Translation and cross-cultural adaptation of the Brazilian Version of the Cardiac Anxiety Questionnaire

Abstracts

INTRODUÇÃO: É crescente a produção científica brasileira na adaptação de instrumentos internacionais para avaliar ansiedade. A tradução e adaptação transcultural de escalas é um primeiro passo na obtenção de instrumentos válidos que permitam a comparação de diferentes populações. O objetivo do presente estudo foi traduzir e avaliar a equivalência semântica do Cardiac Anxiety Questionnaire, realizando um estudo piloto na população brasileira de diferentes níveis de escolaridade. MÉTODO: O processo de adaptação transcultural envolveu duas traduções e retrotraduções realizadas por avaliadores independentes, avaliação das versões e elaboração de uma versão síntese. Também examinamos os comentários dos participantes sobre a versão preliminar do questionário, os quais foram usados no desenvolvimento da versão final. RESULTADOS: Para cada item do instrumento, apresentam-se os resultados das quatro etapas. Os participantes com maior grau de escolaridade não apresentaram dificuldades na compreensão do instrumento, tendo apenas apresentado sugestões controversas acerca do item 5. Entretanto, os participantes apenas com escolaridade em nível fundamental relataram dificuldades com os itens 2, 4, 6, 7, 10, 11 e 14. Algumas alterações semânticas foram realizadas com o intuito de facilitar a 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 proporcionaram maior segurança ao processo de equivalência semântica da versão final brasileira.

Estudos de validação; astenia neurocirculatória; coronariopatia

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ORIGINAL ARTICLE

Translation and cross-cultural adaptation of the Brazilian Version of the Cardiac Anxiety Questionnaire*

Aline Sardinha^I; Antonio Egidio Nardi^II; Georg H. Eifert^III

^IPsychologist. Researcher, Graduate Program in Psychiatry and Mental Health, Panic and Breathing Laboratory, Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil.

^IIPhD, professor. Associate professor, Graduate Program in Psychiatry and Mental Health, Panic and Breathing Laboratory, Instituto de Psiquiatria, UFRJ.

^IIIPhD, Department of Psychology, Chapman University, Orange, CA, USA.

Correspondence

ABSTRACT

INTRODUCTION: There has been a growing interest in the cross-cultural application of psychological questionnaires to assess anxiety. The translation and cross-cultural adaptation of the original instrument is the first step in validating an instrument in a new population that will permit comparisons between different populations. The goals of this study were to translate the Cardiac Anxiety Questionnaire, assess its semantic equivalence, and perform a preliminary test with participants from the Brazilian population that were drawn from different educational backgrounds.

METHOD: The cross-cultural adaptation process consisted of two translations and back translations performed by two independent evaluators; a critical evaluation of the two versions, and the development of a synthesized version. We also examined comments provided by participants on the preliminary version of the questionnaire and used them for the development of the final version.

RESULTS: We report the results of the four stages for each item of the instrument. Participants with tertiary education had no difficulties comprehending the translated items of the questionnaire, only pointing item 5 as ambiguous. Participants from the lower educational level reported comprehension problems regarding items 2, 4, 6, 7, 10, 11 and 14. Some small changes were made in our first version to enhance comprehensibility.

CONCLUSION: The use of two versions of translations, a critical examination of the two versions, and suggestions made by participants resulted in a final Brazilian version with a satisfactory degree of semantic accuracy and semantic equivalence with the original version.

Keywords: Validation studies, neurocirculatory asthenia, coronary disease.

INTRODUCTION

Cardiac patients often present with psychiatric comorbidities.¹ Depression has long been identified as an independent risk factor for cardiovascular diseases.^2,3 More recently, anxiety and panic attacks have also been related to poorer prognosis in cardiac patients.^4,5 In this sense, the recognition of anxiety and panic attacks in cardiac patients is critical to avoid serious complications.⁶

Furze and colleagues have theorized that maladaptive beliefs concerning coronary artery disease may lead to health-related anxiety, reduced activity levels, cardiac deconditioning and, thereby, an increased experience of symptoms and growing anxiety about the heart.⁷ Such beliefs are also a predictive factor for cardiac rehabilitation drop-out.⁸

Cardiac anxiety is the fear of cardiac-related stimuli and sensations based upon their perceived negative consequences.⁹ It is a relevant factor promoting anxiety because cardiac-related events are perceived to be aversive and dangerous. People who have suffered a heart attack have been shown to hold misconceived or maladaptive beliefs that can have a deleterious effect on quality of life and functioning.¹⁰ It has also been noted that clinicians do not routinely elicit these maladaptive beliefs.¹¹

Eifert et al.⁹ regard cardiac anxiety as a type of specific anxiety concern that appears to be relevant to a number of clinical and medical syndromes characterized, in part, by chest pain and heart-focused psychological distress. Heart-focused anxiety may affect individuals with cardiac and non-cardiac chest pain as well as patients with panic disorder. It can also exacerbate the condition of individuals with known heart disease.¹² Unfortunately, cardiac anxiety often is unrecognized as either the primary problem or as a factor contributing to a poorer outcome of an existing medical condition, particularly in cardiology and emergency room patients.

Self-report instruments have been translated and culturally adapted in many countries presenting saving time and money that would otherwise have to be spent on its development. By using an instrument that has already been developed, validated and systematically used, researchers save valuable resources because the development of an instrument is a demanding task. There can be pointed some limitations to this approach, such as the risk of cultural biases, especially if there are differences in the cultural relevance of one item between the original and the target culture, which could also compromise future cross-cultural comparisons of the data. However, more recently, various authors have opted to adapt foreign psychometric instruments to the Brazilian population rather than develop their own from scratch.^13-18 Such adaptations, conforming the psychometric demands, can then be used to compare the results between different samples from different countries.^19,20

One of the processes included in the cross-cultural adaptation is the assessment of the semantic equivalence of scales.²¹ Despite the lack of consensus regarding the best methods to conduct it, the most commonly used and recommended approach includes translation followed by back translation performed by two independent translators.²² In this method, a bilingual person translates from the source to the target language, and another person, "blind" to the original instrument, translates it back to the source. Later, comparisons between the translations and back-translations are made to identify discrepancies between the source and the target, followed by discussions with the original bilingual translators²³ to identify possible issues with the cross-cultural equivalence and to achieve a synthetic version. This results in a preliminary adapted version of the instrument and it is recommended, which should then be submitted to a quantitative validation processes.

The Cardiac Anxiety Questionnaire is a 18-item instrument originally developed by Eifert et al.⁹ to assess cardiac anxiety. Its psychometric properties were evaluated through the processes of factor analysis and an analysis of internal consistency and convergent and divergent validity. The factor structure of the questionnaire includes 3 subscales: fear and worry about heart sensations, cardio-protective avoidance of activities that could bring on symptoms, and heart-focused attention and monitoring of cardiac-related stimuli. Reliability analyses showed that the internal consistency of the CAQ total and subscale scores was high. Cronbachs alpha for the overall scale was high (alpha = 0.83), as were alpha coefficients for each of the subscales (fear, r = 0.83; avoidance, r = 0.82; and attention, r = 0.69). Moreover, the scale presented good convergent and divergent validity, compared to the Body Sensations Questionnaire (BSQ),²⁴ the Anxiety Sensitivity Index (ASI),²⁵ the Activities of Daily Living Scale (ADLS)²⁶ and the Brief Fear of Negative Evaluation Scale (BFNE).²⁷

The present study aimed to translate the Cardiac Anxiety Questionnaire, assess its semantic equivalence, and perform a pre-test with subjects from the Brazilian population, with different educational backgrounds. The goal was to produce a preliminary adapted version that can subsequently be validated further. Another goal was to examine whether the CAQ is applicable to subjects from different educational backgrounds.

METHOD

The process of cross-cultural adaptation of the Cardiac Anxiety Questionnaire included four steps. The first three steps refer to the translation process: translation, back-translation, and the assessment of the semantic equivalence of the preliminary Brazilian Portuguese version. The next step was a pilot study where 23 subjects were asked to complete the questionnaire and to point out whether there were any difficulties in answering the items or come up with suggestions to improve the clarity of the items. This was a convenience sample of non-clinical individuals with different academic backgrounds, recruited among the students and staff of the Psychiatry Institute of Federal University of Rio de Janeiro.

In the first stage, two translations of the original English instrument to Brazilian Portuguese were independently performed by two Brazilian psychologists fluent in English. The translators were blind to each other and not familiar with the original version of the questionnaire, but familiar with the constructs used in the instrument. Translators were informed about the target population of the questionnaire and asked to pay attention to the semantic consistency of the terms and constructs used, instead of simply literally translating the items from English to Portuguese.

The second stage consisted in the back translation into English of each one of the two translations, one by a Brazilian psychologist and the other by a Brazilian psychiatrist, also fluent in English, independent and blind to the original scale.

At stage three, the assessment of the semantic equivalence was performed by the first two authors (AS, AE) with the goal of producing a synthesized Brazilian Portuguese version based on the two translations made. The process of semantic equivalence adopted is a part of the transcultural adaptation, based on the suggestions proposed by Herdman et al.,²¹ which have also been recently employed in Brazil by Reichenheim et al.²⁸

At first, the authors assessed the equivalence between the original instrument and each of the back-translations. Subsequently each item of the original instrument was compared with its correspondent in each Brazilian Portuguese version. To compose the synthesized version, some items were incorporated from one of the two versions, integrally or modified, 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. At the end of this process, we had a preliminary Brazilian Portuguese version of the Cardiac Anxiety Questionnaire that was ready to be tested.

A pre-test was performed with the synthesized version and 23 adults, selected from a convenience sample of the university students and staff. After signing the informed consent agreeing to participate, they were asked by the authors to fill in the questionnaire and to report if each of the items were clear enough and if they had any suggestions to improve the comprehension of the instrument.

In view of the large cultural differences observed in the Brazilian population, and in order to assure the comprehension of the questionnaire by a wide range of people, the sample was selected based on their educational level. Participants were placed in three categories: elementary school (eight years of education or less), high school (eight to eleven years of education) and tertiary education (undergraduate degree or higher).

Participants had no history of mental disorders. To exclude the possibility of a psychiatric diagnosis, subjects were interviewed by the first two authors using the Structured Clinical Interview for DSM-IV (MINI, version 5.0).²⁹ All participants were asked to make comments on the synthesized version and report any difficulties they may have experienced in understanding items. We also asked participants to suggest alternative words or terms that might be more easily understood. We used this feedback and suggestions to develop the final Brazilian Portuguese version of the instrument.

RESULTS

The original instrument, the translations (T1 and T2), their respective back-translations (B1 and B2) and the synthetic version (before the alterations of the pre-test) can be seen in Table 1. The version performed by both translators for the items 1, 3, 6, 8, 9, 12 and 18 were identical, or very similar. In some items, a version had priority on another, or both were combined. In some cases, the authors included or excluded terms that we felt were more in line with the semantic meaning of the original item.

Table 1
- Click to enlarge

In item 2, translation number two "Evito esforço físico" was chosen because the word "extenuantes" is not a commonly used word in Brazil. Therefore, the word "esforço," in English, "effort" was chosen to convey the idea of physical exertion. Again in item 4, translation two was preferred over translation one, because it presents both "pain" and "discomfort" as related to the word "chest," whereas in T1 the grammatical structure of the sentence might make the item more ambiguous.

Item 5 was the most controversial one, since the expression "take it easy" does not exist in Brazilian Portuguese and can be translated in different ways, depending on the situation. Despite translation two "Eu pego leve sempre que possível" had achieved the most literal back translation "I take it easy whenever possible," we decided to take translation number one "Tento não me estressar sempre que possível," as it seemed more appropriate because it refers to the avoidance of stressful situations. Also in this item, the expression "as much as possible" was translated by both translators as "sempre que possível," which literally means "whenever possible." However, "sempre que possível" and "o máximo possível," which would be the literal translation for the expression, have interchangeable meanings in Portuguese, and can be both used in this situation.

In item 7, translation one was preferred. Although the expression "physical work" would be literally translated as "trabalho físico," this is not an expression used in Brazilian Portuguese and "atividade física" would be more appropriate to refer to these situations. Item 10 came out as a merger of translation one and two. The word "if" was correctly translated by T1 as "se," but the adaptation done by T2, using the "mesmo que" sounded better, as it is not common, although correct, to use "se" in Brazil to express this kind of idea.

Item 11 is an adaptation of translation two "Eu me sinto seguro(a) estando próximo(a) a um hospital, a um médico ou a outro serviço de saúde." The changes made were due to grammatical observations that it is not correct in written language to start a sentence with the pronoun "me," even though it is commonly done in the spoken language. Besides, taking away the article "a" and using the plural of the words "hospital," "doctor" and "medical facility" would give a more general sense in Brazilian Portuguese. This is because the use of the article means that the person may be referring to a specific doctor. Thus, the final form of this item came out as "Sinto-me seguro(a) estando próximo a hospitais, médicos ou outros serviços de saúde." In item 13, translation one was chosen over number two, but again we had to correct the beginning pronoun of the sentence.

Items 14, 15 and 16 all belong to the second section of the instrument, referring to the situations "When I have chest discomfort or when my heart is beating fast," which was translated as "Quando eu tenho desconforto no peito ou quando meu coração está acelerado."

In item 14, both translations lacked the sense of likelihood provided by the term "may," so both back-translations did not present this idea. In this case, the authors decided to include the verb "posso," to express it. Eventually, the preliminary translated version resulted in "Preocupa-me que posso ter um ataque cardíaco." For item 15 we used translation number two.

For item 16, the exact translation would be the one done by translator one "Eu fico amedrontado." However, the word "amedrontado" might not be familiar to parts of the Brazilian population. It is frequently replaced by the expression "com medo," which is more commonly used in written and oral Brazilian Portuguese. In this case, the authors decided to accept back-translator number two's suggestion and changed it to "Fico com medo."

Finally, in statement 17 translation two was preferred over translation one. In all cases, the pronoun "I," which would be translated as "Eu," from the beginning of the sentences was excluded for every item, because it is more common to suppress the initial pronoun from the beginning of sentences in Brazilian Portuguese, because the conjugation of the verb already indicates the person of the subject.

During pre-test of the questionnaire with the subjects, our purpose was to test the comprehension and eventually modify any term or sentence that might be difficult to understand. The authors aimed to examine the possibility of using the questionnaire in a wide range of individuals coming from different cultural and educational backgrounds.

The sample used in the pilot study was composed of 6 males and 17 females, with ages ranging from 20 to 75 years. Descriptive statistics and frequencies of this sample are presented in Table 2.

Most suggestions were derived from the group with a tertiary academic education, especially regarding the semantic similarity of some statements, which seemed a little repetitive. This observation was made to a lesser extent in the other groups. However, the items pointed out to be similar were the ones belonging to the same subscales, and logically expected to refer to the same issues. Despite these remarks, we decided to maintain the original structure of the instrument in order to maintain its psychometric properties as much as possible, because the purpose of this study was to translate and culturally adapt it, and to make only minimal structural changes relative to preserve the semantic validity. Also, another expectation was that these subjects could provide valuable suggestions to improve the instrument. These expectations were actually met and most of the changes suggested by these participants turned out to be useful.

Apart from asking the subjects about their comprehension of the scale and their suggestions, the author asked the subjects to respond to the items and thus complete the questionnaire. This served to address a potential social desirability bias, because we thought some subjects, especially the ones with fewer years of education, could feel too embarrassed to admit they did not comprehend an item and just state the scale was comprehensible. Although these measures were taken, only four of the subjects from the lower education group (n = 7) stated they had any problem understanding a statement. Also, none of them voluntarily presented any suggestion of change. They merely did not respond to the item and, when questioned by the researchers, stated they did not understand exactly what the item meant. The items cited by the participants from this group were items 2, 4, 6, 7, 10, 11, 14. Two of them also found it hard to realize that the last 5 items related to the situation described as "When I have chest discomfort or when my heart is beating fast."

None of the participants with eight to eleven years of education reported any problems comprehending the instrument and, therefore, they did not suggest any changes.

In the tertiary education group, every participant stated to have completely understood the items. On the other hand, these subjects presented numerous suggestions and made relevant changes, some of which were chosen by the authors in the final version of the scale. Again in this group, the complaint about the last five items related to the same situation and some participants reported they had to read the statement "When I have chest discomfort or when my heart is beating fast" more than once to understand that all five items related to the same introductory statement.

Of the participants with tertiary education that presented suggestions, all mentioned that in items 2, 7 and 12 it should be specified that the avoidance of the activities were due to cardiac related anxiety. Some examples given by these subjects were that they can avoid physical exertion (item 2) because they are lazy and not because they are afraid of the cardiac symptoms, or, in item 12, they can avoid activities that make them sweat because they do not want to have to shower more than once a day or because they do not want to ruin their hair style. Although these statements made some sense, we decided not to change the items further because such changes of that magnitude could alter the psychometric properties of the original instrument.

The controversies relative to item five, found in the translation process were again verified in this step. Participants argued that the word "tento," from the beginning of the statement, which means "I try" is different from actually being able to take it easy. Thus, they were confused which gap to check, because they normally try to take it easy, but rarely manage to do so. Also, some of them mentioned that the meaning of the word "estressar," that can be translated as "stress oneself" is too broad and can refer to either physical or psychological stress. In this case, one could avoid situations that can cause psychological stress, but feel comfortable about engaging in physically stressful activities. This item was changed in the final version, were the authors opted to maintain the more literal translation suggested by translator number two "Eu pego leve sempre que possível."

Finally, two participants from the most educated group suggested that, in item 10, we add the word "results" to the expression "exames" to convey the idea of "test results," instead of only "tests." We considered this addition to be irrelevant for the general comprehension of the item and hence made no change.

Another participant suggested that, in item 18, the statement "Conto para minha família ou amigos" would give the impression that the person is willing to tell a large number of people about his/her symptoms, because the word "família," which means "family" is a collective noun and the word "amigos," meaning "friends" is in the plural form. Also as suggested, the word "Conto" was substituted with the word "Falo," which also means "I tell," but would be more appropriate in this case.

We also incorporated some of the suggestions made by the subjects from the pilot application of the questionnaire in the final version. Although most comments were interesting, some could not be done without altering the psychometric structure of the instrument and others would promote irrelevant changes in terms of meaning. Relative to the problems pointed in items 14 to 18 referring to the same situation, it was decided that the formatting of the questionnaire sheet should be modified, to make it more explicit that these items all refer to the same statement.

DISCUSSION

Concepts such as anxiety, stress, and illness have different meanings, and may be associated with different behaviors, for people living in different cultural contexts. Before applying psychological questionnaires developed for one cultural context in another context it is therefore necessary to conduct a meticulous evaluation of the semantic equivalence between an original instrument and its adapted version. According to guidelines proposed in the literature,³⁰ this cross-cultural adaptation should emphasize the semantic rather than the literal equivalence of the terms. The goal is to express concepts in ways that make sense to the new target population. This is the general approach adopted in this study. On the other hand, whenever it was possible in the translation process, we chose the closest translation to the original to maintain the core meaning without compromising an accurate understanding of the statement, in order to preserve the psychometric properties of the questionnaire.

Although it is still somewhat controversial whether this is the best method to assess the semantic equivalence, the present work adopted this process using two independent translations and two back translations. Using two translators was considered helpful, because the two versions could be compared and discussed for the purpose of developing a synthesized version. This procedure enabled an extensive discussion when discrepancies were identified in order to arrive at the best possible solution. Although the translators were "blind" and independent, their expertise in the field and familiarity with the constructs was essential and turned out to be helpful in the process of determining semantic equivalence. Some problems usually found in the translation of instruments from the original language to another result from the unfamiliarity of the translators with the research area. The expert translators in this case shed some light on issues that we could have failed to detect, since the authors are typically too close to the subject matter and certainly not blind to the study.

A limitation of this study is the small number of subjects (n = 23) in the pilot application for the evaluation of the instrument. This limitation was somewhat attenuated by using people from different educational backgrounds. Moreover, the use of subjects with different educational backgrounds provided us with the possibility to assess the viability of the application of the instrument in the Brazilian population that is clearly consists of individuals with educational levels that differ widely. In this respect it is noteworthy that some people with less than 8 years of education reported problems comprehending some of the items. This data shed light over the issues that can be faced when using this instrument to this population. Although that should be clarified by the future validation studies of this version of the questionnaire, at the present moment, data derived from the use of the Brazilian version of the Cardiac Anxiety Questionnaire in individuals with less than 8 years of educations must be carefully examined, keeping in mind these limitations.

The pretest application provided useful suggestions, some of which were incorporated in the final version of the instrument. It was also apparent that most of the participants had no problems understanding the situations described in the questionnaire, and on many occasions, were able to identify themselves as acting or feeling similar as the statements regarding fear, avoidance and worry about cardiac symptoms. It seems reasonable to conclude that this brief questionnaire can be used to screen for common cardiac anxiety that may be present both in subjects with and without cardiovascular diseases - as it has in other countries.¹²

Although it is an important step in the validation process of a questionnaire, the cross-cultural adaptation and semantic equivalence are only the first step. In addition, the instrument must also demonstrate good reliability and validity. For instance, the questionnaire should be sensible and present specificity enough to be useful for differential diagnosis purposes.³¹ This study is the first step to determine these factors for the Portuguese version of the Cardiac Anxiety Questionnaire and its applicability in the Brazilian population. The final version of the Brazilian Portuguese version of the Cardiac Anxiety Questionnaire (see Anexo 1) will now have to undergo an examination of its factorial structure and internal consistency. Convergent and divergent validity will also need to be assessed in future studies.

ACKNOWLEDGEMENT

Authors would like to thank Adriana Nunan, Gisele Dias, Maria Cristina Ferreira, Michele Levitan and Rafael Freire for the great contributions to the translation, back translation processes and adaptation.

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*

Este estudo recebeu apoio do Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), processo nº 554411/2005-9.

Publication Dates

• Publication in this collection
  13 Jan 2009
• Date of issue
  Aug 2008

History

• Accepted
  09 Apr 2008
• Received
  17 Mar 2008