Transcultural adaptation, validity, and reliability of the SINBAD System Classification for Brazilian Portuguese

Dias, Julliany Lopes; Borges, Eline Lima; Mendes e Torres, Danubia; Gamba, Mônica Antar; Pereira, Ângela Lima; Malaquias, Suelen Gomes; Barros, Luciana da Silva; Martins, Marlene Andrade; Guimarães, Rafael Alves; Bachion, Maria Márcia

doi:10.1590/1518-8345.7768.4722

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Original Article • Rev. Latino-Am. Enfermagem 33 • 2025 • https://doi.org/10.1590/1518-8345.7768.4722 linkcopy

Transcultural adaptation, validity, and reliability of the SINBAD System Classification for Brazilian Portuguese^*

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective: to perform the cross-cultural adaptation of the SINBAD System Classification for Brazilian Portuguese and analyze its content validity and reliability.

Method: clinimetric study, including cross-cultural adaptation of the SINBAD System Classification, used to assess foot ulcers in people with diabetes. Verification of semantic and cultural equivalence and clinical usability using the inter-rater reliability (IRR) index (≥ 0.80); content validity using the Content Validity Ratio (CVR) p < 0.05, and internal consistency using McDonald’s omega (> 0.70). The sample involved nurses, physicians, and people with diabetes-related foot ulcers. Data collection was performed using online forms and in-person clinical evaluation of patients treated at referral services in Goiânia, Jataí, São Paulo, Belo Horizonte, and primary care center in Palmas

Results: fifteen nurses participated in the cognitive debriefing; 20 experts (physicians and nurses) participated in content validation; and 113 patients with 120 diabetes-related foot ulcers participated. Eight items (terms and expressions) from the SINBAD System underwent cross-cultural adaptation. CVR = 0.84 and McDonald’s omega = 0.635 were obtained.

Conclusion: the SINBAD system is adapted to Brazilian Portuguese and has satisfactory content validity indices, but it needs investment to achieve greater robustness in terms of reliability and internal consistency.

Descriptors:
Translating; Validation Study; Foot Ulcer; Diabetic Foot; Nursing; Brazil

Highlights:

(1) The SINBAD System is recommended for the assessment of diabetes-related foot ulcers. (2) The adaptation of the SINBAD System to Brazilian Portuguese was successful in this study. (3) The SINBAD System adapted for Brazil achieved good evidence of content validity. (4) The internal consistency of the SINBAD System Classification was estimated for the first time. (5) The analysis of the internal consistency of the SINBAD System indicates the need for further studies.

*SINBAD System Classification terms/sentences**	SC ^†	CC ^‡	UPC ^§
SINBAD Assessment System*	0.86	0.86	0.93
Category	1.00	0.93	0.93
Definition	0.93	0.93	0.93
Site	0.8	0.86	0.86
Forefoot	0.93	0.86	0.93
Midfoot and hindfoot	0.93	0.86	0.93
Ischemia	1.00	1.00	1.00
Blood flow unchanged in the foot, with at least one palpable pulse	0.93	0.86	0.86
Clinical evidence of reduced blood flow in the foot	0.80	0.86	0.73
Neuropathy	1.00	1.00	1.00
Protective sensation intact	0.73	0.8	0.73
Protective sensation impaired	0.93	0.93	0.93
Wound infection	0.93	0.93	0.93
Absent	1.00	1.00	1.00
Present	1.00	1.00	1.00
Area	1.00	1.00	1.00
Ulcer < 1 cm²	1.00	1.00	0.93
Ulcer ≥ 1 cm²	1.00	1.00	0.93
Depth	1.00	1.00	1.00
Ulcer affects only skin and subcutaneous tissue	0.93	0.93	0.93
Ulcer affects muscle, tendon, or deeper tissue	0.86	0.93	0.93
Score	1.00	0.93	1.00
Total possible score	1.00	0.93	1.00

Preliminary version - translated			Preliminary version – adapted (cognitive debriefing phase)
SINBAD* Assessment System*			SINBAD* system for diabetic foot ulcer assessment
Category	Definition	Score	Assessment item	Definition	Score
Site	Forefoot	0	Site	Forefoot	0
Site	Midfoot and hindfoot	1	Site	Midfoot and hindfoot	1
Ischemia	Blood flow unchanged in the foot, with at least one palpable pulse	0	Ischemia	Arterial blood flow unchanged in the foot, with at least one palpable pulse	0
Ischemia	Clinical evidence of reduced blood flow in the foot	1	Ischemia	Clinical evidence of reduced arterial blood flow in the foot	1
Neuropathy	Protective sensation intact	0	Neuropathy	Protective sensation preserved	0
Neuropathy	Protective sensation compromised	1	Neuropathy	Protective sensation compromised	1
Wound infection	Absent	0	Wound infection	Absent	0
Wound infection	Present	1	Wound infection	Present	1
Area	Ulcer < 1 cm²	0	Area	Ulcer < 1 cm²	0
Area	Ulcer ≥ 1 cm²	1	Area	Ulcer ≥ 1 cm²	1
Depth	Ulcer affects only skin and subcutaneous tissue	0	Depth	Ulcer affects only skin and subcutaneous tissue	0
Depth	Ulcer affects muscle, tendon, or deeper tissue	1	Depth	Ulcer affects muscle, tendon, or deeper tissue	1
Total possible score		6	Total possible score		6

Items evaluated	n _e ^†	CVR ^‡	CVR ^‡ critical
Title: SINBAD* system for assessing diabetic foot ulcers	15	0.500	0.500
Site	18	0.800	0.500
Ischemia	16	0.600	0.500
Neuropathy	17	0.700	0.500
Wound infection	18	0.800	0.500
Area	18	0.800	0.500
Depth	19	0.900	0.500
Options for assessing Site: (0) forefoot (1) midfoot and hindfoot	15	0.500	0.500
Options for assessing Ischemia: (0) Unaltered arterial blood flow in the foot, with at least one palpable pulse (1) Clinical evidence of reduced arterial blood flow in the foot	13	0.300	0.500
Options for assessing Neuropathy: (0) Preserved protective sensitivity (1) Compromised protective sensitivity	16	0.600	0.500
Options for assessing Wound Infection: (0) Absent (1) Present	17	0.700	0.500
Options for assessing Area: (0) Ulcer < 1 cm² (1) Ulcer ≥ 1 cm²	17	0.700	0.500
Options for assessing Depth: (0) Ulcer only affects skin and subcutaneous tissue (1) Ulcer affects muscle, tendon or deeper tissue	18	0.800	0.500
Average items		0.662	0.500

Items evaluated	n _e ^†	CVR ^‡	CVR ^‡ critical
Title: SINBAD* system for assessing diabetes-related foot ulcers	11	0.833	0.667
Site	11	0.833	0.667
Ischemia	11	0.833	0.667
Neuropathy	11	0.833	0.667
Wound infection	11	0.833	0.667
Area	11	0.833	0.667
Depth	11	0.833	0.667
Options for assessing Site: (0) forefoot (1) midfoot and hindfoot	12	1.000	0.667
Options for assessing Ischemia: (0) Foot with at least one palpable pulse and no signs and/or symptoms of ischemia (1) Foot with non-palpable pulses and/or presence of signs or symptoms of ischemia	11	0.833	0.667
Options for assessing Neuropathy: (0) Preserved protective sensitivity (1) Compromised protective sensitivity	11	0.833	0.667
Options for assessing Wound Infection: (0) Absent (1) Present	11	0.833	0.667
Options for assessing Area: (0) Ulcer < 1 cm² (1) Ulcer ≥ 1 cm²	11	0.833	0.667
Options for assessing Depth: (0) Ulcer only affects skin and subcutaneous tissue (1) Ulcer affects muscle, tendon or deeper tissue	11	0.833	0.667
Overall average of items	---	0.833	0.667

*SINBAD system for assessing diabetes-related foot ulcers**
Evaluation item	Definition	Score
Site	Forefoot	0
Site	Midfoot and rearfoot	1
Ischemia	Foot with at least one palpable pulse and no signs and/or symptoms of ischemia	0
Ischemia	Foot with non-palpable pulses and/or signs or symptoms of ischemia	1
Neuropathy	Preserved protective sensitivity	0
Neuropathy	Compromised protective sensitivity	1
Wound infection	Absent	0
Wound infection	Present	1
Area	Ulcer < 1 cm²	0
Area	Ulcer ≥ 1 cm²	1
Depth	Ulcer affects only the skin and subcutaneous tissue	0
Depth	Ulcer affects muscle, tendon or deeper tissue	1
Total possible score		6

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Escola de Enfermagem de Ribeirão Preto / Universidade de São Paulo Av. Bandeirantes, 3900, 14040-902 Ribeirão Preto SP Brazil, Tel.: +55 (16) 3315-3387 / 3315-4407 - Ribeirão Preto - SP - Brazil
E-mail: rlae@eerp.usp.br

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[1] *SINBAD = Site, Ischemia, Neuropathy, Bacterial Infection, Area and Depth; ^†SC = Semantic comprehensibility; ^‡CC = Cultural comprehensibility; ^§UPC = Usability in clinical practice

Transcultural adaptation, validity, and reliability of the SINBAD System Classification for Brazilian Portuguese*

Highlights:

Transcultural adaptation, validity, and reliability of the SINBAD System Classification for Brazilian Portuguese^*