Sexual risk behavior assessment schedule for adults: translation and cross-cultural adaptation into brazilian portuguese

Abstracts

INTRODUCTION: A systematic and detailed investigation of sexual risk behaviors is one of the main foundations in the development of research projects aimed at designing effective interventions for HIV prevention. OBJECTIVE: This paper presents and discusses the stages of the translation and cross-cultural adaptation of male and female versions of the Sexual Risk Behavior Assessment Schedule for psychiatric patients into Brazilian Portuguese, carried out by the Interdisciplinary Project in Sexuality, Mental Health and AIDS. METHODS: Training of Brazilian investigators in the original questionnaire, comparison between translation and back-translation, followed by linguistic and cultural adaptation in the light of the project formative phase were performed, resulting in a version used to train Brazilian interviewers in interviewing psychiatric patients. Language verification, qualitative reliability and interrater reliability were used to complement the final version of the instrument. RESULTS: Elimination and addition of instrument sections and items covering both conceptual and structural aspects were carried out. Incorporation of formative findings from the pilot study and linguistic changes in terms of register were also performed.

Questionnaires; risk behavior; cross-cultural comparison; communicable disease prevention; intervention studies

INTRODUÇÃO: A investigação sistemática e detalhada dos comportamentos sexuais de risco constitui um dos principais alicerces para o desenvolvimento de pesquisas que visam à criação de intervenções eficazes para a prevenção do HIV. OBJETIVO: Descrever e discutir as etapas do processo de adaptação lingüístico-cultural das versões masculina e feminina da Escala de Avaliação de Comportamento Sexual de Risco para pacientes psiquiátricos para o português brasileiro pelo Projeto Interdisciplinar em Sexualidade, Saúde Mental e AIDS. MÉTODOS: Treinamento dos investigadores brasileiros no instrumento original, comparação da tradução e da retrotradução, seguida de adaptação lingüístico-cultural à luz da fase formativa do projeto, resultando em uma versão utilizada no treinamento dos entrevistadores brasileiros em entrevistas com pacientes psiquiátricos. Verificação lingüística, confiabilidade qualitativa do instrumento e confiabilidade entre entrevistadores constituíram as etapas complementares para a versão final do questionário. RESULTADOS: Exclusão e adição de seções e itens da escala, tanto nos aspectos conceituais quanto estruturais, foram realizadas, bem como a incorporação de achados resultantes da fase formativa do piloto da pesquisa e mudanças lingüísticas relativas ao registro empregado.

Questionários; comportamento de risco; comparação transcultural; prevenção de doenças transmissíveis; estudos de intervenção

ORIGINAL ARTICLE

Sexual risk behavior assessment schedule for adults: translation and cross-cultural adaptation into brazilian portuguese

Diana de Souza Pinto^I; Carlos Linhares Veloso Filho^II; Milton L. Wainberg^III; Paulo Eduardo Luís de Mattos^IV; Heino F. L. Meyer-Bahlburg^V

^IPhD. Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil

^IIMSc., Collective Health, UFRJ

^IIIAssociate Clinical Professor of Psychiatry, Columbia University, NY, USA

^IVPostdoctorate, Psychiatry, UFRJ

^VPhD, Clinical Psychology. Associate director, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY, USA

^{Correspondence}

ABSTRACT

INTRODUCTION: A systematic and detailed investigation of sexual risk behaviors is one of the main foundations in the development of research projects aimed at designing effective interventions for HIV prevention.

OBJECTIVE: This paper presents and discusses the stages of the translation and cross-cultural adaptation of male and female versions of the Sexual Risk Behavior Assessment Schedule (SERBAS) for psychiatric patients into Brazilian Portuguese, carried out by the Interdisciplinary Project in Sexuality, Mental Health and AIDS (PRISSMA).

METHODS: Training of Brazilian investigators in the original questionnaire, comparison between translation and back-translation, followed by linguistic and cultural adaptation in the light of the project formative phase were performed, resulting in a version used to train Brazilian interviewers in interviewing psychiatric patients. Language verification, qualitative reliability and interrater reliability were used to complement the final version of the instrument.

RESULTS: Elimination and addition of instrument sections and items covering both conceptual and structural aspects were carried out. Incorporation of formative findings from the pilot study and linguistic changes in terms of register were also performed.

Keywords: Questionnaires, risk behavior, cross-cultural comparison, communicable disease prevention, intervention studies.

Introduction

Studies aimed at designing interventions to prevent HIV have faced many challenges over the past decades. Forms of virus propagation, such as using injectable drugs and engagement in sexual intercourse without condoms, are often associated with socially and culturally discriminated behaviors and attitudes,^1-3 as well as with stereotyped conceptions of the previously called risk groups.⁴ A systematic and detailed knowledge of sexual risk behaviors is one of the main foundations in the development of research projects aimed at designing efficacious programs for HIV prevention. Such situation is urgent when treating extremely vulnerable populations to the virus, as in the case of patients with severe mental illness (SMI), whose rates are three to five times higher than that of the general population.⁵ SMI comprises individuals with diagnoses of schizophrenia, schizoaffective disorder, schizophreniform disorder, bipolar disorder, major depressive disorder with psychotic symptoms and psychosis no otherwise specified. In Brazil, specifically in Belo Horizonte, Almeida,⁶ in her original study on HIV seroprevalence in users of mental health services, found rates five times higher than that of the general population.

The Interdisciplinary Project on Sexuality, Mental Health and AIDS (Projeto Interdisciplinar em Sexualidade, Saúde Mental e Aids - PRISSMA) is a collaborative study - University of Columbia (USA), Institute of Psychiatry at Universidade Federal do Rio de Janeiro (IPUB/UFRJ) and the Brazilian AIDS Interdisciplinary Association (ABIA) - sponsored by the National Institute of Mental Health (NIMH) (protocol number R01MH65163), which assessed feasibility of designing and applying a new intervention to prevent HIV transmission in male and female adults with SMI users of mental health services.

Efficacious American interventions for HIV prevention, previously tested in the USA,^7-12 were adapted through a participatory research model,¹³ based on local characteristics and cultural needs, investigated by means of ethnographic methods and cultural adaptation.^14-21 This process of cultural adaptation followed the required stages observed by the researchers after an extensive review of the literature on intervention adaptation.^15-18

Due to the absence of Brazilian standard instruments to assess sexual risk behaviors in this population, PRISSMA performed the cross-cultural adaptation of male and female versions of the Sexual Risk Behavior Assessment Schedule (SERBAS) for adults with SMI, an instrument which has shown to be reliable in the collection of information about such behaviors specifically over the past 6 months.¹⁹ This paper describes the stages of linguistic and cultural adaptation of the SERBAS instrument into a Brazilian version for male and female adults with SMI adopted by PRISSMA feasibility project^14,20,21 Those versions will also be used in the next stage, randomized clinical study, submitted to NIMH.

Instrument description

SERBAS, in its male and female versions, is a semi-structured interview, mostly comprised of closed questions. It was originally developed and validated in the USA, with the aim of collecting detailed information about sexual practices and alcohol and drug consumption related to them, and it was used in studies on different populations, including patients with SMI of both genders.^11,19,22-24 SERBAS assesses sexual risk behaviors over the past 3 months, and the original American version resulted from a compilation of other versions developed for different research projects, in which characteristics of investigated populations (age, gender, sexual orientation, ethnic group), study focus (defined by results and dependent variables), details of sexual behavior and available time for instrument application were considered. SERBAS proved to be a flexible instrument, as it allows adaptations required to several issues found in research studies.

The original SERBAS, used with SMI, has 60 questions, with four tables to facilitate register of varied information by the interviewer. In its introduction, there are instructions for the interviewer about how to explain the interview theme to make the interviewee feel comfortable; next is the "terminology" section, in which terms regarding body parts and sexual practices (that will be used along the interview) are explained. For each term (for example: vagina, penis, etc.), the interviewee is requested to present his preference correlates, which will then be used through the whole interview. Next, there is a section of questions about opposed sex partners that includes definition of type of partner (if casual or steady), knowledge about partner's serology and sexual practices (vaginal, oral and anal sex) with each one of them and occasional protections used, as well as sexual exchanges (sex for money, drugs or shelter). The following section, which has a similar structure, assesses knowledge of sexual practices with partners of the same sex, when present. Questions about protection and prevention methods integrate the last section, followed by a closing section and an interviewer's assessment about interview quality. Mean duration of application of both versions was dependent on number of sexual partners and activities reported by the participants. Detailed assessment²² of SERBAS about sexual behavior, use of condom, type of partners, sexual exchanges and use of substances associated with risk allow a range of resulting variables for further analysis.

Reliability of 3-month follow-up interviews to assess key variables for sexual risk behaviors was considered between acceptable and excellent in studies with marginal populations, such as homeless individuals with SMI,²⁵ psychiatric inpatients and outpatients¹⁹ and homosexual urban adolescents.^26,27

Method

Cross-cultural adaptation

Linguistic and cultural adaptation of SERBAS, in its male and female versions into Brazilian Portuguese, developed by PRISSMA team, approved by the authors, followed the methodological stages presented in Figure 1:

^{Click here to enlarge}

a) Training of Brazilian members of the research team was carried out in the USA by the authors of the instrument. Interviews, conducted with sexually active outpatients with SMI at two different psychiatric institutions in New York City, were followed by supervision and discussion of adaptation issues, aiming at future comparisons with other research projects in which SERBAS was used.

b) Translation into Brazilian Portuguese and further back-translation into English by two different teams of experienced bilingual translators to allow quality control; original and back-translated versions were compared by two bilingual researchers of the project and authors of this article, experienced in mental health research projects, one anthropologist, who had worked as an interviewer of the original instrument, in the male version,^11,23 and one linguist to assess content, form, presentation/formatting discrepancies. Discrepancies found in both versions in English were contrasted to assure correspondence of sense translation and analyzed by two bilingual researchers - the linguist who had participated in the previous stage and a psychiatrist experienced in clinical and research work. The next step was to assure instrument adequacy to the context of local populations.

c) Linguistic and cultural adaptation was informed by results of PRISSMA formative stage, in which ethnographic methods were used (ethnographic observations, focus groups and interviews with key informants) that generated a wide understanding of beliefs, norms and attitudes related to sexuality, sexual identity and sexual (risk) behaviors.^14,20,28 Comparison transcended the literal sense of words, expressions and structures, as it incorporated sociocultural aspects involved in any situation of language use.²⁹ The terms presented in the initial terminology section, used to describe body parts, sexual practices and activities, deserved special attention, due to the possible impact on the target population and to the importance of this section for the whole interview development. Adaptations of linguistic and style register were considered essential, since questions should be clear and quickly understood by interviewees. Discrepancies were registered, and sections in Portuguese were then reviewed by two bilingual researchers of the Brazilian team to assure accuracy; these researchers also incorporated linguistic messages and labels resulting from ethnographic focus groups and qualitative interviews.^14,20

d) Training³⁰ of version 3 included a total of 30 hours. Two research assistants, psychology graduates (one male, one female) who would be conducting SERBAS interviews in the PRISSMA feasibility project, were trained. Training included interviews with patients in the satellite outpatient clinic and was initially conducted by the research coordinator of the American team, who had already worked as interviewer in previous studies.¹¹ This training aimed at making interviewers familiar with the correct sequence of instrument sections, stressing the most adequate ways to ask questions to make interviewees more comfortable during investigation of aspects concerning identity, sexual practices and activities.

e) This second version was tested between two research assistants - two psychologists of the same gender - under supervision of the psychiatric researcher. The latter helped consolidate this adapted version, with the aim of assessing interviewers' comfort to approach instrument themes. All interviews with 10 patients (five women and five men) at the satellite clinic day-hospital were recorded in video, with the camera zooming on the interviewer to maintain confidentiality, according to the consent term, read and signed by interviewees. Interviews were monitored by a second interviewer who had her/his own instrument to record information. Answers recorded by the interviewer and the monitor were later compared. This stage aimed at examining and analyzing interviewers' comfort in a real interview situation with psychiatric patients, as well as observing quality of information obtained. Audio and video recordings for these interviews and notes were discussed in group supervision. Constant exchange of interview experiences, based on interviewers' feedbacks, allowed for a standardized application of the instrument. This period was used as a reference of sexual risk behaviors ("Can you remember anything that happened in your life around 3 months ago that makes that period quite remarkable to you?").

f) A linguistic verification was performed (debriefing), with the aim of analyzing to what extent interviewers understood the content of each question. For this stage, six patients of both genders (three women, three men) from the satellite clinic day-hospital were interviewed. Soon after each interviewee's answer for each instrument question, the interviewer asked: "What did I just ask you?" This brief period of time between instrument question and verification of its understanding was considered essential due to cognitive symptoms that can be present in the SMI population. Discrepancies as to question understanding were then recorded in writing by the interviewer and observer/assistant researcher of the interview. Notes and audio recordings subsidized supervision group meetings, in which misunderstandings were discussed.

g) Results of the previous stage were incorporated in a third and final version, submitted to reliability assessment using a test/retest procedure. Nine patients of both genders (four women and five men) were interviewed twice for up to a 1-week period to verify replication and quality of answers by different interviewers. Results of both interviews were compared. The Brazilian version of SERBAS (SERBAS-B) showed excellent test/retest reliability for the past 3 months in relation to sexual activity (kappa = 1.0) and reasonable to good agreement in frequency of anal and vaginal sex, including occasions of unprotected sex (interclass correlation = 0.5-1.0). These results are consistent with previous studies of reliability in SMI in the USA, which examined sexual behaviors during the past 6 months.^19,25

After the fifth interview, still during this stage, assessment of interrater reliability was performed. This procedure was to be performed monthly throughout the PRISSMA feasibility study. The final version adapted to Brazilian Portuguese did not require back-translation based on the process described above. Audio recordings were used to verify if all interviewers would obtain the same information from the same interview in all instrument sections. All interviewers individually marked the answers based on the audiotaped interview and then all answers were compared among all interviewers in group supervision. In this stage, there were small discrepancies, such as characterizing types of partners (steady, casual or exchange). Discrepancies were then discussed by the team; in the example above, it was clarified that definition of type of partner should always be characterized with the interviewee. Choosing one of the options - steady, casual or exchange - for each partner is subjective. Therefore, a sex professional could be characterized under any of the three types, although this aspect requires clarification.

Results and discussion

Given the extension of SERBAS, we grouped the changes in the instrument into the categories below:

a) Conceptual/structural aspects: elimination/introduction of items, themes and questions. Sections or questions that did not specifically address sexual risk behavior were eliminated, such as "prevention and protection methods," which investigated different contraceptive methods by interviewees or interviewees' partners and questions concerning "vaginal/anal insertion of objects." Other parts were also removed because they would not obtain a reliable answer or did not objectively approach risk practice, such as questions about partner's behavior - whether they had symptoms of sexually transmitted diseases (STD) and whether they had been arrested. Other questions referred to circumstances that only tangentially could be related to the instrument target, such as the following question in the female version of the instrument: "Over the past 3 months, did you feel any pain in your vagina or abdomen when having vaginal sex?"

In the terminology section, "clitoris" was a term used in instrument questions, but it was not originally listed/defined, having been added in the Brazilian version. The distinction existing in the original instrument between number of "times" and number of "occasions" in which the person had sex was also excluded for being misunderstood by interviewees. In that distinction, "occasion" is understood as a number of meetings of a sexual nature, differently from "times," which is understood as number of penetrations/sexual contacts occurred in each occasion.

b) Aspects resulting from the findings in the research formative stage and/or previous studies. The term transvestite/transsexual was added, and occasional sexual practices with this population were recorded according to the classification of gender attributed by the interviewee to transvestite/transsexual. The "beach" was added as an option of place for encounters, since the study would be performed in a coastal region. The original instrument allowed specific information about sexual practices over the past 3 months with up to three partners. In the adapted version, the interviewer is instructed to collect information of up to 10 partners, a number that was reached based on interviews conducted during instrument adaptation. With regard to the question concerning use of condoms for any type of sexual practice (vaginal, anal and oral sex), in case the interviewee answered that he/she did not use it, the interviewer would ask him/her the reason for that in a standardized non-judgmental way, recording the exact words used by the interviewee in his/her answer. Soon after the terminology section, the original instrument asked interviewees to identify their sexual orientation, "how do you see yourself: as a heterosexual, gay, lesbian, bisexual or another option?" (which should be specified). However, some studies on gender and sexuality³¹ suggest that the category of self-identity based on sexual orientation in part of the Brazilian population is constructed based on parameters of sexual activity/passivity, regarding the male gender. In the formative stage, frequent reports of sexual practices by interviewees in both genders with partners of the same gender, especially during hospitalization periods in psychiatric institutions, did not imply changes in self-identification of a gay or bisexual orientation. Therefore, this question was eliminated from the adapted version. The use and value of cigarette exchange in psychiatric institutions, previously indicated in several ethnographic studies,³² evident throughout the many stages of the formative stage of the PRISSMA study, was integrated to the question about sexual exchanges ("How many partners did you have sex with in exchange for cigarettes?").

c) Linguistic changes: besides standardizing instruction for interviewers, in the male and female versions, which were originally designed in different moments and purposes, there was a concern about objectivity and clarity of questions, always choosing common forms in the informal oral register of Brazilian Portuguese. For example, when asking female subjects about female sexual partners, the following question is asked: "Other times, they (women) have sex with women in exchange for money, for a place to stay or for helping with expenses."

Conclusion

Cross-cultural adaptation of instruments is known to be a multiple and complex process, which demands methodological care of varied nature. The need of adequacy to the target cultural context is indicated by several authors as an essential stage.^33,34 The use of ethnographic methodologies, such as ethnographic observations, focus groups, and in-depth interviews, suggested by the World Health Organization for adaptation of instruments assessing quality of life,³⁵ proved to be essential in the SERBAS adaptation process. As pointed out by Pechansky et al.,¹ in an adaptation and validation study of the Brazilian version of a questionnaire about risk behavior for AIDS for drug users, knowledge of cultural factors about the local reality of the target population considerably contributed to this adaptation, as it informed which aspects concerning sexual risk behaviors and factors associated with the psychiatric population should be modified and/or incorporated.

Despite the final version adapted into Brazilian Portuguese not being back-translated, according to guidelines recommended in the area,^33,35 we believe that use of the Brazilian version of this instrument will allow a detailed understanding of risk behaviors and associated factors in this population. Using the Brazilian version of SERBAS will allow us to compare the terms used for risk behaviors as well as risk behavior data of Brazilian patients and those from other countries, such as the USA.¹⁹ Therefore, the cross-cultural adaptation of adult SERBAS represented an essential stage to advance research studies on assessing sexual risk behaviors and designing interventions to prevent transmission of HIV/STD in a population that is so vulnerable.

References

Received February 7, 2007

Accepted July 23, 2007

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Publication Dates

• Publication in this collection
  13 Dec 2007
• Date of issue
  Aug 2007

History

• Received
  07 Feb 2007
• Accepted
  23 July 2007