Translation and cultural adaptation of the Illness Perception Questionnaire-Revised for Dental to Brazil

Abstract This study aimed to translate and to perform the cultural adaptation of the instrument Illness Perception Questionnaire-Revised for Dental (IPQ-RD) into Brazilian Portuguese. The IPQ-RD consists of 34 items that assess the cognitive and emotional representation/perception of parents/caregivers of children with dental caries, with response options on a 5-point Likert scale, ranging from “Strongly agree” (score 1) to “Strongly disagree” (score 5). The higher the score, the lower the perception of the disease. The protocol consists of translation into Brazilian Portuguese, back-translation into English, revision by an Expert Review Committee, and pre-test (application in parents/caregivers of children in dental care). For some questions, the translated versions were identical (T1 = T2); for others, one version was preferred (T1 or T2); for still others, it was decided to modify terms to obtain greater clarity on the item (T3). In the first pre-test, three questions were misunderstood by more than 15% of the sample, after which the items were reviewed by the Expert Review Committee. In the second pre-test, the adapted version was applied to a new sample of parents/caregivers (n = 15) and the questions were understood by more than 85% of the participants. The Brazilian Portuguese version of the IPQ-RD was well understood by the evaluated population.


Introduction
Dental caries is one of the most frequent chronic diseases in childhood and the fourth most costly condition for treatment worldwide. 1In Brazil, the prevalence of the disease varies from 20.3% to 53.6%, resulting in a negative impact on the quality of life of both children and families and being considered a public health problem. 2,3However, most parents/ guardians, especially those from a low socioeconomic level, perceive the disease only in severe stages, seeking dental treatment only when there is pain or visible loss of tooth structure. 4In this population, lack of access to dental services, low socioeconomic level, and insufficient knowledge about child oral health and the effectiveness of preventive strategies for caries act as barriers to promoting healthy oral hygiene practices for their children and to seeking dental care. 5,6o reduce the incidence of oral diseases, such as dental caries in childhood, it is necessary to develop public health programs with educational/preventive strategies. 7,8However, the success of these programs will depend on health behaviors, which are determined by social and economic circumstances and parents/ guardians awareness regarding their children's oral health status.Guardian perceptions are particularly important in preschool years due to the difficulty of children to verbalize their emotions at this stage. 9hus, some of the available measures to assess the perception of oral health of children appraise the guardians' knowledge, attitudes, or opinions about dental caries and the quality of life related to oral health reported by parents, which are mainly based on the social context, theories of cognitive behavior, and health. 4he instrument "Illness Perception Questionnaire-Revised for Dental" (IPQ-RD) is a recently adapted version for Dentistry of the instrument "Illness Perception Questionnaire", originally developed in English to assess five cognitive domains (identity, causes, consequences, control, and timeline) of the disease. 10The revised version of the instrument ("Revised Illness Perception Questionnaire") improved the theoretical foundations of the original version by including two domains -disease coherence and emotional representations. 11In 2016, this version was adapted for Dentistry as a complete and dynamic measure to understand how parents/guardians formulate cognitive and emotional representations/ perceptions of their child's oral disease in reaction to their child's risk of disease and what aspects determine their coping strategies. 4he Common-Sense Model of Self-Regulation, a useful but still underutilized approach in dentistry, advocates that the personal beliefs of the patient or caregiver about a specific disease, treatment, and emotional response, influence disease outcomes, mainly through coping responses. 11,12It is important that parents/guardians, as the child's primary oral health caregivers, present the correct representation of the disease, which ranges from the disorganized model (acute phase -presence of the disease only when there are symptoms, such as pain) to the organized model (chronic phase -presence of the disease even in the absence of symptoms), for effective adherence to disease self-regulation strategies. 13herefore, it is important to assess the cognitive and emotional perception of parents/guardians about aspects of caries disease in childhood.To accomplish this, the aim of the present study was to translate and perform the cultural adaptation of the original (English) version of the IPQ-RD into Brazilian Portuguese.

T he Re s ea r c h Et h ics Com m it te e of t he
Federal University of Juiz de Fora approved the research protocol under protocol number CAAE 16525219.0.0000.5147.Parents/guardians of children receiving care at Pediatric Dental Clinic of the Federal University of Juiz de Fora, Governador Valadares Campus, Governador Valadares, MG, Brazil, were invited and those who agreed to participate signed an informed consent form after being informed about the aims of the study.This study was performed from July to December 2019.
Before starting the research, the authors of the original instrument were consulted and authorized its performance.The IPQ-RD was originally developed in English by Nelson et al. 4 to assess the representation/cognitive and emotional perception of parents/guardians about caries disease in children.The instrument consists of 33 multiple-choice items and one open-ended question (No. 34), divided into 8 cognitive dimensions and emotional representations, as shown in Figure .In the present study, the IPQ-RD was self-completed by parents/caregivers.
The response options for each multiple-choice item are on a 5-point Likert scale, ranging from "strongly agree" (score 1) to "strongly disagree" (score 5).The variation of scores for each domain is dependent on the number of items, and the total score is obtained by the sum of the domain scores; the higher the score, the lower the perception of the disease.Question 34 is evaluated by open-ended answers, which are grouped into master ideas with similar meanings.
With the aim of translating the IPQ-RD into Brazilian Portuguese and adapting it to the Brazilian culture, a methodology proposed in specific literature with internationally recommended guidelines was followed. 14,15

Initial translation
The original version of the IPQ-RD was initially translated into Brazilian Portuguese by two English teachers who were native speakers of Brazilian Portuguese, independently and unaware of the purpose of this work, prioritizing the conceptual translation rather than the literal translation (translated versions -T1 and T2).

Back-translation
The researchers, Pediatric Dentistry professors, combined the two Brazilian Portuguese versions (T1 and T2), originating the first translated version.This was back-translated into English independently by two native English teachers, who did not participate in the first stage of translation and did not have access to the original instrument, thus obtaining the versions in English (back-translated versions -BT1 and BT2).The purpose of back-translation is to compare the English back-translation with the original instrument.

Expert review committee
An expert committee, composed of five university professors who are Pediatric Dentistry specialists (M.L.G., M.S.A., V.P.P.C, R.A.S.S.R., T.S.B), one who is also an English teacher (R.A.S.S.R.) and one with experience in processes of translation and validation of health instruments (T.S.B), evaluated the translated and back-translated versions, as well as the original instrument.This step consisted of the following aspects: 16 a.Semantic equivalence: refers to the meaning of words; b.Idiomatic equivalence: formulation of colloquial expressions equivalent to the original language; c.Cultural equivalence of each issue: experiences lived within the society cultural context.

Cultural adaptation (pre-test)
The cultural adaptation of the first translated version of the IPQ-RD (V1) was verified in a population of 15 parents/guardians of children undergoing dental care at the Interdisciplinary Pediatric Dental Clinic at the Federal University of Juiz de Fora, Governador Valadares Campus, representing 10% of the sample required for a validation and reliability study for this instrument.The option "I didn't understand" was added to the Brazilian Portuguese version (V1) as one of the answers to all questions, in order to identify the questions that were not properly understood.The questions with a percentage of misunderstanding above 15% were submitted to the review of the expert review committee, which made the necessary cultural adaptations, resulting in a new revised version (V2).The V2 version was applied to a new group of 15 parents/guardians, who did not participate in the first pre-test [17].The IPQ-RD was to be considered culturally adapted when all questions were understood by at least 85% of the participants, resulting in the final version (FV) that was socioculturally adapted.

Translation, back-translation and expert review
Table 1 summarizes the modifications suggested by the expert review committee after evaluating the original version, the translated versions (T1 and T2), the back-translations (BT1 and BT2), and the version suggested for cultural adaptation.
Questions 4, 5, 6, 7, 8, and 14 were modified from the term "committed" to the term "affected" for a better understanding by parents/guardians.In question eight (8), the terms "your school activities" were replaced by "my child's school activities" to avoid ambiguity in interpretation.In questions 11, 17, 20, and 28, the pronoun "in" was replaced by the pronoun "of (da)" so that the greater sense of ownership is clear, as well as in question 18, in which it was decided to add the terms "his/her".
In items 15, 16, 17 and 23, the term "improvement of dental caries" was preferred to "control of dental caries", since the first option more literally reflects the intent to improve children's tooth decay.The change of terms in questions 31 and 32 ("makes me" for "makes me feel") was due to the choice for a more colloquial language rather than a more sophisticated language.
In questions 18, 21, and 22, the terms "many things" was added to the sentence "there is a lot I can do" so that the phrase reflects a concrete action that can be performed.In some items, some terms were replaced to make understanding clearer, such as: "I clearly understand" instead of "I have a good understanding" (question 27) and "long durability" for "long duration" (question 24), and in questions 25 and 33, in which "in my male/female child" replaced the term "in my child".
In question 29, we preferred to add the term "suffering from tooth decay" to emphasize the fact that tooth decay negatively affects children.
Thus, the first translated version was obtained (V1).

Expert review committee (second step)
To adapt the terms that were misunderstood by more than 15% of the study population, the items in question were resubmitted to the expert review committee (with the same members as the previous one) for evaluation.Questions 9, 17, and 18 were reworded to make the terms clearer to parents/guardians.
In question 9, the expression "The dental caries in my male/female child is disabling" was replaced by the expression "The dental caries in my male/female child makes him/her unable to perform daily activities".In question 17, the phrase "The improvement of my male/female child tooth decay does not depend on chance or fate" was replaced by "The improvement of my male/female child tooth decay does not occur on itself".In question 18, the sentence "What my male/female child does determines the improvement or worsening of his/her tooth decay" was rewritten as "The attitudes of my male/female child determine the improvement or worsening of his/her tooth decay".

Discussion
The IPQ-RD is a measurement instrument used to understand the perception of parents/guardians regarding dental caries in children.The evaluations obtained by this tool can be used to develop effective strategies for the prevention and treatment of dental caries in children.In addition, there is the possibility of restructuring the conceptions of parents/guardians about the disease, considering that the literature reports that the parents' cognitive and emotional representations are mostly based on cultural knowledge or past/current experiences. 18he use of this instrument can improve knowledge about the disease, providing opportunities for improved disease management and, consequently, promote preventive behaviors and the seeking for dental treatment. 4,19e IPQ-RD showed valid and reliable results in studies carried out in other countries and for other chronic conditions, both in general health and oral health.However, to be used in other languages and cultures, the items need to be linguistically and culturally adapted according to the context in which it is to be used. 20,21In this study, translation and cultural adaptation process was aimed at better understanding by the target population.According to Mota Falcão et al., 22 the lack of cross-cultural equivalence of research instruments can compromise the validity of the information collected, as it can be difficult for respondents to correctly understand the concept that is intended to evaluated.Previous studies suggest that the process of adapting instruments to another culture should consider language, cultural, ethnic and socioeconomic differences, since the translation process and cross-cultural adaptation of a questionnaire developed in another language goes far beyond the idiomatic issue and semantics. 23,24The translated instrument must be able to obtain the same effect in the new culture to as the original instrument did in the context in which it was created. 25,26here are protocols to be followed that aim to minimize the loss of the instrument's original characteristics due to language change.In this study, we chose a protocol that advocates the process of translation and back-translation as a way to amplify and reveal errors and misinterpretations in the initial translations. 14,156][27] This can be seen in the translation of the term "has a big effect", which in the literal sense would be translated to "has a great effect", but the term "has affected" was chosen, as it was considered more understandable by the parents / guardians under study.The use of more than one version of translations and back-translations allows selecting the best items to incorporate or even combining items from different versions.This strategy makes it possible to analyze the sequence of procedures, including the translations themselves, the back-translations, and the subsequent assessments.The review by the expert committee is paramount to detecting problems in the earlier stages of the study and then redirecting decisions in the process that might otherwise have been unsatisfactory. 28In this study, most of the changes suggested by the expert review committee were due to the replacement of terms that were more understandable for the studied sample, including: a) replacement of pronouns and terms that indicated ownership to avoid ambiguity in understanding the issue; b) choosing similar terms in Portuguese instead of literal translation, since some words when literally translated, could be difficult to understand in the sample; and c) choice of colloquial language instead of formal language, aiming to facilitate the understanding of the questionnaire by parents/guardians.In all modifications, care was taken to preserve the effect and context of the original instrument. 26he application of the translated and revised versions of the questionnaire in a small sample of the target population is necessary identify possible difficulties in understanding and to confirm, at this stage, the semantic equivalence and the operational equivalence. 29In this study, the number of subjects involved and the characterization of the sample in the pre-test stages were adequately described, in accordance with the methodological criteria recommended for cultural adaptation of questionnaires. 30During the pre-test, some difficulties in the understanding of expressions were identified, such as "it depends on chance or fate", a term considered incomprehensible, as it encompasses an unspecific meaning.In addition, the terms "it is disabling" and "What my male/female child does" were also misunderstood, as they were considered of complex understanding and had to be replaced by simpler expressions that facilitated understanding, namely "makes you incapable for" and "The attitudes of my son (daughter)", while maintaining fidelity to the purpose of the original version.The majority of the population (69.2%) was aware of the causal relationship between lack of toothbrushing and consumption of sugary foods with development of childhood caries.In addition, emotional reasons, daily routine, bacteriology, lack of flossing, and not seeking dental services were also reported as causes of the disease.
After the reformulations, a new pre-test was carried out with a new sample of parents/guardians, following the same methodological criteria implemented in the first pre-test.In the second pre-test, the percentage of "I didn't understand" responses was less than 15%, so the translated version of the IPQ-RD was considered culturally adapted for the population being studied. 17,30It is important to emphasize that the translation and cross-cultural adaptation of the instrument are initial steps that must be followed in subsequent large scale applications of the instrument and in studies of the psychometric properties, such as validity and reliability of the translated and adapted version. 30For a full cultural adaptation, a study of measurement equivalence is also necessary, with an assessment of the reliability and validity of the new version in different populations and clinical conditions.Future studies will be conducted in order to meet these requirements.
Failure to use adequate methodology for the translation and cultural adaptation of research questionnaires can lead to bias and problems, such as using an improperly tested questionnaire that may differ from the original version.Therefore, researchers must report all stages of the process, detailing the results of the validity tests, so that other researchers can make informed decisions about the instrument that will best address their objectives.Considering the limitations of this study, the IPQ-RD should be tested in other regions of Brazil so that it can be considered validated for Brazilian Portuguese.In addition, the instrument should be applied in clinical contexts, such as public or private pediatric dental clinics, where children have already experienced dental care, which would provide different perceptions of the construct in question.Finally, new studies with representative samples should be conducted to test the validity and reliability of the culturally adapted IPQ-RD.

Conclusions
It can be concluded that the IPQ-RD instrument was properly translated into Brazilian Portuguese and adapted to the cultural context of the evaluated population.Considering the cultural dimension of Brazil, new studies must be carried out in different regions to obtaon a fully culturally adapted instrument.

Table 1 .
Assessments suggested by the expert review committee.Only modified items are shown.
ContinueBraz.Oral Res.2023;37:e004Translation and cultural adaptation of the Illness Perception Questionnaire-Revised for Dental to Brazil

Table 2 .
Synopsis of the first pre-test: specification of misunderstood questions regarding sex and age of parents/guardians (n=15).Only items not understood are shown.

Table 3 .
Synopsis of the second pre-test: specification of questions not understood in relation to the sex and age of the evaluated parents/guardians (n=15).Only items not understood are shown.