Translation and Brazilian adaptation of the Relationship Scales Questionnaire (RSQ)

Objectives: To describe the process of translating and adapting the Relationship Scales Questionnaire (RSQ) from English into Brazilian Portuguese and to present the results of its test-retest reliability using the version developed for interview application. Methodology: The process was based on the guidelines of the International Society for Pharmaeconomics and Outcomes Research (ISPOR), which propose 10 steps for the translation and cross-cultural adaptation of self-administered instruments. The original authors of the RSQ have agreed to the translation. The interview version was applied to a sample of 43 healthy elders (≥60 years old) enrolled in a primary health care program in the city of Porto Alegre, state of Rio Grande do Sul, southern Brazil, and then reapplied. The scores of the two applications were compared using the paired sample t-test. Results: Only 6 of the 30 items required the adaptation of words or expressions to maintain its conceptual and semantic equivalence. The self-administered form of the RSQ posed difficulties for elders due to visual deficiencies and lower education level, both common in this age group, demonstrating a need for the development of a version of the RSQ in a structured interview format. Only the measure for secure attachment presented significant differences after the application of the retest, indicating reliability of the version being proposed. Conclusion: Translation of the RSQ is the first step towards the validation of an attachment evaluation instrument for use in the elderly population in Brazil, allowing for future studies on this topic.


Introduction
During the past century, the increase in life expectancy in the majority of countries has turned population aging into a worldwide phenomenon, and it occurs at an even more accelerated pace in developing countries like Brazil. 1 This demographic change will impact health services with an increased demand for treatment of chronic degenerative non-communicable diseases. Dementias are among the most common of such diseases, and are potentially onerous to health systems 2 and stand out for their prevalence of comorbidity, high risk for incapacitation, and increase in high-cost and long-term care. 3 Despite advances in the understanding of the In addition to describing the patterns of attachment in a more detailed manner, the four-category model can offer more personalized analyses, allowing for the possibility of changes in the patterns exhibited by an individual depending on instances of social relation.
Despite theoretical progress, attachment in adults is a recent area of research, with the majority of studies having been conducted with young adults. However, studies with the elderly have shown interesting results that can contribute to a better understanding of the cognitive and behavioral symptoms related to degenerative brain diseases.
In a Dutch study, Miesen investigated the connection between attachment behaviors in relation to family members, parental fixation (understood as the belief that long-deceased parents are still alive), and level of cognitive impairment in patients with Alzheimer's disease. The results showed that the stronger the cognitive impairment, the lower the attachment behavior in relation to current family members, and the higher the parental fixation manifested. Miesen theorized that the cognitive impairments associated with Alzheimer's disease complicate interactions with the environment, turning it into a constant source of stress and leading the elder to seek the proximity of family members (attachment behavior) as a way of feeling safe. Disease progression and the incapacity to recognize family members make the individual turn to older objects of attachment (parents), with parental fixation then becoming the attachment behavior itself, according to Miesen. 11 In an attempt to recreate Miesen's study, Browne & Shlosberg found an association between the pre-morbid pattern of attachment and the manifestation of attachment behaviors (for example, following caretakers or calling for them when they are out of view), with the participants classified with an avoiding pattern of attachment manifesting these behaviors more than those classified as safe. 12 Another study related the pre-morbid pattern of attachment to behavioral and psychological symptoms of dementia in individuals with dementia. 13 The authors

Methodology
The RSQ presents 30 declarative statements that express feelings and thoughts related to close relationships with people. Each of the statements must be answered according to a Likert scale ranging from 1 to 5, where 1 ("nothing like me" in the original) represents total disagreement with the statement and 5 represents total agreement ("totally like me"); answers 2 to 4 correspond to partial agreement ("somewhat like me").

Results
The sentences in the Likert scale were translated, respectively, as "nada a ver comigo," "tudo a ver comigo" and "mais ou menos a ver comigo." In relation to the statements, the translation process did not require many adaptations ( Table 2). Only 6 of the 30 items required the replacement of words or expressions to maintain the conceptual and semantic equivalence of the instrument. No comprehension difficulties were observed in relation to the declarative statements during the pilot application of the instrument. However, self-application proved to be a less than adequate format for this specific demographic group, considering the reading difficulties presented by elders with lower levels of education and those with visual impairments, both common within this age group. Therefore, the decision was made to develop another version to be applied as a structured interview.
The structured interview version was developed, starting with instructions for the interviewer on how to fill out the answers. The interviewer is oriented to read each one of the items and ask the interviewee to answer each one with "yes," "no," or "more or less." If the answer is "more or less," the interviewer should mark 3 on the Likert scale. If the answer is "yes," the interviewer should ask the interviewee to further choose between "a lot" or "totally", and then mark 4 or 5, respectively, according to the answer given.
If the answer is "no," the interviewer must ask the interviewee to choose between "a little" or "nothing," and mark 2 or 1, respectively. Just as in the interview version, only grammatical agreement was modified in order to refer to a third  9. I worry about being alone.
9. I am afraid of being alone.
9. I'm afraid of being alone.

I am comfortable
depending on other people.
10. I feel comfortable depending on others.
10. I'm comfortable if I need to depend on other people.
11. I often worry that romantic partners don't really love me.
11. I am frequently afraid that my partner does not really love me.
11. I am frequently afraid that my mate doesn't really love me.
12. I find it difficult to trust others completely.
12. I find it difficult to trust others completely.
12. I find it difficult to trust completely in other people.
13. I worry about others getting too close to me.
13. I get worried when other people are becoming too intimate with me.
13. I worry myself when other people are becoming too close to me.
14. I want emotionally close relationships.
14. I want my emotional relationships to be intimate.
14. I want my emotional relationships to be intimate.

I am comfortable
having other people depend on me.  person, with each statement beginning with "O(A) Sr(a).
[NOME] é uma pessoa que..." ("Mr. or Ms. [NAME] is a person that..."), in which the interviewer must say the name of the person about whom they wish to gather information. The instructions for the interviewer remain the same as in the interview version. In both versions, the interview and the informant versions, the statements should be read exactly as they are written in order to minimize any biases caused by differences between written and spoken languages.
In order to assess test-retest reliability, statistical analyses were conducted using the Statistical Package for the Social Sciences (SPSS) version 21.0, adopting a significance level of 5% (p<0.05). Quantitative variables were described as mean and standard deviation, with the scores being calculated using the Griffin & Bartholomew model for types of attachment 10 and compared using the paired sample t-test (Table 3).
Although the measure for secure attachment showed differences in the answers between the first and second applications, the other measures of attachment did not present differences, suggesting reliability of the final version of the instrument. We highlight some limitations of this study, such as the small sample size and the long interval between the applications.
Another aspect that should be emphasized in studies on levels of attachment in elderly individuals is that, although there is a tendency for styles of attachment to remain stable throughout one's life, the occurrence of significant life events and environmental changes may lead to modifications.

Conclusion
The Brazilian adaptation of the RSQ is the first step in the development of a standardized attachment evaluation instrument for individuals over 60 years of age. We highlight that the RSQ is designed as a research instrument and is not intended for clinical or diagnostic