Pulmonary rehabilitation adapted index of self-efficacy (PRAISE) validated to Portuguese respiratory patients

Pulmonol. 2019;25(6):334---339 www.jou nalpulmonology.o g ORIGINAL ARTICLE Pulmona y ehabili a ion adap ed index o sel -e ficacy (PRAISE) alida ed o Po uguese espi a o y pa ien s Ca a ina Dua e San osa,d,∗, Ana João San osb, Ma ga ida San osc, Fá ima Rod iguesa,d, C is ina Bá ba aa,d aUni e sidade de Lisboa, Faculdade de Medicina, Ins i u o de Saúde Ambien al, Lisbon, Po ugal bIns i u o Nacional de Saúde Dou o Rica do Jo ge, Depa amen o de Epidemiologia, Lisbon, Po ugal cIns i u o Poli écnico de Lisboa, Escola Supe io de Tecnologia da Saúde de Lisboa, Unidade de Ensino e In es igac¸ão em Psicologia e Sociologia; Uni e sidade de Lisboa, Faculdade de Psicologia, Lisbon, Po ugal dCen o Hospi ala Uni e si á io Lisboa No e, Hospi al Pulido Valen e, Unidade de Reabili ac¸ão Respi a ó ia, Lisbon, Po ugal Recei ed 26 Ma ch 2019; accep ed 5 June 2019 A ailable online 18 Sep embe 2019 KEYWORDS Sel -e ficacy; PRAISE; Validi y; Pulmona y ehabili a ion Abs ac In oduc ion and Objec i es: Recen upda es on Pulmona y Rehabili a ion highligh he impo - ance o pa ien s’ sel -e ficacy on long- e m adhe ence o heal h-enhancing beha io s. The Pulmona y Rehabili a ion Adap ed Index o Sel -E ficacy (PRAISE) is an adap a ion o he Gen- e al Sel -E ficacy Scale. This s udy aimed o ansla e, cul u ally adap and e alua e eliabili y and alidi y o PRAISE in Po uguese espi a o y pa ien s. Pa ien s o Ma e ials and Me hods: Fo wa d-backwa d ansla ion and pilo es ing we e pe - o med. Con en alidi y was assessed by a mul idisciplina y panel o expe judges. To e alua e eliabili y and alidi y, 150 espi a o y ou pa ien s on Pulmona y Rehabili a ion pa icipa ed in a c oss-sec ional s udy. Desc ip i e and eliabili y analyses, and explo a o y ac o ial analysis using p incipal axis ac o ing, ollowed by oblique oblimin ac o o a ion we e conduc ed o iden i y cons uc alidi y. IBM®SPSS® e sion 22 was used o pe o m s a is ical analysis. Resul s: 150 pa ien s wi h a mean age o 67 yea s, 54% male and 83% cu en ly on Pulmona y Rehabili a ion pa icipa ed in he s udy. These included mainly Ch onic Obs uc i e Pulmona y Disease pa ien s (46.7%) bu also B onchiec asis (20%), In e s i ial Lung Disease (20%) and o he espi a o y diseases. PRAISE mean sco e was 49. Explo a o y ac o analysis ex ac ion p o ided a 4- ac o solu ion ha cumula i ely explained 52.3% o o al a iance (F1: 26.6%; F2: 9.7%; F3: 8.7%; F4: 7.3%). Po uguese PRAISE showed a eliabili y o 0.78 (Ch onbach alpha). Conclusions: The Po uguese e sion o PRAISE showed adequa e psychome ic p ope ies o i o be used as an ins umen o measu e sel -e ficacy as a pa ien -cen e ed ou come on Pulmona y Rehabili a ion. © 2019 Sociedade Po uguesa de Pneumologia. Published by Else ie Espa˜ na, S.L.U. This is an open access a icle unde he CC BY-NC-ND license (h p://c ea i ecommons.o g/licenses/by- nc-nd/4.0/). ∗Co esponding au ho . E-mail add ess: fi[email p o ec ed] (C.D. San os). h ps://doi.o g/10.1016/j.pulmoe.2019.06.003 2531-0437/© 2019 Sociedade Po uguesa de Pneumologia. Published by Else ie Espa˜ na, S.L.U. This is an open access a icle unde he CC BY-NC-ND license (h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/). Pulmona y ehabili a ion adap ed index o sel -e ficacy (PRAISE) alida ed o Po uguese espi a o y pa ien s 335 In oduc ion Pulmona y Rehabili a ion is widely ecognized as an essen- ial componen in he in eg a ed ca e o pa ien s wi h ch onic espi a o y disease.1The impac o his comp e- hensi e in e en ion can be assessed by pa ien -cen e ed ou comes, mos ly pe o mance-based, and o a ce ain ex en influenced by pa ien s’ pe cei ed e ficacy.2 Sel -e ficacy was defined by Albe Bandu a as a pe - sonal cons uc o how success ully one can execu e a equi ed beha io o p oduce a desi ed ou come.3Acco d- ing o ‘‘Sel -e ficacy as a uni ying heo y o beha io al change’’, expec a ions o pe sonal e ficacy a e based on ou sou ces o in o ma ion: pe o mance accomplishmen s (pe sonal mas e y expe ience), ica ious expe ience (social obse a ion), e bal pe suasion (sugges ion) and physio- logical s a es (emo ional a ousal and beha io al con ol).3 Pe sonal mas e y is he mos powe ul ac o since i enables sel -pe cep ion o he capaci y o pe o m a ask.4Al hough he cons uc o sel -e ficacy was o iginally ela ed o spe- cific si ua ions, ecen app oaches gene alized he concep sugges ing ha gene al sel -e ficacy ep esen s he confi- dence in one’s abili y o deal wi h di e en demanding si ua ions.5Sel -e ficacy is a key concep in many beha - io change amewo ks such as he Sel -e ficacy Theo y, he T ans heo e ical Model, he Sel -de e mina ion The- o y, he Theo y o Planned Beha io , and he Heal h Belie Model.6 Highe sense o sel -e ficacy has been ound o be posi i ely associa ed wi h: be e ou comes on mobili y, ac i i ies o daily li ing, dep ession and quali y o li e in s oke pa ien s7; highe le els o sel -ca e in young adul s wi h ype 1 diabe es8; be e a endance and imp o emen s in Pulmona y Rehabili a ion9; and educ ion in seden a y ime ollowing Pulmona y Rehabili a ion in people wi h Ch onic Obs uc i e Pulmona y Disease.10 To add ess adap i e beha io change, Pulmona y Reha- bili a ion enhances sel -e ficacy h ough sel -managemen in e en ions, de eloping skills in goal se ing, p ob- lem sol ing, decision-making, and aking ac ion in a p edefined ac ion plan.1,11 Recen upda es highligh he impo ance o pa ien ’s sel -e ficacy on long- e m adhe - ence o heal h-enhancing beha io s.1E idence by esea ch is ha sel -e ficacy baseline assessmen p o ed o be use ul o p edic ing posi i e ou comes8o di ec ing he in e en- ion o pa ien specific needs,9maximizing he ull benefi s o Pulmona y Rehabili a ion. In espi a o y clinical p ac ice, sel -e ficacy has been fi s ly accessed by he COPD Sel -E ficacy Scale, wi h pa ien s a ing on a 5-poin Like scale he amoun o confidence in managing b ea hing di ficul ies in 34 di e se si ua ions.12 This scale p esen s a fi e- ac o s uc u e (neg- a i e e ec , in ense emo ional a ousal, physical exe ion, wea he /en i onmen al, and beha io al isk ac o s) and a significan in e nal consis ency (C onbach’s alpha = 0.95),11 ye no specific o he Pulmona y Rehabili a ion con ex . Fo his pu pose, Vincen and co-au ho s p oposed he Pulmona y Rehabili a ion Adap ed Index o Sel -E ficacy (PRAISE).2The PRAISE ool is an adap a ion o he Gen- e al Sel -E ficacy Scale (GSE) by Schwa ze and Je usalem,5 adding 5 new specific i ems o he p e ious 10. A aújo and Mou a ha e al eady alida ed a Po uguese e sion o he GSE,13 ye he assessmen o such a cons uc emains o be explo ed in he Po uguese Pulmona y Rehabili a ion se - ing. This s udy aimed o: 1) ansla e and cul u ally adap he PRAISE ool in o Eu opean Po uguese; 2) e alua e eliabili y and cons uc alidi y o PRAISE in Po uguese espi a o y pa ien s. Ma e ial and me hods The alida ion o he Po uguese e sion o PRAISE was de eloped in wo phases: 1) ansla ion and c oss-cul u al adap a ion ollowing in e na ional ecommenda ions14 and 2) e alua ion o eliabili y and alidi y acco ding o he Consensus-based S anda ds o he selec ion o heal h Mea- su emen INs umen s (COSMIN) guidelines.15,16 T ansla ion and c oss-cul u al adap a ion Pe mission o ansla e and use PRAISE was gi en by co - esponding au ho o he o iginal pape desc ibing he ins umen .2As GSE has been alida ed in Po uguese,13 pe - mission om au ho s was ob ained o in eg a e he al eady ansla ed answe key and 10 i ems in o he o hcoming PRAISE ansla ion. Subsequen ly, he p ocess p oceeded in 5 s eps: 1) he o iginal 5 i ems om PRAISE we e ans- la ed by 2 independen Po uguese ansla o s (p o essional ce ified ansla o and a physio he apis li ing in an English- speaking coun y o mo e han 5 yea s); 2) a syn hesis e sion was p oposed by an independen bilingual ansla- o (psychologis and ce ified ansla o ); 3) blind backwa d ansla ion by 2 independen bilingual and bicul u al ans- la o s, li ing in an English-speaking coun y o mo e han 5 yea s (medical doc o and an audi execu i e di ec o ); 4) Final syn hesis by a mul idisciplina y commi ee (p e i- ous 5 independen ansla o s and also his s udy’s main esea che , a pulmonologis expe in Pulmona y Rehabili- a ion, and he au ho o he o iginal ins umen ); and 5) a cogni i e deb iefing was pe o med by es ing and e- es ing on a sample o 10 espi a o y pa ien s a ending Pulmona y Rehabili a ion. Reliabili y and alidi y To e alua e empo al eliabili y, a es - e es o PRAISE (a e age o 8-day in e al) was gi en o 10 espi a o y ou pa ien s on Pulmona y Rehabili a ion a Hospi al Pulido Valen e in Lisbon, Po ugal. Pa icipan s we e diagnosed wi h di e se pa hologies (Ch onic Obs uc i e Pulmona y Disease n = 2, As hma n = 2, In e s i ial Lung Disease n = 2, B onchiec asis n = 2 and Lung Cance n = 2). Cons uc alidi y included ac o ial analysis and in e nal consis ency, in a c oss-sec ional s udy wi h a con enience sample o 150 espi a o y ou pa ien s on Pulmona y Rehabil- i a ion a Hospi al Pulido Valen e in Lisbon, Po ugal. Sample size was calcula ed conside ing he ecommenda ion o a leas 10 subjec s pe i em o he ins umen scale.14 All subjec s ga e w i en in o med consen and answe ed he Po uguese PRAISE ool adminis e ed by a physio he apis . S udy conduc ion was app o ed by he E hics Commi ee o 336 C.D. San os e al. Table 1 Po uguese e sion o PRAISE in e -i em co ela ions. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1 1.00 0.34** 0.29** 0.19* 0.32** 0.24** 0.13 0.30** 0.07 0.07 0.24** 0.12 0.24** 0.30** 0.09 2 1.00 0.30** 0.22** 0.32** 0.24** 0.07 0.30** 0.02 0.20** 0.30 0.13 0.21** 0.28** 0.12 3 1.00 0.25** 0.31** 0.37** 0.13 0.23** 0.20** 0.20** 0.17* 0.15* 0.16* 0.38** 0.26** 4 1.00 0.31** 0.32** 0.18** 0.33** 0.09 0.14* 0.07 0.23** 0.11 0.27** 0.28** 5 1.00 0.44** 0.11 0.21** 0.11 0.39** 0.28** 0.17* 0.23** 0.29** 0.25** 6 1.00 0.13 0.30** 0.07 0.30** 0.44** 0.12 0.32** 0.29** 0.23** 7 1.00 0.24** 0.04 0.14* 0.03 0.13 0.12 0.01 0.17* 8 1.00 0.03 0.10 0.27** 0.06 0.26** 0.27** 0.17* 9 1.00 0.11 0.02 0.03 0.03 0.05 0.21** 10 1.00 0.31** 0.03 0.35** 0.35** 0.28** 11 1.00 0.07 0.44** 0.26** 0.20** 12 1.00 0.12 0.20** 0.16* 13 1.00 0.19* 0.20** 14 1.00 0.19* 15 1.00 No e: *p < .05; **p < .01. Cen o Hospi ala Uni e si á io Lisboa No e, EPE and Cen- o Académico de Medicina de Lisboa (numbe 46/17), and ial egis e ed as NCT03875599 a clinical ials.go . S a is ical analyses included p elimina y desc ip i e and eliabili y analyses o he PRAISE, including i em means, co ec ed i em-scale co ela ions, scale means and a i- ances, and alpha eliabili y coe ficien s. Cons uc alidi y was examined h ough Explo a o y Fac o ial Analysis. (EFA). The Kaise ---Meye ---Olkin (KMO) measu es o sampling ade- quacy, and Ba le ’s es o sphe ici y we e used o assess he sui abili y o he da a o ac o analysis.17 P incipal Axis Fac o ing was used o pe o m EFA, usually conside ed mo e accu a e since i es ima es common a iance and consid- e s e o a iance.18,19 The Eigen alue (g ea e han 1), he cumula i e pe cen o a iance explained, and he numbe and magni ude o he ac o loadings de e mined he num- be o ac o s o be e ained. Fac o o a ion was conduc ed o maximize in e p e abili y and, because some co ela ions among ac o s we e expec ed, an oblique oblimin ac o o a ion me hod was applied.18,19 All analyses we e con- duc ed in IBM®SPSS® e sion 22. Resul s Ins umen The PRAISE ool de eloped by Vincen 2is composed o a o al o 15 i ems, combining 10 i ems om Schwa ze and Je usalem GSE scale5and 5 new specific i ems ela ed o a Pulmona y Rehabili a ion p og am. Each i em is sco ed om 1 o 4 wi h a o al ange om 15 o 60, wi h highe sco es indica ing highe le els o sel -e ficacy. I ems 4, 7, 9, 12 and 15 a e specific o Pulmona y Rehabili a ion as p oposed by he o iginal au ho s o PRAISE.2The emaining i ems a e in acco dance wi h he Po uguese GSE by A aújo and Mou a.13 The Po uguese ool e sion o clinical p ac ice is p o ided in appendix 1, wi h pe mission om PRAISE o iginal au ho s. Pa icipan s The 150 pa icipan s had a mean age o 67 ± 1.7 yea s and 54% we e male. Condi ions indica ed o Pulmona y Rehabil- i a ion we e Ch onic Obs uc i e Pulmona y Disease (46.7%), B onchiec asis (13.3%), In e s i ial Lung Disease (13.3%), As hma (8.7%), Lung Cance Su ge y (8.0%) and o he es- pi a o y condi ions (15%). All pa icipan s we e Pulmona y Rehabili a ion ou pa ien s, 83% cu en ly in a p og am and 17% being ollowed-up. PRAISE mean sco e and s anda d de ia ion we e 49 ± 0.5, wi h a median o 50 and ange alues o 32 minimum and 60 maximum. Reliabili y The ela ionship be ween he wo es ing pe iods showed some empo al consis ency o PRAISE, whe he measu ed by Pea son co ela ion coe ficien (0.71) o by In aclass Co ela ion Coe ficien (0.76). Fo he o al o he 150 pa icipan s he in e -i ems co - ela ions we e ela i ely low, specifically o he i ems 7, 9 and 12 (Table 1). C onbach’s coe ficien was 0.78 and inc eased i i ems 9 and 12 we e omi ed om he scale (Table 2). The spli -hal coe ficien was 0.73 and analysis showed no significan di e ences be ween he sco es o he wo pa s o he ques ionnai e. Validi y Be o e conduc ing he EFA, he Ba le sphe ici y es and he KMO es we e pe o med. Fac o analysis seemed o be adjus ed o PRAISE sco es as Ba le ’s es o sphe ici y eached s a is ical significance (␹2= 296.582, p = 0.000) and he KMO a alue o 0.80. A e EFA ex ac ion he p o ided solu ion conside ed 4 ac o s ha accoun ed o a o al o explained a iance o 52.3% (Table 3). Pulmona y ehabili a ion adap ed index o sel -e ficacy (PRAISE) alida ed o Po uguese espi a o y pa ien s 337 Table 2 Po uguese e sion o PRAISE i em o al s a is ics. Mean S anda d de ia ion Scale a iance i i em Dele ed Co ec ed i em- o al co ela ion C onbach’s alpha i i em dele ed 1 3.27 0.77 30.02 0.39 0.77 2 3.15 0.70 30.08 0.43 0.77 3 3.31 0.78 29.14 0.49 0.76 4 3.00 0.91 28.55 0.40 0.78 5 3.35 0.73 27.83 0.55 0.76 6 3.37 0.68 28.97 0.56 0.76 7 3.15 0.88 32.14 0.23 0.78 8 3.29 0.72 30.21 0.43 0.77 9 3.39 0.73 32.54 0.09 0.80 10 3.11 0.76 29.09 0.42 0.77 11 2.97 1.02 30.12 0.41 0.77 12 3.64 0.56 31.66 0.19 0.79 13 3.47 0.75 30.26 0.38 0.77 14 3.33 0.77 29.28 0.49 0.77 15 3.27 0.79 29.79 0.40 0.77 Table 3 Explo a o y ac o ial analysis (P incipal Axis Fac- o ing wi h oblimin o a ion). I ems Fac o 1 Fac o 2 Fac o 3 Fac o 4 1 0.61 2 0.66 3 0.62 5 0.57 6 0.43 11 0.52 13 0.77 10 0.69 12 0.74 4 0.47 7 0.52 15 0.90 8 0.74 9 0.44 14 0.56 Eigen alue 3.99 1.45 1.31 1.10 Pe cen age o a iance explained by each ac o 26.59 9.67 8.72 7.34 Pe cen age o a iance explained by ac o s 52.34 Fac o 1 con ibu ed wi h 26.6% o he explained a iance combining 7 i ems om he o iginal GSE. Fac o 2 explained he a iance in 9.7% and included 2 i ems om each scale. Fac o 3 accoun ed o 8.7% o explained a iance wi h 3 specific i ems om PRAISE. The final ac o con ibu ed wi h 7.3% o a iance and included 2 i ems o GSE and 1 i em o PRAISE. In his ou - ac o solu ion, i ems 4 and 7 did no fi as well s a is ically as o he i ems; hese i ems appea ed o Table 4 Co ela ions be ween ac o s o he Po uguese e sion o PRAISE. Fac o 1 Fac o 2 Fac o 3 Fac o 4 Fac o 1 1 Fac o 2 0.29 1 Fac o 3 0.54 0.33 1 Fac o 4 0.21 0.18 0.11 1 PRAISE o al sco e 0.89 0.67 0.64 0.64 be c oss-loaded gi en ha bo h p esen ed loadings on o he ac o s did no di e mo e han 0.2. In addi ion, i ems 4, 6 and 9 p esen ed he smalle loaded alues in he espec- i e ac o s ex ac ed. The co ela ion coe ficien be ween ac o s was significan as shown on Table 4. Discussion This s udy p esen s a Po uguese e sion o he PRAISE ool as a esul o ansla ion and c oss-cul u al adap a ion by an expe commi ee, including he o iginal au ho o he ins umen , in acco dance wi h in e na ional ecommen- da ions. Au ho s p o ide he Po uguese Ve sion o PRAISE in appendix o enable all Po uguese speaking coun ies o measu e sel -e ficacy as a pa ien -cen e ed ou come o Pul- mona y Rehabili a ion. As PRAISE measu es sel -e ficacy enabling he clinician o iden i y impo an de e minan s o success ul beha - io change,1,2 au ho s applied such an ins umen o he di e si y o espi a o y pa ien s on Pulmona y Rehabili a- ion. Such he e ogenei y may ha e con ibu ed o di e en es ing esul s compa ed wi h he o iginal PRAISE s udy applied exclusi ely o Ch onic Obs uc i e Pulmona y Dis- ease pa ien s. In his s udy, he eliabili y es ima ed o he Po uguese e sion o PRAISE was 0.78, sligh ly lowe han he one ound in he o iginal e sion o he scale, 0.95.2Al hough one 338 C.D. San os e al. s udy has shown his o be a wo-dimensional scale,20 in he p esen s udy ou di e en ac o s we e ound, sugges ing disc imina i e sel -e ficacy quali ies. The fi s ac o included se en i ems om he GSE ela ed wi h o e all sel -e ficacy explaining 26.6% o a iance. The second ac o , explaining 9.7% o a iance, included wo i ems, one om each scale, ega ding indi iduals’ belie abou hei own capaci ies. The hi d ac o included h ee specific i ems om PRAISE, all desc ibing pe o mance accomplishmen , explaining 8.7% o a iance. Finally, he ou h ac o included wo i ems o GSE and one PRAISE i em, oge he ocus on a ionale o coping, as ei he a ai o s a egy, explaining 7.3% o a iance. O e all, he Po uguese PRAISE e sion explained 52.3% o he a iance. While EFA solu ions ha accoun o 60% o he o al a iance can be conside ed sa is ac- o y, i is no uncommon o achie e in e io alues o mul idimensional cons uc s.18,19 In ac , in his pe spec- i e, Bandu a elegan ly explained how expec a ions o pe sonal e ficacy a e dynamic and may a y in magni- ude, gene ali y o s eng h.3The esul s also indica e ha some i ems may no be con ibu ing significan ly o he measu ed cons uc . None heless, conside ing ha he o e all ac o s uc u e is concep ually plausible, he PRAISE p esen s i sel as a p ac ical and scien ifically use ul ins umen . The ac ha i was a con enience sample wi h all pa ien s a ending Pulmona y Rehabili a ion a he same cen e may be a s udy limi a ion. In addi ion, di e ences in he ehabili a ion p og am o clinical condi ions may ha e had an e ec on how he indi iduals pe cei ed hei sel - e ficacy in ega ds o he Pulmona y Rehabili a ion p og am. Hence, u u e s udies should e alua e he eliabili y and alidi y o PRAISE o specific pa ien g oups. Gi en he lack o e idence published abou he o ig- inal PRAISE ac o s uc u e,2 hese findings emain o be compa ed wi h u he s udies. The ou - ac o s uc- u e p oposed enables u u e s udies o PRAISE cons uc con e gen alidi y, by a c oss-sec ional compa ison o sco es o o he Pulmona y Rehabili a ion ins umen s wi h PRAISE esul s,16,21 such as hose p esen ed by Vincen 2 and Song.20 Fu he mo e, con inuing esea ch on longi udi- nal alidi y may inc ease knowledge on clinically impo an sel -e ficacy change and PRAISE esponsi eness. In ac , some s udies al eady applied PRAISE on a home-based Pul- mona y Rehabili a ion22 and sel -managemen p og am,23 bu wi h no di e ences when compa ed wi h adi ional ca e. Conclusions The Po uguese e sion o PRAISE showed adequa e psycho- me ic p ope ies wi h a eliabili y o 0.78 alpha Ch onbach and a alidi y o 52.3% o explained o al a iance. This s udy enables Po uguese clinicians wi h he ins umen o measu e sel -e ficacy as a pa ien -cen e ed ou come on Pulmona y Rehabili a ion, in acco dance wi h in e na ional guidelines. Funding This wo k was suppo ed by Fundac¸ão pa a a Ciência e Tec- nologia (FCT) and Nippon Gases Po ugal unde he PhD s uden ship in Indus y g an PDE/BDE/127785/2016. Conflic s o in e es The au ho s ha e no conflic s o in e es o decla e. Au ho con ibu ions San os C. concei ed, planned and execu ed he s udy, pa - icipa ed in he mul idisciplina y panel o expe judges, analyzed and in e p e ed da a, and w o e and e ised he manusc ip . San os A. analyzed and in e p e ed da a, and w o e and e ised he manusc ip . San os M. in e p e ed da a, and w o e and e ised he manusc ip . Rod igues F. pa icipa ed in he mul idisciplina y panel o expe judges and e ised c i ically he final e sion o he manusc ip o impo an in ellec ual con en . Bá ba a C. e ised c i ically he final e sion o he manusc ip o impo an in ellec ual con en . All au ho s ha e ead and app o ed he manusc ip . Acknowledgemen s Au ho s a e g a e ul o Emma Vincen , José Cos a, Fábio Fe ei a, Liliana Dias, Pa ícia Mon ei o and Ma iana Ce ejo o hei collabo a ion as expe s on he ansla ion and c oss-cul u al adap a ion o he ins umen . Au ho s also hank he Pulmona y Rehabili a ion Team o Hospi al Pulido Valen e, namely Ana Filipe, Paula Raposo, Cla a C uz, Ma a San os, Ru e Robe o, Cláudia Cos a, Susana Ga cia, Ma a Miguéns and Ca la Bap is a, o he oppo uni y o apply he ins umen o pa ien s on ea men . Appendix A. 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