Internet and decision-making regarding health among pregnant woman: cross-cultural adaptation of a questionnaire for use in Brazil A Internet e tomada de decisões sobre saúde entre gestantes: uma adaptação transcultural de um questionário para uso no Brasil Internet y toma de decisiones respecto a la salud entre mujeres embarazadas: adaptación transcultural de un cuestionario para su uso en Brasil

The aim of this study was to translate and cross-culturally adapt the Women’s Use of the Internet in Pregnancy Questionnaire (WUIPQ) to Brazilian Portuguese and analyze the psychometric properties of the Preparation for Decision Making Scale (PDMS). This study consisted of the following steps: translation, synthesis, back-translation, evaluation by the author of the original questionnaire, review by the panel of experts, and pretest of the WUIPQ. For such, Brazilian pregnant women and mothers who were members of Facebook groups participated in the study. We measured test-retest reliability as well as internal consistency and performed confirmatory factor analysis (CFA) of the B-PDMS. In the pretest, 88.14% of the participants considered the items of the B-WUIPQ to be clear and pertinent, and 84.09% rated the sequence and organization of the questionnaire as excellent/good. The intraclass correlation coefficient and Cronbach’s alpha coefficient for the B-PDMS were 0.850 (95%CI: 0.791-0.899) and 0.91, respectively. CFA revealed factor loadings higher than 0.70 for most items, with a comparative fit index of 0.989, Tucker-Lewis index of 0.984, and root mean square error of approximation of 0.08 (95%CI: 0.06-0.09). The B-WUIPQ presented crosscultural adapted, and the B-PDMS demonstrated satisfactory psychometric proprieties to Brazilian pregnant women. Pregnant Women; Internet; Access to Information; Cross-cultural Comparison; Surveys and Questionnaire Correspondence L. G. Rodrigues Faculdade de Odontologia, Universidade Federal de Minas Gerais. Rua Prof. Moacir Gomes de Freitas 688, Belo Horizonte, MG 31270-901, Brasil. lorranygrodrigues@gmail.com 1 Faculdade de Odontologia, Universidade Federal de Minas Gerais, Belo Horizonte, Brasil. doi: 10.1590/0102-311X00244019 Cad. Saúde Pública 2021; 37(2):e00244019 QUESTÕES METODOLÓGICAS METHODOLOGICAL ISSUES This article is published in Open Access under the Creative Commons Attribution license, which allows use, distribution, and reproduction in any medium, without restrictions, as long as the original work is correctly cited.


Introduction
The Internet is considered the main source of information on health among pregnant women 1,2,3 . It is a fast, easy, and accessible resource 2,3,4,5,6,7 and the Google search website is the most widely used by this population 1,8,9 . The most researched topics correspond to the phases of fetal development and nutrition during pregnancy 5,8,9,10,11 . Social media are also cited as a source of information and an important tool to provide emotional support and to sharing of experiences, assisting in the decrease of stress levels and improvements in general health 12 . One of the reasons for the use of the Internet is the search for information to support more conscious health-related decision-making in the gestational period 1,4,5,6,11,12,13,14 .
The limited educational practices at public healthcare services in Brazil 15 may contribute to the online search for information due to the need for pregnant women to complement the counseling received during prenatal follow-up 1,11,14 . Thus, studies on the use and influence of the Internet on health-related decision-making among Brazilian pregnant women may help identify the potential of the Internet for empowering these women in regarding decision-making. Such studies can highlight the effects of online information in the relationship between patient and healthcare provider during prenatal appointments. Additionally, the results may alert healthcare providers to the need of having discussions with their patients on information obtained from the Internet, as well as to counsel them on reliable websites and optimize prenatal care and educational practices by extending care to the virtual environment, thus offering reliable information to this public 1,5,8,10,11,16,17,18,19 .
Due to the lack of validated tools on this topic in Brazil, a search of the international literature was performed to find a questionnaire that could be cross-culturally adapted. This process is considered to be less time-consuming than the development of a new assessment tool 20 and favors comparison of results among different countries through a standardized, validated questionnaire 21 .
The Women's Use of the Internet in Pregnancy Questionnaire (WUIPQ) is based on the Information Search Process Model proposed by Kuhlthau 22 . It was adapted to the Internet by Kalbach 23 , while Lagan 24 included a scale to measure decision-making in this questionnaire, later adapted to pregnancy. A systematic review 25 included two highly regarded studies 1,11 that used this questionnaire. It has 71 items addressing how and why pregnant women use the Internet as a source of health information and its effect on decision-making during pregnancy 1 . Specialists have previously confirmed the content validity of this electronic questionnaire 24 . The Preparation for Decision Making Scale (PDMS) 26 contains 11 items that make up the WUIPQ. The PDMS is based on a reflective model that assumes that these items manifest one underlying correlated construct. This construct is the utility and influence of the Internet in preparing pregnant women to communicate with health professionals and make health-related decisions during pregnancy 1 . This scale showed good reproducibility (0.97) and satisfactory internal consistency (0.91) 1,24 . Our study aimed to describe the translation and crosscultural adaptation of the WUIPQ and to present the psychometric properties of the Brazilian version of the PDMS (B-PDMS). The hypothesis raised by this study is that the Brazilian version of WUIPQ (B-WUIPQ) is equivalent to its original version and that the PDMS presents satisfactory psychometric properties for Brazilian pregnant women.

Questionnaire
The WUIPQ 1 is composed of 71 items organized into sections that address the stages of the information search process: (i) reasons for seeking information on the Internet (15 items); (ii) choice of the Internet as a source of information (5 items); (iii) specific information accessed on the Internet (10 items); (iv) collection of online information (5 items); (v) evaluation of information (6 items); (vi) use of information and the influence of the Internet on decision-making related to pregnancy (16 items), (vii) sociodemographic aspects and skills of the respondent regarding the use of the Internet (14 items).
The PDMS has 11 items that compose section VI of the WUIPQ, and this scale was adapted by Lagan 24 to be used on pregnant women. Each item has five scored response options (not at all = 1, Cad. Saúde Pública 2021; 37(2):e00244019 very little = 2, sometimes = 3, often = 4 and very often = 5) 24 . Higher scores indicate greater use of the Internet for health-related decision making when communicating with healthcare providers during prenatal appointments 1 . The PDMS is a scale that manifests a theoretical construct, and its reliability and internal consistency were previously demonstrated 1,24 . The PDMS may be used separately from WUIPQ.

Study design
The universalist approach was adopted to perform the translation and cross-cultural adaptation of the WUIPQ to Brazilian Portuguese 26,27,28,29,30 , including the analysis of the equivalence of the concepts and items and establishment of the semantic equivalence. The measurement equivalence was performed to the Brazilian version of the PDMS.

Equivalence of the concepts and items and semantic equivalence
A panel of experts evaluated the equivalence of the concepts and items considering the original theoretical references as well as a literature review on the use of the Internet by pregnant women to seek health information. The panel of experts included four researchers in public health who were fluent in English and had experience with the cross-cultural adaptation and validation of research instruments.
The establishment of the semantic equivalence of the WUIPQ consisted of the following steps: translation, synthesis, back-translation, evaluation of the back-translated version by the author of the original questionnaire, revision by the panel of experts, and pre-test with the target population.
The translation of the WUIPQ was performed independently by two Brazilian translators fluent in English, resulting in two versions (T1 and T2). The first translator was a health professional, aware of the concepts and objectives of the questionnaire. The second was a professional translator who was unaware of the study purposes.
Experts created a synthesis version (T1.2) based on the T1 and T2 versions. This process involved selecting one of the translated versions and adapting the terms and expressions to Brazilian culture (healthcare practices of pregnant women in the prenatal period and childbirth in Brazil).
The T1.2 version was then back-translated into the original language by a native English-speaking translator fluent in Brazilian Portuguese who had no access to the original WUIPQ in English. The back-translated version (B1) was sent to the author of the original questionnaire for evaluation. The use of more acceptable terms for the Brazilian population was discussed with the author. The experts revised all versions (T1, T2, T1.2, B1) considering the author's comments regarding B1. The second synthesis of the WUIPQ resulted from expert consensus. This version was submitted to the pre-test.
The target population to pre-test were Brazilian pregnant women or mothers who gave birth less than one year earlier, aged 18 or older, who were residents of Brazil, and members of virtual groups for pregnant women and mothers on Facebook. For this step of this study, a convenience sample from a Facebook group of pregnant women and mothers was invited to participate through a letter with information regarding the study. The participants were required to evaluate each of the items on the questionnaire with regards to clarity, use of language and pertinence (adequate, partially adequate, or inadequate) as well as the sequence and organization of the questionnaire as a whole (excellent, good, fair, poor or very poor). A text box was also made available so that the respondent could propose different wording for each item. The pre-test was concluded with the saturation of the responses to all items. The translated WUIPQ, the statement of informed consent and the evaluation procedure were shared through the SurveyMonkey platform (https://www.surveymonkey.com). The expert panel analyzed the data quantitatively and qualitatively and the researchers discussed the suggestions from the target population until consensus was reached. The final adjustments gave rise to the pre-final Brazilian version of the questionnaire (B-WUIPQ), including the Brazilian version of the PDMS (B-PDMS).

The measurement equivalence
The aim of investigating measurement equivalence is to ensure that different language versions of the same instrument achieve acceptable levels of their psychometric properties. In this study, the internal Cad. Saúde Pública 2021; 37(2):e00244019 consistency and dimensionality of the PDMS (B-PDMS) were evaluated in a sample of the target population. These psychometric properties were assessed by B-PDMS since only this part of WUIPQ is based on a reflexive model, in which the items reflect the construct in regard to health-related decisions during pregnancy 21 . The original authors assessed the internal consistency of the PDMS, but they did not determine the scale dimensionality. Additionally, as performed by original authors, we tested the test-retest reliability for all questions of the B-WUIPQ.
To evaluate test-retest reliability, the B-WUIPQ, including B-PMDS, was administered to pregnant women and mothers who were members of four virtual groups on Facebook. A letter with the research instructions was posted recruiting women based on the eligibility criteria, inviting them to answer the questionnaire twice. A personalized link to access the questionnaire and statement of informed consent were sent via e-mail or Messenger to the women who expressed availability to participate twice, with intervals of 7 to 15 days. The agreement coefficients of the B-WUIPQ questions and the B-PDMS scale between two applications were evaluated using the intraclass correlation coefficient (ICC) (quantitative variable), simple (categorical variables), or weighted kappa (ordinal variables) according to variable characteristics. The two-way random effect model was used to calculate the ICC. For simple kappa in the presence of bias and prevalence index, the prevalence-adjusted bias-adjusted kappa (PABAK) was calculated 31 . The linear weights were adopted to calculate the weight kappa. For categorical and ordinal variables, the percent agreement was also shown.
The internal consistency and the dimensionality of the B-PDMS were assessed in a sample of the target population. COSMIN (COnsensus-based Standards for the selection of health Measurement Instruments) guidelines were adopted to determine the size of the sample with at least four participants to each item of the questionnaire 21 . In order to reach this sample, after approval obtained from group administrators, a link to the B-PDMS and a video with research instructions were posted in 118 groups between December 2017 and April 2018, excluding the four groups who were participants of the test-retest reliability. The sample did not include all group members, but rather those women who agreed to participate voluntarily.
Internal consistency of the B-PMDS was evaluated using Cronbach's alpha coefficient and the confirmatory factor analysis (CFA) to estimate this scale dimensionality. The CFA was performed using the weighted least square mean and variance (WLSMV) to indicate whether the variables observed were indicators for the latent variable (B-PDMS). A good latent variable exhibits convergent validity, demonstrating that its indicators measure the same construct, measured by factor loadings, which should be > 0.40. The standard error and confidence interval were calculated using the bootstrap method with 1,000 replicates. The goodness-of-fit indicators were the Tucker-Lewis index (TLI), comparative fit index (CFI), and root mean square error of approximation (RMSEA). Values higher than 0.90 for the TLI and CFI and lower than 0.08 for RMSEA are considered adequate for a good fit 32,33 . Stata version 15.0 (https://www.stata.com/) and Mplus version 8.3 (https://www.statmodel. com/) were used for the statistical analysis.

Ethical aspects
This study received approval from the Human Research Ethics Committee of the Federal University of Minas Gerais, Brazil (process number: 65970517.6.0000.5149) and the participating women signed the Free and Informed Consent Form.

Equivalence of the concepts and items and semantic equivalence
The panel of experts considered the concepts of the WUIPQ to be pertinent to its adaptation to Brazilian culture. The items were considered equivalent and applicable to the target population. Versions T1 and T2 differed on most items, but no semantic differences were found concerning the original questionnaire. The synthesis version (T1.2) was drafted based on the adaptations presented in Box 1.
Cad. Saúde Pública 2021; 37(2):e00244019 The back-translated version (B1) had no errors or inconsistencies when compared to the original version. The author of the questionnaire recommended a revision of the definition of "prognosis" (forecast) in item 12, which was presented in the T1.2 version as "prognóstico" (consequence). The revision performed by the panel of experts indicated new adjustments for items 7, 12, 31, 32, 59 and 64 (Box 1). The first item of the WUIPQ ("Did you use the Internet for pregnancy-related information during your pregnancy?") was moved and became item 22 in the Brazilian version. The items in Section G of the original questionnaire were transferred to Section A of the B-WUIPQ, where items addressing color or race/ethnicity, number of children, occupation, and number of residents in the house were included. These changes were made after obtaining the agreement of the author of the original questionnaire.
A total of 151 women were recruited for the pre-test, 28 of whom (16.2%) were excluded for not meeting the eligibility criteria. The respondents were pregnant (84.09%) with self-declared white or brown skin color (91.43%), on their first pregnancy (58.06%), had access to the Internet at home (96.6%), had a family income of one to two monthly minimum wages (47.62%) and underwent prenatal care in the public health system (65.6%). Regarding the structure of the questionnaire, 88.1% considered the items adequate in terms of clarity of language and pertinence to Brazilian culture. The sequence and organization of the questionnaire were rated as excellent/good (84.1%). There were 16 comments on ten items that led to the rewriting of items 19, 32, and 63 (Box 1).
After the pre-test, the panel of experts performed the necessary adjustments, resulting in the B-WUIPQ. The item of place of residence (item 60) was excluded since only women residing in Brazil were selected. A filter question was added immediately after the informed consent form to facilitate the selection of the participants: "Are you pregnant or have you had a child less than a year ago?" Items that were changed during the cross-cultural adaptation of WUIPQ are presented in Box 2.
The reliability coefficients were shown in Table 1. The ICC for B-PDMS was 0.85 (95%CI: 0.791-0.899) and most B-WUIPQ items showed substantial agreement, showing coefficient values greater than 0.60. The Cronbach's alpha coefficient for the scale was 0.91, with no important change if an item were removed ( Table 2). The standardized factor loadings ranged from 0.46 to 0.81 ( Figure 1). The CFI was 0.989, the TLI was 0.984, and the RMSEA was 0.08 (95%CI: 0.069-0.091), indicating goodness-of-fit considering the correlations among the items on the scale ( Figure 1).

Discussion
The concepts and items of the B-WUIPQ were considered relevant and acceptable to Brazilian pregnant women, and it showed satisfactory reproducibility for most variables. Few variables of B-WUIPQ (6) did not reach acceptable reproducibility. The largest number of items with kappa < 0.60 was on the frequency of searching for specific information during pregnancy (general information, treatment, and products related to pregnancy). These results may represent the inaccuracy of the measurement used, since it is difficult to accurately indicate the number of times the Internet was consulted during pregnancy. The variables about the searched source and the information quality available on the Internet also showed kappa < 0.6. This inconsistency may be due to the fact that careful selection and evaluation of Internet content sources is not routine for most users.
The goodness-of-fit indicators (CFI, TLI, and RMSEA) of the B-PDMS were adequate, indicating that the adapted scale can be maintained. The factor loadings > 0.70 for most items indicate that the items measure the latent variable (usefulness of the Internet in decision-making). The Q43.9 "Affected Cad. Saúde Pública 2021; 37(2):e00244019

Box 1
Adaptations performed on items of Women's Use of the Internet in Pregnancy Questionnaire (WUIPQ) during the semantic equivalence stage.

Steps of adaptations WUIPQ items Reasons for adaptations
Synthesis Q15/Q16/Q55/Q64 This professional category was removed from these items, since "obstetric nurse" is not yet a widely disseminated category in the Brazilian healthcare system.
Original version.
Synthesis Q16/Q55/Q64 "health visitor"/"GP" In the response options for professional categories in the Irish healthcare system, "health visitor" and "GP" were replaced with "Community Health Agent" and "General Physician/Family Health Physician", respectively, which are the categories used in the Brazilian healthcare system. After the suggestion to rewrite. The decision was made to replace the statement of the item to facilitate the understanding of the target population ("What degree of difficulty did you have in seeking the information you needed on the Internet?") After the pretest Q63. Will this be OR was this your first pregnancy?
("Is/was it your first pregnancy?") A suggestion for rewriting was made ("Is or was this your first pregnancy?").
your relationship with your primary healthcare provider" was the only one of the 11 items to have a lower factor loading (0.54), but this value was still within the acceptable limit 34 . The distribution of the answers to Q43.9 had a different pattern than that found for the other items of the B-PDMS. Two-thirds of the women (66.6%) reported that the use of the Internet did not affect their relationship with their healthcare provider (responses of "not at all"). This finding should be evaluated considering the changes observed in the healthcare provider-patient relationship stemming from the increased access to information on the Internet 35,36 . The dissemination of information through the Internet has contributed to the individuals' empowerment regarding aspects related to the health/illness process, causing changes in the asymmetrical relationship between healthcare providers and patients 35 . The participatory attitude of an informed patient can be understood as questioning the physician's knowledge 36 , and it is often necessary for physicians to explain themselves to strengthen their conduct and counteract erroneous concepts acquired from the Internet, which can affect the healthcare providerpatient relationship. The participants' profile may have contributed to the result on Q43.9, as most of the sample was composed of women with middle to a low level of schooling and in their first pregnancy/child. Women with this profile tend to behave more passively during medical appointments, which favors the maintenance of asymmetry in the healthcare provider-patient relationship. For the other items, most of the respondents chose response options with higher scores (sometimes, often and very often). This result agrees with data described in previous studies, which state that the Internet       exerts an influence on pregnant women regarding health-related decision-making and communication with healthcare providers during prenatal appointments 1,4,5,6,11,12,13,14 .
The sample size was adequate for the evaluation of the psychometric properties of the B-PDMS 21,28,37 . For the confirmatory factor analysis, the ratio of 60 observations per item surpasses the methodological recommendation of 10 per variable 37 . The administration of the scale to the target population in virtual Facebook groups was more viable, considering many active groups of mothers and pregnant women in the social network and the ease of mobilizing participants to adhere to the study.
The Internet influence in increasing decision autonomy and preparing pregnant women for better communication with health professionals has been previously discussed in the literature 1,4,5,6,11,12,13,14 . The cross-cultural adaptation of the WUIPQ to Brazilian Portuguese and the validation of the B-PDMS indicate the possibility of the online use of the questionnaire and its wide-scale applicability to Brazilian pregnant women and mothers. The use of the B-WUIPQ and B-PDMS in future studies could help understand the usefulness of the Internet among pregnant women in the search for health-related information. These instruments can also help identify the potential of the Internet for empowering Brazilian pregnant women and its influence on the healthcare providerpatient relationship during prenatal care. Our results can also contribute to planning strategies for the more qualified use of online information during pregnancy.
A limitation of this study was that operational equivalence was not assessed, since the B-PDMS was not made available on websites targeted at pregnant women, as was the case with the original instrument. A convenience sample was used in a single social network that may be in disuse, so it is not possible to draw representative conclusions for the population. Thus, it is suggested that further studies should be carried out to build a set of evidence on the use of B-WUIPQ and B-PDMS in different Brazilian contexts.

Conclusions
This study provides evidence supporting the cross-cultural validity of a Brazilian Portuguese version of WUIPQ that may be recommended to evaluate the use of the Internet among Brazilian pregnant women via online administration. The B-WUIPQ proved valid and reliable for its use on Brazilian pregnant women. This study also presented a reliable, valid scale adapted to Brazilian culture. The B-PDMS can be used independently to evaluate the influence of information from the Internet on health-related decision-making and communication with healthcare providers during prenatal care.