Cultural adaptation of the short Self ‐ Regulation Questionnaire : suggestions for the speech area Adaptação cultural do Questionário Reduzido de Autorregulação : sugestões de aplicação para área de voz

Accepted: March 21, 2017 Multicenter study carried out at the Group for Research, Evaluation and Treatment of Voice Disorders of the Graduate Program in Human Communication Disorders of the Federal University of São Paulo – UNIFESP São Paulo (SP) Brazil, and at the Integrated Laboratory of Voice Studies – ILVS, Department of Speech and Hearing Therapy, Federal University of Paraíba – UFPB João Pessoa (PB), Brazil. 1 Universidade Federal da Paraíba – UFPB, João Pessoa (PB), Brazil. 2 Universidade Federal de São Paulo – UNIFESP, São Paulo (SP), Brazil. 3 Centro de Estudos da Voz – CEV, São Paulo (SP), Brazil. Financial support: Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), process no 157664/2015-5. Conflict of interests: nothing to declare. ABSTRACT


INTRODUCTION
Abusive behavior is linked to many health problems, such as cigarette smoking (1) , consumption of psychoactive substances like alcohol (2) , obesity, non-adherence to physical exercise (3) , sexual risk behaviors (4) , among others.In the human voice area, behavior may also have greater or lesser participation in the genesis and/or maintenance of most speech disorders.It is understood that the use of voice has a more relevant role in behavioral dysphonia, in which patients present vocal difficulties related to abusive behaviors and/or inadequate vocal tract adjustments.
Thus, it is important to increase the knowledge about cognitive responses and behavioral characteristics of patients, such as associative learning, motivation and regulation of emotion, which may be linked to the genesis and maintenance of dysphonia, especially of the behavioral nature.
With respect to this, it is notable that self-regulation is an essential executive function managed by the prefrontal cortex of the frontal lobe of the brain to keep individuals active in the process of achieving goals.It is believed to be a control responsible for features that distinguish them from other animals, such as self-awareness, complex planning ability, and problem solving.It is a complex phenomenon that involves behavior (activation, monitoring, inhibition, preservation and adaptation), emotions and cognitive strategies to achieve desired goals (5) .
One of the ways to evaluate self-regulation is through tasks/tests that evaluate executive functions (6) or through self-assessment tools, in order to verify the respondent's own perception about the ability of self-regulation.There are some proposals for evaluating the effect of self-regulation on treatment outcomes, particularly focusing on self-determination (7) .
The Self-Regulation Questionnaire (SRQ) (8) , in its original English version, was constructed from the seven-step model of self-regulation that involves (1) receiving relevant information; (2) evaluating the information and comparing it with the standards; (3) provoking change; (4) lookin for options; (5) formulating a plan; (6) executing the plan; and (7) evaluating the effectiveness of the plan, generally encompassing all principles of self-regulation.Subsequently, studies verifying the structure and internal consistency of the SRQ have been carried out based on factorial analysis and resulting in its reduced version, the so-called Short Self-Regulation Questionnaire (SSRQ) with 31 items strongly correlated with the SRQ (9,10) .
This instrument has been used to verify the relationship between self-regulation and various cognitive and behavioral issues, such as drug use and other psychoactive substances (11,12) , learning disorders (13) ; treatment adherence (14) , among others.
Particularly regarding vocal behavior, the acquisition and generalization of new vocal behaviors directly require self-regulation, which may be related to the gains/modifications resulting from voice therapy (6) .
It is important to verify the role of self-regulation in voice therapy and how much it may interfere with its results (15) .The impact of cognitive factors and how much they are involved in the intended changes should be investigated.Self-regulation has implications for the learning and generalization of new skills and is also important for the maintenance of behaviors acquired over time.This reinforces the need to use strategies to improve self-regulation in voice therapy (15) .
Mapping self-regulation in the therapeutic process may be important for a better characterization of the clinical picture and planning of the therapy and selection of strategies for practical guidance of patients, which will favor positive gains.Thus, the objective of this study was to present the translated and linguistically and culturally adapted Brazilian Portuguese version of the Short Self-Regulation Questionnaire (SSRQ), as well as verify its applicability to patients with and without dysphonia.
It is important to mention that the SSRQ has been translated, adapted and validated to other languages, but similar procedures are unknown in the Brazilian Portuguese language.The process carried out in this article can be used both for application in dysphonic individuals and for the application of the instrument in territories that use Brazilian Portuguese in order to verify self-regulation linked to other types of behavior, whether additive or not.

METHODS
This is a multicentric research developed by the Federal University of São Paulo (UNIFESP) and the Federal University of Paraíba (UFPB).It followed the ethical rigor, in accordance with the precepts of resolution 466/12 of the National Commission of Ethics in Research (CONEP) and was approved by the Research Ethics Committee of both institutions of higher education under Opinions nº 811.219/14UNIFESP and nº 906,676/14 UFPB.
The Short Self-Regulation Questionnaire (SSRQ) (9) was translated and culturally adapted to Brazilian Portuguese by two fluent English-speaking speech therapists who were aware of the purpose of the research.Subsequently, consensual adjustments were made for the final version to have a more accessible language.This Portuguese version was back-translated by a third fluent English-speaker speech therapist with experience in validation studies.This version was back-translated by a third experienced speech therapist who did not participate in the previous stage and was not aware of the instrument in question.Translation and back-translation were compared with each other and with the original instrument.Subsequently, five speech therapists analyzed and reached consensus about necessary changes.Thus, the final version of the Short Self-Regulation Questionnaire (SSRQ) was obtained.The theoretical approach adopted for this translation and linguistic and cultural equivalence was in accordance with the Scientific Advisory Committee of Medical Outcome Trust.
Cultural equivalence was carried out by applying this version of the Short Self-Regulation Questionnaire (SSRQ) to 45 individuals, 25 of which were dysphonic and 20 were healthy.The participants were 40.3 (± 5.7) years old on average.Dysphonic participants were randomly selected in the Integrated Laboratory of Voice Studies (ILVS) of the UFPB and those without dysphonia were companions of patients who attended the Speech Therapy teaching clinic of the institution.Eligibility criteria included: being adult, any gender, without the neurological, cognitive and/or psychiatric disorders, and literate, in order to avoid interference in the application of the instrument.Dysphonic participants had their voices deviated based on the auditory-perceptive assessment performed by a speech therapist in voice, and on the otorhinolaryngological evaluation compatible with behavioral dysphonia (lesion in the membranous portion of the vocal fold, glottic opening with no neurological/organic origin or absence of laryngeal lesion).
Volunteers were informed about the research objectives and, if they did not agree, they could withdraw from participating.When they accepted to continue in the research, they would sign the Informed Consent Form (ICF) and answer the Short Self-Regulation Questionnaire (SSRQ).The instrument was orally applied by a researcher, who would not interfere in the choice of answers or interpretation of the items.The option "not applicable" was not selected in any of the items of the questionnaire.Thus, all questions in the protocol were kept.
This application occurred to identify unintelligible or inappropriate questions for the population.Each item contained the option "Not applicable", which could be indicate an invalid aspect for this culture.All items were answered by all participants.Thus, the instrument was considered applicable, since no respondent of the target-public had difficulty to respond neither considered the SSRQ items strange or difficult to understand.

RESULTS
The Questionário Reduzido de Autorregulação (QRAR) is a translated and culturally adapted Brazilian Portuguese version of the Short Self-Regulation Questionnaire (SSRQ) (9) .This questionnaire has 31 items aiming to provide a total index of individual self-regulation capacity, i.e. the ability to plan, guide and monitor a flexible behavior before changing circumstances (Annex A).
Each item has a gradation by means of a Likert-type scale that ranges from 1 to 5, wherein 1 indicates totally disagree, 2 indicates disagree, 3 indicates unsure, 4 indicates agree and 5 indicates totally agree.The score ranges from 29 to the maximum score of 145 points.The protocol provides a total score and two dimensions: goal setting and impulse control.The total score and/or the two dimensions can be calculated.The items 1, 5, 8, 12, 14, 15, 16, 17, 18, 19, 20, 21, 25, 26 belong to the goal setting dimension, and the items 2, 3, 4, 6, 7, 9, 10, 11, 13, 22, 23, 24, 27, 28, 29 to the "impulse control" dimension.A simple sum of all items is performed.It should be noted that the items 2, 3, 4, 6, 7, 9, 10, 11, 16, 19, 22, 23 and 27 must be calculated in reverse order.Items 30 and 31 are not included in the sum or calculation of the isolated dimensions, neither in the total score, because they only serve for internal reliability of the instrument.

DISCUSSION
The Self-Regulation Questionnaire (SRQ) is a 63-item instrument with the specific objective of measuring the generalized ability to regulate behavior in order to achieve desired future results (8) .Studies on the structure and internal consistency of the SRQ have provided sufficient scientific evidence for this instrument to have its convergent and discriminant validity confirmed (9,10) .
From this, a factorial analysis was carried out leading to the reduced version named Short Self-Regulation Questionnaire (SSRQ), with 31 items strongly correlated with the SRQ (9,10) .
Validation and factorial analysis studies of this instrument in other languages, such as Portuguese from Portugal and Spanish from Spain, had been conducted with the aim of checking the sensitivity and specificity of this questionnaire to discriminate other phenomena such as additive behavior (11) and learning disorders (14) .Thus, it is believed that the translated and linguistically and culturally adapted Brazilian Portuguese version can be used not only for dysphonic patients, but also to investigate the self-regulation of other population groups with different characteristics.
Besides the association between cognitive, behavioral and self-regulation phenomena, it has been also verified that the variation in the levels of psychological well-being influences the self-regulation capacity; there is a very strong relation between self-regulation capacity and the dimensions of purpose in life and in the environmental domain (14) .The SSRQ has also proved to be sensitive to indicate the effectiveness of treatment after self-regulation training.
Human behavior is a widely studied theme in Neuroscience.Much is due to the alarming data of modern society, where approximately 40% of mortality in the United States is related to social and behavioral factors such as diet, lifestyle and smoking.The literature reports that ceasing such behaviors is linked to self-control (7) and self-regulation (8,9) .
Voice behavior is fundamental to the genesis and/or maintenance of most speech disorders, particularly in cases of behavioral dysphonia.Behavioral dysphonia, which in some studies may be synonymous with functional dysphonia, corresponds to the voice disorder that takes place in the absence or presence of a laryngeal lesion, resulting from improper use of voice, such as abusive behavior and inappropriate adjustments.In this approach, voice therapy requires interest, effort and attention from patients in order to make decisions in the various communicative situations and to put into practice the new vocal behaviors learned in a conscious way.Having said that, it is logical to propose that speech therapists insert elements to favor the process of self-regulation in therapy (15) .
Knowing the patient's self-regulation factors with dysphonia or vocal symptoms during the evaluation may be important to benefit the planning of the therapy, practical guidance on the patient's daily life, and the generalization and maintenance of gains in voice therapy tasks/techniques (15) .Thus, it is very important to use sensitive instruments to evaluate self-regulation during the evaluation process, in order to be able to set targeted goals and establish the therapeutic goals of the patient.The SSRQ proved to be a very interesting alternative for this purpose.The Brazilian Portuguese version proved to be of easy application and interpretation of results.

CONCLUSION
The translated and linguistically and culturally adapted Brazilian Portuguese version of the Short Self-Regulation Questionnaire (SSRQ), named the Questionário Reduzido de Autorregulação (QRAR) in Portuguese, was presented.It was observed that individuals with and without dysphonia were able to respond to the questionnaire successfully.