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Translation and Cultural Adaptation to Brazilian Portuguese of the Children‘s Physical Activity Questionnaire (C-PAQ)* * Work developed at the Graduate Program in Health Sciences Applied to Sports and Physical Activity, Department of Orthopedics and Traumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil.

Resumo

Objetivo

Realizar a tradução e adaptação cultural para o português do Brasil do Children's Physical Activity Questionnaire.

Métodos

O processo envolveu as etapas de tradução, síntese, retrotradução, e revisão pelo grupo de tradução. Foi então criada uma versão pré-final e, posterior- mente, a versão final do questionário.

Resultados

Devido ao estilo de vida da população, oito atividades descritas no questionário foram mudadas com o objetivo de adaptá-lo à cultura brasileira, sendo seis atividades esportivas e duas atividades de lazer. Oito pais/responsáveis responderam o questionário no pré-teste, com rapidez, sem inconsistências, e sem relatar dificuldades no entendimento quando realizada a entrevista final.

Conclusão

A tradução e adaptação cultural do Children's Physical Activity Questionnaire para o português do Brasil resultou na versão C-PAQ.PT.

Palavras-chave
⧐ exercício físico; ⧐ monitores de aptidão física; ⧐ criança; ⧐ pesquisas e questionários; ⧐ tradução; ⧐ características culturais; ⧐ COVID-19

Introduction

Accelerometers are instruments that act as motion sensors and enable the assessment of the level and frequency of physical activity in children. Its use enables the immediate collection of information, with low cost and great applicability, considering different contexts and the practice of physical activities.11 Bender JM, Brownson RC, Elliott MB, Haire-Joshu DL. Children's physical activity: using accelerometers to validate a parent proxy record. Med Sci Sports Exerc 2005;37(08):1409–1413,22 Cain KL, Sallis JF, Conway TL, Van Dyck D, Calhoon L. Using accelerometers in youth physical activity studies: a review of methods. J Phys Act Health 2013;10(03):437–450 In situations which require social isolation, such as during the pandemic caused by coronavirus disease 2019 (COVID-19), the use of an accelerometer for this kind of research becomes virtually impossible. Therefore, we have sought in the literature other forms that would enables us to assess the level and frequency of physical activity in children without compromising social isolation.

Self-reported questionnaires on physical activity routines are used on a large scale as an option to monitor children. There are several questionnaires, for different age groups, and most have been validated by the comparison with the concomitant use of accelerometers.33 Baster field L, Adamson AJ, Parkinson KN, et al. Surveillance of physical activity in the UK is fl awed: validation of the Health Survey for England Physical Activity Questionnaire. Arch Dis Child 2008;93(12):1054–105866 Welk GJ, Corbin CB, Dale D. Measurement issues in the assessment of physical activity in children. Res Q Exerc Sport 2000;71(2 Suppl)S59–S73 The Children's Physical Activity Questionnaire (C-PAQ) is a tool that can be accessed freely, and is available for download on the website of the Medical Research Council Epidemiology Unit/Univer- sity of Cambridge School of Clinical Medicine (https://www. mrc-epid.cam.ac.uk/wp-content/uploads/2014/08/CPAQ. pdf). The original questionnaire in English has been previously validated77 Corder K, van Sluijs EM, Wright A, Whincup P, Wareham NJ, Ekelund U. Is it possible to assess free-living physical activity and energy expenditure in young people by self-report? Am J Clin Nutr 2009;89(03):862–870and used in a previous study.88 Anderson YC, Wynter LE, Grant CC, et al. Physical activity is low in obese New Zealand children and adolescents. Sci Rep 2017; 7:41822 In our opinion, the advantages of the C-PAQ over the other questionnaires are the fact that it consists of questions on different activities commonly practiced by children, such as sports, leisure, and school activities, as well as sedentary behaviors. Due to these characteristics, we consider this tool to be ideal to evaluate the impact of the social isolation resulting from the COVID- 19 pandemic on the activities of children and adolescents living in Brazil. The translation and cultural adaptation of a self-assessment questionnaire requires little time when compared to the time required to develop a brand-new questionnaire. This methodology enables the use of instruments to perform comparisons between groups who speak different languages and have different cultures, and they are very useful in th clinical practice.99 Ferreira MC, Silva G, Zidan FF, Franciozi CE, Luzo MVM, Abdalla RJ. Tradução e adaptação cultural para a língua portuguesa do instrumento de avaliação para artroplastias de quadril e joelho Forgotten Joint Score. Rev Bras Ortop 2018;53(02):221–2251313 Fernandes CH, Neto JR, Meirelles LM, Pereira CN, Dos Santos JB, Faloppa F. Translation and cultural adaptation of the Brief Michigan Hand Questionnaire to Brazilian Portuguese language. Hand (N Y) 2014;9(03):370–374

The main objective of the present study was to translate and validate the C-PAQ to Brazilian Portuguese.

Materials and Methods

The preent study was sent to the research ethics committee by our university, and it was approved in May 2020. All parents/legal guardians signed the consent form electronically.

Children's Physical Activity Questionnaire (C-PAQ)

Initially, the questionnaire presents blanks to be filled out with data to identify the child, such as name, date of birth, and the relation of the legal guardian who will fill out the questionnaire. Then, a brief explanation and guidance regarding the completion of the questionnaire are provided. The C-PAQ consists of questions regarding the practice by the child of different daily activities, including sports, leisure, and school activities, and sedentary behaviors. The parents or legal guardians should provide answers considering the activities performed by the child in the seven days preceding the completion of the questionnaire. In order to make the questionnaire easier to understand by the parents, there is an example with a hypothetical question and the correct way to answer it. After each question about participation in each activity, the answer options are simple: YES or NO. In case of an affirmative answer, the intensity is evaluated by the number of hours that dedicated to the performance of each activity, both on weekdays and on weekends.

The data contained in a completed questionnaire enables the calculation of the number of hours/minutes spent by the child in the performance of each activity within seven days.77 Corder K, van Sluijs EM, Wright A, Whincup P, Wareham NJ, Ekelund U. Is it possible to assess free-living physical activity and energy expenditure in young people by self-report? Am J Clin Nutr 2009;89(03):862–870,88 Anderson YC, Wynter LE, Grant CC, et al. Physical activity is low in obese New Zealand children and adolescents. Sci Rep 2017; 7:41822

The process of translation and cultural adaptation

Due to their importance in the literature, we decided to use the works by Beaton et al.1414 Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine 2000;25(24):3186–3191 and Guillemin et al.1515 Guillemin F, Bombardier C, Beaton D. Cross-cultural adaptation of health-related quality of life measures: literature review and proposed guidelines. J Clin Epidemiol 1993;46(12):1417–1432 as guidelines for the entire process of translation and cultural adaptation. This methodology follows the specific stages of initial translations and synthesis of translations, back-translation, review by an expert committee, and the pretest, until reaching the final version.

With the cultural adaptation, we can consider the cultural differences in the perception of health, language, cultural context, and lifestyle of the population in question. Through these methods, it is possible to maintain the linguistic and cultural equivalence of the items of the instrument, as well as their relevance, even with the modifications made.

Stage 1

The original C-PAQ was initially translated from English to Brazilian Portuguese by two translators, fl uent in both languages, who developed two versions of the questionnaire (B1 and B2).

Stage 2

Questionnaires B1 and B2 were evaluated, compared, and synthesized by two researchers responsible for the study, resulting in questionnaire B12.

Stage 3

A new translation of the B12 questionnaire into English was made, also by two translators fl uent in both languages, without prior knowledge of the original version, resulting in questionnaires B12.1 and B12.2.

Stage 4

At that time, all documents, original classifications, and translations (B1, B2, B12, B12.1, and B12.2) were reevaluated by an interdisciplinary committee. The committee was composed of the researchers, a PhD student in economics fl uent in both languages, a physiotherapist, and a previously-selected legal guardian of one child participating in the study who was fl uent in English. All discrepancies and misinterpretations were evaluated, reaching a prefinal version (B13).

Stage 5

In this pretest, version B13 was applied to a sample of the target population and, based on the answers, any changes the committee deemed necessary to improve understanding were made. The process ended with the final questionnaire.

Results

Due to the lifestyle of the population in question, the activities contained in the original version that are not commonly performed in Brazil were replaced by activities commonly performed in the country, with the objective of adapting it to the Brazilian culture. The changes are summarized in ⧐Table 1. The sports activities contained in the C-PAQ were arranged s follows: aeróbica, base 4, basquete/vôlei, queimada, dança, futebol, ginástica, handebol, lutas, rouba- bandeira, jogo de taco, corrida, aulas de natação, natação por diversão, and tênis. The leisure activities were arranged as follows: andar de bicicleta (exceto à escola), empinar pipa, jogar boliche, realizar tarefas domésticas, brincar de casinha, brincar no parquinho, brincar com bichos de estimação, andar de patins, de patinete, de skate, brincar de polícia e ladrão, pular corda, brincar de pega-pega (todos os tipos), caminhar com o cachorro, and caminhada/trilha. The school activities werethusarranged:auladeEducaçãoFísica,ir paraaescolaa pé (ida e volta), and ir para a escola de bicicleta (ida e volta). And the sedentary behaviors were arranged as follows: assistir a TV/vídeos, fazer arte e artesanato, fazer desenho e pintura, fazer a lição de casa, brincar de faz de conta, escutar música, brincar com brinquedos dentro de casa, jogar jogos de tabuleiro/cartas, jogar jogos de computador, brincar com eletrônicos, celular e tablet, tocar instrumento musical, leitura, sentar-se e conversar, falar ao telefone, ir e voltar para escola de carro ou ônibus, and navegar na internet ou outras atividades.

Table 1
Summary of changes in activities due to the lifestyle of the Brazilian population

In the pretest, the questionnaire was sent to eight parents, who filled it out and returned it. All questions were answered, and we did not observe inconsistencies in the answers. We made contact by telephone for an interview with the parents, who reported not having had difficulty answering the questions.

After the last stage, the prefinal version (B13) of the translation and cultural adaptation to Brazilian Portuguese of the C-PAQ was established. We named this final version C-PAQ.PT (⧐Appendix 1, online version only).

Discussion

The pandemic caused by COVID-19 has impacted the everyday life of children around the world. Social distancing directly refl ected on the intensity and frequency of sports and leisure activities. In the education of children and youths, it is essential to ensure a daily routine regarding physical activity habits to maintain a healthy life.

The C-PAQ enables an assessment that is low cost, easy to apply, and well accepted by the participants due to agility in data collection.77 Corder K, van Sluijs EM, Wright A, Whincup P, Wareham NJ, Ekelund U. Is it possible to assess free-living physical activity and energy expenditure in young people by self-report? Am J Clin Nutr 2009;89(03):862–870,88 Anderson YC, Wynter LE, Grant CC, et al. Physical activity is low in obese New Zealand children and adolescents. Sci Rep 2017; 7:41822 Despite containing 49 questions, the answers are simple, and the questionnaire can be filled out in approximately 10 minutes.

The decrease in the frequency and intensity of physical activity among children during the period of social isolation prompted by COVID-19 may impact the orthopedic practice. Raitio et al.1616 Raitio A, Ahonen M, Jääskelä M, et al. Reduced Number ofPediatric Orthopedic Trauma Requiring Operative Treatment during COVID-19 Restrictions: A Nationwide Cohort Study. . [published online ahead of print, 2020 Oct 26]Scand J Surg 2020;110(02): 254–257 observed a significant decrease in surgical procedures due to injuries related to daily, school and sports activities performed by children during the period of social isolation. In an Italian trauma center,1717 Gumina S, Proietti R, Villani C, Carbone S, Candela V. The impact of COVID-19 on shoulder and elbow trauma in a skeletally immature population: an Italian survey. JSES Int 2021;5(01):3–8 the number of pediatric patients decreased by 84.6% in this period, with no observed cases of trauma related to injuries at school, high-energy lesion, or lesions due to the practice of sports. However, a sedentary lifestyle in children is related to obesity, which in turn is related to orthopedic complications during the child's growth and development.1818 Taylor ED, Theim KR, Mirch MC, et al. Orthopedic complications of overweight in children and adolescents. Pediatrics 2006;117(06): 2167–2174

The methods of translation and cultural adaptation are widely described and used for the evaluation, follow-up and comparison of different conditions or situations in the clinical practice of orthopedics and sports medicine.8,11,19 Cultural adaptation is performed through two basic components: translation of the instrument from its original language to another, and its adaptation to the culture and lifestyleof the populationtowhom it will beapplied.1414 Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine 2000;25(24):3186–3191 In this process, certain situations or questions may be completely or partially changed. These changes, however, must maintain the same characteristics as those of the original instrument to ensure the same measurement.2020 Dortas Junior SD, Lupi O, Dias GA, Guimarães MB, Valle SO. Adaptação transcultural e validação de questionários na área da saúde. Braz J Allergy Immunol 2016;4(01):26–30 The original C-PAQ is objective, contains short questions and answers, which facilitated the work of literal translation from English to Brazilian Portuguese. However, our greatest difficulty was regarding questions about sports activities that are not practiced by children in Brazil. This situation is described as experience equivalence, when a particular activity cannot be performed, even if it can be translated. In this situation, the term should be replaced by another term that indicates something that can be carried out by the target population of the translation.2020 Dortas Junior SD, Lupi O, Dias GA, Guimarães MB, Valle SO. Adaptação transcultural e validação de questionários na área da saúde. Braz J Allergy Immunol 2016;4(01):26–30 As recommended by Reichenheim et al.,2121 Reichenheim ME, Moraes CL. Operacionalização de adaptação transcultural de instrumentos de aferição usados em epidemio- logia. Rev Saude Publica 2007;41(04):665–673 we promoted discussions with experts and consulted members of the target population to exchange and approve the equivalence of the items. As described in ⧐Table 1,the activities not commonly practiced by children in Brazil were substituted for activities practiced in our country, trying to maintain the same level of intensity. In the changes in question, a physical activity little practiced in Brazil was substituted for another physical activity practiced more frequently. Thus, the physical activity ‘Skiing, snowboarding, sledging' was substituted for another frequent physical activity, in this case, the game called polícia e ladrão (cops and robbers), without the need to choose a physical activity that uses a board. We must keep in mind that the C-PAC assesses not only the intensity of the physical activity, but also leisure activities, school activities and sedentary behaviors. What we could not do would be to substitute a physical activity for a non-physical activity. The establishment of an interdisciplinary committee in stage 4 of the process has the goal of avoiding biases related to the authors' preferences regarding the cultural adaptation, such as the preference for a type of physical activity, and regarding the translation, to avoid technical jargon not commonly used by people.

The pretest, which comprises the application of the questionnaire to a small target population, has a minimum recommended number that ranges from ten to forty participants.1414 Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine 2000;25(24):3186–31912222 Baiardini I, Bousquet PJ, Brzoza Z, et al. Recommendations for assessing patient-reported outcomes and health-related quality of life in clinical trials on allergy: a GA(2) LEN taskforce position paper. Allergy 2010;65(03):290–295 Regarding its structure, the questionnaire consists of words used in the daily life of any person, such as the types of activities, yes or no answers, and time measurements such as minutes, hours and days of the week. This feature of the questionnaire prevents us from getting different individual responses or lower or higher scores. In our research, the pretest was only applied to eight participants; we considered this number sufficient due to the speed with which we received the answers, the consistency of these answers, and the result of the interview with parents/legal guardians, who reported its easy understanding and completion. To evaluate the final version, the C-PAQ.PT, we started a research to assess the impact of social isolation on the activities of children and adolescents; data from 136 questionnaires are being compiled, and they will become the topic of the study.

As Brazil is a country with a large area, with some internal cultural differences, we believe that the few substitutions made do not affect the structure of the questionnaire, which contains a many different options of physical activities.

Conclusion

We consider that the C-PAQ has been translated and culturally validated to Brazilian Portuguese, which we called C-PAQ.PT.

References

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    Cain KL, Sallis JF, Conway TL, Van Dyck D, Calhoon L. Using accelerometers in youth physical activity studies: a review of methods. J Phys Act Health 2013;10(03):437–450
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    Baster field L, Adamson AJ, Parkinson KN, et al. Surveillance of physical activity in the UK is fl awed: validation of the Health Survey for England Physical Activity Questionnaire. Arch Dis Child 2008;93(12):1054–1058
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    Corder K, van Sluijs EM, Wright A, Whincup P, Wareham NJ, Ekelund U. Is it possible to assess free-living physical activity and energy expenditure in young people by self-report? Am J Clin Nutr 2009;89(03):862–870
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    Anderson YC, Wynter LE, Grant CC, et al. Physical activity is low in obese New Zealand children and adolescents. Sci Rep 2017; 7:41822
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    Ferreira MC, Silva G, Zidan FF, Franciozi CE, Luzo MVM, Abdalla RJ. Tradução e adaptação cultural para a língua portuguesa do instrumento de avaliação para artroplastias de quadril e joelho Forgotten Joint Score. Rev Bras Ortop 2018;53(02):221–225
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    Fernandes CH, Neto JR, Meirelles LM, Pereira CN, Dos Santos JB, Faloppa F. Translation and cultural adaptation of the Brief Michigan Hand Questionnaire to Brazilian Portuguese language. Hand (N Y) 2014;9(03):370–374
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    Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine 2000;25(24):3186–3191
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    Guillemin F, Bombardier C, Beaton D. Cross-cultural adaptation of health-related quality of life measures: literature review and proposed guidelines. J Clin Epidemiol 1993;46(12):1417–1432
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    Raitio A, Ahonen M, Jääskelä M, et al. Reduced Number ofPediatric Orthopedic Trauma Requiring Operative Treatment during COVID-19 Restrictions: A Nationwide Cohort Study. . [published online ahead of print, 2020 Oct 26]Scand J Surg 2020;110(02): 254–257
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    Gumina S, Proietti R, Villani C, Carbone S, Candela V. The impact of COVID-19 on shoulder and elbow trauma in a skeletally immature population: an Italian survey. JSES Int 2021;5(01):3–8
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    Taylor ED, Theim KR, Mirch MC, et al. Orthopedic complications of overweight in children and adolescents. Pediatrics 2006;117(06): 2167–2174
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    Silva ALP, Croci AT, Gobbi RG, Hinckel BB, Pecora JR, Derange MK. Translation and validation of the new version of the Knee Society Score - The 2011 KS Score - into Brazilian Portuguese. Rev Bras Ortop 2017;52(04):506–510
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    Dortas Junior SD, Lupi O, Dias GA, Guimarães MB, Valle SO. Adaptação transcultural e validação de questionários na área da saúde. Braz J Allergy Immunol 2016;4(01):26–30
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    Reichenheim ME, Moraes CL. Operacionalização de adaptação transcultural de instrumentos de aferição usados em epidemio- logia. Rev Saude Publica 2007;41(04):665–673
  • 22
    Baiardini I, Bousquet PJ, Brzoza Z, et al. Recommendations for assessing patient-reported outcomes and health-related quality of life in clinical trials on allergy: a GA(2) LEN taskforce position paper. Allergy 2010;65(03):290–295

Publication Dates

  • Publication in this collection
    17 Dec 2021
  • Date of issue
    Nov-Dec 2021

History

  • Received
    24 Feb 2021
  • Accepted
    15 June 2021
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