The Brazilian version of Michael Bond's defense style questionnaire (DSQ): problems and achievements

Abstracts

O Defense Style Questionnaire (DSQ) é um instrumento para avaliação de derivados conscientes dos mecanismos de defesa do ego, desenvolvido e validado por Michael Bond em 1983 no Canadá. O presente trabalho consistiu da tradução e adaptação desse instrumento para o português, assim como do estudo de confiabilidade estatística da tradução em relação ao original. MÉTODOS: A tradução foi feita por um grupo de profissionais (psiquiatras, psicólogos e professores de inglês) segundo a técnica de retrotradução. O estudo da confiabilidade da tradução foi realizado em uma amostra de 51 bilíngües (inglês/português), os quais responderam aos testes nas duas versões (original e traduzida). A análise estatística da consistência interna e das correlações item por item e sujeito por sujeito, assim como entre os escores médios de cada uma das formas (original e traduzida), demonstrou que as duas versões são equivalentes e, portanto, a tradução para o português é precisa. Foram ainda avaliadas as abstenções às respostas e a taxa de concordância entre as versões. RESULTADOS E CONCLUSÃO: Todos os resultados foram bastante satisfatórios e estatisticamente significantes, o que nos permite concluir que o instrumento traduzido é adequado para uso no Brasil.

Tradução; confiabilidade; questionário; mecanismos de defesa do ego; DSQ

ORIGINAL ARTICLE

The Brazilian version of Michael Bond's defense style questionnaire (DSQ): problems and achievements

Mônica Andrade^I; Itiro Shirakawa^II

^IAssistant Professor of Psychiatry, MD, Department of Medical Clinic, Universidade Federal de Uberlândia, Brazil

^IIProfessor of Psychiatry, MD, Department of Psychiatry, EPM, Universidade Federal de São Paulo, SP, Brazil

^{Correspondence}

ABSTRACT

The Defense Style Questionnaire (DSQ) is an instrument designed to measure conscious derivatives of ego defense mechanisms. It was developed and validated by Michael Bond in 1983 in Canada. This study presents a translation and adaptation of the DSQ into Portuguese, as well as an evaluation of the statistical reliability of the Portuguese version compared to its original form.

METHODS: The translation was carried out by a group of psychiatrists, psychologists and English teachers, using the back-translation technique. The reliability study was administered to a sample of 51 bilingual respondents (English/Portuguese), who performed the tests in both versions (original and translated). Statistical analysis of internal consistency and item by item and subject by subject correlations, as well as mean score between the two versions (original and translated) have demonstrated that both forms are equivalent; therefore, the translation into Portuguese is accurate. Agreement rate and unanswered items were also evaluated.

RESULTS AND CONCLUSION: All results were quite satisfactory and statistically significant, which leads to the conclusion that the translated instrument is adequate for application in Brazil.

Keywords: Translation, reliability, questionnaire, ego defense mechanisms, DSQ.

INTRODUCTION

Lack of resources for scientific research in developing countries naturally leads to a growing interest in the translation and adaptation of psychiatric assessment instruments that have been developed by foreign researchers. Other reasons include the perspective of standardizing data and presenting more findings, besides the enrichment provided by multi-centered and cross-cultural studies. However, the obstacles and difficulties of this kind of procedure are far from being overcome. Several authors have discussed the problems found in translating psychiatric assessment instruments. Cultural, linguistic, grammatical and statistical aspects have been pointed out, studied and discussed based on different perspectives. This paper aims at developing a Portuguese language version of the Defense Style Questionnaire (DSQ), developed by Michael Bond,¹ professor of psychiatry at McGill University in Montreal, Canada. A reliability study of the translation will also be performed, in order to make its application feasible in Brazil.

MATERIAL AND METHODS

The questionnaire

The DSQ has been developed based on an entire line of research associated with the need of instruments for the empirical or experimental study of ego defense mechanisms described by Sigmund Freud² in 1894. The importance and usefulness of such instruments for clinical practice have been widely recognized in the psychoanalytical and psychiatric literature.

George Vaillant³ considers that perhaps Sigmund Freud's most original contribution to human psychology was his inductive postulation that "unconscious defense mechanisms" protect the individual from painful emotions, ideas and drives. In delineating the nature of ego defense mechanisms, Freud not only established that upsetting affects, as well as ideas, underlie psychopathology, but he also established that much of what is perceived as psychopathology reflects a potentially healing process. That author strongly emphasizes that "no mental status or clinical formulation should be considered complete without an effort to identify the patients' dominant defenses," which are crucial not only for diagnostic purposes, but for treatment planning as well.

However, Michael Bond⁴ has noted that the accurate empirical measurement of ego defense mechanisms has been confounded by lack of reliability, validity, and conceptual clarity. In March 1983, his research group published a study with data validating the DSQ, as an attempt to eliminate the problem of inter-rater reliability. Several findings have confirmed the validity of the instrument.^1,3,4 Its internal consistency has been demonstrated by two experimental findings: first, the item-total correlations between the questions and the defenses they represent were all significant (p < 0.001); second, a factor analysis showed that the defenses clustered in a way that can be confirmed by theoretical studies previously carried out. Thus, immature defensive maneuvers clustered in factor 1 or defense style 1 (isolation, regression, acting out, inhibition, passive aggression and projection); omnipotence, splitting and primitive idealization clustered in factor 2 or defense style 2 (image-distorting defense style); reaction formation and pseudo-altruism constituted factor 3 or defense style 3 (self-sacrificing defenses); finally, adaptive or mature defenses (suppression, sublimation and mood) formed factor 4 or defense style 4. In addition, the fact that primitive defenses were highly negatively correlated with higher level defenses provides further evidence for internal consistency.

Besides the significance and importance of ego defense mechanisms, there is also the issue related to the difficulty of assessing any phenomenon on clinical judgment basis alone.

The need to establish an empirical basis for the identification and assessment of this kind of data is thus a major premise for modern psychodynamic research.

Several authors^5-11 have been trying to unify concepts and uniform nomenclature, as well as to establish the empirical and theoretical basis to the notion of psychic defense, thus achieving a higher degree of operational use of this concept in clinical and research contexts.

Based on the work by George Vaillant, Michael Bond has developed the DSQ, which has already shown its qualities in clinical and research applications.^7-12

Bond¹³ has reviewed several previous works that have tried to develop experimental methods to assess defense mechanisms; however, none of them was able to discard clinical judgment.

Aware of the impossibility of direct observation or measurement of unconscious phenomena, the authors have worked with self-assessment of conscious derivatives, which, although are not able to directly measure defense mechanisms, seem to be related with them. They also stress that, in this context, the term "defense" describes not only the unconscious intrapsychic processes, but also behaviors that are consciously or unconsciously destined to balance internal drives and external demands. To support the possibility of self-detecting unconscious processes, two premises were considered: there are moments when defenses fail; therefore, it is possible to become aware of unacceptable drives and usual ways to defend against them. A person's usual functioning is often pointed out socially.

Due to the non-existence of an instrument that could dismiss the therapist's subjectivity, a self-administered 88-item questionnaire has been created. It taps conscious derivatives of 24 ego defense mechanisms, indicating self-perceived defensive styles. In order to answer the test, subjects are asked to indicate their degree of agreement or disagreement with each statement on a nine-point Likert scale. All items were developed in such a way that a high score indicates that the defense was being used by that subject.^1,13

Considering the extensive and judicious study to which the DSQ has been submitted^1,4,13-15, its translation into Portuguese is important, useful and significant, especially because there is no similar instrument in this language. Furthermore, the incipient tradition of empirical research of psychodynamic concepts in Brazil calls for contributions to that line of investigation.

We should mention that, after the presentation of the masters' thesis¹⁶ from which this paper was prepared, Blaya et al.¹⁷ have repeated the work of translation of the DSQ into Portuguese; this time, a shorter form of the questionnaire, developed by Andrews et al.¹⁵ was used, and a different focus was chosen.

The translation of the DSQ

The technique used in the translation of the DSQ was the back-translation, developed by Werner & Campbell¹⁸ and currently considered by specialized literature^19-25 as the most suitable to achieve a higher degree of equivalence, compared, for instance, to direct translation.

The original questionnaire was translated by three professionals: two psychiatrists and one psychologist; one was bilingual^* and the other two were highly proficient in English. They had no previous knowledge of the questionnaire nor had been given any previous recommendation.

A draft version was presented by each translator and a consensual form of the questionnaire was discussed. All discussions were based on Brislin's¹⁹ criteria to verify translations, i.e., each statement was evaluated according to that scale.

The final version was then submitted to two bilingual Americans, both English teachers residents in Brazil for over 20 years, who performed back-translations. Back-translated items that were considered exact matches of the original phrases were promptly accepted. Twelve of the 88 items were deemed dubious and were then discussed again by the translators and back-translators until reaching a new consensus. Two of the statements had predictably difficult words for Brazilian bilinguals and were then presented in two versions, the original item followed by a simplified one:²⁶

Item 2: People often call me sulker. (or) People often call me moody.

Item 26: Sometimes when I am not feeling well I am cross. (or) Sometimes when I am not feeling well I get ill humoured.

Aware of the fact that repetition takes to progressive improvement of the material,20 at the end of the process, one of the translators and both back-translators reviewed the final consensual version one more time. Small changes were agreed upon as a result of this last revision, and two items were rephrased in a less precise but more contextual translation ("fico de cara feia" for "I am cross" and "emburrado" for "sulker").

Reliability study of the DSQ translated into Portuguese

In order to test the reliability of the translated DSQ (1984 version), both versions were administered to 51 subjects: 22 bilingual and 29 fluent in English. All subjects were advanced English students at three different private institutes. One of the groups was attending a professional training program for translators and interpreters. They were recruited on a voluntary basis through a classroom call made by one of the researchers.

Spielberger et al.²¹ suggested the following procedure to test the reliability of a translation and its equivalence to the original instrument: if the two forms are equivalent, bilingual subjects should obtain approximately the same scores when answering the tests in both languages and correlation between them should be high.

A 15-day interval was kept between the applications and each group was split in halves receiving the two versions in alternate orders to minimize the effects of memory.

The final scores of both versions of the questionnaire were tabulated for frequency and percentage of unanswered items. This was done as a means to identify particularly difficult items for Brazilian bilinguals, which would contribute to reevaluation of the translation and thus its improvement.^20,25 The frequency and agreement rates of identical answers to each item in both versions might be an indicator not only of the degree of the respondents' knowledge of the English language, but also as a marker of translation problems to be reviewed.²⁵

The following step was to calculate the differences between mean scores and standard deviations of each item in each version. These results were analyzed using Student's t test, which measures the statistic significance of the differences between matched samples.^24,25,27

Cohen's kappa is considered a highly adequate test to verify reliability of the translated instrument as compared to its original.^{22,23,26,28,29} This correlation index is a chance corrected per cent agreement measure with a statistical base. The kappa correlation was applied to the answers to each separate item in both versions. The same measure was applied to each subject's score in the two languages.

Internal consistency of the DSQ was computed separately for the two different forms of the instrument through Cronbach's coefficient, which is "an estimate of the correlation between two random samples of items from a universe of items like the ones in the test."^23,24,30

RESULTS

The 51-subject sample was composed of: 22 bilinguals and 29 fluent in the English language; 27 women and 24 men; 23 married, 24 single, three divorced and one widower; 41 had a university degree, nine had not finished college, one had a full secondary education and one was a high school junior. Mean age was 30±8 years (range, 13 to 54).

Initially, the frequency and percentage of unanswered items were calculated for each version separately and for both at the same time. Most abstentions referred to the original form of the questionnaire: items 84 (9.80%) and 17 (5.88%). In the translated version, only item 84 had more than one abstention (3.92%).

The frequency and agreement rates of each subject in the two different versions are presented in Table 1. The number of equal answers was 2,508, which corresponds to a mean agreement of 55.88%. We might work here with two agreement bands: items 5 (39%), 13 (33%) and 81 (37%) were under 40%; statements 60 (94%), 79 (83%) and 85 (92%) showed an agreement higher than 80%.

Mean and standard deviations of total scores for each item in each version are presented in Table 2. The Student's t test (p 0.001, bilateral) was applied to the differences of mean scores for each pair of responses from each subject in each item. The result (t = 0.91) corresponds to a 3.4 probability, thus showing no statistical significance between those differences. The confidence interval was set in 0.99.

Correlation of the answers to each separate item in English and Portuguese as well as to each subject's response in each version was also calculated. Resulting Cohen kappa correlation coefficients are shown in Table 3 and 4. The item-by-item correlation coefficients were all statistically significant (a z-test was run for decision; p 0.001). The subject-by-subject correlation showed five cases of non-significant results. All the others presented statistically significant correlations (z-test; p 0.001).

The internal consistency of the questionnaire was computed separately for the two versions and the resulting a coefficients (Cronbach) were quite high and very similar: original (English) = 0.88; translated version (Portuguese) = 0.91.

DISCUSSION

Sechrest²⁰ mentions the need to be more careful with the translation of instructions and commands, since those are frequently neglected in the translation of assessment instruments. In our case, even after the whole process of multiple translations, back-translation, readings and discussions, only during the first application were we able to notice that the original author had mentioned an answer sheet, which did not exist, and the answering scale was printed right below each statement. This double mistake not only confirmed Sechrest's warning but also demanded reprinting of the questionnaires because of comprehension biases.

Another difficulty to be mentioned was the translation and search of synonyms for words related to the description of feelings, mood or affection in general. This illustrates Flaherty's²² concerns when he reminds us of the trouble one usually has translating adjectives or other emotional states, a wide variety of which were present in the DSQ. The author also emphasizes the complex task of making the described personal experiences often found in psychiatric assessment instruments culturally comparable. He comments that the essential meaning of a word or expression cannot usually be literally translated. This requires a more flexible attitude from back-translators. We consider that in our experience this problem was minimized through numerous and repeated discussions undertaken by the group of translators and back-translators after the first stage of the process. This aspect had already been mentioned by de Figueiredo,³¹ who, upon reviewing the back-translation technique, recommends that the initial part of the process should be independent and blinded (translators should not communicate to each other); on the other hand, the final part should be one of frequent and intense exchange among professionals involved, added by consultations to multiple and diverse experts (e.g., psychiatrists, linguists, grammarians, etc.), thus resulting in a true "screening" of the material.

Still another question that came to our attention during the discussions was the need to consider the context involved in the meaning of the statements, opposed to a more literal translation. It was consensual among the professionals who worked in this study that context was more important in most cases even when there could be loss of accuracy in the translation. Werner & Campbell,¹⁸ designers of the back-translation technique, have also developed the notion of "decentering," which recommends that both versions (source and target) should be considered equally important in the preparation of the new material, thus allowing changes to be made in the original form of the instrument in order to achieve higher comprehensibility of meaning in the resulting wording in the target language. This concern accounts for a difference between a literal or linguistic translation and a cultural one, which allows for the summing up of both. Berkanovic³² agrees with this approach and adds that one should always be very careful in assuring that any translation, culturally specific or not, has a linguistic usage level equivalent to that of the source language, even if the form should suffer any loss.

The latter condition is here illustrated through the decision to replace words related to usual habits in the original culture of the instrument by analogous activities of the target public, rather than by plain synonyms. That was, for instance, the case of substituting "woodwork" for "handwork" in the Portuguese version of the questionnaire. The same problem arises in the translation of the modal verb "can," which receives in Brazil a different connotation when literally translated. It also seems important to point out that the same care should be taken when literally translating present continuous tense forms into Portuguese.

Sechrest²⁰ comments that it is often more important to explain the meaning of a word or expression than to simply try to pair up synonymous nouns regardless of contextual and/or cultural nuances in meaning. We also noticed in this study that in less concise languages, such as Portuguese in comparison to English, it might be better to sacrifice concision for the benefit of understanding.

A picturesque aspect of this process can be pointed out as anecdotal: one of the subjects asked whether the word "palhaço" (chosen to translate "clown") should be taken as meaning "funny" or "dumb;" both are very common uses of this word in Portuguese. We could then realize that, despite all cares taken along the process, the whole team of professionals had missed a contextual bias, since the word "clown" in the original allows more than one interpretation. We once more should stress that translating has to be a very dynamic process, constantly reviewed and reexamined.

Finally, it was surprising that so few works could be found dealing with the matter of translation of psychiatric assessment instruments into Portuguese. Garyfallos²³ reports the same surprise in relation to his mother tongue (Greek), highlighting the importance of being careful about translation and adaptation procedures, as well as about the reliability study of the translated instrument. He also reminds us that "words and expressions are actually symbols that comprehend a distinctive set of meanings, a specific semantic network of a given culture. Thus, the cultural concept plays a major role that turns cultural differences into problems for translating and standardizing tests and instruments, which makes such procedure a very complex one."

The work of Blaya et al.¹⁷ is a face validity study in which there is no discussion of the linguistic or terminological difficulties found by the authors in translating the DSQ. Perhaps the face validity added to the reliability study and linguistic reflections presented here may be complementary contributions to the development of better versions of this questionnaire to be used in Brazil. It is our view that the complexity of such procedures has to be faced and shared, so that greater exchange could be promoted in the cross-cultural use of psychiatric instruments for multi-centered studies, thus increasing their possibilities of generalization.

The reliability study

The descriptive statistical analysis of the results revealed that items 17 and 84 showed the highest degree of abstention. Both items present English idiomatic expressions, which could possibly account for difficulties in understanding by Brazilian natives. This may also indicate a need for rephrasing item 84, since the verbal expression chosen brought doubts to the translation team. Statistics confirm the consistency of the doubts; however, we consider the abstention rate quite acceptable, since it is below 5%.

Two bands were chosen to analyze this rate: bellow 40% agreement was found for items 5 (39%), 13 (33%) and 81 (37%); above 80% agreement were items 60 (94%), 79 (83%) and 85 (92%). As for item 5, besides presenting an idiomatic expression, its phrasing was modified in its content - "handwork" to translate "woodwork". Items 13 and 81 present expressions easily identifiable as particularly difficult even for bilingual Brazilians, which might have contributed to problems in understanding. Item 60 refers to a quite serious psychotic symptom with very low probability of being present in a presumably normal sample. In addition, its bizarre content should induct people to a high degree of certainty and intensity in their disagreement. Items 79 and 85 refer to drugs, medication and tobacco use, which by the social stigma involved may lend assertiveness to the answers in both versions. Such characteristics may have contributed to higher agreement rates found for the last items. It seems opportune to comment that, in a Likert-type scale with such a wide range in degrees of intensity for agreement or disagreement, small differences will not be considered significant and that is corroborated by the statistical significance of the correlation of scores in both versions. In this specific case, this is due to the differences between scores in each version found by the t test. Garyfallos²³ comments that such small differences may occur even when the same subjects take the same test in two different occasions.^23,27

The item-by-item kappa estimates revealed statistical significance for all correlations of all items, which indicates equivalence of translation. The subject-by-subject kappa correlation showed three non-significant cases, which indicates that these subjects probably have less knowledge of the English language than the other components of the group.

As for internal consistency of the instrument, results were highly satisfactory, since the available literature^22,28 points out a limit of a = 0.60 and we found a = 0.88 for the original questionnaire and a = 0.91 for the Portuguese version. Several authors^20,22,24,27 have been trying to build consistent theories and guidelines for cross-cultural translation of psychiatric or psychological instruments. Chart 1 is an attempt to correlate the various approaches found in the literature as an effort was made to take all of the appointed dimensions into consideration in the present study.

The above set of results allows for the conclusion that there is equivalence in the translation and that the translated instrument has proved to be statistically reliable to be used by Brazilian researchers. The present work is to be seen as a first step towards further studies of the Portuguese version of the DSQ (^{Appendix 1}), as larger samples should be tested and validity studies undertaken.

REFERENCES

Received January 4, 2006. Accepted July 13, 2006.

• 1. Bond M. Manual for the defense style questionnaire. Sir Mortimer B. Davis-Jewish General Hospital, Department of Psychiatry. Montreal: Canada. 1991. [mimeographed by the author].
• 2. Freud S. As neuropsicoses de defesa. Rio de Janeiro: Imago; 1977.
• 3. Vaillant GE. Ego mechanisms of defense. Washington, DC: American Psychiatric Press; 1992.
• 4. Bond M, Gardner S, Christian J, Sigal J. Empirical study of self-rated defense styles. Arch Gen Psychiatry. 1983;40(3):333-8.
• 5. Haan N. A tripartite model of ego functioning values and clinical and research applications. J Nerv Ment Dis. 1969;148(1):14-30.
• 6. Semrad EV, Grinspoon L, Fienberg SE. Development of an ego profile scale. Arch Gen Psychiatry. 1973;28(1):70-7.
• 7. Vaillant GE. Theoretical hierarchy of adaptive ego mechanisms: a 30 year follow-up of 30 men selected for psychological health. Arch Gen Psychiatry. 1971;24(2):107-18.
• 8. Vaillant GE. Why men seek psychotherapy: results of a survey of college graduates. Am J Psychiatry. 1972;129(6):645-51.
• 9. Vaillant GE. Natural history of male psychological health. II. Some antecedents of healthy adult adjustment. Arch Gen Psychiatry. 1974;31(1):15-22.
• 10. Vaillant GE. Natural history of male psychological health. III. Empirical dimensions of mental health. Arch Gen Psychiatry. 1975;32(4):420-6.
• 11. Vaillant GE. Natural history of male psychological health: V. The relation of choice of ego mechanisms of defense to adult adjustment. Arch Gen Psychiatry. 1976;33(5):535-45.
• 12. Vaillant GE, Bond M, Vaillant CO. An empirically validated hierarchy of defense mechanisms. Arch Gen Psychiatry. 1986;43(8):786-94.
• 13. Bond M. An empirical study of defensive styles: the defense style questionnaire. In: Vaillant GE, ed. Ego mechanisms of defense. Washington: American Psychiatric Press; 1992. p. 127-58.
• 14. Pollock C, Andrews G. Defense styles associated with specific anxiety disorders. Am J. Psychiatry. 1989;146(11):1500-2.
• 15. Andrews G, Singh M, Bond M. The defense style questionnaire. J Nerv Ment Dis. 1993;181(4):246-56.
• 16. Andrade MPM. Tradução e adaptação do DSQ (Defense Style Questionnaire) para uso no Brasil [Dissertação]. São Paulo: Universidade Federal de São Paulo; 1996.
• 17. Blaya C, et al. Versão em português do Defense Style Questionnaire (DSQ-40) para avaliação dos mecanismos de defesa: um estudo preliminar. Rev Bras Psiquiatr. 2004;26(4):255-8.
• 18. Werner O, Campbell DT. Translating, working through interpreters, and the problem of decentering. In: Naroll R, Cohen R, eds. A handbook of method in cultural anthropology. New York: American Museum of Natural History; 1970. p. 398-420.
• 19. Brislin RW. Back translation for cross-cultural research. J Cross-Cultural Psychol. 1970;1(3):185-216.
• 20. Secherest L, Fay TL, Zaidi SMH. Problems of translation in cross-cultural research. J Cross-Cultural Psychol. 1972;3(1):41-56.
• 21. Spielberger CD, Gorsuch RL, Lushene RE. Inventário de ansiedade traço-estado. Rio de Janeiro: CEPA; 1979.
• 22. Flaherty JA, Gaviria FM, Pathak D, Mitchell T, Wintrob R, Richman JA, et al. Developing instruments for cross-cultural psychiatric research. J Nerv Ment Dis. 1988;176(5):257-63.
• 23. Garyfallos G, Karastergiou A, Adamopoulou A, Moutzoukis C, Alagiozidou E, Mala D, et al. Greek version of the General Health Questionnaire accuracy of translation and validity. Acta Psychiatr Scand. 1991;84(4):371-8.
• 24. Plass AM. Adaptação para o português da escala de memória de Wechsler-revisada: fidedignidade e validade [Dissertação]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 1991.
• 25. Carvalho FR, Lima MG, Azevedo RCS, Caetano D. Tradução do inglês para o português do questionário de auto-avaliação da escala de Hamilton para a depressão. J Bras Psiq. 1993;42(5):255-60.
• 26. Chan DW. The Chinese version of the general health questionnaire: does language make a difference? Psychol Med. 1985;15(1):147-55.
• 27. Mumford DB, Tareen IA, Bajwa MA, Bhatti MR, Karim R. The translation and evaluation of an Urdu version of the Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 1991;83(2):81-5.
• 28. Bartko JJ, Carpenter WT Jr. On the methods and theory of reliability. J Nerv Ment Dis. 1976;163(5):307-17.
• 29. Karno M, Burnam MA, Escobar JI, Hough RL, Eaton WW. The Spanish language version of the diagnostic interview schedule. In: Eaton WW, Kessler LG, eds. Epidemiology field methods in psychiatry. Washington: American Psychiatric Press; 1993. p. 171-90.
• 30. Cronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrika. 1951;16(13):297-334.
• 31. De Figueiredo JM, Lemkau PV. Psychiatric interviewing across cultures: some problems and prospects. Soc Psychiatry. 1980;15:117-21.
• 32. Berkanovic E. The effect of inadequate language translation on Hispanics' responses to health surveys. Am J Public Health. 1980;70(12):1273-6.

Appendix 1

*

The notion of bilingual is mentioned by Garyfallos

²³ regarding someone who is fluent in two languages and has lived at least one year in each country, thus being bicultural. The author emphasizes that the central aspect of this concept is the fact of living in both countries, which is necessary for the person to understand the different meanings of the words and not being merely able to translate from one language to another.

Publication Dates

• Publication in this collection
  16 Nov 2006
• Date of issue
  Aug 2006

History

• Received
  04 Jan 2006
• Accepted
  13 July 2006