Cross-cultural adaptation of a questionnaire assessing the child and parents’ expectations of orthodontic treatment in Brazil

ABSTRACT Introduction: The Sayers and Newton questionnaire was developed in England to assess the child’s and parent’s expectations about orthodontic treatment. Objective: The aim of this study was to carry out the cross-cultural adaptation of the questionnaire for the Brazilian Portuguese language, to test its reliability, and to compare patients’ and their parents’ expectations of orthodontic treatment. Methods: After translation and cross-cultural adaptation, the questionnaire was applied to 98 patients (12-14 years), who had been referred for treatment, and their caregivers. The internal consistency of the instrument was assessed by Cronbach’s Alpha Coefficient and the test-retest reliability, by Intraclass Correlation Coefficient (ICC). Results: Internal reliability was confirmed by a Cronbach’s alpha coefficient of 0.75. Test-retest reliability revealed satisfactory reproducibility (ICC = 0.85). The results showed some significant differences between the expectations of the patients and their caregivers (p < 0.05). There were no significant gender differences (p > 0.05). Conclusions: The process of cross-cultural adaptation of the Sayers and Newton questionnaire for the Brazilian Portuguese was concluded. This study demonstrated that this instrument is reliable and applicable to assess the child’s and parent’s expectations about orthodontic treatment in Brazil, and it has acceptable psychometric properties.


INTRODUCTION
A full understanding of patient motivation and expectations regarding orthodontic treatment leads to improved treatment plan design, better cooperation throughout therapy, and successful results. 1,2 Expectations can be influenced by several factors, such as the differences between health systems, ethnic diversity, and cultural differences. [3][4][5][6][7][8] As expectations are an important psychological factor, they can influence the evaluation of the patient regarding the quality of the treatment or the final satisfaction with the results. 9 This is even more relevant in long-term treatments, for which esthetics is a significant component of treatment outcome. In addition, patients can be presumed to perceive the efficacy of treatment by comparing their expectations with their actual experiences. 5 Previous studies have revealed that the expectations of patients and their parents in relation to orthodontic treatment are based on improving facial or dental appearance and improving health and oral function. 3,10 In addition, improved attractiveness and psychological confidence are also benefits sought with therapy. 5 However, they also have expectations regarding the events that will occur during this time, such as the duration of treatment, possible extractions, pain and discomfort with feeding, talking, and cleaning teeth. Some studies were performed after the initial consultation or during treatment 1,11 and reported a belief that orthodontic treatment would enhance the appearance, self-confidence and oral function. Other studies that evaluated only the caregivers' expectations 10 reported an improvement of children's self-esteem with treatment.
Previous studies, however, have indicated that parental expectations differ and often outweigh those of patients, as parents expect greater improvements in their children than the children themselves. 7,[12][13][14] However, few studies have measured the expectations of patients and their caregivers before the initial appointment. 3,6,11 In England, Sayers and Newton assessed the expectations of patients and their caregivers regarding orthodontic treatment prior to their initial consultation using a validated questionnaire. 6,12 Their results showed similar expectations regarding orthodontic treatment.
The Sayers and Newton questionnaire (SNQ) was the first to provide a reliable measure of patients' expectations prior the orthodontic treatment, and has been widely used in the literature. [6][7][8][9][10][11][12][13][14][15][16] It was formulated according to cultural and ideological aspects of the English population, which hinders its application in the Brazilian population. As valid instruments in Portuguese are not yet available to evaluate the patients' expectations before orthodontic treatment, it is necessary to translate and validate this questionnaire into this language. 12 Ribeiro MGE, Oliveira EFF, Pantuzo MCG, Côrtes MISG, Andrade Jr. I -Cross-cultural adaptation of a questionnaire assessing the child and parents' expectations of orthodontic treatment in Brazil 6 Translation and cultural adaptation of instruments are internationally recognized methods. The translation consists of obtaining a version in the chosen language that is semantically equivalent to the original language version. Cross-cultural adaptation is necessary when the instrument will be used in a population that is culturally different from the population used in the development of the original instrument. This process is important, since each society has characteristics that reflect its culture and differentiate it from others. Thus, it is necessary to propose the application of a data collection instrument with simple, clear language and equivalence in relation to cultural concepts. 12 The development of a valid and reliable method of evaluating the expectation of orthodontic treatment will be useful in planning and implementing a more effective treatment. Moreover, it will help in the creation of a public policy that can implement Orthodontics in the Brazilian Health System. Orthodontists will be able to use the questionnaire to assess patients' expectations and, possibly, determine a more appropriate treatment plan for the patient, which can avoid premature abandonment of treatment and dissatisfaction with the results. 4,13,15 It was hypothesized that the SNQ, whose design was largely based on focus group interviews, was reliable and valid in the Brazilian Portuguese language. Thus, the objective of this study Ribeiro MGE, Oliveira EFF, Pantuzo MCG, Côrtes MISG, Andrade Jr. I -Cross-cultural adaptation of a questionnaire assessing the child and parents' expectations of orthodontic treatment in Brazil 7 was to cross-culturally adapt the SNQ, to test the reliability and validity of the questionnaire in the Brazilian Portuguese language, and to compare patients' and their parents' expectations of orthodontic treatment.

STUDY DESIGN AND ETHICAL CONSIDERATIONS
The methodology emphasizes the cross-cultural adaptation of the SNQ and its psychometric testing for test-retest reliability, internal consistency and construct validity. The study was approved by the Research Ethics Committee of the Pontifícia Universidade Católica de Minas Gerais (PUC MINAS, Brazil).
All the participants signed the consent term. The present questionnaire validation process followed the steps suggested by Guillemin et al. 17

DESCRIPTION OF THE SAYERS AND NEWTON QUESTIONNAIRE
The SNQ consists of 10 questions that encompass the following domains: (1) content of the initial consultation, (2) type of device to be used, (3) problems expected during treatment, such as pain and difficulty in eating, (4) other people's reactions to treatment, (5) total duration of treatment, (6) frequency of appointments, and (7) expectations with treatment outcome. Eight out of these questions should be answered using a 10-point scale ranging from "not at all likely" to "very likely," where one corresponds to a very low expectation of Some questions were re-evaluated and rewritten, and through consensus, the initial version of the questionnaire was obtained.   All the results were considered significant for a probability of significance of less than 5% (p < 0.05). A paired t-test was used to compare the expectations regarding orthodontic treatment between patients and caregivers. Furthermore, the t-test was used to compare the two independent groups regarding the measure of a variable of interest of the scalar type.

RESULTS
Characterization of the sample in relation to personal data is described in Table 1.
Ribeiro MGE, Oliveira EFF, Pantuzo MCG, Côrtes MISG, Andrade Jr. I -Cross-cultural adaptation of a questionnaire assessing the child and parents' expectations of orthodontic treatment in Brazil

INTERNAL CONSISTENCY
The value of Cronbach's alpha was greater than 0.75, showing that the questionnaire had an acceptable internal consistency ( Table 2). The overall inter-item value was 0.76 and the corrected item-total correlation of > 0.3 was achieved in over 50% of the questions, producing a good level of internal consistency. Testretest reliability revealed satisfactory reproducibility (ICC = 0.85). Ribeiro MGE, Oliveira EFF, Pantuzo MCG, Côrtes MISG, Andrade Jr. I -Cross-cultural adaptation of a questionnaire assessing the child and parents' expectations of orthodontic treatment in Brazil

EXPECTATION OF PATIENTS AND CAREGIVERS
Patients and their caregivers presented some significant differences (p < 0.05) regarding the expectation of orthodontic treatment (Table 3). The comparison between gender expectations revealed no significant differences between these two groups (Table 4).
In addition, no significant differences were found between the caregivers from male and female patients (  Table 4: Comparative analysis between female and male patients regarding the expectation of orthodontic treatment. The probability of significance (p) refers to Student's t-test for independent samples. Most participants were not able to specify the total treatment time that they would need to wear the orthodontic devices.
In addition, regarding the periodicity during which the patients should attend appointments, a diversity of perceptions was observed ( Table 6).  Table 7 shows the answer options that denotes the worst and the best expectation for each one of the questions on the research instrument. Since it has a total of 23 questions, the floor and ceiling effects were constructed by observing    Definition of the answer option that denotes the worst and the best expectation for each one of the questions on the research instrument. Therefore, the second alternative is considered more economic, efficient and practical.

Question
Studies that evaluate the expectations of orthodontic treatment are scarce in the literature and have been developed in Englishspeaking countries. 6,7,8,11,16,18 In order to be used in a non-English population, instruments need to be translated, adapted, and validated. This process should follow internationally accepted methods to ensure that the new language versions resulting from the original questionnaires can be used in international comparative studies. 19 The SNQ has been widely used in other studies to evaluate patients' expectations on orthodontic treatment. 6,7,8,11,15,18 However, this was its first cross-cultural adaptation in another language. The process of translation and cultural adaptation of the questionnaire was carefully conducted following the criteria of Guilhemin et al. 17 The results showed a translated Reliability is defined as an assessment of the reproducibility and consistency of an instrument. 21 The reliability of a study is threatened by bias and error. [22][23][24] In this study, the bias could have been a result of personal characteristics, that is, the mood Internal consistency was tested using Cronbach's alpha in regards to the overall inter-item and item-total correlations.
A previous study 10 used Cronbach's alpha to assess the reliability of their questionnaire. However, these authors measured parents' expectations of orthodontic treatment, but not children's expectations.
Similarly to other studies, the present results found significant differences (p < 0.05) between the patients' and caregivers' expectations. 7,11,13,14 These findings refute previous studies that evaluated the patients' expectations by addressing the questions that were asked to the parents, and assumed that patients had similar expectations to their caregivers. 22 In addition, these findings confirm the need to evaluate people individually to determine individuals' autonomy. The expectation of an orthodontic appliance installed at the initial appointment was significantly higher for the patients than for the patients.
As found in the UK questionnaire application 6   found in previous studies 6, [25][26][27] , which demonstrated that the need for orthodontic treatment is mainly determined by a concern with appearance, and the caregivers expected to improve the appearance of their children. [22][23][24][25][26][27][28] Some studies have shown that the gender variable can influence people's expectations. Women tend to have higher expectations regarding orthodontic treatment than men. 11,24,28 However, the present results, which are in agreement with other studies, 7,28 did not present significant differences (p > 0.05) between genders. The present study sample could not be divided according to ethnicity, as in the study of Sayers and Newton, 6

CONCLUSIONS
In conclusion, significant differences were found between patients' and caregivers' expectations for orthodontic treatment. There were no significant differences between gender expectations, nor were there significant differences in the caregivers' expectations of the male and female patients.
The internal consistency of the process of translation and cross-cultural adaptation of the Portuguese version of the SNQ was satisfactory. The Portuguese version of the questionnaire developed by Sayers and Newton can be used as an instrument