Brazilian transcultural adaptation of an instrument on physicians' knowledge and attitudes towards dementia

Objective The aim of this study was to obtain a Brazilian transcultural adaptation of an instrument developed in the United Kingdom for assessing the knowledge and attitudes towards dementia by physicians. Methods The "Knowledge Quiz" (KQ) contains 14 items on epidemiology, diagnosis and management of dementia, while the "Attitude Quiz" contains 10 sentences about physicians' thoughts on the management of demented patients. The Quizzes were translated, back-translated and the resultant version applied to five physicians. Results The transcultural equivalence process was performed and four items of the KQ needed adapting to the Brazilian context. After changes suggested by a panel of specialists, the final version was applied to another five physicians and the transcultural equivalence considered adequate. Conclusion The Brazilian version of the instrument was successfully transculturally adapted for future validation and application in Brazil.


INTRODUCTION
T he prevalence of dementia in Brazil has increased in the last three decades amidst a rapidly aging population. 1 An estimated 24.3 million people worldwide have dementia with an incidence of 4.6 million new cases each year. According to the same group, cases of dementia are set to double every 20 years, rising to 81.1 million by 2040. Currently, 61% of all cases of dementia are found in underdeveloped countries. 2 Physicians often overlook cognitive impairment (CI) in the elderly, especially in its early stages. [3][4][5][6] The lack of CI detection by physician has been studied in a number of countries. In Brazil, only one Brazilian study has investigate this issue. 7 Considering evidence-based medicine, it is unclear whether early detection of dementia improves patients' outcomes, although cognitive impairment assessment is part of the global geriatric assessment. 8,9 Few studies [10][11][12][13] have identified dementia knowledge deficits among health workers and caregivers. Basically, two instruments designed for this purpose have been used in these studies: the Alzheimer's Disease Knowledge Scale 14 and the "Knowledge Quiz and Attitude Quiz". 10 It is important for this type of instrument to be short and easy to answer. Instruments should also have good reliability in measuring what they propose to assess. International use of the instrument is also of importance since it enables comparisons between different medical educational systems. Of the two instruments cited, the "Knowledge Quiz and the Attitude Quiz" by Turner et al. 10 seems a promising tool for the assessment of CI by Brazilian General Practitioners, having been used for this purpose in the United Kingdom.
The aim of this study was to obtain a cross-cultural adaptation of an instrument 10 previously used in the United Kingdom for assessing the knowledge and the attitudes towards dementia of Brazilian physicians.

METHODS
The translation of the instrument comprising the Knowledge Quiz (KQ) and Attitude Quiz (AQ) questionnaires was authorized by their authors and this project was approved by the Ethics Committee of the Escola Paulista de Medicina, Universidade Federal de São Paulo. Subjects. Numerous cross-cultural adaptation studies have shown that the instrument's final version can be applied to a small sample of subjects since its characteristics accommodate diversity of individuals. 15 In this study, the participants of the cross-cultural adaptation of the KQ and AQ were five recently graduated physicians from different Brazilian medical schools. Five other physician could be assessed if necessary, in a second application of the instrument. The inclusion criterion was to be on the first year of a medical residence program of the "Escola Paulista de Medicina, Universidade Federal de São Paulo". There were no exclusion criteria.
The physicians were invited to participate in the study during a "Welcome section" of the residence programs run by the institution. The physicians were randomly selected and asked to fill out the instrument. None of the physicians refused to participate.
Instruments. The Knowledge Quiz (Table 1, original)  consists of 14 tests with five multiple choice answers, including "I don't know". Only one of the answers is correct. This questionnaire covers three issues on dementia: epidemiology, diagnosis and management. The Attitude Quiz (Table 2, original) contains 10 sentences about physicians' thoughts on the management of demented patients on a 5-point "Likert type" scale (from "strongly agree" to "strongly disagree").
Procedures. The following cross-cultural adaptation method was applied: 16 The quiz items were translated from English into Portuguese by two bilingual professionals who were independent and were aware of the aims of the study. The two versions were compared by the authors, a consensual translation was created and the two bilingual professionals subsequently approved it.
The consensual translation was back-translated into English by two other bilingual professionals. These two versions were compared and a consensual back-translated instrument created to guarantee semantic equivalence of the items. The two bilingual professionals subsequently approved it.
Finally, cross-cultural equivalence was performed to identify those items that were not readily understood. To this end, the answer option "not applied" was included for each item and the quizzes applied to five physicians. The AQ raised no doubts among these physicians and the consensual translated version was established as the final Brazilian version (Table 2). However, four items of the KQ needed adapting (questions 1, 2, 11 and 14). A panel of specialists (a geriatrician and a psychiatrist, both specialized in cognitive impairment in elderly) suggested changes of an idiomatic, cultural and conceptual nature: Questions 1 and 2 describe dementia prevalence in the general population in an unusual way for Brazilian medical culture, and were therefore modified: (i) Question 1 , from "a general practitioner with a list of 1,500-2,000 people can expect to have the following number of people with dementia on their list" to "a general practitioner with a list of 1,000 people aged 60 years or older can expect to have the following number of people with dementia on their list"; (ii) Question 2, from "by 2021, the prevalence of dementia in the general population in the UK is expected to" to "from 65 years of age, the prevalence of dementia…".
An explanation was included (in brackets) about the meaning of "stepwise disease course" on answer "c" of question 11.
On question 14, Alzheimer's Disease Society was changed to Brazilian Alzheimer's Disease Association.  After these changes, the KQ was reapplied to another five physicians and the cross-cultural equivalence was performed with no doubts raised. The definitive Brazilian version of the KQ is given in Table 1.
Descriptive analyses of the subjects in both applications were performed. Table 1 shows the KQ and Table 2 depicts the AQ instrument, in both the original and cross-culturally translated versions. Table 3 contains the distribution of socio-demographic and graduation characteristics of both applica-Jacinto AF, et al.

RESULTS
Physicians' attitudes towards dementia tions. In the first application, the residents were 40% female, with mean age of 26.2 (±1.9) years, and mean time since graduation of 16.4 (±13.1) months; 80% were on a specialization program of internal medicine, and 80% graduated from a Federal medical school. Sixty percent of the physicians considered they had good training on the cognitive impairment issue during medical school. In second application, the residents were also 40% female, with mean age of 27.0 (±2.6) years, and mean time since graduation of 11.6 (±13.1) months; 60% were on a specialization program of internal medi-cine, and 80% graduated from a private medical school. Sixty percent of the physicians also considered they had good training on the cognitive impairment issue during medical school.

DISCUSSION
In terms of public health, physicians' knowledge about dementia in elderly and the attitude they have toward demented patients is important to guarantee reliable clinical care for patients with dementia. Dementia cases have been increasing in Brazil and worldwide 1,2 , repre-  senting an issue of concern across all spheres of Medicine. Straight-forward instruments that can better train physicians to deal with dementia are fundamental. The internationality of these instruments is also important to allow comparisons of medical education, thus cross-cultural adaptation is a method of promoting this exchange of experience. There were no apparent difficulties translating and back-translating the instrument, but the conceptual and semantic equivalence raised more doubts for the KQ than the AQ. Ultimately, both questionnaires were successfully cross-culturally adapted, and the Brazilian version of the KQ about dementia and the AQ toward dementia patients can be used to compare Brazilian physicians to other physicians worldwide. The panel of specialists contributed to the cultural equivalence of KQ by changing some questions about epidemiology. Brazilian studies on prevalence express these numbers as percentages according to age. 17 The importance of dementia as an epidemic issue in public health was the priority to be emphasized in questions 1 and 2. These questions address basic information about dementia prevalence that all physicians in Brazil should know. Question 14 also underwent adaptation to the Brazilian context, reflecting the role of a Brazilian equivalent of the Alzheimer Disease Society. On the other hand, the change in question 11 was more straight-forward, entailing adaptation to include a linguistic explanation of the term "stepwise disease course".
A limitation of this study was the profile of the physicians to whom the Brazilian version was applied. These physicians were young and recently graduated which may have facilitated comprehension of the instrument, as compared to older doctors. Nevertheless, these recently graduated physicians represent the next generation of physicians to attend as general practitioners in public health.
In the dementia field, primary care physicians in the United Kingdom have been studied periodically by the KQ and AQ instrument. The authors of the present study intend to discuss the quality of teaching on this issue in Brazil.
In conclusion, the Brazilian version of the instrument was successfully cross-culturally adapted for future validation and application in Brazil, serving to improve health-care assistance in primary care.
Author contributions. Alessandro Ferrari Jacinto participated in the translation and back-translation of the questionnaire, and also wrote and revised the manuscript. Érika Correa de Oliveira interviewed the residents and applied the questionnaires. Vanessa de Albuquerque Citero wrote and revised the manuscript.