CULTURAL ADAPTATION OF THE ADAPTATION SCALE TO ELIMINATION OSTOMY FOR USE IN BRAZIL

ADAPTACIÓN CULTURAL DE LA ESCALA DE ADAPTACIÓN A LA OSTOMÍA DE ELIMINACIÓN PARA USO EN BRASIL

ABSTRACT

Objective:

to culturally adapt the Adaptation Scale to Elimination Ostomy for the Brazilian Portuguese language and to evaluate the content validity.

Method:

a methodological study, which stages of cultural adaptation were: adaptation to Brazilian Portuguese; committee of seven experts to evaluate the semantic, idiomatic, cultural and conceptual equivalences; and pre-test with 30 people with ostomy, performed between 2016 and 2017. The content validation was then performed, according to the Content Validity Coefficient greater than or equal to 0.80 and kappa coefficient.

Results:

the target population demonstrated good understanding in the pre-test. The Content Validity Coefficient of the scale reached values of 0.9 for the criteria: language clarity, practical relevance and theoretical relevance, and for the “dimension” category, the kappa mean value (0.587).

Conclusion:

the Adaptation Scale to Elimination Ostomy, built and validated originally in Portugal, was culturally adapted to Brazil, constituting an easy-to-understand resource, but it is still necessary to attest the psychometric properties of this version.

DESCRIPTORS:
Ostomy; Nursing; Validation studies; Colostomy; Intestinal elimination

RESUMEN

Objetivo:

adaptar culturalmente la Escala de Adaptación a la Ostomía de Eliminación a la lengua portuguesa de Brasil y evaluar la validez de contenido.

Método:

estudio metodológico, cuyas etapas de la adaptación cultural fueron las siguientes: adaptación al portugués de Brasil; comité de siete especialistas para evaluar las equivalencias semántica, idiomática, cultural y conceptual; y pre-evaluación con 30 estomizados, realizado entre 2016 y 2017. Luego se llevó a cabo la validez de contenido, según el Coeficiente de Validez de Contenido mayor o igual a 0,80 y se calculó el coeficiente kappa.

Resultados:

la población-meta demostró un buen entendimiento en la pre-evaluación. El Coeficiente de Validez de Contenido de la escala alcanzó valores de 0,9 en los criterios: claridad del lenguaje, pertinencia práctica y relevancia teórica, y en la categoría “dimensión” el kappa medio obtuvo un valor moderado (0,587).

Conclusión:

la Escala de Adaptación a la Ostomía de Eliminación, construida y validada en un principio en Portugal, se adecuó culturalmente para Brasil, constituyéndose así en un recurso de fácil comprensión, pero aún es necesario que las propiedades psicométricas de esta versión sean testadas.

DESCRIPTORES:
Ostomía; Enfermería; Estudios de validez; Colostomía; Eliminación intestinal

RESUMO

Objetivo:

adaptar culturalmente a Escala de Adaptação à Ostomia de Eliminação para a língua portuguesa do Brasil e avaliar a validade de conteúdo.

Método:

estudo metodológico, cujas etapas da adaptação cultural foram: adequação para o português do Brasil; comitê de sete especialistas para avaliar as equivalências semântica, idiomática, cultural e conceitual; e pré-teste com 30 estomizados, realizado entre 2016 e 2017. Em seguida realizou-se a validação de conteúdo, segundo o Coeficiente de Validade de Conteúdo maior ou igual a 0,80 e calculou-se o coeficiente Kappa.

Resultados:

a população-alvo demonstrou boa compreensão no pré-teste. O Coeficiente de Validade de Conteúdo da escala atingiu valores de 0,9 para os critérios: clareza de linguagem, pertinência prática e relevância teórica, e, para a categoria “dimensão”, o kappa médio teve valor moderado (0,587).

Conclusão:

a Escala de Adaptação à Ostomia de Eliminação, construída e validada originalmente em Portugal, foi adaptada culturalmente para o Brasil, constituindo-se em um recurso de fácil compreensão, porém é necessário ainda que sejam atestadas as propriedades psicométricas dessa versão.

DESCRITORES
Estomia; Enfermagem; Estudos de validação; Colostomia; Eliminação intestinal

INTRODUCTION

“Ostomy” is a surgical opening that allows communication between an internal organ and the external environment. Depending on the segment that will be externalized, the ostomy will have purpose of breathing, feeding or elimination ad it may be temporary or permanent/definitive.1 In the group of ostomies, there are those of elimination, which may be intestinal - colostomy and ileostomy -, or urinary - urostomies -, the most found in clinical practice.2

Among the various causes of the creation of an intestinal ostomy, the main one is colorectal cancer. Estimates of new cases in Brazil were 34,280, of which 16,660 were men and 17,620 were women. In Piauí, eight cases are estimated for every 100,000 men and 7.31 cases for every 100,000 women.3

It is important to emphasize that this surgical procedure has an impact on the individual's life. Besides taking care of the ostomy, it alters the normal functionality of intestinal and urinary eliminations and, due to its exposure, it interferes with the sensation of privacy of the person with ostomy.4^-5To adapt to the new life, it is necessary to undergo a process of readjustment to the psychosocial, sexual, self-concept and self-care conditions, with the support and multiprofessional assistance, especially of the stomaterapist nurse, in a more competent and welcoming way.5

The ostomy surgery changes the life of the individual and, consequently, of his family, repercussions on his quality of life.6 Therefore, it is important to clarify the reasons that led to the need for surgery and whether the ostomy will be temporary or permanent, its possible complications and the care that must be taken in handling and maintaining it.7

In addition to changes in the life of the patient, which range from acceptance of the new condition to the need to adapt to new materials and knowledge, getting used to this “element” in the body can cause fears, constraints and doubts. Thus, the patient needs to acquire skills and competences for self-care,8^-9making it essential to use procedures that guarantee reliable indicators, especially at the moment of data collection, so that quality can be achieved.10

Thus, a search was made in the national and international literature, carried out in July 2016, in the CINAHL, PubMed and SciELO databases, on the instruments of measurement to aspects related to ostomies; the quality of life was the most found construct.

Regarding the adaptation of the person with an ostomy to the new situation, the studies point to few instruments, most internationally, and bring only some aspects of the construct under study. Two of these instruments that approach the “adaptation” construct are: Ostomy Adjustment Scale,11 relating to the preoperative preparation and the time from the surgery to the return to work, evaluating the psychological adjustment to the life with the ostomy; and the Ostomy Adjustment Inventory-23,12 which was developed to assess psychosocial adjustment in the areas of “acceptance”, “anxious worry”, “social commitment”, and “anger”.

Considering the scarcity of multidimensional instruments that evaluate the construct “adaptation of the person with an ostomy in Brazil”, a tool constructed and validated in Portugal was identified in the search to measure the concept of adaptation to the ostomy: Adaptation Scale to Elimination Ostomy (EAOE), which, however, did not yet have a version adapted to the Brazilian culture.13

EAOE has 35 items, Likert type with 7 points, subdivided into six dimensions: Self-Conception, Positive Acceptance, Social/Religious Support, Sexual Interaction, Self-Care and Negative Acceptance, in which good indicators of internal consistency were found, with a Cronbach Alpha coefficient of 0.87.

The scale was used only in this study and has not yet been translated into other languages. It is a scale that must be self-applied and easy to understand. For this, it has become necessary to bring this tool into our cultural context to guarantee the integral assistance to the patient with an ostomy, since its use allows the health professional to detect the patient's most needy aspects of adaptation and, from this, to systematize the patient’s care with a view to the improvement in his or her quality of life.

In view of the above, the objectives of this research were: to culturally adapt the EAOE to the Brazilian Portuguese language and to analyze the content validity.

METHOD

Participants were informed of the research objectives as well as their confidentiality. The authors of the scale were requested, by electronic mail, to permit the adaptation of the instrument for use in Brazil.

This is a methodological study, which purpose was to adapt and analyze the validity of the instrument content (EAOE), designed to evaluate the patient's adaptation to the elimination ostomy. The processes of cultural adaptation and validation of content were based on established authors in the area.14^-15Data collection occurred between July 2016 and January 2017. The study site was a health center in (Brazil) Teresina-PI (outpatient clinic), an institution in which patients with elimination ostomies are registered to receive collecting equipment.

Regarding the stages of cultural adaptation, according to an updated document,16 there was no need for translation, since the language of the original instrument of the scale being studied (Portuguese of Portugal) is the same as that of the country to be adapted.

Cultural adaptation was thus carried out in three stages. Step 1 consisted of the semantic adaptation of the Original Portugal Portuguese Version (OPPV) to Brazilian Portuguese. At this stage, the OPPV of the EAOE instrument was firstly semantically adapted for use in our country by the researchers of this through a Portuguese teacher for grammatical analysis. This first Version in Brazilian Portuguese (VBP-1) was submitted to the appreciation of a Committee of Specialists.

Step 2 was the evaluation by a committee of seven experts of the two versions for the analysis of semantic, cultural, idiomatic and conceptual equivalence, with the second Version for Brazilian Portuguese (VBP-2) being obtained. A professor of scientific methodology, nurse with Ph.D in the area, knowledgeable about the process of cultural adaptation participated in this stage; a specialist in clinical dermatology, a nurse, master and professor at a university also participated in this stage; a proctologist, an area physician, and a hospital employee and four stomatherapy nurses, two doctors and two masters were also participants int his stage.

The members of the committee were invited by means of an invitation letter sent by e-mail, containing the research objective and the necessary guidelines on the evaluation of equivalences. Upon acceptance, a form (Google Forms), containing the Informed Consent Form and the EAOE items in the original version and the semantically appropriate version, was sent.

Each committee component compared the two versions (OPPV and VBP-1), using an equivalence scale, with a score of 1 to 3, where 1 represents a different meaning, 2 about the same meaning and 3 exactly the same meaning. To items judged with values 1 or 2 other suggestions were presented to be reevaluated by the researchers. After this step, the version for stage 3 was produced, which consisted of the application of the pre-test (VBP-2) to a group of 30 patients.

The selected patients were enrolled in the Ostomy Program of the Teresina Integrated Health Center. The convenience sample consisted of persons with ostomy who met the following inclusion criteria: 18 years of age or older; with a temporary or permanent ostomy; with physical and mental conditions to respond to the interview and consent to participate in the study.

The data were collected at the health center of Teresina, through individual interviews with two instruments: one with questions related to sociodemographic data, with the variables: date of birth, gender, origin, occupation/main activity, marital status, schooling, whether he/she resides alone/with whom, what type and temporality of the elimination ostomies, how much time he/she has been with the ostomy, who takes care of the ostomy, and if there is any health problem; and another was the appropriate VBP-2 version.

The respondents responded to each item on the scale read by the researcher to see if they understood the statements or suggested any changes. It should be emphasized that the participation of people with ostomy with different levels of schooling was guaranteed to obtain the understanding of all strata.15

After all the stages of cultural adaptation, the content validation process began. For this step, through the Lattes Platform, using the indicated criteria,17three expert judges - two nurse practitioners in the nursing area of southern Brazil and a master nurse from the Northeast, attending stomatherapy -, with a high degree of experience and knowledge in their area of practice. At this stage, the judges evaluated the criteria “language clarity”, “practical relevance”, “theoretical relevance” and “theoretical dimension”.15

For the clarity, pertinence and relevance criteria, the judges evaluated the items according to the Likert scale of four points, with the following levels: (1) “nothing”, (2) “little”, (3) “a lot” or (4) “fairly” clear, pertinent and/or relevant. A concordance of more than 80% among judges is a decision criterion for the relevance of the item to which it theoretically refers.15 For the items evaluated at levels “1” or “2”, at this stage, rationale and suggestion for reformulation were requested. The theoretical dimension was evaluated categorically, according to the domains of the original instrument. Items that scored lower than recommended and/or received change suggestions were redesigned and resubmitted for evaluation.

The results of the evaluation on cultural adaptation, measured on an ordinal scale, were descriptively evaluated, verifying the level of concordance between the judges, according to the evaluations.

For the content validation data analysis, the Content Validity Coefficient (CVC) was used, in which items that obtained CVCc>0.8.18 were considered acceptable. The kappa coefficient, defined as a measure of association used to describe and test the degree of concordance between judges was also calculated to assess the theoretical dimension.15 After the statistic, the adapted version aof EAOE was sent to the lead author, for his information.

RESULTS

In the semantic adaptation (first phase), the items in which the words are not used in Brazil were changed, passing through a syntactic and lexical adequacy, without prejudice, however, to the meaning of the affirmations. The changes done were the exchanges of “Ostomia” (Ostomy) by “Estomia”, “em” (in) by “de”, “diminuído” (diminished) by “inferior” and “saco” (ostomy bag) by “bolsa”. In addition, there was the adequacy of pronominal placements (Chart 1). Of the 35 items on the scale, eight remained unchanged (1, 5, 6, 9, 20, 22, 26, 30).

Chart 1
Items of the Adaptation Scale to Ostomy Elimination instrument suitable for Brazilian Portuguese. Teresina, PI, Brazil, 2017

Items	Original version of EAOE for Portugal (OPPV*)	Version proposed by the researchers of the study for use in Brazil (VBP-1†)
Title	Escala de Adaptação a Ostomia de Eliminação (Ostomy Elimination Adaptation Scale)	Escala de Adaptação à Estomia de Eliminação
1	Estou satisfeito(a) com a aparência do meu corpo 74. (I am satisfied with the appearance of my body)	Maintained original writing
2	Estar ou sair com os meus vizinhos, amigos e/ou colegas de trabalho é para mim difícil (Being or going out with my neighbors, friends and/or co-workers is difficult for me)	Estar ou sair com os meus vizinhos, amigos e/ou colegas de trabalho é difícil para mim
3	O meu estoma impede-me usar a roupa que gusto (My ostomy prevents me from wearing the clothes I like)	O meu estoma me impede de usar a roupa que gosto
4	Procuro esconder que tenho uma ostomia (I try to hide that I have an ostomy)	Procuro esconder que tenho uma estomia
5	Tento não pensar na minha situação (I try not to think about my situation)	Maintained original writing
6	Descarrego nas outras pessoas a minha revolta(I put my revolt over others)	Maintained original writing
7	Acreditar em alguém divino dá-me força e ajuda-me a viver (Believing in someone divine gives me strength and helps me live)	Acreditar em alguém divino me dá força e me ajuda a viver
8	Faz-me bem falar dos meus sentimentos e preocupações com familiares e amigos (I feel good talking about my feelings and concerns with family and friends)	Eu me sinto bem ao falar dos meus sentimentos e preocupações com familiares e amigos
9	Estou satisfeito(a) com a minha vida sexual	Maintained original writing
10	Sinto orgulho em mim (I feel proud of myself)	Sinto orgulho de mim
11	Identifico alterações no estoma, pele em redor, fezes ou urina (I identify changes in the ostomy, surrounding skin, stool or urine)	Identifico alterações no estoma, na pele ao redor, nas fezes ou na urina
12	Sinto-me diminuído(a) devido ao meu estoma (I feel diminished due to my ostomy)	Eu me sinto diminuído(a) devido ao meu estoma
13	Procuro a ajuda de familiares, amigos ou profissionais, quando necessito (I seek the help of family, friends or professionals when I need)	Procuro a ajuda de familiares, amigos ou profissionais quando preciso
14	Participar nos divertimentos que aprecio (convívios, festas, actividades sociais) é para mim doloroso (Participating in activities I enjoy [social gatherings, parties, social activities] is painful for me)	Participar de atividades que gosto (convívios, festas, atividades sociais) é doloroso para mim
15	O meu cônjuge/companheiro(a) interessa-se sexualmente por mim (My spouse/partner is sexually interested in me)	O meu cônjuge/companheiro(a) se interessa sexualmente por mim
16	Tenho medo dos gases, cheiros ou que o saco descole, quando estou em público (I am afraid of the gases, smells or that the bag takes off, when I am in public)	Tenho medo dos gases, cheiros ou que a bolsa descole, quando estou em público
17	Preocupa-me viajar por causa do meu estoma(I am worried about traveling because of my ostomy)	Fico preocupado(a) em viajar por causa do meu estoma
18	Perdi o meu interesse sexual por causa da minha ostomia (I lost my sexual interest because of my ostomy)	Perdi o meu interesse sexual por causa da minha estomia
19	O meu estoma interfere com o meu trabalho, a minha profissão ou a escola (My ostomy interferes with my job, my profession or school)	O meu estoma interfere no meu trabalho, na minha profissão ou na escola
20	Estou otimista em relação ao future (I'm optimistic about the future)	Maintained original writing
21	Acredito que as minhas orações vão-me ajudar (I believe my prayers will help me)	Acredito que as minhas orações me ajudarão
22	Tenho prazer de viver (I'm happy to live)	Maintained original writing
23	A ostomia aumentou o meu bem-estar (Ostomy has increased my well-being)	A estomia aumentou o meu bem-estar
24	Aceito a minha ostomia (I accept my ostomy)	Aceito a minha estomia
25	O meu relacionamento sexual piorou com a ostomia (My sexual relationship worsened with the ostomy)	O meu relacionamento sexual piorou com a estomia
26	Acredito que vou realizar os meus sonhos (I believe that I will fulfill my dreams)	Maintained original writing
27	Sinto-me culpado(a) pela minha situação (I feel guilty for my situation)	Eu me sinto culpado(a) pela minha situação
28	Acho que os outros me olham como uma pessoa diminuída (I think others look at me as an inferior person)	Acho que os outros me olham como uma pessoa inferior
29	O apoio da minha família e amigos é para mim importante (The support of my family and friends is important to me)	O apoio da minha família e dos meus amigos é importante para mim
30	Evito intimidade sexual por causa do meu estoma (Evito intimidade sexual por causa do meu estoma)	Maintained original writing
31	Sinto-me sexualmente atraente (I feel sexually attractive)	Eu me sinto atraente sexualmente
32	Olhar para a minha ostomia é doloroso (Looking at my ostomy is painful)	Olhar para a minha estomia é doloroso
33	Tocar na minha ostomia é para mim difícil (Touching my ostomy is difficult for me)	Tocar na minha estomia é difícil para mim
34	Cuido da higiene da minha ostomia sozinho(a) (I take care of the ostomy hygiene myself)	Cuido da higiene da minha estomia sozinho(a)
35	Mudo o saco da minha ostomia sozinho(a) (I change my ostomy bag myself)	Mudo a bolsa da minha estomia sozinho(a)

• *OPPV=Original Portugal Portuguese Version; †VBP-1= first Version in Brazilian Portuguese.

In the analysis of the semantic, cultural, idiomatic and conceptual equivalences (second phase), the results for each item proposed by the specialists on the versions (OPPV and VBP-1) are described in Chart 2.

Seven specialists participated in this process, five women and three men, all from the Northeast, four married. In relation to training, three had specialization; three, masters; and one, Ph.D; five had more than 11 years of training, and four judges had between 1 and 6 years of experience with ostomies.

Chart 2
Items of the Ostomy Elimination Adaptation Scale (OEAS) instrument, Brazilian version, changed after recommendations of the expert committee. Teresina, PI, Brazil, 2017

Items	Original version of EAOE for Portugal (OPPV)	Version proposed by the authors of the study for use in Brazil (VBP-1)	ES*	EI†	EE‡	EC§	Version after assessment by the Judges Committee (VBP-2)
14	Participar nos divertimentos que aprecio (convívios, festas, actividades sociais) é para mim doloroso (Participating in activities I enjoy [social gatherings, parties, social activities] is painful for me)	Participar de atividades que gosto (convívios, festas, atividades sociais) é doloroso para mim	2	2	2	3	Participar de atividades de lazer (convívio com família, festas, atividades sociais) é doloroso para mim
			3	2	3	3
			3	3	3	3
			3	3	3	3
			3	3	3	3
			3	3	3	3
			3	3	3	3
15	O meu cônjuge/ companheiro(a) interessa-se sexualmente por mim (My spouse/partner is sexually interested in me)	O meu cônjuge/companheiro(a) se interessa sexualmente por mim	3	2	3	3	O meu cônjuge/companheiro(a) demonstra interesse sexual por mim
			3	3	3	3
			3	3	3	3
			3	3	3	3
			3	3	3	3
			3	3	3	3
16	Tenho medo dos gases, cheiros ou que o saco descole, quando estou em público (I am afraid of the gases, smells or that the bag takes off, when I am in public)	Tenho medo dos gases, cheiros ou que a bolsa descole quando estou em público	3	2	3	3	Tenho medo dos gases, do mau cheiro ou que a bolsa descole quando estou em público
			3	3	3	3
			3	3	3	3
			3	3	3	3
			3	3	3	3
			3	3	3	3

• *ES=Semantic Equivalence; †EI=Idiomatic Equivalence; ‡EE=Cultural or Experiential Equivalence; §EC=Conceptual Equivalence.

In Chart 2, items 1, 2, 3, 6, 13, 19, 22, 26, 29 and 31 were not arranged, since all of them obtained a score 3 (exactly the same meaning) of all specialists. The items cited in Chart 2 are restricted to those in which, in at least one of the equivalences, one of the judges assigned 2 (roughly the same meaning).

According to the committee of experts, one of them suggested modifying the preposition “a” (to) by “sobre” in the title of the instrument, but it was decided to maintain the proposed version due to the use of the noun “adaptação” (adaptation), which writing needs the preposition “a”.

In items 5, 10, 11, 17 and 30, one of the judges scored 2 (approximately the same meaning), but did not make any suggestions as requested in the submitted form, choosing to keep the proposed version. In item 7 it was suggested to change “alguém divino” (someone divine) by “uma religião”, but this was not changed, since “divino” (divine) is a broader term, encompassing people who practice religion or not. In paragraph 12, an exchange of “devido” (due to) by “porque” (because) - “Sinto-me diminuído porque tenho um estoma” (I feel diminished because I have an ostomy), but both are explanatory terms.

We consider accepting the suggestion of item 14, since it became more complete and perhaps easier to understand for the population of people with ostomy: “Participar das atividades que gosto (convívio com família, festas, atividades sociais) é doloroso para mim” (Participating in the activities I enjoy (socializing with family, parties, social activities) is painful for me); and item 15: “O meu cônjuge/companheiro(a) demonstra interesse sexual por mim” (My spouse/partner shows sexual interest in me), besides maintaining the same meaning, it is clearer.

In item 16, the version proposed by one of the judges was chosen: “Tenho medo do mau cheiro, gases ou que a bolsa descole quando estou em público” (I'm afraid of the bad smell, the gases or the bag take off when I'm in public), because the term “mau cheiro” (bad smell) would be a more explicit expression of the meaning of the phrase. It was suggested that the word “descole” (be removed) by “caia”, which we did not accept due to the fact that the bag does not necessarily fall off after it is removed from the body, and in item 20 “estou” (am) by “sou”, i.e.: “Sou otimista em relação ao futuro” (I am optimistic about the future), but the person who will be evaluated will respond as he or she feels at that moment, and the word “sou” (am) denotes a more enduring condition.

The word “fé” (faith), indicated in item 21: “Acredito que as minhas orações e fé me ajudarão” (I believe that my prayers and faith will help me) was not accepted because it involves people who believe in some religion, which does not cover the entire population. And, in item 25, it was recommended to remove the word “sexual” (sexual): “O meu relacionamento piorou com a estomia” (My relationship worsened with the ostomy), but the question refers specifically to the sexual relationship of the person, thus discarding the suggestion.

One of the experts agreed with all adapted items of the scale, evaluating all equivalences of all items as 3, and only one of the members disagreed with the change in the word “ostomia” (ostomy) by “estomia”, which was not accepted by the authors of the study, due to the grammatical question and because it is consensus in the literature to standardize the term started with “e” (and).

In the third stage (pre-test), 30 people with ostomy participated, 21 (70%) were men and 8 (30%) were women, aged between 29 and 72 years old. The ostomy time ranged from one month to 28 years. As to the type, 14 (70%) had a colostomy; three had an ileostomy; one had an urostomy; and two patients carried both (colostomy and urostomy). The educational level ranged from higher education (n=2) to between 1 and 12 years of schooling. Eight patients were retired, two were self-employed, two were receiving sickness benefits, and the remaining patients varied between general services, public servants, technicians and others.

During the individual interviews, all the participants stated that they understood the items on the scale, ensuring the clarity of the language and the easy understanding of the questions, remaining the version applied for the pre-test (VBP-2).

After evaluating the comprehension of the items, the moment was also used to analyze the level of agreement using the Likert scale of 7 points, equally distributed in the original scale.

As for the content validation process (last step), an excellent score was obtained (total CVC=0.9), according to Table 1. Three judges participated in this phase, following recommended criteria:18 two nurse practitioners in the nursing area of southern Brazil and a master nurse in the northeast region. All are specialists in stomatherapy and active in the area.

Table 1
Calculation of the content validity coefficient of the Elimination Ostomy Adaptation Scale (BPV-2). Teresina, PI, Brazil, 2017

Scale items	Final Content Validity Coefficient
	CL*	PP†	RT‡
I. Autoconceito
II. Aceitação positive
1. Estou satisfeito(a) com a aparência do meu corpo	0.96	0.88	0.88
10. Sinto orgulho de mim	0.96	0.96	0.96
20. Estou otimista em relação ao futuro	0.96	0.96	0.96
22. Tenho prazer de viver	0.96	0.96	0.96
23. A estomia aumentou o meu bem-estar	0.96	0.88	0.88
24. Aceito a minha estomia	0.96	0.96	0.96
26. Acredito que vou realizar os meus sonhos	0.96	0.88	0.88
III. Suporte social/religioso
2. Estar ou sair com os meus vizinhos, amigos e/ou colegas de trabalho é difícil para mim	0.96	0.88	0.96
7. Acreditar em alguém divino me dá força e me ajuda a viver	0.88	0.96	0.96
8. Eu me sinto bem ao falar dos meus sentimentos e preocupações com familiares e amigos	0.96	0.96	0.96
13. Procuro a ajuda de familiares, amigos ou profissionais quando preciso	0.96	0.96	0.96
21. Acredito que as minhas orações irão me ajudar	0.80	0.88	0.88
29. O apoio da minha família e dos meus amigos é importante para mim	0.96	0.96	0.96
IV. Interação sexual
9. Estou satisfeito(a) com a minha vida sexual	0.96	0.96	0.96
15. O meu cônjuge/companheiro(a) demonstra interesse sexual por mim	0.96	0.96	0.96
18. Perdi o meu interesse sexual por causa da minha estomia	0.96	0.96	0.96
25. O meu relacionamento sexual piorou com a estomia	0.96	0.96	0.96
30. Evito intimidade sexual por causa do meu estoma	0.96	0.96	0.96
31. Eu me sinto atraente sexualmente	0.96	0.96	0.96
V. Autocuidado
11. Identifico alterações no estoma, na pele ao redor, nas fezes ou na urina	0.96	0.88	0.96
16. Tenho medo do mau cheiro, gases ou que a bolsa descole quando estou em público	0.96	0.96	0.96
17. Fico preocupado(a) em viajar por causa do meu estoma	0.96	0.96	0.96
19. O meu estoma interfere no meu trabalho, na minha profissão ou na escola	0.96	0.96	0.96
34. Cuido da higiene da minha estomia sozinho(a)	0.96	0.96	0.96
35. Mudo a bolsa da minha estomia sozinho(a)	0.96	0.96	0.96
VI. Aceitação negative
3. O meu estoma me impede de usar a roupa que gosto	0.96	0.96	0.96
4. Procuro esconder que tenho uma estomia	0.96	0.96	0.96
5. Tento não pensar na minha situação	0.96	0.96	0.96
6. Descarrego nas outras pessoas a minha revolta	0.80	0.80	0.80
12. Eu me sinto diminuído(a) devido ao meu estoma	0.96	0.96	0.96
14. Participar de atividades de que gosto (convívio com família e rede de apoio, festas, atividades sociais) é doloroso para mim	0.80	0.96	0.96
27. Eu me sinto culpado(a) pela minha situação	0.96	0.88	0.88
28. Acho que os outros me olham como uma pessoa diminuída	0.96	0.96	0.96
32. Olhar para a minha estomia é doloroso	0.96	0.96	0.96
33. Tocar na minha estomia é difícil para mim	0.96	0.96	0.96
Total Content Validity Coefficient	0.90	0.90	0.90

• ⁎CL = clarity of language; †PP = practical relevance; ‡RR = theoretical relevance.

From the judges who participated in the validation of content, all agreed to the change the term “ostomia” (ostomy) by “estomia” in the title, adopting, then, in the Brazilian version: Adaptation Scale to Elimination Ostomy (EAEE), thus converging with the conclusion of a study on specialized nursing terminology.19 In addition, only one suggested, in item 14, to add the preposition “de”, i.e: “Participar de atividades de que gosto (convívio com família e rede de apoio, festas, atividades sociais) é doloroso para mim” (Participating in activities I like (socializing with family and support network, parties, social activities) is painful for me), and in item 21 the verb “ir” (to go): “Acredito que as minhas orações irão me ajudar” (I believe my prayers will help me), and these alterations are being complied with.

For the evaluation of the theoretical dimensions, performed through the Kappa, the data are contained in Table 2.

Table 2
Calculation of Kappa between the evaluators for the theoretical dimensions of the instrument. Teresina, PI, Brazil, 2017.

Dimension	Kappa	CI 95%	p-value
I. Autoconceito	-0.061	0.131 - -0.252	*
II. Aceitação positiva	0.514	0.705-0.323	<0.001
III. Suporte social/religioso	0.464	0.655-0.272	<0.001
IV. Interação sexual	1.0	1.0-0.809	<0.001
V. Autocuidado	0.53	0.721-0.338	<0.001
VI. Aceitação negativa	0.651	0.842-0.46	<0.001
General KAPPA	0.587	0.678-0.495	<0.001

• * It is not interpretable and does not apply significance test

The mean value of the Kappa coefficient was considered moderate (Kappa_mean =0.587), an acceptable value in relation to the agreement between the judges. However, this value would probably be higher if there had not been a discrepancy in the dimension “Autoconceito” (Self-concept), in which one of the judges did not evaluate for any item. The “Aceitação negativa” (Negative acceptance) dimension was considered substantial for the level of agreement, and “Interação sexual” (Sexual interaction) was almost perfect.15

DISCUSSION

The use of reliable instruments presents itself as a valuable resource in the evaluation of nursing care, especially during professional training, since it facilitates the production of data, favors the analysis of techniques and approaches adopted and provides the standardization of efficient behaviors in the teaching and clinical practice.20^-21

The EAOE, originally constructed and validated in Portugal and now adapted culturally for use in Brazil, was developed with the intention of covering the analysis of the different aspects of the adaptation of the stomates. In this sense, the 35 items of the scale were evaluated and discussed by the committee of experts and the judges, whose suggestions were analyzed, with a view to making it clearer, in line with current literature.22 The items of the scale were, therefore, systematically adapted to the semantic, idiomatic, experimental and conceptual equivalences.

Thus, in relation to the suggestions of the judges, we opted for the modification in the items that could present some impediment to the perfect understanding of its meaning, as is the case of item 21, in which there was the substitution of the form grammatically accepted by a more colloquial construction, of easy understanding, demonstrating that the scale can be understood by people with different levels of schooling.23

The different backgrounds and professional experiences of the members of the committee of experts and the judges provided the guarantee that the final result is as close as possible to the ideal, ensuring its cross-cultural equivalence, as the pre-test with the target public allowed to confirm.

CONCLUSION

The Adaptation Scale to Elimination Ostomy, constructed and validated originally in Portugal, was culturally adapted for use in Brazil, following the steps recommended in the literature.

The semantic, idiomatic, cultural and conceptual equivalences obtained by a committee of experts in relation to the original Portuguese version were attested, and good content validity indexes were evaluated by the judges' committee.

The adapted Brazilian version of the scale is not available for the general public, since it still needs to go through the analysis of important measurement properties of the scale, for better reliability of information and, later, its use in Brazil, as a contribution in clinical practice and better assessment of aspects of patient adaptation with elimination stomies.

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NOTES

• ORIGIN OF THE ARTICLE
  Article extracted from the thesis - Cultural adaptation and validation of content of the Adaptation Scale to Elimination Ostomy (EAOE) for use in Brazil, presented to the Graduate Program in Nursing, Universidade Federal do Piauí, in 2017.
• ETHICS COMMITTEE IN RESEARCH
  Approved by the Research Ethics Committee of Universidade Federal do Piauí, under Opinion No. 1,554,321, Certificate of Presentation for Ethical Assessment: 52526915.6.0000.5214.

Publication Dates

• Publication in this collection
  04 July 2019
• Date of issue
  2019

History

• Received
  21 June 2018
• Accepted
  15 Oct 2018