Open-access Brazilian Portuguese version of the Anger Rumination Scale (ARS-Brazil)

Versão em português brasileiro da Escala de Ruminação de Raiva (ARS-Brasil)

Abstract

Objective  To describe the cross-cultural adaptation of the Anger Rumination Scale (ARS) for use in Brazil.

Methods  The cross-cultural adaptation followed a four-step process, based on specialized literature: 1) investigation of conceptual and item equivalence; 2) translation and back-translation; 3) pretest; and 4) investigation of operational equivalence.

Results  A final Brazilian version of the instrument (ARS-Brazil) was defined and is presented. Pretest results revealed that the instrument was generally well understood by adults as well as indicated a few modifications that were included in the final version presented here.

Conclusion  The Brazilian Portuguese version of the ARS seems to be very similar to the original ARS in terms of conceptual and item equivalence, semantics, and operational equivalence, suggesting that future cross-cultural studies may benefit from this early version. As a result, a new instrument is now available for the assessment of rumination symptoms of anger and irritability for adults in community, clinical, and research settings.

Keywords Rumination; anger; irritability; anger rumination scale

Resumo

Objetivo  Descrever a adaptação transcultural da Escala de Ruminação de Raiva (Anger Rumination Scale, ARS) para uso no Brasil.

Método  A adaptação transcultural seguiu um processo de quatro etapas baseado em literatura especializada: 1) investigação da equivalência conceitual e dos itens; 2) tradução e retrotradução; 3) pré-teste; e 4) investigação da equivalência operacional.

Resultados  Uma versão final brasileira do instrumento, denominada ARS-Brasil, foi obtida e é apresentada. Os resultados do pré-teste demonstraram que a escala foi predominantemente bem entendida entre adultos, e indicaram algumas modificações que foram incluídas na versão final.

Conclusão  A versão da ARS adaptada para o português brasileiro mostra-se muito similar à versão original da ARS no que diz respeito à equivalência conceitual e dos itens, semântica e equivalência operacional, sugerindo que futuros estudos transculturais poderiam se beneficiar desta primeira versão. Como resultado, um novo instrumento está agora disponível para a avaliação de sintomas de ruminação da raiva e da irritabilidade para adultos, em contextos comunitário, clínico e de pesquisa.

Descritores Ruminação; raiva; irritabilidade; escala de ruminação de raiva

Introduction

Anger is a basic emotion characterized by a state of negative unpleasant feelings, specific cognitive assessments and biased action and behavior.1,2 Anger rumination is regarded as a relatively independent component within the larger sequence of anger phenomenology, and can be defined as conscious thoughts about the experience of anger occurring without the demands of the immediate situation.2-4 The Anger Rumination Scale (ARS) was developed to assess this construct.2 This is important because the tendency to ruminate about anger may be partly responsible for maintaining anger as a trait, and therefore it may be related to several negative health outcomes associated with trait anger.5

The ARS was built to measure the tendency to focus on the angry mood, to remember past episodes of anger, and to think about the causes and consequences of episodes of anger. Authors suggest that memories of past episodes of anger can trigger new episodes of state-angry; attention to anger experiences can lead to an amplification of its intensity and duration; and counterfactual thoughts can be related to a tendency to retaliation. The term “counterfactual thinking” refers to cognitions about antecedents and consequences of episodes of anger.2 Previous psychometric studies using the ARS have shown that the instrument has adequate internal consistency (Cronbach's alpha of 0.93). Factor analysis revealed four subscales: angry afterthoughts, thoughts of revenge, angry memories and understanding the causes, all with Cronbach's alpha values ranging from 0.77 to 0.86, with item total correlations ranging from 0.39 to 0.75. Further analyses also revealed a good test-retest reliability of 0.77 over a 1-month period and good concurrent validity with other measures of anger, negative affectivity and the individual's ability to reflect on emotions.2 The psychometric properties of the ARS were evaluated in validations in other countries, and the factorial structure (four factors) of the original scale was also observed in most of the studies. For example, in the validation study of Mexico, the four-factor model had better goodness of fit indices than rival models with three and two factors. Alpha reliabilities were acceptable (0.72-0.89).3 In the Australian sample, the four-factor model provided a good fit: Satorra-Bentler chi-square (S-B X2) (degrees of freedom [df] = 146) = 489.48, p < 0.001; root mean square error of approximation (RMSEA) = 0.06 (90% confidence interval [90%CI] = 0.06-0.07); comparative fit index (CFI) = 0.91; standardized root-mean-square residual (SRMR) = 0.05.6

Despite its importance, anger rumination has received little attention in the Brazilian literature. One potential reason is that scales such as the ARS are not available in a validated form to the Brazilian population. Although studies in this matter have mostly concentrated in the United States, other countries and populations have successfully adapted the ARS to their languages and cultural contexts, such as the Spanish,7 the Mexicans3 and the Iranians,8 among others.6,9,10 The overall good factor structure properties of the original scale and its cross-cultural adaptations demonstrate that Brazilian researchers would benefit from a cross-cultural adaptation that would make this instrument available as a possibility to investigate anger rumination in our populational context. Therefore, the objective of the present study was to conduct and describe the process of cross-cultural adaptation of the ARS for use in Brazil.

Method

The study protocol was approved by the ethics committee of Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS; project 15-0032). Translators and collaborators who rated the clarity of the items verbally assented to participate in the study.

Instrument: Anger Rumination Scale (ARS)

The ARS was developed to measure the “tendency to think about current anger-provoking situations and to recall anger episodes from the past.”2 In each item, respondents are instructed to check the word that best describes how often they experience the behaviors, feelings, and reactions described in the scale (reflecting angry symptoms and/or anger rumination symptoms). In the original study, factor analysis results revealed the presence of four factors or subscales: 1) angry afterthoughts (six items); 2) thoughts of revenge (four items); 3) angry memories (five items); and 4) understanding of causes (four items). A four-point word scale is used: almost never, sometimes, often, almost always. For the purposes of this study, participants were asked to answer based on how they felt over the last six months. All items are phrased so that higher scores represent higher levels of anger rumination. Participants are instructed that there are no right or wrong answers when answering to the scale items.

Steps of the cross-cultural adaptation process

First, the authors of the present study contacted the author of the original ARS so that she could authorize the cross-cultural adaptation process. Once permission was granted, a four-step process was followed, based on specialized literature11,12 and on the International Test Commission Guidelines for Translating and Adapting Tests.13 The four steps were: 1) investigation of conceptual and item equivalence; 2) translation and back-translation; 3) pretest; and 4) investigation of operational equivalence.

Investigation of conceptual and item equivalence

In the first step, the scale was analyzed in terms of conceptual and item equivalence between the original and target contexts.11,12 Equivalence was assessed through a literature review about anger rumination and the instruments available for the assessment of anger in Brazil, and based on the analysis and opinion of a committee organized to evaluate the Brazilian version of the ARS (two experts in the field of psychometrics, cited below). The objectives were: 1) to investigate if the relationship between the scale and its underlying concept (i.e., anger rumination) in the original setting would be the same in Brazil; and 2) to investigate if the items comprising the original scale would remain relevant and acceptable in the Brazilian context. Instrument analysis was performed by two experts in the field: a researcher with experience in psychometric research (GAS) and a psychologist specialized in cross-cultural adaptation of instruments (DADS).

Translation and back-translation

In the second step, the scale was translated from English into Brazilian Portuguese and then back-translated into English. Two independent translators produced forward-translations of the ARS, and a third one synthesized both translations into a single version in Brazilian Portuguese. This synthesized version was then back-translated independently by two other translators, and again a third one synthesized both back-translations into a single version in English.11,14,15 All translators involved in this step were fluent in both languages: English and Brazilian Portuguese.

The original version of the ARS, the synthesized forward-translation, and the synthesized back-translation were all evaluated by the same expert committee that assessed conceptual and item equivalence.11,14,15 The committee assessed whether the items included in the three versions reflected the same ideas regarding the target construct (i.e., anger rumination). The objective was to make sure that the translation process was adequately conducted and that the translated items were relevant to the Brazilian context. Adjustment of instrument items was performed after consensus was reached among all members of the committee.

Pretest

The third step of the cross-cultural adaptation process consisted of a pilot study.11,14 The aim of this step was to evaluate the understanding of the scale by the target population – Brazilian adults aged 18 years or older. Participants were recruited via e-mail with a link to access the initial version of the scale. The authors contacted graduate students of UFRGS, asking them to share the study link with acquaintances or family members, giving priority to family members/friends/acquaintances with low socioeconomic status. Forty-nine adults answered the ARS in the pretest. In addition to responding the scale, participants were asked to assess the degree of understanding of each sentence responding to the question “How clear is this sentence?,” with the following response options: “I understood it completely,” “I understood it more or less” and “I did not understand it.” We also asked participants to give suggestions for each of the scale items. Answers were analyzed in an attempt to identify any problems in the wording of the items, as well as any confusing or misleading items.

Investigation of operational equivalence

In the fourth step, the scale was analyzed in terms of the operational equivalence between the original and target contexts.11,12 The following aspects were evaluated considering the use of the instrument in Brazil: instructions, method of administration, questionnaire format, and measurement methods used in the original ARS. Operational equivalence was analyzed through a literature review focusing on operational models of other anger evaluation instruments available in Brazil.

Results

Results obtained in each step of the adaptation process of the ARS-Brazil are described below (Table 1).

Table 1
Translation and back-translation of the ARS to Brazilian Portuguese

Investigation of conceptual and item equivalence

Both experts agreed that the domains and theoretical foundation that formed the basis for the original ARS, as well as the items representing them, were equally relevant and important to the target context, and that the actual construction was likely to be equally valid in Brazil. However, both experts identified problems in a specific item of the ARS: “I ruminate about my past anger experiences.” In the Brazilian context, the term “ruminate” is not clear to many people as a cognitive process, since it is predominantly used to describe the act of swallowing/regurgitating/chewing/swallowing of a suborder of herbivorous mammals (e.g., cows). This consideration was taken into account and this item was edited as follows: “Eu penso muito sobre momentos passados em que tive raiva,” replacing the term “ruminar” (to ruminate) with “penso muito” (over think, think too much). Another term was also identified by the experts as misleading in the Brazilian context: “I have daydreams and fantasies of violent nature.” There is no perfect translation to the term “daydreams” in Portuguese, therefore “I have daydreams” was translated as “Eu imagino” (I imagine). Also, the term “fantasies” can be interpreted in Brazilian Portuguese in different ways, and thus it was replaced with “pensamentos,” as follows: “Eu imagino coisas e tenho pensamentos de conteúdo violento.” Finally, the experts suggested the inclusion of a limiter of time “in the last 6 months” in the questionnaire's instructions. After discussion, they judged that the definition of “in the last six months” would not change the original construct and would facilitate understanding in the Brazilian context.

Translation and back-translation

The forward- and back-translations followed the steps described above, involving six translators throughout the process. Few items showed discrepancies between the versions of the two independent translators and the two back-translators, which facilitated the task of the translators responsible for synthesizing the versions. The expert committee checked the synthesized forward- and back-translations, comparing them to the original ARS. The committee observed that the words “anger” and “angry,” used in many items of the original instrument, were randomly translated into Portuguese as “raiva” and “chatear,” not following a pattern. The same happened with the word “rumination,” which was translated as “penso muito” and “rumino.” After discussing this issue, adjustments were performed and a decision was reached about the final wording of items in the ARS-Brazil. Table 1 shows the original items of the ARS, results of the translation and back-translation stages, and the final version of the Brazilian Portuguese correlate items after the pilot study and review by the expert committee.

Pretest

The mean age of participants was 35.3 years (standard deviation = 15.96), 64.7% were women. Level of education was high school or lower in 36% and college or higher in 64%. The mean level of clarity of the questions was very high, ranging from 84.3 to 100% of understanding. Of all 49 participants, only two had difficulties understanding two distinct items (each of these two participants did not understand one specific item): item 7 – “Depois que uma discussão acaba, eu continuo brigando com essa pessoa no meu pensamento”; and item 11 – “Eu analiso as situações que me deixam com raiva.” None of these participants made suggestions to change the items, and none of the other 47 participants suggested changes to such items. After evaluation of the experts, it was decided to respectively modify them to “Depois que uma discussão acaba, eu continuo imaginando brigas com essa pessoa no meu pensamento”; and “Eu tento entender as situações que me deixam com raiva.”

The items with the highest number of suggestions for clarity were items 1 and 10, respectively, “Eu penso muito sobre minhas experiências passadas de raiva” and “Algumas vezes eu não consigo parar de me preocupar com um determinado conflito.” Nine participants suggested changes in item 1, and eight in item 10. The number of participants who answered “fully understood” was 43 (87.75%) for item 1 and 41 (83.67%) for item 10 (no one answered “I did not understand it” to such items).

For item 1, some of the suggestions were that the expression “experiências passadas de raiva” would be too formal, and the use of “situações/experiências no passado em que senti raiva” was suggested. Another participant suggested “Eu penso muito nos momentos que fiquei com muita raiva.” This item was then modified by the expert committee to “Eu penso muito sobre momentos passados em que tive raiva.” As for item 10, some participants suggested removing the word “algumas vezes” from the question, and others suggested replacing the word “conflito” because they judged this was not a clear question. This item was changed by the experts to “Eu não consigo parar de me preocupar com uma determinada situação que me deixou com raiva.”

Investigation of operational equivalence

There were no sources of difficulty regarding the format, instructions, method of assessment, or measurement methods of the ARS in the Brazilian context. The review of the literature also demonstrated that many of the instruments used for assessing anger symptoms in Brazilian adults follow operational procedures similar to those of the ARS, e.g., the Brazilian version of the State-Trait Anger Expression Inventory (STAXI).16

Discussion

Here we presented the Brazilian version of the ARS. The scale showed proper conceptual and item equivalence, translation and back-translation procedures were performed adequately, and the scale demonstrated good levels of clarity among participants, as well as operational equivalence.

The ARS-Brazil is presented as a new instrument now available for the assessment of anger rumination symptoms. The scale can be used in community settings, serving as a screening tool to identify people at risk for developing maladjustment behaviors because of anger symptoms, assisting in preventive interventions. It can also be used in academic settings in studies designed to assess anger rumination indicators or symptoms in terms of their frequency, severity, or structure. Finally, another possible application of the ARS-Brazil is its use in clinical settings, as an auxiliary tool for diagnostic and therapeutic evaluations regarding the structure and severity of diseases linked to anger symptoms.

The ARS-Brazil is now among the few scales, such as the STAXI, which is available for assessing anger in Brazilian individuals.17 Nonetheless, the ARS focuses specifically on the cognitive processes of rumination, while the STAXI assesses broad aspects of anger as a state and personality trait of individuals.16 As described in previous studies, anger and anger rumination are different cognitive processes, and the Brazilian literature, so far, lacked an instrument designed to address anger rumination thoroughly. Anger rumination covers not only the aspects of irritability and anger per se (as measured by the STAXI), but also the detailed and fine-grained cognitive processes of angry afterthoughts, angry memories, thoughts of revenge and understanding of causes – the very foundations of anger rumination.2

Some limitations to this work should be noted. First, even with the attempt by the authors to prioritize participants with lower socioeconomic level and less educated, clarity levels were mainly investigated with a very selected sample, consisting of a majority of participants with higher education, which do not represent the Brazilian population. Second, and also very important, the pretest was conducted in just one site in Brazil, making national validation assurance difficult given the cultural and linguistic variances between different parts of Brazil. Nevertheless, this pretest was mainly focused on investigating suggestions for the translation process and on detecting important clarity issues. Despite that, further studies should be investigated with larger and diverse samples to assure the appropriateness of the ARS properties to the Brazilian population.

The ARS-Brazil seems to be very similar to the original ARS, suggesting that future cross-cultural studies may benefit from this early version. However, other studies are needed in order to take on further steps in the cross-cultural adaptation process of the ARS-Brazil. For example, next steps could include administering the scale to Brazilian samples, so as to collect evidence of instrument validity based on psychometric properties of the ARS-Brazil through recognized statistical methods.11,13,18

Acknowledgements

This project was funded by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) and Fundo de Incentivo à Pesquisa e Eventos – Hospital de Clínicas de Porto Alegre (FIPE-HCPA).

We would like to thank Dr. Denis G. Sukhodolsky for generously approving the scale translation developed by him (ARS) for the Brazilian Portuguese version. We are also grateful to Drs. André Luiz Moreno, Bruno Figueiredo Damásio and Susana Núñez Rodriguez for their important contribution to ARS-Brazil's translation and back-translation process.

References

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Publication Dates

  • Publication in this collection
    Jan-Mar 2018

History

  • Received
    06 Mar 2017
  • Accepted
    17 July 2017
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Associação de Psiquiatria do Rio Grande do Sul Av. Ipiranga, 5311/202, 90610-001 Porto Alegre RS/ Brasil, Tel./Fax: (55 51) 3024 4846 - Porto Alegre - RS - Brazil
E-mail: trends@aprs.org.br
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