Cross-cultural adaptation of the Brazilian version of the protocol Evaluation of the Ability to Sing Easily Equivalência cultural da versão brasileira do protocolo Evaluation of the Ability to Sing Easily

Purpose: To present the cross-cultural equivalence of the Brazilian version of the Evaluation of the Ability to Sing Easily (EASE) protocol, through its cultural and linguistic adaptation. Methods: After the EASE was translated to Brazilian Portuguese, the back-translation into English was done. The items of the translated version were compared with the original instrument and the discrepancies were modified by consensus of a committee composed of five speech language pathologists. The Evaluation of the Ability to Sing Easily for Brazil (EASE-BR) has 22 questions with four alternatives: “no,” “mildly,” “moderately,” and “extremely.” The score is obtained by the simple sum of all answers. The three positive items (6, 12, and 21) require reverse score. For cultural equivalence, the EASE-BR was applied with 41 Brazilian singers, with an extra item in the answer key — “not applicable.” The aim of this extra key was to identify issues that might not have been understood or were not appropriate for the target population and the Brazilian culture. Results: Of the 32 singers, 5 who were initially evaluated had difficulties to answer 3 of the 22 questions. Therefore, the adaptation of those sentences was necessary. Afterward, the modified EASE-BR was applied to nine singers, and no more cultural and/or conceptual barriers were found. Conclusion: Cultural equivalence was observed between EASE and its translated version to the Brazilian Portuguese, the EASE-BR. Validation of the EASE for Brazilian Portuguese is in progress.


INTRODUCTION
Voice self-assessment protocols have been developed and specified since the 1990s (1) , and are considered as important tools to measure the knowledge of an individual about the impact of the problem in social and professional relationships (2) .Despite being frequently used, most protocols, and their respective translations, cultural adaptations (3) , and validation to Brazilian Portuguese (4)(5)(6)(7)(8)(9) , are still addressed to specific conditions.Therefore, they are not adequate for individuals with healthy voices, such as voice professionals, who deserve specific evaluation (10)(11)(12) .To fill this gap, the protocol Evaluation of the Ability to Sing Easily (EASE) was created (13) to assess the perception of the singers about the status of their singing voice after a performance, thus promoting the immediate overview about the use of voice.
The EASE was created in English, so, for it to be used in other languages, it must be translated and culturally adapted according to the international rules from the Scientific Advisory Committee of the Medical Outcome Trust (14) .
The objective of this study was to perform the cultural equivalence of the Brazilian version of the EASE protocol, through its cultural and linguistic adaptation.

METHODS
The study was approved by the research ethics committee of Hospital Municipal e Maternidade Escola Dr. Mário de Moraes (report no.721.483 and CAAE: 32107014.2.0000.5454).All the participants signed the informed consent.
41 Active Brazilian singers participated in the study, without distinguishing musical style, gender, age, or socioeconomiccultural level.
The original version was translated to Brazilian Portuguese by two speech language pathologists who were fluent in the foreign language (translator 1, T1; translator 2, T2).These translations were superimposed, which resulted in the first Portuguese version (PV).A third speech language pathologist, who was also fluent in English, and had no access to the original version of the instrument and to the objectives of the study, back-translated it.
Translation and back-translation were compared between themselves and with the original instrument.The existing discrepancies were analyzed and discussed by a committee composed of five speech language pathologists specialized in voice, with proficiency in English and knowledge of specific vocabulary for the population of singers.The necessary changes were carried out by consensus and the final protocol was achieved.It is called Evaluation of the Ability to Sing Easily for Brazil (EASE-BR).
As in the original protocol, the EASE-BR remained with 22 questions and 4 alternatives to mark how often the described situation occurred: "no," "mildly," "moderately," and "extremely".Of the 22 questions, 19 were usual describers of fatigue and vocal limitations, and the other 3 were positive and new aspects in the literature.The score was a simple sum of the 19 negative items, being 0=no, 1=mildly, 2=moderately, and 3=extremely, with the three positive items (questions 6, 12, and 21) added reversely, as follows: 3=no, 2=mildly, 1=moderately, and 0=extremely.
For cultural equivalence, the EASE-BR was applied among 41 Brazilian singers (32 in the first stage and 9 in the second stage), and the option "non-applicable" was added to identify questions that were not understood or inappropriate for the target population and the Brazilian culture.

RESULTS
In the first stage, 5 of the 32 singers who were initially assessed found difficulties to fill out three questions (items 3: "My voice is cracking and breaking"; 8: "My voice sounds tense"; and 21: "If I had to, I could sing again").So, the committee of speech language pathologists modified sentences that were not understood or considered to be inappropriate.Item 8 was altered to "I feel my voice tense" after the consensus of the judge committee.Items 3 and 21, which were, respectively, modified to "My voice is failing and breaking" and "If I had to, I could sing again now," were changed after the target population did not understand it as it had been first translated.The modified EASE-BR was then applied to nine other singers who were vocally healthy, and cultural and/or conceptual barriers were not identified.The whole process of translation, semantic, and cultural equivalence of the EASE to Brazilian Portuguese is shown in Chart 1.
The final composition of the Brazilian version that was translated and culturally adapted from the EASE, called EASE-BR (Appendix 1), presents 22 items, just as the original protocol.

DISCUSSION
Obtaining cultural equivalence is the first stage to validate protocols, and it is essential so that no barriers remain between the instrument and its target population in different countries (14) .This stage has been successfully reached in validations of other protocols in Brazil (4)(5)(6)(7)(8)(9) , which served as example and model for this project.In the case of the stage of adaptation of the EASE to Brazil, 3 of the 22 sentences had to be revised until the protocol could be accepted by the target population.
The EASE is a specific protocol for singers, developed to be sensitive to the vocal subtleties of this population (13) .After the conclusion of the process of translation and adaptation to Brazilian Portuguese, the process of validating the EASE-BR will take place.In this stage, the possibility to use it as an instrument of prevention and early detection of vocal problems will be assessed, considering the high demand of singers.Its use will be important, because most voice self-assessment protocols are addressed to specific conditions (4)(5)(6)(7)(8)(9) and are not adequate for individuals with healthy voices.

CONCLUSION
Cultural equivalence was observed between the EASE and its version translated to Brazilian Portuguese, the EASE-BR.The validation of EASE to Brazilian Portuguese is ongoing, after the conclusion of this stage.Brazilian cross-cultural adaptation CoDAS 2014;26(6):535-9 Chart 1. Process of translation and cultural adaptation of the protocol Evaluation of the Ability to Sing Easily (EASE) (13) (13) , called Evaluation of the Ability to Sing Easily for Brazil (EASE-BR) Por favor, responda às seguintes perguntas com base em como você sente a sua voz ou em como ela soa agora.Se ela tem variado ao longo do dia, basta escolher a resposta que mais combina com como sua voz está agora.