Translation and adaptation of the Competencias Esenciales en Salud Pública para los recursos humanos en salud 1

ABSTRACT Objective: to perform the translation and cultural adaptation of the document named Marco Regional de Competencias Esenciales en Salud Pública para los Recursos Humanos en Salud de la Región de las Américas (Regional Framework of Core Competencies in Public Health for Health Human Resources in the Region of Americas) from Spanish to Brazilian Portuguese. Method: a methodological study comprising the following phases: authorization for translation; initial translation; synthesis of translations and consensus; back-translation and formation of an expert committee. Result: in the translation of domain names, there was no difference in 66.7% (N = 4); in the translation of domain description and competencies there were divergences in 100% of them (N = 6, N = 56). A consensus of more than 80% was obtained in the translation and improvement in the expert committee by the change of words and expressions for approximation of meanings to the Brazilian context. Conclusion: the translated and adapted document has the potential of application in research, and use in the practice of collective/public health care in Brazil.


Introduction
The essential competencies in public health are defined by the knowledge, skills and attitudes for professional practice in public health care (1)(2) that are relevant for decision-making and resolution of population's health problems effectively and efficiently.
They refer to the competencies all health professionals working in public health must possess, regardless of the practice scenario in which they develop their activities (2)(3) .
The Regional Core Competency Framework for Public Health (MRCESP -Marco Regional de Competências Essenciais em Saúde Pública) can be an instrument to characterize public health knowledge, skills and attitudes. The document is a response to the challenges identified by the region of Americas to facilitate training of excellence, collaborate and give consistency to the public/collective health workforce of health systems (2)(3) .
The fundamental strategy of this proposal is based on the following fundamental axes: construction of the MRCESP and measurement of competencies; planning of regional and national capacitation, among other initiatives such as the virtual field of public health (2)(3) . The In the search for professionals prepared for the predominant health care model reality in Brazil and its epidemiological context, the importance of studies in the area of development of health human resources stands out. They point to new work models based on new ways of management and teaching in order to adjust to changes in the health care model (4) . To this end, the adoption of the MRCESP reference may contribute to the construction of instruments that help in the development of professionals. This view justifies the translation and adaptation of this document to the Brazilian context. Given the exposed, the objective of this study was to translate into Brazilian Portuguese and adapt to the Brazilian context the essential competencies for public health professionals suggested by the Pan American Health Organization, as described in the document Marco Regional de competencias esenciales en salud pública para los recursos humanos en salud de la región de las Américas (Regional Framework of Core Competencies in Public Health for Health Human Resources in the Region of Americas).

Methodology
This is a methodological study for translation and cross-cultural adaptation of the essential public health competencies suggested by PAHO for human resources in health, which followed international recommendations (5)(6) . Translation and cross-cultural adaptation followed the phases: 1. Authorization of the lead author and PAHO for translation; 2. Initial translation; 3. Synthesis of translations and consensus; 4. Back-translation; 5. Composition of an expert committee.
These recommendations (5)(6) are for translation and cultural adaptation of research instruments. In Almeida ML, Peres AM, Ferreira MMF, Mantovani MF. this article, the adopted procedures varied because the translation and cultural adaptation were based on a PAHO document and not on a research instrument. Therefore, the pre-test application phase was not performed for psychometric evaluation and the phase of content evaluation by the expert committee closed the process.
The process of translation and cross-cultural adaptation requires a method for achieving equivalence between the source language and the target language.
For instruments and documents used by cultures other than that of the source language, the ideal is not only the language translation, but a cultural adaptation to maintain the instrument content validity in different cultures (7)(8) . This situation demands planning before starting the process (8) .
This process of translation and adaptation was A web conference was held with this purpose, because a meeting face-to-face was difficult considering that translators were in different places from researchers.

A new version in Spanish and the definitive version in
Portuguese (P3) were obtained as a result of this phase.
The fifth phase comprised the cultural adaptation, content evaluation and analysis of cross-cultural equivalence. For the process, was formed a committee including two teaching nurses from the collective health area, a dentist and a physician acting in basic health care management in the studied municipality, and a teacher of the undergraduate course in languages (emphasis on Spanish), all of which with mastery of the Spanish language.
Members of the expert committee were selected according to the inclusion criteria: mastery of the Spanish language; active health professional working in teaching, research or practice of collective health management; or a professional of the studied language.

Results
In the translation of the names of the six domains, there was no translation difference in 66.7% (N = 4), and in 33.3% (N = 2) there were divergences in domain one and domain four, which were resolved with discussion between translators and the researcher. In all domains, were found differences in the translation of the competency description, but the majority (above 80%) obtained consensus in this same round, and the same happened with the words pointed as divergent. First domain: Análisis de situacion de salud Análise da situação de saúde (Analysis of the health situation) Implica la evaluación de la situación de salud poblacional y sus tendencias en función Del estudio de sus determinantes para la toma de decisiones y la definición de políticas públicas de salud Implica na avaliação da situação de saúde da população e suas tendências em função do estudo de seus determinantes para a tomada de decisões e definição de políticas públicas de saúde essenciais na análise de situação de saúde (It implies on the evaluation of the health situation of the population and its trends in function of the study of its determinants for decision making and definition of core public health policies in the analysis of the health situation).
Vigilancia y control de riesgos y danos Vigilância e controle de riscos e danos (Surveillance and control of risks and threats) Se refiere al escrutinio continuo de todos los aspectos de la ocurrencia y propagación de riesgos y daños para la salud que son pertinentes para su control efectivo en la población. Es la capacidad para llevar a cabo la investigación y vigilancia de brotes epidémicos y los modelos de presentación de enfermedades transmisibles y no transmisibles, factores de comportamiento, accidentes y exposición a sustancias tóxicas o agentes ambientales perjudiciales para la salud Faz referência ao escrutínio contínuo de todos os aspectos da ocorrência e propagação de riscos e danos para a saúde e que são pertinentes para o seu efetivo controle na população. É a capacidade para realizar a pesquisa e a vigilância do surgimento de epidemias, e os modelos de apresentação de doenças transmissíveis e não transmissíveis, fatores de comportamento, acidentes e exposição a substâncias tóxicas ou agentes ambientais prejudiciais para a saúde (It refers to the continuous scrutiny of all aspects of the occurrence and spread of risks and damages to health that are relevant to their effective control in the population. It is the ability to conduct research and surveillance of the outbreak of epidemics, and presentation models of communicable and noncommunicable diseases, behavioral factors, accidents and exposure to toxic substances or environmental agents harmful to health).

Promoción de La salud y participación social
Promoção da saúde e participação social (Health promotion and social participation) La Promoción de la Salud se define como el proceso político y social que abarca no solamente las acciones dirigidas directamente a fortalecer las habilidades y las capacidades de los individuos, sino también las dirigidas a modificar las condiciones sociales, ambientales y económicas que impactan la salud. Es el proceso que permite a las personas incrementar su control sobre los determinantes de la salud y em consecuencia, mejorarla. Utiliza la educación para la salud y la participación social como herramientas de cambio A promoção da saúde se define como o processo político e social que envolve não somente as ações dirigidas diretamente a fortalecer as habilidades e as capacidades dos indivíduos, como também as dirigidas a modificar as condições sociais, ambientais e econômicas que impactam sobre a saúde. Consiste no processo que permite as pessoas incrementar seu controle sobre os determinantes da saúde e em consequência melhorá-la. Utiliza a educação para a saúde e a participação social como ferramenta de mudança (Health promotion is defined as the political and social process involving not only actions directed directly at strengthening individuals' abilities and capacities, but also those aimed at changing the social, environmental and economic conditions that impact on health. It consists on the process that allows people to increase their control over health determinants and, consequently, to improve health. It uses education for health and social participation as a tool for change).

Políticas, planificación, regulacón y control
Políticas, planificação, regulação e controle (Policy, planning, regulation and control) Todo sistema de salud rige su gestión de acuerdo a las políticas, planes de salud y regulaciones acordadas. Los que trabajan en el sector de la salud deben tener La capacidad para la gestión en el marco reglamentario de protección y fiscalización en salud pública y para la cooperación internacional. Deben además tener la capacidad de generación de nuevas leyes y reglamentos para el desarrollo de entornos saludables y La protección de los ciudadanos Todo o sistema de saúde rege sua gestão de acordo com as políticas, planos de saúde regulatórios e regulações acordadas. Os que trabalham no setor de saúde devem ter a capacidade de gestão no marco regulatório de proteção e fiscalização na saúde pública e para a cooperação internacional. Devem também, ter a capacidade de gerar novas leis e regulamentos para o desenvolvimento de entornos saudáveis e a proteção dos cidadãos (The entire health system governs its management according to the policies, regulatory health plans and agreed regulations. Those working in the health sector must have the management capacity in the regulatory framework of protection and enforcement in public health and for international cooperation. They must also have the capacity to generate new laws and regulations for the development of healthy environments and the protection of citizens).

Equidad em El accesso, y calidad em los servicios individuales y colectivos
Equidade ao acesso e qualidade nos serviços individuais e coletivos (Equitable access and quality of individual and public health services) Una de las condiciones esenciales en la práctica de la Salud Pública es garantizar El acceso a los servicios, los cuales deben ser otorgados universalmente sin ningún tipo de barreras, promoviendo la calidad y seguridad en su provisión y desde un enfoque multisectorial para la solución de las inequidades en la atención de salud a la población.
Uma das condições essenciais na prática de saúde pública é garantir acesso aos serviços, os quais devem ser dispensados universalmente sem nenhum tipo de barreira, promovendo a qualidade e segurança na provisão e no enfoque multisetorial para a solução das iniquidades na atenção à saúde da população (One of the essential conditions for public health practice is the guarantee of universal access to services provided without any kind of barrier, promoting quality and security in the provision and multisectoral approach for solving inequities in the care of the population's health).

Salud internacional y salud global
Saúde Internacional e saúde global (International and global health) Es el enfoque transdisciplinario que aborda la salud desde la perspectiva del derecho universal a la salud y el bienestar social. En un mundo globalizado e interconectado se requieren abordajes globales con implicaciones locales que consideren los determinantes sociales de la salud y que con equidad, ética, y respeto por los derechos humanos, se avance en soluciones transnacionales, regionales y globales que mejoren la salud de todos los ciudadanos del mundo. Utiliza como herramientas las relaciones entre las autoridades sanitarias nacionales, a través la diplomacia en salud y la cooperación técnica É o enfoque transdisciplinar que aborda a saúde desde a perspectiva do direito universal à saúde e o bem-estar social. Num mundo globalizado e interconectado se requerem abordagens globais com implicações locais que considerem os determinantes sociais da saúde e que com equidade, ética e respeito pelos direitos humanos, desenvolva soluções transnacionais, regionais e globais que melhorem a saúde de todos os cidadãos do mundo. Utiliza a ferramenta das relações entre as autoridades sanitárias nacionais, através da diplomacia na área da saúde e da cooperação técnica (It is the interdisciplinary approach that addresses health from the perspective of the universal right to health and social welfare. In a globalized and interconnected world, are required global approaches with local impact that consider the social determinants of health, and which, with equity, ethics and respect for human rights, develop transnational, regional and global solutions that improve the health of all the citizens of the world. It uses the tool of relations between national health authorities through health diplomacy and technical cooperation). Rev. Latino-Am. Enfermagem 2017;25:e2896.

Discussion
Despite the suggestions of core competencies for Latin America, in the process of translation and adaptation to the Brazilian context it was more difficult to reach consensus in the initial translation performed by three independent translators. The expert committee acted to review the versions and carry out the cultural adaptation.
The first domain, Análise da Situação de Saúde (Health Situation Analysis), describes the competencies required from public health professionals for this analysis. It can be a support instrument for decision making and health action planning by setting priorities and building prospective scenarios that consider the evaluation of health actions, programs and policies (8) . health and education, and also related to the lack of safe and healthy housing, sanitation, making certain population groups, the poorest in particular, vulnerable to disasters (9) .
In Health and education policies, when pointing guidelines for the training and performance of health professionals, take the promotion of health into consideration. This focus still persists in health services, although during operationalization and in response to demands there is greater concern with addressing the problem than with health promotion. in the epidemiological logic contributes to directing the formulation and evaluation of health policies (12) .  (13) .
The competencies of the sixth domain, Saúde Internacional e Global (International and Global Health) are as important as current, and in times of globalization, it is essential that public health professionals have such competencies. The term global health goes beyond the existing divide between the rich and poor, the developed and in development, and the national boundary lines (14)(15) . This domain is focused on the cultural, social, economic and political possibilities outlining the world scope (14) . It showed an international concern with the theme in this area, facing a new health scenario and the demand for professionals prepared for it (4) . The aim of this event was the promotion of dialogue and knowledge exchange among international scholars on areas of competency, norms and ways of ensuring quality in the preparation of professionals and specialists in health education for the practice of health promotion (16) .
The identification of these competencies aims at the development of the workforce because it is a Almeida ML, Peres AM, Ferreira MMF, Mantovani MF.
starting point and reinforcement for health organizations understanding the need for this type of investment for improving health care provision (1) . It is an institutional role to solve the population health problems efficiently and effectively, with the necessary requisites for all professionals who practice in public health, regardless of their field of activity or activity developed (2) .
More specifically, core competencies can be used for assessment of public health personnel performance in order to identify needs for training, development and planning for continuing education, and elaboration of job description. Therefore, organizations providing public health services can interpret and adapt core competencies for meeting specific organizational needs (2) .

Final considerations
The document named