The cross-cultural adaptation to Portuguese of the Trauma History Questionnaire to identify traumatic experiences

A adaptação transcultural para o português do instrumento Trauma History Questionnaire para identificar experiências traumáticas

BRIEF REPORT

The cross-cultural adaptation to Portuguese of the Trauma History Questionnaire to identify traumatic experiences

A adaptação transcultural para o português do instrumento Trauma History Questionnaire para identificar experiências traumáticas

Adriana Fiszman^{I, II}; Mariana Cabizuca^II; Claudia Lanfredi^II; Ivan Figueira^{II, III}

^IPh.D. undergraduate at the Institute of Psychiatry of the Federal University of Rio de Janeiro - UFRJ

^IIResearch group on stress-related disorders of the Institute of Psychiatry of the Institute of Psychiatry of the UFRJ

^IIIMedical School of the UFRJ

^{Correspondence}

ABSTRACT

BACKGROUND: Despite the high prevalence of exposure to traumatic events in Brazil, there are few studies on trauma and post-traumatic stress disorder. This paper presents the cross-cultural adaptation to Portuguese of the Trauma History Questionnaire.

METHODS: Two translations and their respective back-translations were made, as well as the evaluation of the semantic equivalence, the preparation of the synthesis version, the pre-testing in the target population and the definition of the final version.

DISCUSSION: Similar levels of referential meaning between the two back-translations and the original instrument were observed. Priority was given to the first translation in the decision process for the elaboration of the synthesis version. The pre-testing of this version in the target population confirmed the goal to achieve the semantic and the operational equivalence criteria. This work offers the first adaptation of a specific instrument to detect traumatic experiences in the Brazilian context.

Keywords: Stress disorder, post-traumatic; Questionnaires; Translating; Semantics

RESUMO

INTRODUÇÃO: Apesar da prevalência elevada de exposição a eventos traumáticos no Brasil, há poucos estudos sobre trauma e transtorno de estresse pós-traumático. Este artigo apresenta a adaptação transcultural para o português do Trauma History Questionnaire.

MÉTODOS: Foram feitas duas traduções e suas respectivas retraduções, avaliação da equivalência semântica, elaboração da versão síntese, pré-teste na população-alvo e realização da versão final.

DISCUSSÃO: Observaram-se níveis semelhantes de significado referencial das duas retraduções em relação ao instrumento original. Deu-se primazia à primeira tradução no processo de decisão para a elaboração da versão síntese. O pré-teste na população-alvo confirmou o objetivo de atingir os critérios de equivalência semântica e equivalência operacional. Este trabalho torna disponível a primeira adaptação para o contexto brasileiro de um instrumento específico para a detecção de experiências traumáticas.

Descritores: Transtorno de estresse pós-traumático, Questionários; Tradução (processo); Semântica

Introduction

The increasing attention for the high prevalence and morbidity of disorders related to emotional trauma¹ has spurred the development of investigation lines in this field. In Brazil, there are few theoretical and empirical studies about traumatic events and post-traumatic stress disorder, despite the high rates of exposure to car accidents and homicides.²

The study of traumatic events is important, as they are part of the diagnosis of post-traumatic stress disorder; without the occurrence of a traumatic event, according to the definition, there is no post-traumatic stress disorder. Besides, several psychiatric diagnosis have been associated with the history of trauma.³ The authors have not found in the Brazilian literature specific instruments to gauge traumatic experiences, be they developed in Portuguese or adapted from other languages.

This article presents the stages for the translation and adaptation into Portuguese of the instrument Trauma History Questionnaire (THQ).⁴ The THQ is a 24-item self-reported questionnaire which comprises the exposure to traumatic events included in the criterion A1 of post-traumatic stress disorder and acute stress disorder of the DSM-IV.⁵

The psychometric data of the THQ include high test-retest reliability within the period of 2 and 3 months and correlation between items varying from 0.47 to 1.00, with mean of 0.70.⁶ The questionnaire was employed to gauge the prevalence of trauma and post-traumatic stress disorder in different types of samples: children of Holocaust survivors,⁷ cancer patients,⁸ chemical dependence,^6,9 gynecological disorders,¹⁰ psychogenic non-epileptic crises¹¹ and severe mental disorders.¹² It is intended to describe the stages of the process of transcultural adaptation between the original THQ instrument and a Portuguese version proposed to be used in Brazil.

Methods

The process of transcultural adaptation, based on the script developed by Herdman et al,¹³ occurred in six stages: translation, back-translation, assessment of the semantic equivalence, elaboration of the synthesis version, pre-testing in the target population and elaboration of the final version.

Stage 1 consisted of two translations of the original instrument into Portuguese, independently performed by a psychiatrist and a college professor, both mastering the English language. In stage 2, the two translations (V1 and V2) were back-translated into English (R1 and R2, respectively), also independently, by two bilingual translators, who have English as their native language.

In stage 3, the authors assessed the semantic equivalence, which consists of the transference of the significance between the two languages.¹³ Firstly, it was assessed the equivalence between the original instrument and each of the back-translations (R1 and R2), considering the perspective of the transferential meaning, which is related to the degree of literal correspondence between the words.¹⁴ Next, the authors compared the general meaning of the original instrument with each Portuguese version (V1 and V2). The general significance is related to the correspondence between the words in more subtle than literal aspects, taking into account the impact that they have in the cultural context to which the instrument is being adapted.¹⁴

In stage 4, it was elaborated a synthesis version, based on discussions about the concordances and divergences arisen during the analyses performed in stage 3. Some items were incorporated from one of the two versions, integrally or modified, whereas other items resulted in the combination of the two versions. In some items, the content of this combination was modified to better meet criteria of semantic equivalence.

Stage 5 involved a pre-test of the synthesis version in a sample of the target-population which the questionnaire aims cover, in order to detect possible incongruences of significances between this version and the original instrument. The synthesis version was applied in 20 outpatients at the Federal University of Rio de Janeiro - UFRJ, with diagnosis of anxiety disorder and/or depressive disorder (DSM-IV).⁵ Ten women and ten men (aged 21 to 50 years), whose schooling levels ranged between some elementary school to high school, were assessed. From the results of this stage, the team debated, in stage 6, the need of performing modifications to elaborate the final version.

Results

Table 1 exemplifies the results of stages 1, 2 and 3 for the two first questions of the instrument. The authors have assessed the referential significance (stage 3) between the pairs of items of the original instruments and of the back-translations with scores varying from 0% to 100% (A1). The assessment of the general significance (stage 3) was performed comparing the pairs of items of the original instrument and of these translations, using a 4-level qualification: unaltered, slightly altered, much altered or totally altered (A2).

The items of the two back-translations (R1 and R2) obtained very similar percentages of referential significance regarding the items of the original instrument. As to the general significance, it remained unaltered regarding the original instrument in all items (100%) of the first translation (V1), although in only 15 items (60%) of the second one (V2).

In stage 4, the superior behavior of V1 compared to V2 caused the choice of 16 items of V1 and only three items of V2, and in six situations we decided to combine the content of both translations. The back-translation of the synthesis version into English was sent to the author of the instrument, who gave her complete approval.

Some modifications were necessary to assure the connotative and social correspondence of the final version with the original instrument. For example, in the question of natural disasters, the word 'tornado' was withdrawn, as there is no such phenomenon in our society, and it was included 'earth slide', a very usual occurrence. In other questions, it was chosen to eliminate literal translations which, although correct, have little circulation in the target population. Therefore, the expression 'risco de morte' although being the correct translation for danger of death, was replaced by 'risco de vida', risk of life, which was consecrated by its ordinary use.

In stage 5 the pre-test revealed a full understanding of the synthesis version by the target population, what confirmed the objective of achieving the criteria of semantic equivalence. The format of the final version (stage 6), its way of administration and its instructions were similar to those of the original instrument, what have also assured the accomplishment of the criteria of operational equivalence.

Discussion

This study provides the first adaptation into the Brazilian context of a specific instrument for the detection of traumatic experiences. Up to now, there is no consensus in the literature regarding the best strategy to perform transcultural adaptations. The process chosen was based on the script proposed by Herdman et al,¹³ as this is detailed and comprehensive, besides including a stage of interlocution with the members of the population to be covered by the instrument. Besides, this method has been already successfully applied in Brazil by researchers of the family violence field.^14-15

The six stages of the transcultural adaptation of the instrument Trauma History Questionnaire (THQ) achieved the objective of meeting criteria of semantic and operational criteria. However, this study has not performed the assessment of measurement equivalence. This stage consists of an important task in order to achieve the transcultural equivalence between the original instrument and the version herein proposed.¹³ Therefore, further studies should perform this task comparing the psychometric properties of the Portuguese version of the THQ to those of the original instrument.

The authors provide readers with the integral version of table 1, which displays the results of stages 1, 2 and 3, including all items of the original instrument, of the translations (V1 and V2) and of their respective back-translations (R1 and R2). The final version of the transcultural adaptation of the THQ into Portuguese, which was proposed in this study, is also available.

Acknowledgements

The author thank to Dr. Liliane Vilete for the scientific assistance and to professors Marlene Fiszman, Kelly Hayes and Beijamin Lessing for the translation.

Submitted: 31 November 2003

Accepted: 17 February 2004

Financing and conflict of interests: non-existent

Versão original aceita em português

Department of Psychiatry and Mental Health of the Federal University of Rio de Janeiro - UFRJ

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Publication Dates

• Publication in this collection
  14 Apr 2005
• Date of issue
  Mar 2005

History

• Received
  30 Nov 2003
• Accepted
  17 Feb 2004