TRANSCULTURAL TRANSLATION AND ADAPTATION OF CONDOM EMBARRASSMENT SCALE FOR THE BRAZILIAN CONTEXT

TRADUCCIÓN TRANSCULTURAL Y ADAPTACIÓN DE LA CONDOM EMBARRASSMENT SCALE PARA EL CONTEXTO BRASILEÑO

ABSTRACT

Objective:

to describe the process of cross-cultural adaptation of the Condom Embarrassment Scale for use in the Brazilian context.

Method:

methodological study that included the following steps: initial translation of the original scale by two independent translators, summary of translations, reverse translation, evaluation of the reverse translation by the author of the original scale, adaptations in the Portuguese version by a committee of experts and completion of pre -test. Such steps allowed the necessary adaptations to be made to the socio-cultural reality and to the level of understanding of the target population. 42 university students aged 18 to 28, of both sexes, from a university located in the Midwest Region of Brazil participated in the pre-test.

Results:

considering the idiomatic and cultural variations evaluated, the Portuguese version demonstrated equivalence with the North American version.

Conclusion:

the Brazilian Portuguese version of the scale demonstrated comprehensibility when applied to university students. Further studies evaluating the psychometric properties of the scale are needed.

DESCRIPTORS:
Instrument adaptation studies; Scales; Cross-cultural comparison; Condoms; Sexually transmitted diseases

RESUMEN

Objetivo:

describir el proceso de adaptación transcultural de la Condom Embarrassment Scale (Escala de restricciones en el uso de condones) para su uso en el contexto brasileño.

Método:

estudio metodológico que comprendió los siguientes pasos: traducción inicial de la escala original por dos traductores independientes, síntesis de traducciones, traducción inversa, evaluación de la traducción inversa por el autor de la escala original, adaptaciones en la versión en portugués por un comité de expertos y realización del pretest. Estos pasos han permitido realizar las adaptaciones necesarias a la realidad sociocultural y al nivel de comprensión de la población-objetivo. Participaron del pretest 42 estudiantes universitarios de ambos sexos, de 18 a 28 años, de una universidad situada en la región del medio oeste del Brasil.

Resultados:

teniendo en cuenta las variaciones idiomáticas y culturales evaluadas, la versión en portugués demostró equivalencia con la versión norte americana.

Conclusión:

la versión en portugués brasileño de la escala demostró ser comprensible cuando se aplicó a estudiantes universitarios. Se necesitan más estudios que evalúen las propiedades psicométricas de la escala.

DESCRIPTORES:
Estudio de adaptación de instrumentos; Escalas; Comparación transcultural; Condones; Enfermedades sexualmente transmisibles

RESUMO

Objetivo:

descrever o processo de adaptação transcultural da Condom Embarrassment Scale (Escala de Constrangimento no uso do Preservativo) para utilização no contexto brasileiro.

Método:

estudo metodológico que compreendeu as seguintes etapas: tradução inicial da escala original por dois tradutores independentes, síntese das traduções, tradução reversa, avaliação da tradução reversa pela autora da escala original, adaptações na versão em português por comitê de especialistas e realização do pré-teste. Tais etapas permitiram realizar as adaptações necessárias à realidade sociocultural e ao nível de compreensão da população-alvo. Participaram do pré-teste 42 universitários com idades entre 18 e 28, de ambos os sexos, de uma universidade localizada na Região Centro-Oeste do Brasil.

Resultados:

levando-se em consideração as variações idiomáticas e culturais avaliadas, a versão em português demonstrou equivalência com a versão Norte-Americana.

Conclusão:

a versão da escala no português do Brasil demonstrou compreensibilidade quando aplicada em universitários. Novos estudos avaliando as propriedades psicométricas da escala são necessários.

DESCRITORES:
Estudo de adaptação de instrumentos; Escalas; Comparação transcultural; Preservativos; Doenças sexualmente transmissíveis

INTRODUCTION

Sexually transmitted infections (STIs) are a group of infections that can be acquired through unprotected sex.1 This represents a major public health challenge worldwide, especially in developing countries whose growing socio-cultural and economic contexts have a major influence on the occurrence of these infections.2

Each year, there are about 357 million new cases of curable STIs in the world, affecting both sexes, mainly in the ages between 15 and 49 years, and most of them occur in developing countries.3 In addition, STIs increase the risk of transmission of the Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS). Approximately 36.7 million people are living with HIV/AIDS in the world.4

Specifically in Brazil, the detection rate for AIDS cases per inhabitant doubled from 2007 to 2017 in the 15 to 24 age group. Among young people aged 15 to 19, it went from 3.0 in 2007 to 7.0 cases/100,000 inhabitants in 2017, and among those aged 20 to 24, it went from 15.6 in 2007 to 36.2 in 2017.5

As teenagers and young adults are a heterogeneous group with regard to experiences, social practices and lifestyle are different in their biological, mental and social development.6 They have specific needs in the areas of disease prevention and health promotion that can be reached by health policies focused on the development of critical thinking and decision making in the face of their vulnerabilities.

Upon entering university, young people will experience greater social and economic freedom and adopt new lifestyles.7^-8 It is at this stage that a greater number of interpersonal relationships is established and a greater likelihood of sexual intercourse, especially without the use of condoms, in addition to being more exposed to alcohol and other legal and illegal drugs.9

Consistent condom use in all sexual relations has been considered an effective method to prevent STIs.10 Thus, instruments that assess the use of condoms have been developed in order to gain a better understanding of this contraception and STI prevention method.11

The feeling of embarrassment when purchasing the condom, negotiating its use with the sexual partner and in the use itself are the main factors that influence its non-use. In this sense, with the objective of evaluating the embarrassment in relation to the use of condoms when purchasing, negotiating the use sexual intercourse, Vail-Smith and Durham11 developed the Condom Embarrassment Scale (CES) for use in a group of American university students.

The scale consists of 18 items, with a Likert-type answer format, with five answer options, ranging from totally disagree to totally agree. In these 18 items, three dimensions are evident: the first, which assesses the acquisition, purchase, obtaining or possession of condoms (items 1, 2, 3, 4, 5, 6, 7 and 12); the second, associated with the negotiation of use with the sexual partnership (items 8, 9, 10, 11 and 13); and, the third, related to condom use (items 14, 15, 16, 17 and 18). The final score varies between 18 and 90 points; scores ranging from 18 to 54 indicate a low level of embarrassment and those between 55 and 90 indicate a higher level of embarrassment in condom use.11^-12 Currently, CES has already been translated and adapted into the Portuguese language from Portugal by Cunha-Oliveira et al., which was called the Escala de Embaraço face ao Preservativo12.

Considering the absence of instruments to assess embarrassment regarding condom use in Brazil, as well as the absence of Brazilian studies dedicated to analyzing this behavior in university students, this study aimed to carry out the cross-cultural adaptation of CES to the Brazilian context. Research on the topic are relevant because they provide greater knowledge of the reasons for using condoms, as well as supporting policies for the prevention of HIV transmission and other STIs.

METHOD

This is a methodological cross-cultural adaptation study13 of CES in a sample of Brazilian university students. The procedure consisted of five steps: initial translation, summary of translated versions, reverse translation, expert committee and pre-test, as suggested by the specialized literature.14

The cross-cultural adaptation process ensures that the adapted instrument can be used in other cultures, provided that all stages of the process have been completed, and the adjustments of words, expressions and format are made. A flow chart of the entire procedure is presented in Figure 1.

Figure 1 -
Flowchart of the Transcultural Adaptation Process. Rio Verde, Goiás, Brazil, 2016.

Initially, contact was made with the original authors of the scale and permission was requested to proceed with the translation and cultural adaptation process for the Brazilian context.

After authorization, the original scale was translated from English into Brazilian Portuguese independently by two native bilingual translators (T1 and T2) in the target language. Translator 1, was aware of the objectives of the study and was an English language teacher. Translator 2, did not know the objectives of the study, had proficiency in the English language, in addition to developing work on translating scientific articles and materials from English into Brazilian Portuguese.15

The translations of T1 and T2 were compared by researchers and translators to obtain a summary of the translations.14 In this stage, a careful attempt was made to identify the items translated in different ways in T1 and T2, which were discussed, observing the meaning of words in the English and Brazilian Portuguese languages ​​and the substitution of equivalent terms or expressions and, by means of a consensus (summary), the first translation into Brazilian Portuguese was established.

Subsequently, this initial translation was submitted to back-translation into English by two bilingual specialists,16 who did not participate in the previous steps and who did not know the scale.17 These translations were unified through consensus between researchers and translators, resulting in the back-translation.

The version with the back translation was sent to the first author of the original instrument (Dr. Karen Vail-Smith) in order to assess the accuracy of the translated version,18 which made it possible to create a new version in Brazilian Portuguese.

This new version was reviewed by a Committee of Experts composed of five professionals,17 involving specialists with a command of the English and Brazilian Portuguese; four with professional and academic experience in the area of sexually transmitted infections and one with knowledge in validating instruments. The formation of this committee was aimed at the evaluation of semantic, idiomatic, experiential and conceptual equivalences.18

The expert committee evaluated the original instrument and the translations individually and independently, evaluating discrepancies and adequacy of terms.

In order to obtain semantic equivalence, the committee analyzed whether the Brazilian version had the same meanings between the terms and expressions and the correct translation of the items in relation to the original instrument. To analyze the idiomatic equivalence, it was verified whether the colloquial expressions of the source language had equivalent expressions in the target language, without changing the meaning of the item. Experiential equivalence was verified by observing whether the translated items were applicable to Brazilian culture, and conceptual equivalence sought to assess whether the meanings of terms and expressions contained different meanings between English and Brazilian culture. This phase gave rise to the consensual Brazilian version (VBC).

The fifth phase consisted of a pre-test of the consensual Brazilian version in order to analyze the adequacy of the items and the structure of the instrument as a whole (understanding, clarity and proximity to reality) by the target population. This phase was characterized by the previous application of the instrument in a convenience sample composed of 42 undergraduate students from the nursing (47.62%) and Dentistry (52.38%) courses, of both sexes (45.24% male; 54.76 % female), aged between 18 and 28 years, from a university located in the Midwest Region of Brazil. The literature recommends a sample of between 30 and 40 people from the target population.14

The participating university students were informed about the objectives of the study. Afterwards, they were asked to respond individually and critically to the 18 VBC questions, being guided by the researchers who asked for clarification in case of doubts and difficulties regarding the lack of terms, problems understanding the items and scale format. They were also asked to verify that the expressions used correspond to those used in the university environment and that they could propose some modification if necessary. Then, after answering the questionnaire, a discussion was held with the group to identify the understanding and clarity of the consensual version, thus obtaining the final Brazilian Portuguese version.

All participants expressed their agreement to participate by signing the Informed Consent Form. The study was approved by the Research Ethics Committee.

RESULTS

The stages of translation from English into Brazilian Portuguese and the summary of the translations proved to be similar in relation to the general meaning. The terms and expressions that showed different disagreements or translations were evaluated and modified together with the translators. For the term condom, we opted to use condom and in relation to the term drug store, we opted to use pharmacy, since in Brazil the term pharmacy is less used.

From the summary of the two translations, a summary of the Condom Embarrassment Scale for Brazilian Portuguese was obtained (Chart 1).

Chart 1 -
Translations 1 and 2 and the Brazilian Portuguese summary of the Condom Embarrassment Scale (CES). Rio Verde, Goiás, Brazil, 2016.

	Translator 1	Translator 2	Synthesis
Title	Escala de constrangimento do preservativo	Escala constrangimento frente ao uso do preservativo	Escala de constrangimento no uso do preservativo
Instruction:	Instruções: Os itens a seguir avaliam o quanto você fica (ou sente) constrangido com relação ao uso da camisinha. Usando a seguinte escala, por favor responda cada um dos itens abaixo listados.	Instruções: Os itens a seguir pretendem avaliar como você se sente ou sentiria sobre o uso do preservativo. Responda a cada um dos itens listados abaixo de acordo com o item que melhor representa sua opinião.	Instruções: Os itens a seguir pretendem avaliar como você se sente ou sentiria sobre o uso do preservativo. Responda a cada um dos itens listados abaixo de acordo com o item que melhor representa sua opinião.
Scale	A= Discordo com veemência B= Discordo C= Não concordo nem discordo D= Concordo E=Concordo com veemência	A = Discordo fortemente B = Discordo C = Indeciso D = Concordo E = Concordo fortemente	A = Discordo fortemente B = Discordo C = Indeciso D = Concordo E = Concordo fortemente
01	Fico constrangido ou ficaria constrangido com relação a comprar preservativo em uma drogaria perto do campus.	Fico ou ficaria constrangido se tivesse que comprar uma camisinha na drogaria perto do campus.	Fico constrangido ou ficaria constrangido se tivesse que comprar um preservativo na farmácia perto do campus.
02	Fico constrangido ou ficaria constrangido com relação a comprar preservativo em uma drogaria perto da casa dos meus pais.	Fico ou ficaria constrangido se tivesse que comprar uma camisinha em uma farmácia perto de onde meus pais moram.	Fico constrangido ou ficaria constrangido se tivesse que comprar um preservativo em uma drogaria perto da casa dos meus pais.
03	Fico constrangido ou ficaria constrangido com relação a comprar preservativo em um lugar onde eu pudesse ter certeza de que ninguém que eu conheça me veria.	Fico constrangido ou ficaria constrangido com a compra de uma camisinha onde eu poderia estar certo de que ninguém que eu conheça me veria.	Fico constrangido ou ficaria constrangido com relação a comprar preservativo em um lugar onde eu pudesse ter certeza de que ninguém que eu conheça me veria.
04	Fico constrangido ou ficaria constrangido com relação a arranjar preservativo nos Serviços de Saúde Estudantil (Enfermaria da Escola).	Fico ou ficaria constrangido se tivesse que pegar camisinhas em posto de saúde dentro da universidade.	Fico constrangido ou ficaria constrangido em relação a obter preservativo nos Serviços de Saúde Estudantil (Enfermaria da Escola).
05	Fico constrangido ou ficaria constrangido em relação a arranjar preservativo em posto de saúde.	Fico ou ficaria constrangido se tivesse que pegar camisinhas em uma unidade de saúde.	Fico constrangido ou ficaria constrangido se tivesse que pegar preservativos em uma unidade de saúde.
06	Fico constrangido ou ficaria constrangido com relação a perguntar onde na loja ficam os preservativos ao balconista ou farmacêutico da drogaria.	Fico ou ficaria constrangido se tivesse que perguntar para um farmacêutico ou atendente da farmácia onde ficam as camisinhas.	Fico constrangido ou ficaria constrangido se tivesse que perguntar para um farmacêutico ou atendente da farmácia onde ficam os preservativos.
07	Fico constrangido ou ficaria constrangido com relação a fazer perguntas relacionadas ao uso do preservativo ao médico ou profissional da saúde.	Fico ou ficaria constrangido em conversar assuntos sobre o uso da camisinha a um médico ou outro profissional da saúde	Fico constrangido ou ficaria constrangido em fazer perguntas sobre o uso do preservativo a um médico ou outro profissional da saúde.
08	Fico constrangido ou ficaria constrangido com relação a interromper as preliminares e pedir ao meu parceiro que coloque o preservativo.	Fico ou ficaria constrangido se tivesse que durante as preliminares sexuais pedir ao meu parceiro (a) para usar a camisinha.	Fico constrangido ou ficaria constrangido se tivesse que durante as preliminares sexuais pedir ao meu parceiro para usar o preservativo.
09	Eu ficaria constrangido se um novo parceiro insistisse que nós usássemos preservativo.	Fico ou ficaria constrangido se um novo parceiro (a) insistisse para usarmos camisinha.	Eu ficaria constrangido se um novo parceiro insistisse que nós usássemos preservativo.
10	Fico constrangido ou ficaria constrangido em dizer ao meu parceiro, durante as preliminares, que não estou disposto a ter relações sexuais a não ser que usemos preservativo.	Fico ou ficaria constrangido se durante as preliminares sexuais tivesse que falar ao meu parceiro que não teria relação sexual se não usarmos uma camisinha.	Fico constrangido ou ficaria constrangido em dizer ao meu parceiro, durante as preliminares sexuais, que não estou disposto a ter relações sexuais a não ser que usemos preservativo.
11	Fico constrangido ou ficaria constrangido com relação a estar preparado e fornecer o preservativo quando fizer amor e meu parceiro não tiver uma.	Fico ou ficaria constrangido de ter uma camisinha e pedir para usá-lo caso o meu parceiro não tivesse.	Fico constrangido ou ficaria constrangido por estar preparado e fornecer um preservativo caso o meu parceiro não tivesse um.
12	Fico constrangido ou ficaria constrangido com relação a carregar um preservativo na carteira/bolsa.	Fico ou ficaria constrangido em carregar uma camisinha em minha carteira ou bolsa.	Fico constrangido ou ficaria constrangido em carregar um preservativo em minha carteira ou bolsa.
13	Fico constrangido ou ficaria constrangido em relação a conversar com meu parceiro sobre o que penso e sinto relacionado ao preservativo.	Fico ou ficaria constrangido em falar com o meu parceiro sobre o que penso e sinto sobre o uso da camisinha.	Fico constrangido ou ficaria constrangido em falar com o meu parceiro sobre o que penso e sinto sobre o uso do preservativo.
14	Fico constrangido ou ficaria constrangido se meu parceiro me assistisse descartar um preservativo depois de o termos usado.	Fico ou ficaria constrangido se o meu parceiro me visse com uma camisinha na mão depois que termos usado.	Fico constrangido ou ficaria constrangido se meu parceiro me visse descartar um preservativo depois de o termos usado.
15	Fico constrangido ou ficaria constrangido com relação a assistir meu parceiro colocar um preservativo OU se meu (minha) parceiro (a) me assistisse colocar um preservativo.	Fico ou ficaria constrangido se o meu parceiro me visse colocar uma camisinha.	Fico constrangido ou ficaria constrangido em ver meu parceiro colocar o preservativo OU se meu parceiro me visse colocar o preservativo.
16	Fico constrangido ou ficaria constrangido em ajudar meu parceiro a colocar um preservativo OU se minha parceira me ajudasse a colocar um preservativo.	Fico ou ficaria constrangido em ajudar o meu parceiro colocar uma camisinha em mim ou se tivesse que ajudá-lo a colocar.	Fico constrangido ou ficaria constrangido em ajudar meu parceiro a colocar um preservativo OU se meu parceiro me ajudasse a colocar um preservativo.
17	Fico constrangido ou ficaria constrangido com relação a assistir meu parceiro remover um preservativo OU se minha parceira me assistisse remover um preservativo.	Fico constrangido ou ficaria constrangido se o meu parceiro me visse retirando uma camisinha.	Fico constrangido ou ficaria constrangido ao ver meu parceiro retirar um preservativo OU se meu parceiro me visse retirar um preservativo.
18	Fico constrangido ou ficaria constrangido em ajudar meu parceiro retirar um preservativo OU se minha parceira me ajudasse a retirar um preservativo.	Fico ou ficaria constrangido em ajudar o meu parceiro a retirar a camisinha.	Fico constrangido ou ficaria constrangido em ajudar meu parceiro retirar um preservativo OU se meu parceiro me ajudasse a retirar um preservativo.

• Note: The underline represents the discrepancies between translations 1 and 2 and the final summary.

After the summary and adjustments, the Brazilian version was translated back into English (back-translation), obtaining a new English version. This version was sent to the first author of the original scale for evaluation. The author made suggestions for adjustments in items 1, 5, 6, 8, 11 and 15, which considered that the translation had differed from the original idea (Chart 2).

Chart 2 -
Comparison of the original scale and version with back translation. Rio Verde, Goiás, Brazil, 2016.

Title	Original scale	Back translation version
	Condom Embarrassment Scale	Scale of Embarrassment on condom use
Instructors	The following items assess how embarrassed you do feel (or would feel) about condom use. Using the following scale, please respond to each of the items listed below.	The following items intend to evaluate how you feel (or would feel) regarding the use of condoms. Read each statement carefully and mark with an x ​​the option that best reflects your opinion, according to the scale:
Scale	A = Strongly disagree B = Disagree C = Neither agree or disagree D = Agree E = Strongly agree	A = Strongly disagree; B = Disagree; C = Neither agree nor disagree; D = Agree; E = Strongly agree.
01	I am embarrassed or would be embarrassed about buying a condom from a drug store near campus.	I get embarrassed or would get embarrassed If I had to buy condoms in pharmacies or supermarkets near the university.
02	I am embarrassed or would be embarrassed about buying a condom from a drug store close to where my parents live.	I get embarrassed or would get embarrassed if I had to buy condoms in pharmacies or supermarkets near my parents' house.
03	I am embarrassed or would be embarrassed about buying a condom from a place where I could be certain no oneI know would see me.	I get embarrassed or would get embarrassed about buying condoms in a place where I could assure nobody I know would see me.
04	I am embarrassed or would be embarrassed about obtaining condoms from Student Health Services (School Infirmary).	I get or would get embarrassed about getting a condom in a school and / or university's ward.
05	I am embarrassed or would be embarrassed about obtaining condoms from a local health department.	I get embarrassed or would get embarrassed if I had to get condoms in a health center.
06	I am embarrassed or would be embarrassed about asking a pharmacist or drug store clerk where condoms are located in the store.	I get embarrassed or would get embarrassed if I had to ask a pharmacist or a pharmacy attendant where the condoms are in the store.
07	I am embarrassed or would be embarrassed about asking a doctor or other health care professional questions about condom use.	I get embarrassed or would get embarrassed to talk about the use of condoms with a doctor or other health care provider.
08	I am embarrassed or would be embarrassed about stopping during foreplay and asking my partner to use a condom.	I get embarrassed or would get embarrassed if I had to interrupt foreplay to ask my partner to use a condom.
09	I would be embarrassed if a new partner insisted that we use a condom.	I would get embarrassed if a new partner insisted that we used a condom.
10	I am embarrassed or would be embarrassed to tell my partner during foreplay that I am not willing to have sexual intercourse unless we use a condom.	I get embarrassed or would get embarrassed to tell my partner, during foreplay, that I am not willing to have sexual intercourse unless we use a condom.
11	I am embarrassed or would be embarrassed about being prepared and providing a condom during lovemaking if my partner didn't have one.	I get embarrassed or would get embarrassed about being prepared and provide a condom in case my partner did not have one.
12	I am embarrassed or would be embarrassed about carrying a condom around in my wallet / purse.	I get embarrassed or would get embarrassed to carry a condom in my wallet or purse.
13	I am embarrassed or would be embarrassed about talking to my partner about my thoughts and feelings about condom use.	I get embarrassed or would get embarrassed to talk with my partner about what I think and feel regarding condom use.
14	I am embarrassed or would be embarrassed if my partner watched me dispose of a condom after we had used it.	I get embarrassed or would get embarrassed if my partner saw me discard a condom after we used it.
15	I am embarrassed or would be embarrassed about watching my partner put on a condom OR if my partner watched put me on a condom.	I get or would get embarrassed if my partner observed me putting a condom or if my partner saw me put a condom.
16	I am embarrassed or would be embarrassed about helping my partner put on a condom OR if my partner helped me put on a condom.	I get embarrassed or would get embarrassed to help my partner put a condom OR if my partner helped me put a condom.
17	I am embarrassed or would be embarrassed about watching my partner remove a condom OR if my partner watched remove me a condom.	I get embarrassed or would get embarrassed to see my partner remove a condom OR if my partner saw removes me a condom.
18	I am embarrassed or would be embarrassed about helping my partner remove a condom OR if my partner helped me remove a condom.	I get embarrassed or would get embarrassed to help my partner remove a condom OR if my partner helped me remove a condom.

• Note: the underline represents points that differed from the original idea of the instrument.

Regarding items 1, 2, 5, 6 and 8, the author highlighted the need to emphasize that the scale assesses the embarrassment when obtaining the condom, as a routine behavior. As it was written: “if I had to buy a condom”, for the author, it implied that the young man did not want to buy or did not have the habit, but was compelled to do so. In item 11, the author requested the inclusion of the expression “during sex”. The translated item omitted that the occasion was during sex.

All of the author's suggestions were included in the scale, generating the second Brazilian version, which was submitted for analysis by the expert committee.

During the review of the committee, semantic, idiomatic and experiential equivalences were evaluated. Conceptual equivalence was obtained both by the committee's evaluation and by the pre-test. This stage gave rise to the consensual Brazilian version.

The changes made by the committee started with the title considering that the term “condom” is suitable for translation, but in Brazil the term condom is used. We chose to use the expression “condom (condom)” in the title and the entire scale and wait for the evaluation by the target audience to choose the term that would provide greater clarity to young people.

Letters were replaced by numbers, in the form of the Likert scale response, A = Strongly disagree; B = Disagree; C = Neither agree or disagree; D = Agree; E = Strongly agree, understanding that the use of numbers can facilitate the completion of the scale and has more similarity with intensity, in addition to the use of the word "totally": 1 = Totally disagree; 2 = Disagree; 3 = I neither agree nor disagree; 4 = I agree; 5 = I totally agree. The word fully is used in several Brazilian instruments and is easy to understand.

In item 1, to facilitate understanding and because it is more familiar, the word campus was changed to “university” and the term “supermarket” was included, since in Brazil condoms are sold in pharmacies and supermarkets.

In item 3, the expression “buying a condom from a place where I could be sure that nobody I know would see me”, to facilitate the understanding of the statement was modified to “buy condoms in a place where I could be sure that no one I know would see me”.

In item 4, the term school infirmary, was changed to “school and/or university infirmary” for better understanding by the target population. Although in Brazilian universities there are rarely any infirmaries, the committee opted to maintain the statement.

In item 7, in relation to the term questions about condom use, in the translated version, “asking questions related to condom use” was used, but to designate a dialogue with the doctor or another health professional, it was modified to “talk about condom use with a doctor or other health professional ”.

In item 10, there was a consensus that there would be no need for the expression “sexual foreplay” to characterize the moment that precedes the sexual act and avoid the repetition of the sexual word, choosing to keep only “during the foreplay, which I am not willing to having sex ”.

In the pre-test, all 42 university students (100%) responded to the scale, classifying it as containing very clear instructions. Most participants, 32 (78%), classified the questions as easy to understand and 10 (22%) as regular comprehension. However, everyone considered the scale to be very repetitive. As a suggestion, it was requested to use the term “camisinha” instead of the term “condom” throughout the scale, as it is a term that is more widely disseminated among the target audience, in this case, university students. The university students were also questioned if there was a need to use the term partner on the scale to facilitate understanding, which everyone considered unnecessary, and should only use the term “partner” to designate a man or woman.

After the adjustments were made, the final Brazilian Portuguese version was obtained, which was called the Condom Embarrassment Scale - CEP (Chart 3).

Chart 3 -
Brazilian version of the Condom Embarrassment Scale. Rio Verde, Goiás, Brazil, 2016.

Os itens a seguir pretendem avaliar como você se sente ou sentiria sobre o uso da camisinha. Leia com atenção cada uma das afirmativas e assinale com um X a opção que melhor traduz sua opinião, de acordo com a seguinte escala: 1-Discordo totalmente; 2-Discordo; 3-Não concordo, nem discordo; 4-Concordo; 5-Concordo totalmente.
	1	2	3	4	5
1. Fico constrangido ou ficaria constrangido ao comprar camisinha na farmácia ou supermercado perto da universidade.
2. Fico constrangido ou ficaria constrangido ao comprar uma camisinha em uma farmácia ou supermercado perto da casa dos meus pais.
3. Fico constrangido ou ficaria constrangido ao comprar camisinha em um lugar onde eu pudesse ter certeza de que ninguém que eu conheça me veria.
4. Fico constrangido ou ficaria constrangido em pegar camisinha em uma enfermaria da universidade.
5. Fico constrangido ou ficaria constrangido ao pegar camisinhas em uma unidade de saúde.
6. Fico constrangido ou ficaria constrangido ao perguntar para um farmacêutico ou atendente da farmácia onde ficam as camisinhas.
7. Fico constrangido ou ficaria constrangido em conversar sobre o uso da camisinha com um médico ou outro profissional da saúde.
8. Fico constrangido ou ficaria constrangido ao interromper as preliminares sexuais para pedir ao meu parceiro que use camisinha.
9. Eu ficaria constrangido se um novo parceiro insistisse que nós usássemos camisinha.
10. Fico constrangido ou ficaria constrangido em dizer ao meu parceiro, durante as preliminares que não estou disposto a ter relações sexuais a não ser que usemos camisinha.
11. Fico constrangido ou ficaria constrangido em estar preparado durante o sexo e ter uma camisinha caso o meu parceiro não tivesse uma.
12. Fico constrangido ou ficaria constrangido em carregar uma camisinha em minha carteira ou bolsa.
13. Fico constrangido ou ficaria constrangido em falar com o meu parceiro sobre o que penso e sinto sobre o uso da camisinha.
14. Fico constrangido ou ficaria constrangido se meu parceiro me visse descartar uma camisinha depois de a termos usado.
15. Fico constrangido ou ficaria constrangido em ver meu parceiro colocar a camisinha ou se meu parceiro me visse colocar a camisinha.
16. Fico constrangido ou ficaria constrangido em ajudar meu parceiro a colocar uma camisinha OU se meu parceiro me ajudasse a colocar uma camisinha.
17. Fico constrangido ou ficaria constrangido ao ver meu parceiro retirar uma camisinha OU se meu parceiro me visse retirar uma camisinha.
18. Fico constrangido ou ficaria constrangido em ajudar meu parceiro retirar uma camisinha OU se meu parceiro me ajudasse a retirar uma camisinha.

DISCUSSION

The CES translation and cultural adaptation process was carried out according to the methodology suggested in the literature.14^,17^-18 This process is characterized by a careful methodology, with the aim of achieving the maximum correspondence between the original instrument and the version translated, prioritizing the search for a cultural approach and an adaptation of language to the population to whom the instrument is addressed.13^,19

In the initial and back translation stages, two independent translations were performed for the detection of errors and divergent interpretations of ambiguous items in the original instrument, in order to eliminate linguistic and cultural bias.1 The literature recommends that the translation is performed by at least two independent translators, qualified professionals and that their mother tongue is the target language.20

The translating process from one language to another must consider the language, the cultural context and the lifestyle, observing the technical, linguistic and semantic aspects.21 Changes in the format of the original instrument should not occur in the translation and back-translation stages, as addition or exclusion of items, as it may compromise its applicability and equivalence with the original instrument,22 since the translation of an instrument alone does not guarantee its applicability.21

In the back-translation stage, the translators must not have participated in the previous stage, they must be bilingual and not know the objectives of the study, reducing the possibility of generating prejudices and expectations.23

The back translation, when sent to the author of the original scale evaluated the accuracy of the translated version and an additional quality control check of all semantic and idiomatic adjustment procedures. Thus, it can be said that the CEP in Portuguese maintained the coherence and integration of the items.

It is important to mention that the meanings attributed to facilitate the understanding of the scale by the target population in the evaluation of the committee of experts, gave the university students a good understanding and acceptance of the items, thus ensuring unanimity and correspondence with the Brazilian cultural context, preserving the contents of the original scale. In other words, the participation of specialists was essential for a thorough evaluation, without any change in the essence of the instrument. This procedure corroborates the literature on cross-cultural adaptation of psychometric instruments.24

The committee's evaluation took into account the knowledge of the target culture, in which the approximation of the Brazilian reality was sought, such as the inclusion of “supermarkets” in the scale.

In the responses to the items on the scale, the Likert-type format was maintained with the same number of response options with only one change, from letters to numbers, to express a greater intensity relationship. The committee can modify the initial guidelines and format of the instrument, change or reject inappropriate items so that the instrument is truly understandable to the target audience.25

The evaluation by the target audience in the pre-test stage allowed greater methodological rigor in the cross-cultural adaptation process of the instrument. This procedure allowed the analysis of the adequacy of the items and the structure of the instrument, in addition to verifying whether the terms are clear and in accordance with reality, as well as verifying practical aspects of their application.13^-14^,21

The evaluation performed by the target audience, according to Guillemin (1995), 23 can be performed by applying the instrument to a small group of the target population, with the aim of identifying words or expressions that are difficult to understand, assessing acceptability and requesting comments on the instrument in general.

Thus, the target audience consisted of university students in a very wide age group and for which the instrument is intended, from 18 to 28 years old, so that the translated and adapted version can be applied in different populations of university students and in different locations. There was a good acceptability of the scale, and there was no doubt about the items or meanings.

The comprehension and clarity reported by the target audience during the pre-test stage demonstrated that the stages of the cross-cultural adaptation process were successfully completed, which resulted in the final version of the instrument.

Additional studies aimed at investigating the psychometric properties and other forms of validity of the scale are necessary for its application in the Brazilian context.

CONCLUSION

The CES's cross-cultural adaptation process aimed to achieve the maximum correspondence between the original and the translated scale, prioritizing idiomatic, cultural and methodological aspects. The steps taken during the process allowed the necessary adaptations to be made to the socio-cultural reality and the level of understanding of the target population. Thus, the Brazilian Portuguese version, called the Embarrassment Scale for the use of Condoms, proved to be well understood when applied to university students. The results of the translation and cross-cultural adaptation demonstrated that the CES maintained equivalence with the North American version.

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NOTES

• ORIGIN OF THE ARTICLE

  Extracted from the Research - Knowledge about sexually transmitted infections, attitudes and embarrassment towards condom use in young university students, presented to the Pro-Rectory of Research and Graduate Studies of the Universidade de Rio Verde, Research Support Program, 2016.

• FUNDING INFORMATION

  Research Support Program of the Universidade de Rio Verde, Research Grant, internal call 01/2016 - Dean of Research and Graduate Studies. Process Number: 007.2016.4.04.

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH

  Approved by the Ethics Committee in Research with Human Beings of the Universidade de Rio Verde, opinion no. 1,359,296/2015. CAAE: 50823915.1.0000.5077.

Publication Dates

• Publication in this collection
  08 Jan 2021
• Date of issue
  2020

History

• Received
  12 Aug 2019
• Accepted
  18 Mar 2020