Research Article
ISSN: 2574 -1241
DOI: 10.26717/BJSTR.2023.54.008487
Validation and Translation of Bengali Version of
Functional Assessment of Anorexia Cachexia Therapy
(Anorexia/Cachexia Subscale) for Measuring Cancer
Related Anorexia Cachexia (CRAC) in Advanced
Cancer Patients
Iftekhar Hossain Chowdhury
1
*, Yeasmin Jahan Afroze
2
, Shahrin Sultana
3
, Farjana Haque Mitu
4
,
Shirin Aktar
5
and Kamrun Nahar
1
1
Department of Pharmacology, Mugda Medical College and Hospital, Bangladesh
2
Department of Surgery, National Institute of Cancer Research & Hospital, Bangladesh
3
Department of Pharmacology, Eastern Medical College, Bangladesh
4
Department of Pharmacology, Bangabandhu Sheikh Mujib medical college, Faridpur
5
Department of Pharmacology, Shahabuddin Medical College, Bangladesh
*Corresponding author: Iftekhar Hossain Chowdhury, Department of Pharmacology, Mugda Medical College and Hospital,
Dhaka-1214, Bangladesh
Copyright@ : Iftekhar Hossain Chowdhury | Biomed J Sci & Tech Res | BJSTR.MS.ID.008487.
45371
ABSTRACT
Objective: The cornerstone of treating cancer-related anorexia-cachexia in patients with advanced cancer
is routine anorexia-cachexia assessment. There isn’t yet a validated instrument to evaluate anorexia among
Bengali-speaking people who have terminal illnesses. The study’s objectives are to translate the Functional
Assessment of Anorexia Cachexia Therapy (Anorexia/Cachexia Subscale) Version 4 questionnaire into Bengali
and evaluate it while making cultural adaptations.
Methods: There were two stages of the investigation. Four translators worked independently to translate
the Functional Assessment of Anorexia Cachexia Therapy (Anorexia/Cachexia Subscale) questionnaire from
oncology department of Bangabandhu Sheikh Mujib Medical University and NICRH, Dhaka, Bangladesh
(content, face, and construct validity) were evaluated.
Result: Every participant answered every item. Thirty percent of participants struggled with three problems,
whereas seventy percent of participants understood every question completely. The questionnaire’s face
and content validity were deemed satisfactory by the expert committee. High dependability was also seen in
Subscale) principal component analysis distribution of varimax rotation ranged from 0.53 to 0.85 in Bengali.
Conclusion: The Bengali version of the FAACT ACS was shown to be valid, relible, and culturally appropriate
for the Bengalis peaking people. As a result, it can be used in clinical and research settings to assess symptoms
and monitor treatment responses of patients suffering from advanced cancer in Bengali-speaking nations.
Keywords: FAACT ACS Bengali; Symptom Assessment; Bengali; Advanced Cancer; Bangladesh
Abbreviations: QoL: Quality of Life; FACT: Functional Assessment of Cancer Therapy; LCS: Lung Cancer
Subscale; FAACT: Functional Assessment of Anorexia Cachexia Therapy
ARTICLE INFO
Received: November 09, 2023
Published: December 07, 2023
Citation: Iftekhar Hossain Chowdhury,
Farjana Haque Mitu, Shirin Aktar and
Kamrun Nahar. Validation and Transla-
tion of Bengali Version of Functional As-
sessment of Anorexia Cachexia Therapy
(Anorexia/Cachexia Subscale) for Meas-
uring Cancer Related Anorexia Cachex-
ia (CRAC) in Advanced Cancer Patients.
Biomed J Sci & Tech Res 54(1)-2023.
BJSTR. MS.ID.008487.
Copyright@ : Iftekhar Hossain Chowdhury | Biomed J Sci & Tech Res | BJSTR.MS.ID.008487.
45372
Volume 54- Issue 1
DOI: 10.26717/BJSTR.2023.54.008487
Introduction
Patients with advanced cancer often experience anorexia
(i.e., the subjective sense of poor appetite) and cachexia (i.e., the
physiologic state of muscle catabolism and weight loss) [1]. These
often occur together and constitute the “cancer related anorexia-
5 %, or weight loss greater than 2 % in individuals already showing
depletion according to current bodyweight and height (body-mass
index<20KM/M) or skeletal muscle mass (sarcopenia) [4]. We have
previously shown that when using these criteria, patients with overt
in quality of life (QoL) [5], and shorter overall survival [6]. The
measurement of QoL impairments related to CRAC is therefore
important both in clinical practice and in research efforts [7] that
seek to improve patients’ lived experience with advanced cancer. The
Functional Assessment of Cancer Therapy (FACT) is a set of measures
designed to assess health related QoL and is one of the most well-
validated instruments established for use exclusively among cancer
patients [8]. The FACT family is built around the core instrument
FACT-General (FACT-G) and its four subscales: physical well-being,
emotional well-being, functional well-being, and social well-being.
The FACT-G is frequently paired with extra subscales that incorporate
additional items relevant to certain therapeutic situations.
There is a “lung cancer subscale” (LCS) for patients with lung
cancer, for example, which when combined with the FACT-G generates
the FACT-L [9]. There is also anorexia and cachexia subscale (ACS)
[10]. When paired with the FACT-G, the Functional Assessment of
Anorexia Cachexia Therapy (FAACT) is formed. While both scales
are said to cover crucial dimensions of health related QoL in cancer
patients, some have questioned the FAACT scale’s utility and validity
[11]. Because the FAACT and its anorexia-cachexia subscale (ACS) are
relevant measures of QoL in patients with advanced cancer and CRAC,
they were used in this study.
Methods
Functional Assessment of Anorexia Cachexia Therapy (Anorexia/
Cachexia Subscale) Version 4 questionnaire was devised in 2000 and
choice answers (not at all, little bit, somewhat, quite a bit, very much).
The scoring system awards points from 0 to 4 for each question and is
arranged so that the higher values equate to healthier scenarios. Each
patient’s response applies to the previous week and a total score of
up to 48 is possible. In this regard, we must mention that the FAACT
ACS questionnaire is widely used in the clinical trials of CRAC, and
Translation Procedure
The Beaton et al.7 criteria were followed during the English to
Bengali translation procedure. Two separate translators who spoke
Bengali completed the forward translation; one knew about the scale’s
notion (T1), while the other did not (T2). Two forward translators
were involved in the project: one had a medical background (T1),
while the other was a non-medical expert in English literature (T2).
A third, impartial party then integrated the two versions to create
a combined one (Ts). Since the Ts version included practically all
local customs, habits, and word usage, only a few alterations were
and BT2) back translated the questionnaire from its Ts version into
English. Both of them had a strong background in English language
from these two back translators to reduce information bias and
extract unexpected meanings from the translated questionnaire’s
items. Uncertain language in the translations was accentuated by
the back-translation procedure. Then an expert committee was
formed with two experts from the Department of Chemistry, Dhaka
College. Both were trained in the English version of FAACT ACS. The
expert committee and all translators reviewed and compared all the
the semantic, idiomatic, experiential, and conceptual equivalence
between the English and Bengali versions. After reaching a consensus
was made for pre-testing (Table 1).
Table 1: Translation process of FAACT ACS Bengali.
Stage I: Translation Two Translations (T1 and T2) Informed and Uninformed Translators
Written Report for Each into Target Language
Version (T1 and T2)
Stage II: Synthesis
Synthesize T1 and T2 into Ts Resolve any discrepancies with the trans-
lator’s reports
Written report
Stage III: Back trans-
lation
Two re-translated versions from Bengali to English translations by
procient English teachers Work from Ts version Create two back
translations (B1 and B2)
Written report for each into target language
version (B1 and B2)
Stage IV: Expert com-
mittee Review
Review all reports Methodologists, developers, language profession-
als, translators Reach a consensus on discrepancies Produce pre-nal
version
Written report
Stage V: Pilot-testing
n=10 (patients) Complete questionnaire Probe to get an understanding
of the i
Written report
Copyright@ : Iftekhar Hossain Chowdhury | Biomed J Sci & Tech Res | BJSTR.MS.ID.008487.
Volume 54- Issue 1
DOI: 10.26717/BJSTR.2023.54.008487
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Pilot-Testing
Thirty postgraduate medical students at Bangabandhu Sheikh
version of the FAACT ACS. The participants were asked to explain
their understanding of each question and how they would respond
if the condition applied to them. In August 2022, ten Bengali-
questionnaire was administered to them. Their information was not
questionnaire was being administered, the patients were questioned
about any terms that they found challenging, perplexing, or disturbing.
For words and phrases that were challenging or unclear, substitute
examination and approval.
Setting and Participants for the Final Validation Phase
For the last validation stage, we included eighty patients. 80
responders in total were contacted to discuss a 10% dropout rate.
could read and understand Bengali and who had advanced cancer and
NICRH. The patients were aged approximately 18 years. The study
excluded patients with psychotic illnesses or any form of cognitive
impairment.
Data Collection
The period of data collecting was October 2022–December 2022.
A sequential sampling technique was used to collect the samples. It
was requested that eligible patients complete the questionnaire on
their own. When necessary, the primary investigator provided them
with succinct explanations of each item in case there was any doubt
Data Analysis
The face validity was assessed during the routine translation
standard translation, expert committee evaluation, and literature
reviews. Construct validity was investigated using factor analysis
along with principal component analysis and varimax rotation
(Figure 1).
Figure 1: Functional Assessment of Anorexia Cachexia Therapy Sub scale Bengali Version 4.
Copyright@ : Iftekhar Hossain Chowdhury | Biomed J Sci & Tech Res | BJSTR.MS.ID.008487.
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DOI: 10.26717/BJSTR.2023.54.008487
Ethical Consideration
The Department of Oncology, BSMMU, and NICR&H gave their
consent. After reviewing the protocol, the BSMMU institutional
review board (IRB) issued a clearance letter memo with the date
BSMMU/2022/4293 on April 25. All eligible patients were made
aware of the study’s goals and the intervention. The participants’
privacy was scrupulously protected. The participant’s private
information, including name, age, sex, and other details, was kept
Result
Validity Analysis
Face Validity: The translation and adaptation procedure also
included the face validity methodology. Both the naive responders
(uninformed translators) and the expert committee members agreed
that the exam’s objective was clear: it should quantify the symptoms
of patients who are nearing the end of their lives. 90% of the 30
students who took the pre-test comprehended every question, with
the remaining 10% needing some explanation. Eighty percent of
the patients fully understood seven questions during the cognitive
elements of the Bengali version were all connected to the subject of
the measurement. The only two that needed a long explanation were
“I have a good appetite” and “My general health is improving.” Both
the measurement technique and the measure itself worked well for
was deemed by the expert panel to be a trustworthy tool for evaluating
symptoms in the Bengali-speaking community.
Content Validity:
assessed by two experts: Item-level content validity index (I-CVI) was
found to be 1 (Table 2) for each item and scalelevel content validity
index (S-CVI) was therefore 1 by the averaging calculation method
(Table 2).
Table 2: Item descriptive of content validity of the adapted Bengali
version of the FAACT ACS.
Item Rating by Experts I-CVI S-CVI
Expert Expert
1 4 4 1 0.92
2 4 4 1
3 4 3 0.66
4 4 4 1
5 4 4 1
6 3 4 0.66
7 4 4 1
8 4 4 1
9 4 4 1
10 4 4 1
11 4 4 1
12 4 4 1
Construct Validity: Most participants, who were almost equally
divided between the sexes and aged between 30 and 60, took part
(59%) had completed secondary or higher secondary school. Using
a principal component and varimax rotation, exploratory factor
The observed Kaiser-Meyer-Olkin (KMO) score of 0.71 indicates
that the factor analysis could be performed with the current data.
The range of the FAACT-ACS Bengali varimax rotation distribution
was 0.53 to 0.85. The item 8 (My family and friends are urging me to
eat) received the highest score of 0.83. Item 11 (I feel stomachache)
received the lowest score of 0.53 (Table 4). Out of the twelve items,
just one component was taken out.
Table 3:
Variable Participants
Frequency Percentage
Age groups
18–30years 14 17.5
31–40years 29 36.25
41–50years 31 38.75
51–60years 6 7.5
Educational level
Primary level 13 16.25
Secondary level 47 58.75
Higher secondary level 20 25
Sex
Male 63 78.75
Female 17 21.25
Table 4: Principal component analysis with the distribution of
varimax rotation of FAACT ACS Bengali.
Component Matrix
Items Component I
Q1 0.72
Q2 0.61
Q3 0.81
Q4 0.62
Q5 0.84
Q6 0.51
Q7 0.61
Q8 0.85
Q9 0.63
Q10 0.64
Q11 0.53
Q12 0.71
Note: Extraction method: principal component analysis I component ex-
tracted.
Copyright@ : Iftekhar Hossain Chowdhury | Biomed J Sci & Tech Res | BJSTR.MS.ID.008487.
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DOI: 10.26717/BJSTR.2023.54.008487
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Reliability Analysis
Table 5: Internal consistency of the FAACT ACS Bengali.
Reliability statistics Value
Cronbach’s alpha 0.84
Cronbach’s alpha based on standardized items 0.81
Number of items 12
Discussion
of cultural adaptation of a standard scale or instrument. Finding
appropriate words in translated language sometimes becomes a great
challenge for translators. In this study, we have translated and validated
the FAACT ACS questionnaire which is one of the most important tools
patients. Several well-validated instruments in the FACT family are
relevant to patients with advanced lung cancer; nevertheless, some
issues have been raised concerning the validity of the FAACT scale and
the ACS [11]. As a result, we investigated the scales’ cross-sectional
appropriate levels of Internal consistency, convergent validity, and
divergent validity are all compatible with the other instruments in the
validation of the FACT instruments outside of the current setting,
indicate that give assurance regarding using the FAACT and the ACS
to people suffering with advanced cancer. This tool’s face validity has
likewise been determined to be highly consistent with the original
version. The expert group determined that the version was correct
for the symptom assessment of the Bengali-speaking population. Two
factors (loss of appetite and well-being) required brief explanations
There are multiple synonyms and expressions for the term “I Have
Good Appetite.”
Usually in Bengali when two positive words are used at a time,
with lower educational status needed either further explanation or
elaboration of the meaning of this phrase. Other studies showed that
patients who evaluated the FAACT ACS stated that the term “Good
Appetite” was a double positive and therefore led to confusion. Item
number 12 is “My general health is improving” The term “general
further explanation was needed to clear their confusion. So, the expert
committee decided to use a conceptual synonym for the meaning of
general health. Where the meaning of the word “general health was
not understood by the patients and hindered the overall rating of
the instrument. The internal consistency of the Bengali version was
0.84, which denotes high reliability. It is as reliable as other language
During data collection, we had trouble determining whether the
symptoms occurred “before or after receiving chemotherapy,” “at the
time of admission,” or “at the time of data collection.” We wanted to
existed “at the time of data collection. One limitation of our study is
that we were unable to do test-retest reliability because many of our
repeat this questionnaire. Another limitation is that we were unable
alternative tool in Bengali for symptom evaluation in advance cancer
patients.
Conclusion
The Bengali version of the FAACT (anorexia/cachexia subscale)
was shown to be valid, reliable, and culturally appropriate for
the Bengalis peaking people. As a result, it can be used in clinical
and research settings to assess symptoms and monitor treatment
responses of patients suffering from advanced cancer in Bengali-
speaking nations.
Acknowledgements
The authors gratefully acknowledge the contribution of Dr. Md
Najmul Kabir Chowdhury, Associate Professor, Dhaka College, Dhaka;
Khairul Alam, Assistant Professor, Dhaka College, Dhaka for their
participation in the translation process of FAACT ACS Bengali version.
They also acknowledge Shamima Rahman, SSN, NICRH, Dhaka, for
Author Contributions
acquisition, investigation, methodology, project administration,
resources and software, validation, writing original draft,
methodology, supervision, validation and writing original draft. SS:
methodology, supervision, writing original draft, editing, and review.
draft, editing, and review.
Declaration of Conicting Interests
respect to the research, authorship, and/or publication of this article.
Copyright@ : Iftekhar Hossain Chowdhury | Biomed J Sci & Tech Res | BJSTR.MS.ID.008487.
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DOI: 10.26717/BJSTR.2023.54.008487
Funding
for the research, authorship, and/or publication of this article: This
work is funded by Bangabandhu Sheikh Mujib Medical University,
Dhaka, Bangladesh.
Informed Consent
Written informed consent was obtained from all subjects before
the study.
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ISSN: 2574-1241
DOI: 10.26717/BJSTR.2023.54.008487
Iftekhar Hossain Chowdhury. Biomed J Sci & Tech Res
