Semantic equivalence of the Brazilian Portuguese Version of the Social Avoidance and Distress Scale (SADS)

Abstracts

INTRODUÇÃO: É crescente a produção científica brasileira na adaptação de instrumentos internacionais da fobia social. A adaptação transcultural é o primeiro passo na realização de comparações entre diferentes populações e se apresenta como um método que envolve pouco custo financeiro. O presente estudo consistiu no processo de equivalência semântica da Social Avoidance and Distress Scale para sua utilização na população brasileira de diferentes níveis socioeconômicos. MÉTODOS: O processo envolve duas traduções e retrotraduções realizadas por avaliadores independentes, avaliação das versões com elaboração de uma versão sínteses e pré-teste comentado. RESULTADOS: Para cada item do instrumento, apresentam-se os resultados das quatro etapas. A maioria dos participantes não apresentou dificuldades na compreensão do instrumento. CONCLUSÃO: A utilização de duas versões de tradução e retrotradução, discussão sobre a versão síntese e a interlocução com a população-alvo proporciona maior segurança ao processo de equivalência semântica.

Adaptação transcultural; escalas de ansiedade social; equivalência semântica; fobia social

ORIGINAL ARTICLE

Semantic equivalence of the Brazilian Portuguese version of the Social Avoidance and Distress Scale (SADS)

Michelle Nigri Levitan^I; Isabella NascimentoII; Rafael C. Freire^III; Marco André Mezzasalma^IV; Antonio Egidio Nardi^V

^IStudent, Training Program, Graduate Program, Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil

^IIPhD in Psychiatry, Instituto de Psiquiatria, UFRJ. Scholarship holder, CNPq. Psychiatrist, Instituto de psiquiatria, UFRJ

^IIIMasters student, Graduate Program, Instituto de Psiquiatria, UFRJ

^IVMasters degree in Psychiatry. Student, Graduate Program, Instituto de Psiquiatria, UFRJ. Psychiatrist, Instituto de Psiquiatria, UFRJ

^VAssociate professor, Instituto de Psiquiatria, UFRJ. Assistant professor, School of Medicine, Instituto de Psiquiatria, UFRJ

Correspondence

ABSTRACT

INTRODUCTION: There has been a growing scientific production on the adaptation of international instruments for social phobia. The cross-cultural adaptation is the first stage on the comparisons between different populations and presents the advantage of a low financial cost. This paper consisted in the process of semantic equivalence of the Social Avoidance and Distress Scale for the Brazilian population of different sociocultural levels.

METHODS: The semantic equivalence involved two translations and back-translations performed by two independent evaluators, an evaluation of the versions and the development of a synthetic version, and a commented pretest.

RESULTS: The results of the four stages were showed for each item of the instrument. Most participants had no difficulties in understanding the instrument.

CONCLUSION: Use of two versions of translations, critical appraisal of the versions, and assessment of the target population provides more safety to the process of semantic equivalence.

Keywords: Cross-cultural adaptation, social anxiety scales, semantic equivalence, social anxiety.

Introduction

Social anxiety disorder (SAD) is characterized by an experience of intense fear of being humiliated or judged negatively in social situations.¹ In a feared situation, people experience somatic symptoms such as blushing, palpitations, and trembling. Anxiety often leads to avoidance of the feared settings, which range from discrete situations to all interpersonal contacts.2,3

Self-report instruments for SAD are being culturally adapted in many countries,4-7 presenting some advantages such as reduced time and money spent on its application. By using an instrument already developed and systematically used in trials with SAD, researchers can easily compare the results between different samples8 and build cross-cultural data.9

Validation is the process that examines the degree to which the results of measurements correspond to the real state and/or presence of the phenomenon being measured10. Studies in transcultural validation of scales enable researchers to expand the psychometric knowledge and to make comparisons between the data found in different countries.11

Transcultural aspects could modify the results found in distinct samples, not because they are really different, but because they may reflect inherent characteristics of the sample (not directly related to the condition studied). When adapting scales to different languages, it is important to make sure that the sense of the questions and instructions of the scales are being interpreted equally by the two languages.12 The first stage of the validation is the cross-cultural adaptation, which systematically compares and analyzes the version of the scale to be used in a specific culture.

Despite the lack of consensus concerning the best methodology indicated to conduct a semantic equivalence between scales, recommended approach includes back-translation performed by two independent translators.13,14 In this model, the bilingual person translates from the source to the target language, and the other "blindly" translates back to the source. After this process, comparisons are performed to identify discrepancies between the source and the target, followed by discussions with the original bilingual translators15 and the construction of a synthetic version.

Although there are some scales that serve as diagnostic instruments for SAD, few instruments assess the social limitations and negative feelings that the subject may experience in social settings. The Social Avoidance And Distress Scale (SADS)16 consists of 28 items that evaluate two aspects of social-evaluated anxiety characterized by avoidance of social situations and the discomfort experienced.

The scale consists of 28 items, and each of the items is rated as "true" or "false." The respondent scores one point for each of the items that are rated "true" (15 items) and each of the items that are rated "false" (13 items). Socially phobic patients usually have higher scores and are expected to feel uncomfortable and to avoid social situations.17 In the original version, tested in American university students, SADS had an excellent internal consistency of 0.94 and a significant correlation with measures of audience sensitivity, anxiety and social evaluative anxiety. Data from test-retest reliability were obtained from a sample of students over a 1-month period and it was found to range from 68 to 79.17

It appears that the SADS is more appropriate for evaluation of general distress and avoidance than social anxiety18 due to the fact that individuals with other anxiety disorders also have high scores in this scale. Thus, SADS seems to be sensitive for emotional distress, but not specific to SAD, therefore demanding caution in its use.19 The SADS was chosen due to the simplicity of the instrument and good psychometric proprieties. As there is no published data on cultural adaptation in Brazilian Portuguese, we decided to develop the translation and cultural adaptation of the Brazilian Portuguese version of the SADS.

This study integrates the great amount of Brazilian scientific production on SAD.19-30 Some of these studies19,24,25,29,30 have focused on validation and transcultural adaptation of scales, which allowed us to expand the findings of international studies, since we could replicate the study in the Brazilian population. These papers have an important notoriety, since they reinforce research on SAD around the SAD centers.

The aim of this study was to perform a semantic equivalence of the English version of the SADS into Portuguese in a heterogeneous Brazilian population sample.

Methods

The process of semantic equivalence adopted is a part of the transcultural adaptation based on the script proposed by Herdman et al.31 This process, recently employed in Brazil by Reichenheim et al.,32 consists of four stages: translation, back-translation, assessment of semantic equivalence and a pretest in the target population with the elaboration of a synthetic version.

In the first stage, two translations of the original English instrument were independently performed by two bilingual translators (IN, MN), both fluent in English. In the second stage, both translations were back-translated into English, also independently and blindly to the original scale, by two bilingual translators (RF, BN), who were also fluent in English. Three of the translators were in the psychiatric area and one was a fluent English speaker.

Stage 3 consisted of the assessment of semantic equivalence performed by the two authors (ML, AE) and the elaboration of a synthetic version. The equivalence between the original instrument and each of the back-translations was firstly assessed, and then each item of the original instrument was compared to its correspondent in each Portuguese version. To compose the synthetic version, some items were incorporated from one of the two versions, integrally or modified by the group, whereas the other items stemmed from the combination of the two versions. The result of this combination was sometimes modified to better meet the criteria of semantic equivalence.

A pretest was performed with the synthetic version, applied to eight people with elementary study (8 years of school), eight with intermediate study (11 years of school) and eight with higher education (college degree). These subjects were adults selected from our university students and staff. They had no history of mental disorders and were openly interviewed by the authors by answering the Structured Clinical Interview for DSM-IV33 to eliminate any chance of a diagnosis. All the participants commented on the synthetic version, pointing out difficulties and suggesting words or terms that could be more easily understood. Considering these suggestions, a final version of the SADS in Brazilian Portuguese was developed.

Results

Table 1 shows the original instrument, the translations (T1 and T2), their respective back-translations (B1 and B2) and the synthetic version (before pretest alterations).

Table 1 - Click to enlarge

The version performed by both translators for the items 2, 3, 13, 14, 16, 24 and 27 were identical, or practically identical. In some items, a version had priority over another, or both were combined.

In item 1, "I feel relaxed even in unfamiliar social situations," we maintained T2 translation over T1, since the term "não-familiar" in Brazilian Portuguese also means "a person who is not a relative," and could cause some confusion in understanding the sentence. The term "não-familiaridade" in Brazilian Portuguese refers to "not knowing someone so well" and seemed more appropriate when compared to the original term "unfamiliar."

In item 4, although the T2 translation of the term "special desire" for the term "desejo especial" is a literal translation, the T1 term "desejo qualquer" seems to be more suitable to the Brazilian language.

In item 5, we could not agree with the translators on the word "upsetting," which was translated as "transtorno" (something distressful) and "desconcertante" (something disconcerting). During the development of the synthetic version, in our understanding, the original word referred to "something that bothers." By this way, we replaced it for the word "chateação," which seems to present the same meaning as "upsetting."

In item 6, "I usually feel calm and comfortable at social occasion," we replaced both translations of the term "social occasion," since the term used in Portuguese "acontecimentos sociais" appears to indicate "a big social event." The term was replaced for "situações sociais," which mostly refers to "social meeting." Besides, we maintained the structure of the T2 translation, since T1 skipped the word "comfortable."

The statements 1, 7, 12, 15, 23 and 28 contain the terms "relaxed" and "at ease," translated with similar words as "tranqüilo" and "relaxado." However, we opted for the translation to the word "à vontade," which means "to be comfortable," differently from the first translations, expressing "sleepy or not well dressed."

In items 8 and 11, both T1 translations did not include the literal translation of the word "unless," but replaced the word for similar terms in Portuguese. We considered the T2 translation "a menos que" more adequate to preserve the structure of the sentence.

In item 9, we opted for the T1 word "aproveito," which has a closer meaning to the word "take it," rather than the word "aceito" (accept). We also opted for another structure of the sentence, since the options suggested by the translators were a little "posh." We constructed the sentence as "Eu freqüentemente aproveito a oportunidade de conhecer novas pessoas."

In item 10, we opted for T2 translation, since the term "reuniões informais" (informal gatherings) seemed more similar to the English expression "casual get together" than T1 translation, which has opted for "encontros casuais" (casual meetings). In Brazilian Portuguese, "casual" is a word with a similar meaning to "informal," and may not be completely understood.

In item 17, we chose T1 translation, due to the lack of the translation of the word "easily." We also replaced both translations of the English word "strangers," for the Portuguese word "desconhecidos." T1 and T2 used the Portuguese word "estranhos," which may denote "bizarre people."

Item 18 was particularly difficult to the translators. The word "walk up" could not be fully understood, since most of the dictionaries do not contain this verb. The verb is mostly translated in Portuguese as "caminhar" (to sidewalk; to stroll). We were oriented by an American native speaker to translate the verb as "abordar."

In statement 19, the word "willingly" had two different translations: "com gosto" and "bom grado." Both translations have the same meaning, but the first appeared to fit better only because it is a more usual word in Brazilian Portuguese to denote someone does not have any problem doing something, and so does it gladly.

The term "on the edge" in item 20 also had two translations: "nervosa" (nervous) and "impaciente" (impatient). To the synthetic version, the authors brought a new term, "extremamente nervosa" (extremely nervous), which gives the impression of a person that is truly bothered by the situation with the feeling of being at his limit, and this was considered to have a closer meaning to the original term.

In item 21, the sentence "I tend to withdraw from people" was better translated by T2 translation "eu tendo a me afastar da pessoas," than T1 "eu tenho a tendência a afastar as pessoas." In the first translation, the person voluntarily isolates from people, is active in the process in isolating; and in the second, the person is isolated independent of his wish.

In statement 22, the term "I don't mind" had two translations into Brazilian Portuguese: "eu não me importo" (T1) and "eu não faço questão" (T2). The first translation indicates "I don't have a problem doing something" and the second "It is not important to me to do something." The first translation seemed closer in meaning to the term in English, which appears to refer to "a lack of a problem in doing something."

In item 25, "introducing people to each other" was translated according to T1 translation as "apresentar pessoas" and according to T2 translation as "apresentar pessoas umas às outras." Both have the same meaning of "introducing people;" however, the second translation was not considered grammatically correct because in Brazilian Portuguese it denotes a redundant sentence.

In item 26, the term "social occasions" was translated into Brazilian Portuguese as "ocasiões formais" (T1) and "compromissos formais" (T2). The first term refers to "formal meetings" and the second to "formal commitments." T1 was considered to have a more similar meaning of "social occasions."

During the pretest with the participants, our purpose was to modify any term or sentence that could be difficult to be understood. Most suggestions were derived from the group with higher education regarding statement similarity, which seemed a little repetitive. This claim was not observed in the other groups. There was only one person in the group of basic study that had some difficulty understanding the meaning of "social occasions." As this case constitute an exception in the group of persons with the same schooling level, we opted for not including an explanation of the meaning of this particular phrase in the scale. People with college degree seemed to be the most demanding participants in the study, and this may be considered a bias, since they naturally feel more compelled to pay attention to any possible problem with the items than people with lower schooling level, who generally pay more attention to the global meaning of the sentences.

Discussion

It is still difficult to point out the best methodology to perform semantic equivalence. Our work outlined this process using two independent translations and two back-translations. Based on guidelines proposed by the literature, we emphasized the semantic equivalence rather than the literally equivalence of the terms to express concepts of the new population.29

Differences in definitions, beliefs and behaviors regarding many populations make it necessary for instruments developed for other cultural contexts to be preceded by meticulous evaluation of the equivalence between the original and its adapted version.34 Use of an instrument for another culture is an attempt to investigate a symptom in a specific culture, but can be sometimes questioned, since it will never remove all biases when adapted for use in another population.35

In our study, we had to discuss some issues related to specific English terms, such as "on the edge" and "to walk up," which could not be easily translated into Brazilian Portuguese. Therefore, they were transformed into local terms according to our culture. We also found that some translators tended to skip some words that in current Brazilian Portuguese may be omitted, but we opted for the maintenance of the original instrument structure with the fewest possible changes.

Some problems usually found in the translation of instruments from the original language to the target result from the unfamiliarity faced by the translators with the research area. The difference in subjective meaning of words or terms that exist in English to another language and culture may not make any sense in a direct translation, retaining many of the literally grammatical forms of the source.13,36 Problems such as these have been a potential cause of data contamination in many cross-cultural research studies, and an obstacle for achieving equivalence.15

We observed that using two translators was extremely helpful in the construction of the synthetic version, since the versions could be confronted and discussed. If discrepancies were identified, we discussed extensively the reasons and proposed solutions. Weeks et al.15 oriented the authors to repeat the procedure for several rounds as different translators work with the efforts of their predecessors. One limitation of our study was the small number of subjects (n = 24) that read and evaluated the instrument. This limitation was attenuated by using people from different schooling levels who were naïve to the SADS in any version.

Although we recruited "blind" and independent evaluators, it would be interesting to ask an expert to help the authors through the process of semantic equivalence. The expert could shed some light in issues that we failed to detect, since the authors are rarely completely blind to the study. We considered this another limitation of our work.

The pretest application showed that most participants understood the situations described in the scale, and often identified themselves as acting or feeling similar as the statements regarding social avoidance and social distress. It is possible that this instrument, rather than diagnosing social phobia, screens for common social difficulties presented by a large group of people.

The cross-cultural adaptation and semantic equivalence are only the first stage to the validation of an instrument in any language. For an adequate use of the instrument, it must have good reliability and validity, besides good sensibility and specification.24 This study is the first step toward determining these factors with the application of the Portuguese version of SADS to a large sample of Brazilian people.

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Publication Dates

• Publication in this collection
  01 Dec 2008
• Date of issue
  Apr 2008

History

• Accepted
  19 Feb 2008
• Received
  02 Jan 2008