Published online Sep 20, 2026. doi: 10.5662/wjm.120002
Revised: March 6, 2026
Accepted: March 25, 2026
Published online: September 20, 2026
Processing time: 146 Days and 18.2 Hours
Sarcopenia is common among cancer patients and is associated with adverse clinical outcomes. The strength, assistance in walking, rising from a chair, clim
To translate and culturally adapt the SARC-F questionnaire into Hindi and assess its reliability and content validity.
This single-center cross-sectional study was conducted at a tertiary cancer center in India. The questionnaire was translated using forward-backward translation following World Health Organization and International Society for Pharmacoeconomics and Outcomes Research guidelines. Pilot testing assessed clarity and cultural relevance. Adult Hindi-speaking cancer patients completed the finalized questionnaire. Reliability and content validity were evaluated using Cronbach’s alpha and content validity indices, and descriptive statistics with Pearson corre
A total of 100 patients were included (mean age 50.9 ± 12.6 years; 63% female). The Hindi SARC-F demonstrated acceptable internal consistency (Cronbach’s α = 0.70). Content validity was excellent, with a scale-level content validity index of 0.92 and item-level indices ranging from 0.80 to 1.00. The median SARC-F score was 1 (interquartile range 0-3). No statistically significant correlations were observed between SARC-F scores and age, performance status, or body composition parameters (all P > 0.05).
The Hindi SARC-F is linguistically valid, culturally appropriate, and suitable for functional sarcopenia screening in Hindi-speaking cancer patients.
Core Tip: This study presents the first Hindi translation and cross-cultural adaptation of the strength, assistance in walking, rising from a chair, climbing stairs, and falls questionnaire for sarcopenia screening among cancer patients in India. Using standardized forward-backward translation and international adaptation guidelines, the Hindi version demonstrated acceptable internal consistency and strong content validity. The translated tool provides a linguistically and culturally appropriate instrument for functional assessment in Hindi-speaking populations and may facilitate routine sarcopenia screening in resource-constrained oncology settings.
- Citation: Prakash HS, Sehrawat A, Rana A, Swamy AM, Prasath S, Koulagi M, Sundriyal D. Translation of the strength, assistance in walking, rising from a chair, climbing stairs, and falls questionnaire into Hindi. World J Methodol 2026; 16(3): 120002
- URL: https://www.wjgnet.com/2222-0682/full/v16/i3/120002.htm
- DOI: https://dx.doi.org/10.5662/wjm.120002
Sarcopenia is described as a “progressive and generalised skeletal muscle disorder that is associated with increased likelihood of adverse outcomes including falls, fractures, physical disability and mortality” by the European Working Group on Sarcopenia in Older People 2 (EWGSOP2)[1]. Sarcopenia in adult cancer patients has been associated with worse overall survival, post-operative problems, and higher chemotherapy toxicity[2]. The prevalence of sarcopenia among cancer patients ranges from 15% to 70%, depending on tumor type, stage, and assessment method[3]. Despite its clinical relevance, routine screening for sarcopenia in oncology practice remains limited due to the complexity, cost, and time requirements of gold-standard diagnostic tools such as dual-energy X-ray absorptiometry (DXA), computed tomography -based skeletal muscle index, and bioelectrical impedance analysis (BIA).
The Asian Working Group for Sarcopenia has population-specific cutoffs for measures and defines the condition as “age-related loss of skeletal muscle mass plus loss of muscle strength and/or reduced physical performance”[4].
To address the challenges of sarcopenia screening, the strength, assistance in walking, rising from a chair, climbing stairs, and falls (SARC-F), a simple five-item self-report tool has been recommended by international guidelines (e.g., EWGSOP2) as a rapid screening instrument for sarcopenia[1,4-6]. Multiple studies in Western and Asian populations have demonstrated its utility, but language and cultural differences limit its applicability in non-English-speaking settings[7,8]. Currently, no validated Hindi version of SARC-F exists. Given that a large proportion of Indian cancer patients are Hindi-speaking, especially in North India, this represents a significant barrier to sarcopenia screening in routine oncology practice. A validated Hindi version of SARC-F will enable easy screening of sarcopenia, especially in high-volume outpatient settings. Translation and validation of this tool will ensure linguistic and cultural appropriateness, and allow broader implementation in Indian oncology practice.
This was a single-center, cross-sectional study conducted in the Department of Medical Oncology and Hematology at the All India Institute of Medical Sciences (AIIMS), Rishikesh, India. The study was carried out over a period of six months, from August to December 2025. The primary objective was to develop and validate a Hindi version of the SARC-F que
The study population comprised adult (≥ 18 years) patients with histologically confirmed malignancy who were fluent in spoken and written Hindi. Participants were eligible if they had an Eastern Cooperative Oncology Group (ECOG) Per
Formal permission for the use and adaptation of the SARC-F questionnaire was obtained from the original SARC-F development team prior to translation[5,6]. The Hindi version of SARC-F was developed following a standardized forward–backward translation method to ensure conceptual and linguistic equivalence. Ethical clearance for the study was granted by the Institutional Ethics Committee of AIIMS, Rishikesh (AIIMS/IEC/25/597).
The SARC-F questionnaire was used to screen for sarcopenia and includes five domains: SARC-F. Each item is scored on a 3-point ordinal scale, where 0 indicates no difficulty, 1 indicates some difficulty, and 2 indicates severe difficulty or inability. Strength assesses difficulty in lifting and carrying 4.5 kg; assistance in walking evaluates difficulty walking across a room; rising from a chair assesses difficulty transferring from a chair or bed; and climbing stairs evaluates difficulty climbing a flight of 10 stairs. The falls domain is scored based on the number of falls in the previous 12 months (0 = none, 1 = one to three falls, 2 = four or more falls). Total SARC-F scores range from 0 to 10, with higher scores indicating greater functional impairment and increased risk of sarcopenia (Supplementary Table 1).
Poor physical performance, a higher risk of hospitalization, and a higher risk of death are all associated with a total score of ≥ 4, which is thought to be predictive of sarcopenia. The survey is brief, simple to administer, and has been pro
The translation and validation process was conducted in accordance with guidelines provided by the SARC-F development team. Cross-cultural validation followed World Health Organization (WHO) and International Society for Pharmacoeconomics and Outcomes Research (ISPOR) guidelines. To ensure conceptual and linguistic equivalency with the source version, the SARC-F questionnaire was translated from English into Hindi. The forward translations were prepared by two separate translators who were proficient in both Hindi and English. A third bilingual translator examined and balanced the two forward translations to produce a single, harmonized Hindi version that most accurately captured the original English questionnaire’s meaning. An independent translator who was fluent in both Hindi and English then back-translated the reconciled Hindi version into English. The SARC-F development team was tasked with reviewing the back-translated version in addition to the forward and reconciled versions. The finalized Hindi version of the questionnaire was authorized for pilot testing after all disagreements and questions were addressed and settled by consensus (Supplementary Tables 2 and 3). Following SARC-F team approval, 20 patients enrolled in AIIMS Rishikesh’s Department of Medical Oncology and Hematology participated in a pilot study of the completed Hindi and English versions of the questionnaire. All participants were Hindi or English-speaking adult cancer patients recruited for pilot evaluation (Figure 1). Participants were asked to complete the questionnaire and provide feedback on clarity, comprehension, and acceptability. Based on this feedback, minor revisions were made, if necessary, before the final version was validated (Supplementary Table 2).
Internal consistency: Cronbach’s alpha was used to determine internal consistency in order to assess the level of homo
Validation: Following translation, a panel of experts assessed the content validity of the Hindi SARC-F using a 4-point relevance scale. Items achieving an item-level content validity index (I-CVI) of ≥ 0.78 and a scale-level CVI (S-CVI) of ≥ 0.90 were considered acceptable.
Construct validity: BIA was used to obtain objective body composition parameters for exploratory comparison with questionnaire scores. Although DXA is considered a reference technique for body composition assessment, BIA provides a practical, non-invasive, and feasible alternative in clinical settings and has demonstrated strong agreement with DXA measurements (intraclass correlation coefficient > 0.95; r = 0.79)[1,7]. In the present study, BIA-derived muscle mass indices were utilized to examine construct validity by assessing correlations between Hindi SARC-F scores and objective body composition measures, rather than to establish diagnostic classification.
Instrument and measurements: Baseline demographic and clinical data were collected after written informed consent, including age, body mass index (BMI), weight, height, sex, state of residence, education level, and occupation. BMI categories were defined according to Indian population-specific criteria as underweight (< 18.5 kg/m2), normal (18.5-22.9 kg/m2), and overweight/obese (≥ 23 kg/m2). Additional variables included cancer stage according to the American Joint Committee on Cancer staging system, ECOG performance status, treatment status, and prior or ongoing therapy. These variables were recorded to account for potential confounding factors. BIA was performed to obtain objective measures of body composition, including appendicular skeletal muscle index (ASMI). These measurements were collected to enable exploratory assessment of associations between questionnaire scores and objective muscle mass parameters as part of construct validity evaluation. Muscle strength and physical performance measures were not included in the present phase of the study, as the primary objective was linguistic translation and psychometric validation of the Hindi SARC-F questionnaire within a routine oncology outpatient setting. For BIA measurement, we used Charder MA601 Body Composition Analyzer for muscle mass analysis. BIA measurements were performed under standardized conditions to minimize hydration-related variability. Participants were assessed in a non-fasting but resting state, after bladder emptying, and were advised to avoid vigorous physical activity for at least 12 hours prior to measurement. Patients with clinically significant edema, ascites, or fluid overload were excluded. The device was calibrated according to manu
Descriptive statistics, such as the mean and standard deviation, were used to summarize the numerical continuous socio-demographic characteristics, such as body weight. Categorical socio-demographic characteristics (e.g., gender) were displayed in frequency tables, presenting data in percentage form. Pearson’s correlation test was used to look at the relationship between the SARC-F score and socio-demographic and clinical variables. We used Cronbach’s α to check for internal consistency. A P value of less than 0.05 with 95% confidence intervals was used to determine statistical signi
The study included 100 patients, with an average age of 50.9 ± 12.6 years and an average BMI of 22.1 ± 4.5 kg/m2. The majority of participants (63%) were women, and most of them (68%) lived in the Indian state of Uttar Pradesh. Fifty-one percent had primary-level education only, and 61% were housewives. 92% of the cases had advanced disease (stage III-IV), and 93% had ECOG performance status of 1. The most common primary cancer was breast (28%) followed by genitourinary (17%). Most patients (73%) had received therapy for ≥ 3 months, and most (72%) had systemic treatment. Only 19% had received radiotherapy and 51% had undergone surgery. The detailed baseline characteristics are presented in Table 1.
| Characteristic | Value |
| Age, years, mean ± SD (range) | 50.9 ± 12.6 (20-79) |
| Body mass index, kg/m2, mean ± SD (range) | 22.1 ± 4.5 (15-33) |
| Weight, kg, mean ± SD (range) | 53.6 ± 11.2 (27-84) |
| Height, cm, mean ± SD (range) | 156.6 ± 10.1 (138-185) |
| Sex | |
| Female | 63 (63.0) |
| Male | 37 (37.0) |
| State of residence | |
| Uttar Pradesh | 68 (68.0) |
| Uttarakhand | 32 (32.0) |
| Education level | |
| Illiterate | 20 (20.0) |
| Primary school | 51 (51.0) |
| Secondary school | 12 (12.0) |
| High school | 7 (7.0) |
| Graduate | 4 (4.0) |
| Postgraduate | 6 (6.0) |
| Occupation | |
| Housewife | 61 (61.0) |
| Farmer | 18 (18.0) |
| Other | 15 (15.0) |
| Professional | 4 (4.0) |
| Unemployed | 2 (2.0) |
| Body mass index category | |
| Underweight | 19 (19.0) |
| Normal | 57 (57.0) |
| Overweight/obese | 24 (24.0) |
| Cancer stage (American Joint Committee on Cancer) | |
| I | 4 (4.0) |
| II | 4 (4.0) |
| III | 42 (42.0) |
| IV | 50 (50.0) |
| Eastern cooperative oncology group performance status | |
| 1 | 93 (93.0) |
| 2 | 7 (7.0) |
| Treatment-naïve | 27 (27.0) |
| On treatment ≥ 3 months | 73 (73.0) |
| Prior systemic therapy | 73 (73.0) |
| Prior radiotherapy | 19 (19.0) |
| Prior surgery | 51 (51.0) |
The internal consistency of the Hindi version of the SARC-F questionnaire was assessed using Cronbach’s alpha (Table 2). Item-wise analysis demonstrated acceptable variability in internal consistency, with Cronbach’s alpha if item deleted ranging from 0.541 to 0.728. The highest internal consistency was observed for the “falls in the last year” item (α = 0.728), while the “stair climbing” item showed the lowest alpha value (α = 0.541). The overall Cronbach’s alpha for the Hindi SARC-F scale was 0.70, indicating acceptable internal consistency and reliability of the translated instrument.
| Questionnaire item | Cronbach’s alpha |
| Strength | 0.595 |
| Assistance in walking | 0.642 |
| Rising from chair | 0.661 |
| Stair climbing | 0.541 |
| Falls in last year | 0.728 |
| Overall scale | 0.70 |
Using a 4-point relevance scale, five subject-matter experts independently assessed the content validity of the Hindi version of the SARC-F questionnaire. Excellent overall content validity was shown by the S-CVI of 0.92. The I-CVI showed a high level of expert agreement across individual questions, ranging from 0.80 to 1.00. Supplementary Table 4 provides detailed expert ratings, agreement counts, and matching I-CVI values for each questionnaire item. These results show that there is broad expert agreement on the application and usefulness of all SARC-F items for sarcopenia ass
Responses to individual SARC-F questionnaire items are presented in Supplementary Table 5. A SARC-F score ≥ 4 was observed in 17 patients (17.0%) in the study population. The distribution of total SARC-F scores in the study population is shown in Supplementary Table 6. The total SARC-F score had a median (Q1-Q3) of 1 (0-3). The mean health score was 65.55 ± 11.10. Mean skeletal muscle index (SMI), ASMI, and fat-free mass index (FFMI) were 7.87 ± 1.30 kg/m2, 5.54 ± 1.11 kg/m2, and 14.84 ± 2.26 kg/m2, respectively (Supplementary Table 7).
Pearson correlation analysis showed no statistically significant associations between total SARC-F score and clinical or body composition parameters (Supplementary Table 8). Age (r = 0.14, P = 0.165) and ECOG performance status (r = 0.111, P = 0.271) demonstrated small positive correlation coefficients; however, these were not statistically significant. Similarly, ASMI (r = -0.094, P = 0.352), SMI (r = -0.091, P = 0.366), FFMI (r = -0.064, P = 0.525), and basal metabolic rate (BMR) (r =
India has a large Hindi-speaking population, underscoring the need for validated clinical assessment tools in the Hindi language. According to the census of India 2011, Hindi is the mother tongue of approximately 528 million individuals (43.6% of the population) and is spoken as a first, second, or third language by nearly 692 million people (57.1%)[9]. However, commonly used sarcopenia screening tools such as the SARC-F questionnaire have predominantly been developed and validated in English or other non-Indian languages. Given the high cancer burden and routine use of Hindi for clinical communication across much of India, particularly in North India, validation of a Hindi version of the SARC-F questionnaire is essential to improve screening accuracy and its applicability in routine oncology practice.
The present study translated, culturally adapted, and evaluated the psychometric properties of the SARC-F ques
The Hindi SARC-F demonstrated adequate item homogeneity while maintaining clinical variability, as evidenced by its satisfactory internal consistency (Cronbach’s α = 0.70). This result is comparable to the Polish validation (α = 0.70), exceeds the German version (α = 0.67), and is only marginally lower than the Arabic version (α = 0.81) and the original English cohorts (0.76-0.81)[5,8,10,11]. These findings suggest that the translated Hindi questionnaire maintains reliability characteristics similar to other language adaptations, supporting its linguistic consistency and cultural suitability rather than establishing diagnostic performance.
The Hindi SARC-F demonstrated no statistically significant associations with age, ECOG performance status, or muscle mass indices (ASMI, SMI, FFMI) and BMR. Although small correlation coefficients were observed, these did not reach statistical significance, suggesting that SARC-F scores may not directly reflect objective measures of muscle mass in this cohort. These findings are consistent with the conceptual design of the instrument, which primarily evaluates self-perceived functional impairment rather than quantitative muscle depletion. Similar observations have been reported internationally. While French and Polish validation studies demonstrated stronger associations with objective physical performance measures, the Spanish SARC-F showed correlations with grip strength, gait speed, knee extension torque, Short Physical Performance Battery, and quality of life outcomes[11-13]. The Arabic validation also reported associations with fatigue markers and domains of the Short Form-12 Health Survey[10]. Across studies, correlations with body composition parameters have generally been weaker, supporting the notion that functional limitation, rather than muscle mass alone, more strongly influences SARC-F scores and patient-reported experience.
This study represents the first cross-cultural translation and adaptation of the SARC-F questionnaire into Hindi for use among Indian cancer patients, addressing an important linguistic gap in sarcopenia screening. The translation process followed standardized forward-backward methodology in accordance with WHO and ISPOR guidelines, ensuring conceptual and linguistic equivalence. Pilot testing and expert content validation further supported clarity, cultural appropriateness, and acceptability of the translated instrument within a real-world oncology outpatient setting.
The study was conducted at a single tertiary-care center with a relatively modest sample size, which may limit generalizability to broader populations. Objective measures of muscle strength and physical performance were not included, as the primary aim was methodological translation and cultural adaptation rather than clinical validation. Consequently, diagnostic accuracy parameters such as sensitivity, specificity, and predictive validity were not assessed. This work represents the first phase of an ongoing research program focused on the Hindi adaptation of the SARC-F questionnaire; a second phase is currently underway in a larger cohort (approximately 500 patients) to evaluate diagnostic performance metrics and associations with clinical outcomes.
The SARC-F questionnaire was successfully translated and culturally adapted into Hindi using a standardized cross-cultural methodology. The Hindi version demonstrated acceptable internal consistency and strong content validity, supporting its linguistic accuracy and cultural appropriateness for Hindi-speaking cancer patients. As this study focused on methodological translation and psychometric evaluation, diagnostic performance was not assessed. The Hindi SARC-F provides a practical tool for functional sarcopenia screening in oncology practice and offers a foundation for future multicenter studies evaluating clinical validity and outcome associations.
We sincerely acknowledge the valuable support and guidance provided by Dr. Vikas Kumar (Department of Pharmacology, AIIMS Bathinda, India) and Dr. Monika Pathania (Department of Geriatric Medicine, AIIMS Rishikesh, India) in the preparation of the ESMO Asia Congress 2025 poster. Preliminary findings from this study were presented as a poster at the ESMO Asia Congress 2025 (Poster No. FPN-856P).
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