CROSS-CULTURAL ADAPTATION OF THE BURNS SPECIFIC PAIN ANXIETY SCALE - BSPAS TO BE USED WITH BRAZILIAN BURNED PATIENTS

Los objetivos del estudio fueron traducir y adaptar la “Burns Specific Pain Anxiety Scale SPAS” y la “Impact Event Scale IES” para el portugués, poner a disposición dos instrumentos simples, cortos y de fácil aplicación y describir los participantes del estudio, según los scores obtenidos por medio de la aplicación de la Escala Visual Analógica y del Inventario de Ansiedad Trazo-Estado. El proceso de adaptación de las escalas siguió las siguientes etapas: traducción de las escalas; obtención del consenso en portugués; evaluación por un comité de jueces; “back-translation”; obtención del consenso en holandés; comparación de las versiones originales y en holandés; análisis semántica y pretest de las versiones en portugués. Los resultados mostraron índices elevados de consistencia interna de los ítems de la escala. La media de los escores de dolor fueron más altos después del baño y curaciones. Los scores medios de ansiedad fueron clasificados como bajos o medios.


INTRODUCTION
Burns injuries are some of the most painful types of trauma, even more when, besides the pain of their wounds, burns victims are submitted to a great number of procedures every day until they recover, including bathing, wound dressing and physiotherapy (1) . Besides pain, anxiety, depression and fear are frequently associated with burns (2) . A pain and anxiety assessment instrument is necessary to be used with burns victims, considering long hospitalization and the realization of different procedures which, although painful, are needed for the patients' recovery (2) .

Various instruments (scales and inventories)
have been produced, generally in Europe and North America. To be used in Brazil, they first need to go through cross-cultural adaptation (3) . Nowadays, a large quantity of pain measurement instruments is available.
Researchers need to select the most appropriate one, in view of the particularities of the population (like, for example, culture, level of education and physical limitations), what they intend to measure (presence, intensity and/or characteristics) and the characteristics that make the chosen instrument more appropriate for the object of study (4) .
Although a wide range of instruments is available to assess anxiety and measure pain, we did not find any studies in literature that describe the use of pain and anxiety instruments in Portuguese, specifically for Brazilian burn patients.

Literature shows that Numerical, Verbal
Descriptor and Visual Analogue Scales are the most frequently used measurement tools, due to their practicality and easy understanding by patients (5) .
Moreover, in care for burns victims, the following scales are most used, although they are not specific for pain and/or anxiety assessment in burned patients: Visual Analogue Scale (VAS) (6) , Numerical Scale (6) , Hamilton's Anxiety Scale (7) , McGill's Pain Questionnaire (8) and Spielberger's State-Trait Anxiety Inventory (STAI) (9) . As to specific instruments for burns victims, we found the Visual Analogue Thermometer (10) (adaptation of the VAS for pain assessment) and the "Burns Specific Pain Anxiety Scale" (BSPAS), developed by Luc Taal and Bertus Faber and applied to a sample of Dutch burned patients (10) .
The "Burns Specific Pain Anxiety Scale -BSPAS" is a unidimensional scale with nine items that describe patients' feelings related to the healing of their burns, fear of losing control during wound dressing and anticipatory anxiety about pain during and immediately after care (such as wound cleansing, bathing, wound dressing and skin grafting). Each item is evaluated on a 100-milimeter visual analogue line (without sequential numbering), with the anchor words "absolutely not" and "in the worst form imaginable" as a reference (10) . In order to assess the reliability of the instrument, the authors of the scale ( pain increases anxiety and anxiety increases pain (11) .
Next, to assess the reliability, validity and specificity of the reduced five-item version of the  (1) .
This study aimed at translating and adapting the Burns Specific Pain Anxiety Scale -BSPAS (10) and the Impact of Event Scale -IES (11) into Portuguese; making available two simple, short and easily applicable instruments and describing the study participants according to their scores on the Visual Analogue Scale (6) and the Trait-State Anxiety Inventory (9) .  (11,13) . The authors of the BSPAS used an adapted version for burned patients (11) . In this study, we adapt the version used by these authors. Each scale item is evaluated on a visual analogue line with scores ranging from zero to ten and the total score of the scale is calculated by adding up the scores of the subscales (intrusive thoughts and avoidance behavior). Maximum total score is 150 and, the higher the total score, the greater the impact of the event.

Burns Specific Pain Anxiety Scale -This scale
was originally proposed in Dutch in a nine-item (10) and five-item version (1) . It evaluates pain and anxiety manifestations related to painful situations, such as wound dressing, bathing, debridements and skin grafting, which occur while the patient is hospitalized.
Each item is answered on a visual analogue line ranging from zero to ten and the total score is calculated by adding up the scores of all items (maximum 90 points). The higher the score, the greater the patients' level of anxiety about painful procedures.

Spielberger's State-Trait Anxiety Inventory
(STAI) -Inventory adapted to Portuguese (9) . This The cross-cultural adaptation process of the BSPAS was carried out according to literature (3) and a change in the order of the steps, proposed in a study that was presented at a scientific meeting*. for translation into the instrument's language of origin, so that the objective of this step is not reached, which is to preserve the original idea contained in the instrument as a whole. The semantic analysis of each instrument item before the pretest was aimed at verifying the understandability of all items for the entire instrument, according to a representative group of the target population (14) .

Achievement of first consensus version in
Portuguese -A meeting was held with the two translators, according to the following steps: 1.
Explanation about the objectives of the meeting, the study and the instrument.   We did not find great differences when testing how the exclusion of each item would affect the total Alpha of the scale.

DISCUSSION
This study aimed at adapting and making available the Burns Specific Pain Anxiety Scale (comprising the IES and the BSPAS itself) to assess, respectively, stress caused by the impact of the burn event, pain and anxiety in Brazilian burns victims.
Patients' ages ranged from 15 to 73 years, which is similar to other studies (10,12) . According to literature, age is an important variable in the study of burns victims (15) . A study about the characteristics of 377 patients hospitalized at a burns unit in Japan found that accidents were more frequent in the age range from 15 to 60 years (89.2%). In Brazil, studies (16) have demonstrated that approximately 50% of burns accidents involve children and approximately 10% people over 60. Data indicated that, in about 40% of burns accidents, victims were under 40 (productive age). This implies lost work days, first due to a frequently long hospitalization (acute phase and rehabilitation phase) and moving into the long-term rehabilitation phase.
In terms of gender, 66% of participants were men (14). These data are in line with other studies (10,12) . The TBSAB has been the subject of controversies about its relation with pain perception and anxiety in burned patients. In an analysis of pain experiences during painful procedures and rest periods, authors found that the percentage of TBSAB was associated with increased procedural anxiety. This fact could also influence an increase in these persons' pain sensations (17) . Other studies found that patients with larger burn injuries tended to report more affective pain and tended to have a pattern of high and low reports that differed from patients with severe burn injuries (18) . Other authors found a low correlation between TBSAB and pain manifestations but mentioned a statistically significant coefficient when pain evaluations during the first week post-trauma were correlated with TBSAB in patients with predominantly superficial burns, as these are very painful (2) .
We found higher average pain scores immediately after bathing and wound dressing and low and medium average state-anxiety scores at the end of the first week of hospitalization. Other studies (1,(10)(11) evidenced that these pain manifestations were related to painful procedures and that anxiety was frequent in this kind of patients.  (14,19) , a low level error variation and measurement errors can be inferred for both scale, but this affirmation can only be confirmed through factorial analysis (14) , which would require more participants.
To assess the extent to which both adapted scales (BSPAS-VP and IES-VP) measured the intended constructs, we obtained Spearman's Correlation Coefficient, which revealed a statistically significant correlation between the BSPAS -VP and the IES -VP and with the BBS. These data could suggest a relation between pain-related anxiety manifestations and the TBSAB in burns victims (11,18) .

CONCLUSION
This study aimed at translating and adapting the Burns Specific Pain Anxiety Scale -BSPAS as a specific instrument to assess anxiety related to pain manifestations in burns victims. We conclude that: -After the cross-cultural adaptation process, the BSPAS-VP and the IES-VP reached the criteria of idiomatic, semantic, cultural and conceptual equivalence.
-Participants' range of average pain scores was wide.
Higher concentrations of pain scores after painful procedures like bathing and wound dressing were observed.
-We also found a wide range of average anxiety scores. Scores tended to concentrate in medium anxiety. We did not find any scores indicating high anxiety levels.