Cultural adaptation and reliability of the General Comfort Questionnaire for chronic renal patients in Brazil

ABSTRACT Objective: to make the cultural adaptation and evaluate the reliability of the Brazilian version of the General Comfort Questionnaire for chronic hemodialytic renal patients. Method: methodological study with the following steps: translation; consensus among judges; back-translation; validation of equivalence (semantic, idiomatic, experimental and conceptual) by 12 judges; and pre-test with 80 chronic renal patients on hemodialysis. Reliability was checked through measures of internal consistency (Cronbach’s alpha). Results: the overall consensus of the instrument had 94.3% of equivalence. Twenty-one items of the instrument were modified. Of these, only two needed semantic and idiomatic changes. The other 19 underwent few modifications, such as reversing words in the sentence and replacing some corresponding synonym terms. The Cronbach’s alpha was 0.80, indicating optimal internal consistency. In the application, the total score ranged from 116 to 172 points (M = 151.66; SD = ± 12.60). Conclusion: the validation of the Portuguese version of the instrument represents one additional resource to be made available to nephrologist nurses; it will aid in directing the decision-making so that the nursing interventions be performed according to the level of comfort and domain, either physical, socio-cultural, environmental or psycho-spiritual. The tool was named in Portuguese: General Comfort Questionnaire - Brazilian version.


Introduction
The need for comfort is common to all people at any stage of their life cycle. However, in situations when health is compromised, in the presence of a disease, in socially vulnerable situations or others that leave people more vulnerable, this concept gains particular interest, given its scope and applicability.
Comfort is an individual and subjective concept,

Method
Methodological study, quantitative, with crosssectional design. The cultural adaptation and validation of the GCQ, used to measure the comfort level of patients based on self-perception, was carried out.
The process was carried out in accordance with international standards for adaptation of measuring instruments (10) , and involved six sequential steps: initial

Results
Before the process of validation of equivalences carried out by the judges, a general equivalence of 94.3% was obtained. Regarding the validity of the instrument, the reviewing committee indicated a consensus of 100% of concordance in 27 items of the instrument, evaluating them as pertinent and ensuring their semantic, cultural, idiomatic and conceptual coherence, which did not undergo any changes.
Twenty-one items of the instrument were modified.
Of these, only two (items 37 and 41) underwent semantic and idiomatic changes ( Figure 1).  "My condition depresses me", the term "depresses me" was suggested to be replaced by "makes me sad," since not everyone knows the term "depressed".
In the question 10, "I feel motivated by knowing that I am loved" was suggested to be modified to "I feel satisfied knowing that I am loved", because the term motivated is far from reality of the study population.
In the question 12, "The sounds keep me from resting" was suggested to be rephrased as "The noise keeps me from resting", since two judges justified that the expression used is considered abstract and generalist, taking into consideration that some people initiate and maintain a pattern of sleep while listening to instrumental songs (sounds) capable of favoring muscle relaxation. With this, it was decided to change the term to "noise", as this is more suitable to the idea conveyed by the item.
In the question 15, "I am inspired to do my best", it was suggested that the term "inspired" be replaced by "determined"; and in the question 21, "This environment makes me feel scared" was suggested to be modified to "This environment makes me afraid". The changes were justified by the better known words.  Regarding the application of the QCG -Brazilian version, interviews were preferred instead of self-report, and the time needed to fill the instrument ranged from  (Table 1). However, in view of the importance of the item for comfort assessment, we decided to keep it. may improve the sense of comfort and well-being. (17) Another item that generated discussion was the item 41; the term "miserable" has a very strong connotation in the Portuguese language, and it was agreed among all the judges to replace it by "uncomfortable", to smooth the question.

Discussion
The last step, the face-to-face meeting with the judges was essential to enrich the process, ensuring an improved pre-final version. The comprehension of all items was evaluated in the pre-test, and none was excluded. Only changes in the order of the sentences and/ or search for synonym terms for a better understanding were done.
It should be emphasized that the process of translation and cultural adaptation of an instrument requires a greater effort, involving more than just language and semantic aspects; it is necessary to adapt the terms from the cultural and conceptual point of view of the reality of the study population, considering its uniqueness to identify the construct to be measured. (18) In this study, the validation of the QCG was carried out with nephropathic patients in hemodialysis therapy, which constituted a clientele subjected to long, chronic and difficult coping processes. The comfort construct has been applied to several clinical and epidemiologically distinct clienteles in order to verify how this dimension relates to care and selfcare in the perspective of understanding how the level of comfort can positively or negatively influence the therapeutic processes in health. (20) A systematic review identified that the relationships between self-care and the outcome comfort did not present strong evidence for a clientele that had undergone chemotherapy/radiation therapy to control cancer, thus raising the need for more comprehensive studies. (21) Regarding the applicability of the Scale for

Evaluation of Comfort in Patients Admitted to Psychiatric
Clinic Services (ECIP), it was verified that the internal consistency of the instrument obtained a Cronbach's alpha ranging from 0.72 to 0.91, and the psychospiritual and transcendence dimensions presented greater discomfort, that is, lower comfort. (22) In turn, the End of Life Comfort Questionnaire in its Another limitation to be mentioned is that the study did not consist in the allocation of items in the dimensions of the construct proposed by the comfort theory. This step, as well as the clinical validation will be, therefore, carried out in later studies.

Conclusion
The adaptation steps of the GCQ allowed the