was used [11]; however, in the present study, all data were obtained through an online form to ensure access to geographically distant participants and a more representative sample. Recruitment posts were shared on institutional social media channels (university webpages and research group profiles), patient association pages, and open calls in chronic disease support groups on Facebook® and WhatsApp®. This strategy allowed broad outreach while maintaining transparency regarding the study's academic and noncommercial nature.

2.1. Translation Process

The translation process of the PROMIS® item bank followed the FACIT methodology based on a universal translation approach. This method includes reviews conducted across multiple countries to ensure both semantic and measurement equivalence between versions, using a decentered translation model and advanced statistical methods [14, 15]. The translation and linguistic validation process was conducted systematically and rigorously, following a well‐defined sequence of steps.

Two independent professionals (one from Brazil and one from Portugal), fluent in English, translated the original items into Portuguese. The Brazilian translators were selected according to the criteria established by the PROMIS® Statistical Center based on the FACIT methodology and were recruited by convenience to ensure compliance with these criteria. Subsequently, a third independent Brazilian translator reconciled the two initial translations, producing a hybrid version. This reconciled version was back‐translated into English by a translator from the United States who was blinded to the original English version. The back‐translation was reviewed by the research team to identify and rectify discrepancies, allowing for a preliminary assessment of harmonization between the versions.

Subsequently, three experts—two Brazilian and one Portuguese, all linguists with expertise in healthcare—independently evaluated the previous steps, selecting or suggesting the most appropriate translation for each item. These experts were not listed as co‐authors, as their contributions did not meet authorship criteria, but their professional background ensured the accuracy and conceptual equivalence of the adapted instrument. Experts' feedback was carefully analyzed to develop the preliminary version. The research team then conducted a detailed review, defined the final translation, and produced both literal and refined back‐translations for each item. To ensure the accuracy and equivalence of the final translation, the research team submitted the final version to the PROMIS® Statistical Center, which thereafter conducted a quality assessment of the translation. During the formatting steps, the final version was reviewed and reconciled, typeset, and proofread by S.J.A.L. and K.M.

For the linguistic validation, the translated version was pretested with native speakers of Portuguese through cognitive debriefing interviews conducted with participants in Brazil and Portugal. This step ensured that each item was equivalent to the original English version. Participants first completed the item bank independently and later attended a scheduled interview with the researchers to provide feedback on the clarity and relevance of the items. Interviews were recorded, transcribed verbatim, and analyzed qualitatively by two authors (S.J.A.L. and J.B.). Responses were mapped directly to item clarity and comprehension, rather than using thematic coding. Any disagreements in interpretation were resolved by a third author (K.M.). K.M. reviewed the transcripts, compiled participant observations, and back‐translated them into English, summarizing the issues raised. The language coordinator reviewed the suggestions and proposed adjustments, which were reviewed and verified by K.M. to ensure consistency with the source text and other language versions. A comprehensive report detailing all stages of the translation and validation process was submitted for further evaluation by the PROMIS® Statistical Center and final approval. Figure 1 outlines the process.

FIGURE 1.

FACIT methodology process. FACIT, Functional Assessment of Chronic Illness Therapy.

2.2. The Item Bank

The Portuguese version of the questionnaire is available through the HealthMeasures platform for a fee and can be retrieved by searching for the instrument's name. The instrument evaluates patients' self‐efficacy in managing chronic conditions, encompassing confidence in performing daily activities, managing symptoms, and engaging in health‐related behaviors. The short forms comprise 4 or 8 items addressing core aspects of these domains, whereas the full item bank offers a comprehensive assessment of self‐efficacy across multiple dimensions of daily functioning. This item bank does not specify a recall period (time frame) for responses.

The patient's score can be calculated using automated tools, such as the Health Measures Scoring Service (https://www.assessmentcenter.net/ac_scoringservice), which applies item‐level calibrations. This is the most accurate and recommended method, as it accounts for individual responses, handles missing data, and generates a proportional score. In PROMIS® measures, higher T‐scores indicate higher levels of self‐efficacy.

The items refer to the patient's experiences over the past 30 days. For short forms (4 or 8 items), responses are summed to obtain the raw score, which can then be converted to T‐scores using the PROMIS® scoring software (e.g., HealthMeasures Scoring Service). For the full item bank, however, scores are not derived from a direct sum; instead, the data are processed using an Item Response Theory (IRT) algorithm, as performed in the validation study [11].

Alternatively, manual calculation can be performed using scoring tables that convert the sum of responses into a final score; however, these tables are currently available only for short forms and are not applicable to this item bank.

2.3. Ethics Considerations

The Research Ethics Committee of the Federal University of Rio Grande do Norte (Process No. 6.858.493) approved this study. This study commenced only after obtaining the license agreement from the PROMIS® Health Organization and ethical approval. All participants provided informed consent before participating. The reporting of this study adheres to the COSMIN guidelines for cross‐cultural adaptation of PRO measures. The lead author affirms that this manuscript is an honest, accurate, and transparent account of the study being reported, and that no important aspects have been omitted. Online data collection complied with data protection standards, with anonymized responses stored on secure servers to ensure confidentiality.

3. Results

The Self‐Efficacy for Managing Chronic Conditions ‐ Managing Daily Activities item bank was successfully translated and linguistically adapted for use in Portuguese‐speaking countries. In the initial stages of the process, the versions of the two translators, which were similar, were reconciled into a single version. At this stage, only minor variations in culturally specific vocabulary were observed. The subsequent stage made minimal suggestions regarding maintaining formal language standards without making the language overly complex or archaic.

The cognitive debriefing involved seven participants (four from Brazil and three from Portugal), and their demographic, educational, and clinical characteristics are described in Table 1.

TABLE 1.

Characteristics of cognitive debriefing participants.

Characteristics
Sex, n (%)
Female	6 (85)
Male	1 (15)
Age, mean (range)	41 (30–75)
Place of birth, n (%)
Brazil	4 (57)
Portugal	3 (42)
Education level, n (%)
Advanced degree	2 (29)
College degree	3 (43)
Technical degree	1 (14)
High school	1 (14)
Health conditions, n (%)
Cardiovascular disease	1 (14.3)
◦ Heart failure
Respiratory disease	3 (42.9)
◦ Asthma	2 (28.6)
◦ Post‐COVID syndrome	1 (14.2)
Neurological disorders	3 (42.9)
◦ Stroke	1 (14.3)
◦ Multiple sclerosis	1 (14.3)
◦ Neuromuscular disorder	1 (14.3)

Based on the feedback, some terms were removed or modified to enhance cultural appropriateness for Portugal and Brazil, without modifying the conceptual meaning. The word “trotar” (item 13) was removed as it only made sense in the Brazilian Portuguese context, and its exclusion did not affect the item comprehension. Similarly, the word “écrã” was added as a synonym for “tela” (item 25), and “telemóvel” was included as a synonym for “celular” (item 26), as both terms are more commonly used in Portugal. The most substantial modifications made during the different stages are detailed in Table 2. Other suggestions focused on enhancing clarity and eliminating ambiguity to improve comprehension. These adaptations were incorporated into the final version. The Portuguese final version is available at https://www.healthmeasures.net/search-view-measures?task=Search.search, where it can be accessed by searching for the title of the item bank.

TABLE 2.

Description of the item modification process.

Item	Original version	Translated version	Participants' suggestions	Final version
Tittle	Self‐Efficacy for Managing Chronic Conditions ‐ Managing Daily Activities	Autoeficácia para Gestão de Condições Crônicas ‐ Gestão de Atividades Diárias	Addition of the word “crónica” as an alternative translation for European Portuguese (as was done with other items throughout the questionnaire).	Autoeficácia para gestão de condições crônicas/crónicas ‐ Gestão de atividades diárias
13	I can exercise at a vigorous level for 10 min (e.g.: running, jogging).	Eu consigo fazer exercício a um nível intenso por 10 minutos (por exemplo: correr, trotar)	Removal of the word “trotar” as it is used only in Brazil, with no expected loss of content.	Eu consigo fazer exercício a um nível intenso por 10 minutos (por exemplo: correr).
25	I can use a computer (e.g.: use keyboard, see screen, login).	Eu consigo usar um computador (por exemplo: usar teclado, ver a tela, fazer login).	Addition of the word “écrã” (with its masculine article), to ensure clarity in both countries.	Eu consigo usar um computador (por exemplo: usar teclado, ver a tela/o écrã, fazer login).
26	I can use a telephone to schedule an appointment.	Eu consigo usar o telefone para agendar um compromisso	Addition of the terms “telemóvel/celular” to ensure clarity in both countries.	Eu consigo usar o telefone ou telemóvel/celular para agendar um compromisso.

4. Discussion

The translation and cultural adaptation of the PROMIS® Self‐Efficacy for Managing Daily Activities for Patients with Chronic Conditions for Portuguese‐speaking countries involved a meticulous process of linguistic and cultural analysis, with the participation of experts from different Lusophone countries. The steps of the proposed methodological process were crucial in ensuring refined adjustments of the final version and an accurate assessment of the construct [16].

The initial translation process involved contributions from native Portuguese speakers with expertise in scientific research, which facilitated technical accuracy and the proper use of terminology. The reconciliation of the versions from two translators revealed minimal variations in culturally specific vocabulary, indicating that Brazilian and European Portuguese share a common linguistic foundation that eases the adaptation of instruments between the two countries [11, 17, 18]. Most discrepancies observed in the versions were related to lexical preferences for more commonly used terms in each context, as evident in the modifications of items of the tittle and the items 13, 25, and 26.

We considered cultural and contextual differences among Portuguese speakers to ensure clarity and accuracy without compromising technical rigor. Experts in psychometrics and Portuguese language contributed to ensure the fluidity, coherence and relevance of the language while avoiding unnecessarily complex or outdated expressions. The back‐translation allowed us to identify potential comprehension issues and ensured the conceptual equivalence of the original items, avoiding ambiguities. The final version, approved by the PROMIS® Statistical Center, reflects the quality and consistency of the adaptation of the version, confirming its appropriateness for a global context [19].

The cognitive debriefing provided a deeper analysis of comprehension issues [18]. The removal of terms like “trotar” (item 13), which was culturally relevant only in Brazil, and the inclusion of more familiar terms in both variants of Portuguese, such as “telemóvel” for Portugal and “cellular” for Brazil, underscored the cultural sensitivity of the adaptation. The cultural adaptation process was conducted using methodological procedures consistent with those applied in other studies adapting PROMIS® instruments into Brazilian Portuguese [20, 21, 22]. Similar to the validation of other item banks, the linguistic adaptations were minor and intended to ensure clarity, semantic equivalence, and cultural appropriateness, without modifying the original conceptual meaning of the items [20, 21, 22].

During the adaptation process, a particular challenge emerged regarding the response options. A wheelchair user suggested adding an additional alternative, as he felt that the existing categories did not fully capture his experience. However, following the guidance of the PROMIS® Statistical Center, the response scale is not modifiable, since this would change the psychometric properties and scoring comparability of the instrument [11]. In this case, the participant was instructed to choose the option that best represented his situation. This example illustrates the inherent difficulty of fully accommodating the heterogeneity of experiences in chronic conditions and reinforces the need for future studies to explore strategies for better addressing such nuances in PRO outcomes [23]. Moreover, this situation also highlights the strength of the instrument in maintaining comparability of scores across different populations and contexts.

The adjustments related to the adaptation process also highlighted the importance of linguistic flexibility when translating psychometric scales [24]. Adapting a self‐efficacy measure for managing daily activities among individuals with chronic conditions requires considering how different cultures perceive everyday activities, the vocabulary used to describe them, and the patient's experience with them [25]. This emphasizes the complexity of the cross‐cultural adaptation process, which extends beyond linguistic translation and involves a thorough examination of sociocultural differences [26]. To maintain a rigorous approach and ensure that the PROMIS® item banks are consistent and comparable, we employed a methodology similar to that used in translations of other item banks and for other languages [12, 27, 28, 29].

In this study, we included participants only from Brazil and Portugal, despite the existence of other Portuguese‐speaking countries, which may limit the generalizability of the findings to other Lusophone contexts, particularly in Africa, where cultural and linguistic variations may influence item interpretation [30]. Additionally, participants were recruited online, which may have introduced selection bias by including individuals with internet access and those who self‐selected to participate due to interest in the study. Although participants confirmed their diagnosis through an online eligibility form and were further questioned during the cognitive debriefing interviews, self‐reporting may still introduce bias; to mitigate this risk, additional questions were included to verify when and how the diagnosis was made, and participants with self‐reported cognitive or memory impairments were excluded. Furthermore, the relatively high educational level of the sample, with most participants holding college or advanced degrees, may limit generalizability to populations with lower literacy levels. Nonetheless, the sample size adhered to guidelines from COSMIN and PROMIS®, supporting the robustness of the cognitive analysis despite these limitations.

On the other hand, this study adhered to recent methodological recommendations for cross‐cultural, multi‐lingual or multi‐country scale development and validation in health care research [31]. The process involved systematic translation and cultural adaptation using the FACIT universal method, expert review, cognitive debriefing, and a comprehensive psychometric evaluation, including factor analyses, reliability testing, item response theory modeling, differential item functioning, convergent validity, and test–retest reliability [32]. Although broader inclusion across countries is recommended, resource and partnership constraints limited this first application to Brazil and Portugal [31]. Nonetheless, the procedures employed provide a rigorous foundation for subsequent adaptations in other Portuguese‐speaking settings, thereby reinforcing the applicability of the proposed universal translation. Although the PROMIS® Statistical Center has approved the final version of the item bank for translation and cultural adaptation, full psychometric validation is still required to establish its measurement properties, and this process is currently underway.

5. Conclusion

This study successfully adapted the PROMIS® Self‐Efficacy for Managing Chronic Conditions – Managing Daily Activities item bank for Portuguese‐speaking populations. The methodological steps ensured conceptual equivalence and cultural appropriateness, while preserving the original meaning of the items. The process highlighted cultural nuances between Brazilian and European Portuguese, resulting in a version that is both linguistically accurate and culturally adaptable across different Portuguese‐speaking contexts. These findings provide an instrument to assess self‐efficacy in managing daily activities among patients with chronic conditions in Portuguese‐speaking countries.

Author Contributions

Sarah Joysi Almeida Leite: conceptualization, writing – original draft, funding acquisition, writing – review and editing, visualization, methodology, formal analysis, project administration, data curation. Thayla Amorim Santino: funding acquisition, writing – review and editing, supervision, methodology. Sara Ahmed: funding acquisition, writing – review and editing, supervision. João Carlos Alchieri: methodology, writing – review and editing. Joubert Barbosa: writing – original draft, data curation. Karolinne Souza Monteiro: funding acquisition, writing – review and editing, methodology, supervision, project administration. Karla Mendonça: conceptualization, writing – review and editing, funding acquisition, supervision, project administration, methodology.

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

The lead author, Sarah Joysi Almeida Leite, affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Leite S. J. A., Santino T. A., Ahmed S., et al., “Portuguese Version of the PROMIS® Self‐Efficacy for Managing Daily Activities for Patients With Chronic Conditions: Translation and Cross‐Cultural Adaptation,” Health Science Reports 9 (2026): 1‐7, 10.1002/hsr2.71589.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.