Cross-cultural adaptation of the Brazilian version of the Speech-Specific Reinvestment Scale – SSRS

ABSTRACT Purpose To present the cross-cultural equivalence of the Brazilian version of the Specific Reinvestment Scale in Speech – SRRS through its cultural and linguistic adaptation. Methods After the SSRS was translated into Brazilian Portuguese, the back-translation was done and the items were compared. Discrepancies were modified by consensus of a committee of SLPs. The SSRS, named “Escala de Reinvestimento Específico na Fala – EREF”, has 39 questions and six alternatives in the answer key: “strongly disagree”, “disagree”, “slightly disagree”, “slightly agree”, “agree” and “strongly agree”. The mean score is computed by the sum of each subdimension. Negative items may not be included in the EREF scoring or need reversed coding process before using them. For cultural equivalence, the EREF was applied to a total of 74 professionals working in an activity involving communication with the public, speakers of Brazilian Portuguese as a first language, with an extra item in the answer key - “not applicable” - to identify issues that might not have been understood or were not appropriate for the target population and Brazilian culture. Results The scale was initially applied to 56 participants, thirteen of whom found it difficult to complete 27 questions. After adaptation of those sentences, the modified EREF was applied to 13 more participants and no further cultural and / or conceptual barriers were found. Conclusion Cultural equivalence between the SSRS and its translated version to Brazilian Portuguese – EREF was verified. The next steps for the EREF validation for Brazilian Portuguese will be carried out.


INTRODUCTION
Communication is fundamental in all spheres of human relationships, whether in personal, business, or educational relationships. The term communicate comes from the Latin -communicare -which means "to make it common" (1) . In other words, communication is efficient when the interlocutor can transmit the desired message to the receiver, who fully understands it. The message can be encoded in different ways, whether verbal -through speech or writing -or non-verbal -such as using gestures and facial expressions. In an oral speech, verbal and non-verbal language is always present, whether the interlocutor is aware of them or not, and for good communication, one must agree with the other, completing each other and in coherence.
Communication has always been important and has stood out more and more since the professions that use communication as the main factor in the development of their work are increasing at the expense of manual work (2) . At the end of the 20 th century, 62% of the workforce based their livelihood on communication skills -hearing, voice, speech, and language -and 38% who did not use communication for work -such as farmers and workers -needed it for proper insertion into society. In other words, communication is fundamental for professional and personal growth, and its competence is increasingly demanded in society (3) .
Developing communication skills and bringing verbal and non-verbal language into agreement requires training and knowledge. To help those people with difficulty and make this training more specific and direct, it is important to assess the skills involved in communication, including self-assessment protocols.
Self-assessment protocols are important tools for measuring individuals' knowledge about the impact of their conditionwhether it is a problem or something to be improved -on their social and professional relationships (4) . Despite their frequent use, most of them are still aimed at health issues such as quality of life questionnaires. In Brazil, there are still few instruments capable of investigating the self-assessment of an individual's communication. However, this panorama should change due to the importance of communication.
The "Speech-Specific Reinvestment Scale -SSRS" (5) is a new psychometric measure that aims to quantify someone's predisposition to exercise conscious control and monitoring of speech. It encompasses issues not only of conscious control over speech movements (tongue, lip, and jaw movement) but also conscious monitoring of the content and manner of speaking, as well as facial and body movement to achieve the ultimate goal of communication, that is, to allow the recipient to perceive and understand the speech.
The scale was developed based on the reference of the Reinvestment Theory (6)(7)(8) on body limb motor control. According to this theory, motor skills require two types of processing: implicit and explicit. The first is beneficial for well-practiced, relatively automated motor skills, working with pre-established knowledge and requiring little attention and working memory resources. On the other hand, the second is rule-based and requires considerable attention and working memory resources.
People can be high or low reinvestors and those who reinvest high are more likely to fail in stressful situations that involve complex skills and are linked to rules (6)(7)(8) . Thus, when elaborating the SSRS scale, the authors hypothesized that the personality trait predisposing to awareness of control and monitoring of speech would be negatively related to performance in conversational speech. The results pointed to the confirmation of the hypothesis.
Also, the results validated four SSRS sub-dimensions, one of control and three of speech monitoring: 1. Sub-dimension of self-awareness of speech movement -SASN, 2. Sub-dimension of public awareness of the way of speaking -PASC, 3. Subdimension of public awareness of movement during the speaking content -PMASC, 4. Sub-dimension of public awareness of movement during speech -PAMS (5) . The scale enables to assessment of the sub-dimensions distinctly or jointly, which makes it even more robust to examine any variable effects on speech performance, including non-verbal ones, as suggested by the Reinvestment Theory literature (9) .
Since the Speech-Specific Reinvestment Scale -SSRS (5) was developed in English, to use it in other languages, it must be translated and culturally adapted according to the international rules of the Scientific Advisory Committee of Medical Outcome Trust (10) .
This study aimed to carry out the cultural equivalence of the Brazilian version of the SSRS scale, through its cultural and linguistic adaptation.
We should emphasize that, as this is a new scale, there is still no repercussion of its use, although it has great potential. The Brazilian adaptation is the first to be carried out with the instrument.

METHODS
After formal authorization from the authors to use the Speech-Specific Reinvestment Scale -SSRS (5) instrument, the research was approved by the Research Ethics Committee of the Federal University of São Paulo/CEP UNIFESP (opinion number 4.356.465 and CAAE: 36606720.0 .0000.5505). All participants signed the Informed Consent Form -ICF.
Adult professionals participated in an activity involving oral communication with the people, with a minimum experience of three months in the position. There was no distinction of the level of communication use, age, or socioeconomic-cultural level for this study.
The original version was translated into Brazilian Portuguese by two speech-language therapists fluent in the foreign language (Translator 1 and Translator 2). These translations were superimposed, resulting in the first version in Portuguese -PV, maintaining the conceptual integrity of the items. The backtranslation was performed by a third speech-language therapist, also fluent in English, without access to the original version of the instrument and the study objectives.
The translation and back-translation were compared to each other and the original instrument. A committee composed of five speech-language therapists specialized in voice, with proficiency in English and knowledge of specific vocabulary for communication assessment analyzed and discussed the existing discrepancies. The necessary changes were carried out by consensus resulting in the Committee's version 1 -the semantic and language equivalence version, entitled Escala de Reinvestimento Específico da Fala -EREF.
The EREF followed the original protocol, remaining with 39 questions and six alternatives to mark the frequency of occurrence of the situation described in: totally disagree (1), disagree (2), slightly disagree (3), slightly agree (4), agree (5), totally agree (6). At that time, the four sub-dimensions of the scale were still maintained: 1. Sub-dimension of self-awareness of speech movement, 2. Sub-dimension of public awareness of the way of speaking, 3. Sub-dimension of public awareness of movement during the speaking content, 4. Sub-dimension of public awareness of movement during speech. The score for each sub-dimension of SSRS (5) is calculated using the average scoring method. The average composite score for the EREF is calculated by the equally weighted sum of the four average scores for the sub-dimensions. To calculate the averages of each sub-dimension and composite average score, these steps are followed: Q.1-13: Sub-dimension of self-awareness of speech movement Total score: ___ ÷ 13 = Average sub-dimension score: ___ Q.15-27: Sub-dimension of public awareness of the way of speaking Total score: ___ ÷ 13 = Average sub-dimension score:___ Q.29-33: Sub-dimension of public awareness of movement during the speaking content Total Score: ___ ÷ 5 = Average sub-dimension score: ___ Q.35-38: Sub-dimension of public awareness of movement during speech Total Score: ___ ÷ 4 = Average sub-dimension score: ___ Total = Sum of average scores:_________ It is important to emphasize that there are four negative questions in the EREF -one for each subdimension of the scale. Questions 14, 28, 34, and 39 are not part of the total EREF score, as they were developed to check the quality of individuals' responses, including reliability. If the evaluator feels the need to include them in the score, he must remember to perform the reverse score, as described in the original protocol (5) .
For cultural equivalence, the EREF was applied to 74 speaking voice professionals with the addition of the option "not applicable" to identify issues not understood or inappropriate for the target population and Brazilian culture. A space for filling in observations was also added at the end of the scale, allowing volunteers to explain their difficulties or doubts. If volunteers found any difficulty in answering the scale, a new translation and adaptation should be carried out until cultural and/or conceptual barriers were no longer found.

RESULTS
In the first stage, 61 individuals responded to the EREF online. Five answers were incompletes. Therefore, 56 individuals were included in the sample. Of these, 13 indicated "not applicable" in at least one of the scale's questions. A total of 27 questions were identified as not understood or not appropriate for the target population and Brazilian culture and were discussed by the Speech-Language Pathologist committee. Question two, for example, was changed from "I am aware of how my mouth moves when I speak" to "I notice how my mouth moves when I speak" to use an easily accessible language and closer to all respondents. Also, it was decided to add the pronoun "I" to all questions, excluding sentences with hidden subjects to avoid any misinterpretation. As an example, we have question five, in which the phrase "I think of the movement of my lips when speaking" was adjusted to "I think of the movement of my lips when I speak".
Also, the Committee of Speech-Language Pathologists analyzed what the respondents had written in the space for observations, and they concluded that many had marked "not applicable" not because the questions had not been understood, but because those individuals had never paid attention to the context of the question. Thus, they should have marked "disagree" as they do not agree with that statement instead of "not applicable". Therefore, the instructions for filling out the scale were revised for proper filling.
The initial instruction was: "Select the most appropriate options to indicate how much you agree with each of the statements: (1) Totally Disagree, (2) Disagree, (3) Slightly Disagree, (4) Slightly Agree, (5) Agree, (6) Totally agree (Note: There is no right or wrong answer for each sentence). If you do not understand any of the phrases or understand that it is not appropriate for the scale, select the option "not applicable". At the end of the sentences, there is a space to fill in "comments." After deliberation by the Committee of Speech-Language Pathologists and the understanding that the instructions should be clearer, there was a change to: "Select the most appropriate options to indicate how much you agree with each of the statements: (1) Totally disagree, (2) Disagree, (3) Slightly disagree, (4) Slightly agree, (5) Agree, (6) Totally agree (Note: There is no right or wrong answer for each sentence). If you do not understand any of the phrases or understand that this question within the questionnaire does not make sense, select the option "not applicable". This marking should only be performed in these cases. If you select "not applicable", we ask that you explain your difficulties or doubts in the space dedicated to filling in the comments at the end of the sentences." The adjusted EREF -version 2 of the Speech-Language Pathologist Committee -was applied to 13 new respondents, totaling 69 volunteers included in the sample and no cultural and/or conceptual barriers were identified. Figure 1 shows the mapping of the participants and Chart 1 shows their characterization.
This last version applied, then resulted in the final version of the EREF, following cultural and linguistic equivalence. Chart 2 shows the entire process of translation, semantic and cultural equivalence of the SSRS into Brazilian Portuguese.
The final composition of the translated and the culturally adapted Brazilian version of the SSRS, called EREF (Annex 1), has 39 items, like the original protocol.

DISCUSSION
Communication plays a great power within today's society. Using communication, we can convince, persuade, influence, arouse interests and feelings, and even provoke expectations in the interlocutor (11) . Within an organization, for example, well-used communication can establish peaceful relationships, homogenization, and integration of ideas. Communication is a means as well as a tool and, considering its fundamental role, there must be a way to evaluate it, in its different aspects. For this purpose, the SSRS was created.
When a new protocol is proposed, there are rules in its development so that there are no difficulties in its application with the target population. The same must be thought for the use of this protocol in other countries. Therefore, the validation of the protocol for each language and culture is essential. Obtaining cultural equivalence is the first step for the validation of protocols and aims to eliminate cultural and linguistic barriers between the instrument and its target population in different countries (10) . The cultural equivalence model used for this research has already been successfully performed in validations of other protocols in Brazil (12)(13)(14)(15) .
The cultural equivalence of the SSRS began with the cultural and linguistic adaptation, in which the version of the scale for semantic and language equivalence is applied. In this phase, 27 questions were identified as not understood or not appropriate for the target population and Brazilian culture and were discussed by the Speech-Language Pathologist Committee. The high number of questions with barriers for the target population (69%) raised the discussion by the Speech-Language Pathologists Committee regarding the understanding of the scale by the target population. Many respondents had not understood the real function of the "not applicable" option and instead of ticking it when they believed the question was not appropriate to the scale, some were checking this option because they did not fulfill the context of the question in their tasks of communication. That is, instead of answering the question following the frequency of responses from 1 to 6, the respondents put "not applicable". This situation led to the need to review the instructions for filling out the scale and, in a new application, no difficulties were observed.
The cultural adaptation step is essential for the scale's language to approach the target population and for the consistency of the form of communication to be maintained in all questions. This step should be performed as many times as necessary until the scale/protocol is accepted by the target population. The SRSS for Brazilian Portuguese needed two reviews to be accepted.
With the completion of the cultural and linguistic equivalence process for Brazilian Portuguese, the EREF validation process that is the name of the adapted scale will begin. Its use will be important, as most voice self-assessment protocols are diseasespecific, are not suitable for individuals with healthy voices, and do not address other oral communication issues. The SSRS is a specific scale for voice professionals and will be essential in Brazil to assess those who use the voice as their work tool, regardless of the level of classification of professional voice use.

Questions
Original version in English

CONCLUSION
Cultural equivalence between the SSRS and its version translated into Brazilian Portuguese called the EREF was verified. Therefore, the other validation of the EREF for Brazilian Portuguese will be started.