Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 16 nº 3 - Jul/Sep - 2019

Original Article Imprimir 

Páginas 80 a 92


Transcultural adaptation: translation and validation of content of the Brazilian version of the the international fitness scale instrument

Adaptación intercultural: traducción y validación de contenido de la versión brasileña del instrumento internacional fitness scale

Adaptação transcultural: tradução e validação de conteúdo da versão brasileira do instrumento the international fitness scale

Autores: Débora de Almeida Pereira1; Nelson Carvas Junior2; Jânio Luiz Correia Júnior3; Ricardo de Freitas Dias4

1. Master student in Hebriatry - Determinants of Adolescent Health - from the University of Pernambuco (UPE). Camaragibe, PE, Brazil
2. Master in Health Sciences from the Institute of Medical Assistance to the State Public Servant (IAMSPE). Teacher at Ibirapuera University (UNIB). Sao Paulo, SP, Brazil
3. Graduating in Physiotherapy from the University of Pernambuco (UPE). Petrolina, PE, Brazil
4. Doctor in Functional and Molecular Biology by the the State University of Campinas (UNICAMP). Master in Human Motricity Science from the Castelo Branco University (UCB/RJ). Teacher at the University of Pernambuco - UPE/Petrolina and Teacher at the Postgraduate Program in Hebiatry - UPE/Recife, Brazil

Débora de Almeida Pereira
(debora.almeidapereira@hotmail.com)
Universidade de Pernambuco (UPE), Programa de Pós-Graduação em Hebiatria
Avenida General Newtom Cavalcanti, 1650, Tabatinga
Camaragibe, PE, Brasil. CEP: 54753-220

Submitted on 12/29/2018
Approved on 3/18/2019

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How to cite this article

Keywords: Physical Fitness; Translating; Cross-Cultural Comparison.
Palabra Clave: Aptitud física; Traducción; Comparación Transcultural.
Descritores: Aptidão Física; Tradução; Comparação Transcultural.

Abstract:
OBJECTIVE: Achieve cross-cultural adaptation through translation, content validation, clarity and understanding of the questionnaire The International Fitness Scale (IFIS).
METHODS: Cross-cultural adaptation of the IFIS was performed through the following stages: translation, translation synthesis, back-translation, back-translation synthesis and review by an expert committee (n= 5), followed by the evaluation of understanding and clarity by 25 professionals in the area and application of the instrument in adolescents (n= 40). To evaluate the construct that the instrument propose to measure, as well as the quality of the translation, were carried out descriptive analyzes and the CVC. The Cronbachs alpha coefficient was used to verify the degree of internal consistency of the questions.
RESULTS: After the evaluation of the specialists, only the item (title) presented value less than 80% of the Likert scale of five points, related to the idiomatic equivalence (3.40) and conceptual (3.80). After the requested adjustments, the final version of the questionnaire presented a total CVC of 0.94. The degree of clarity and comprehension assessed by health professionals ranged from 4.5 to 5.0 and a CVC of 0.95. The total Cronbachs alpha was 0.88, which is equivalent to a high internal consistency.
CONCLUSION: Transcultural adaptation proved to be valid, presenting both content quality and clarity and comprehension, as well as being able to move on to the next psychometric analyzes, which will allow future recommendations for its application and evaluation of the physical aptitude of adolescents in Brazil.

Resumen:
OBJETIVO: Realizar una adaptación intercultural a través de la traducción, validación de contenido, claridad y comprensión del cuestionario The International Fitness Scale (IFIS).
MÉTODOS: La adaptación transcultural de IFIS se realizó a través de los siguientes pasos: traducción, síntesis de traducción, traducción inversa, síntesis de traducción inversa y revisión del comité de expertos (n = 5), seguido de 25 evaluaciones de comprensión y claridad por profesionales en el campo de la salud y aplicación del instrumento en adolescentes (n = 40). Para evaluar el constructo que el instrumento propone medir, así como la calidad de la traducción, se realizaron análisis descriptivos y el Coeficiente de Validez de Contenido (CVC). Para verificar el grado de consistencia interna de las preguntas, se utilizó el coeficiente alfa de Cronbach.
RESULTADOS: Después de la evaluación de los expertos, solo el ítem (título) presentó un valor por debajo del 80% de la escala Likert de cinco puntos, relacionado con la equivalencia idiomática (3.40) y conceptual (3.80). Después de los ajustes solicitados, la versión final del cuestionario presentó un CVC total de 0,94. El grado de claridad y comprensión evaluado por los profesionales de la salud varió de 4.5 a 5.0, y un CVC de 0.95. El alfa de Cronbach total fue de 0,88, lo que equivale a una alta consistencia interna.
CONCLUSIÓN: La adaptación intercultural demostró ser válida, presentando tanto la calidad del contenido como la claridad y la comprensión, así como la posibilidad de pasar a los próximos análisis psicométricos, lo que permitirá futuras recomendaciones para su aplicación y evaluación de la aptitud física de los adolescentes en Brasil.

Resumo:
OBJETIVO: Realizar a adaptação transcultural por meio da tradução, validação de conteúdo, clareza e compreensão do questionário The International Fitness Scale (IFIS).
MÉTODOS: Foi realizada a adaptação transcultural do IFIS por meio das seguintes etapas: tradução, síntese da tradução, retrotradução, síntese da retrotradução e revisão por comitê de especialistas (n=5), seguido da avaliação da compreensão e clareza por 25 profissionais da área de saúde e da aplicação do instrumento em adolescentes (n=40). Para avaliar o construto que o instrumento propõe medir, bem como a qualidade da tradução, foram realizadas análises descritivas e o Coeficiente de Validade de Conteúdo (CVC). Para verificar o grau de consistência interna das questões, foi utilizado o coeficiente alfa de Cronbach.
RESULTADOS: Após a avaliação dos especialistas, apenas o item (título) apresentou valor inferior a 80% da escala Likert de cinco pontos, relativo à equivalência idiomática (3,40) e conceitual (3,80). Após os ajustes solicitados, a versão final do questionário apresentou um CVC total de 0,94. O grau de clareza e compreensão avaliado pelos profissionais de saúde variou de 4,5 a 5,0, e um CVC de 0,95. O alfa de Cronbach total foi de 0,88, o que equivale a uma consistência interna alta
CONCLUSÃO: A adaptação transcultural mostrou ser válida, apresentando tanto qualidade de conteúdo quanto clareza e compreensão, além de estar em condições de passar para as próximas análises psicométricas, o que possibilitará recomendações futuras da sua aplicação e avaliação da aptidão física de adolescentes no Brasil.

INTRODUCTION

Low physical fitness is considered one of the main risk factors for cardiovascular diseases, surpassing classic factors such as dyslipidemia, hypertension and obesity1. Consequently, its assessment is of interest to public health worldwide2.

However, the evaluation of physical fitness components depends on laboratories, the presence of specialists, high funding and timely exams, which makes impractical large-scale measurement and use in population studies2,3. In this sense, there is a need to look for alternative methods, such as questionnaires, which are widely used in epidemiological research due to their simplicity of use and their low cost4. In this sense, there is a need to look for alternative methods, such as questionnaires, which are widely used in epidemiological research due to their simplicity of use and their low cost4.

However, it is necessary that these instruments have psychometric qualities that guarantee the reliability of the indicators evaluated, and their validity is one of the most important, since it analyzes whether the instrument is capable of evaluating what it proposes4. Content validity verifies if the approach represents the behavior of the sample to be evaluated, determining if the choice of the items that make up the instrument is adequate4.

Thus, The International Fitness Scale (IFIS) questionnaire was designed and tested in European adolescents, whose objective is the self-reported assessment of general physical fitness and its components (cardiorespiratory capacity, muscle strength, speed/agility and flexibility)2. Subsequently, it was validated in different populations (children, youth and adults of both sexes, and women with fibromyalgia) 5,6,1,3, proving to be valid and reliable, besides being associated with health parameters6,5, 1.

Thus, given the difficulty of assessing the physical fitness of adolescents in Brazil, as well as the scarcity of alternative methods in Brazil, cross-cultural validation for the Brazilian Portuguese language, and the investigation of the validity and reliability of the IFIS questionnaire are essential. Thus, the aim of the present study was to perform cross-cultural adaptation through translation, content validation, clarity and understanding of the IFIS questionnaire.


METHODS

Initially, the author's authorization was requested for the cross-cultural validation of the IFIS questionnaire. After obtaining digital consent from Francisco B Ortega Ph.D, from the University of Granada, Spain, The International Fitness Scale questionnaire was cross-culturally adapted from the steps described by Beaton et al. (2000)7.

a) Translation: Two Brazilian certified translators, officially proficient in English, registered with the Pernambuco Commercial Board (JUCEPE), performed the translation independently from English into Brazilian Portuguese;

b) Synthesis of the translation: After the translation, a meeting was held between the researchers and the translators to compare the original version and the versions of each translator. The team identified discrepancies, analyzed the wording, the use of language and the equivalence of the meaning of the questions and answers, seeking consensus and obtaining a single version, preserving the meaning of the original instrument;

c) Back translation: from the version constructed in the translation synthesis, two native American translators, proficient in Portuguese and who did not know the original version of the instrument, performed the back translation (new translation) into the original language instrument independently. This step aimed to check the validity, seeking to make sure that the translated version reflects the content of the original version, identifying possible misinterpretations and failure to adapt the different cultural contexts;

d) Synthesis of back translation: followed by back translation, a meeting was held between researchers and translators to select the most appropriate and best-phrased phrases. After consensus, the final version of back translation was obtained;

e) Expert Committee Review: A committee of five experts proficient in English and Brazilian Portuguese, graduates in Physical Education, PhDs in Psychology, Nutrition, Human Movement Sciences and Public Health, with an average experience of eight years in this type of study. and with the researched theme. In order to achieve cross-cultural equivalence, experts with all versions (original, translation synthesis and back-translation synthesis) evaluated equivalences: semantics (identifies whether the word has the same meaning as the original version), idiomatic (assesses colloquial languages that are difficult to translate), cultural (assesses the cultural context of the target population) and conceptual (assesses the conceptual meaning of words when similar and compares cultural contrasts).

The transcultural equivalence of the four areas evaluated by the specialists was performed by a Likert scale: 1 - Strongly disagree; 2 - Partially disagree; 3 - Indifferent; 4 - I partially agree and; 5 - I totally agree. If the expert did not understand the question or the language did not seem appropriate, he was asked to suggest changes, justifying the reasons.

Considering the review and suggestions of the experts, the final version of the instrument to be tested in the Brazilian Portuguese language was prepared.

f) Clarity assessment and comprehension: In order to evaluate the clarity and comprehension of each question and the scale instruction, the questionnaire was evaluated by 25 health professionals (physical education, nursing, physiotherapy, nutrition and psychology).

Each professional answered the following question: "Do you understand what was asked?" The answers were of the Likert scale type: 1 - I didn't understand anything; 2 - I understood just a little; 3 - I understood more or less; 4 - I understood almost everything, but I have some doubts; 5 - I understood perfectly and I have no doubts. If the professional did not understand the question or the language did not seem appropriate, he/she was asked to suggest changes, justifying the reasons. Finally, the final version of the instrument was prepared. All procedures were followed and applied as described by Reichenheim and Moraes (2007) 8 and Conti et al. (2009)9.

g) Pre-test: To assess whether the adapted instrument retains equivalence in the context in which it is being applied for cultural adequacy, comprehension, clarity of questions and answers, errors and difficulties encountered, the final version of the IFIS questionnaire was applied in 40 adolescent high school students of both sexes, aged 15 to 17 years (Figure 1). The recommended sample size for this step is five to eight volunteers per number of items or manifest variables7. All adolescents agreed to participate voluntarily and were randomly selected.


Figure 1. The International Fitness Scale cross-cultural validation steps for Brazilian Portuguese



All procedures adopted in this study met the Ethics Criteria in Research with Human Beings, according to Resolution No. 466 of December 12, 2012, of the National Health Council and were approved by the Research Ethics Committee of the University of Pernambuco - Brazil, obtaining opinion under the number = 3,015,407 and CAAE = 93550718.0.0000.5207.


DATA ANALYSIS

Data were processed and analyzed using Microsoft Office Excel for Windows software and entered by double-typing and back-testing. Descriptive analyzes were developed (mean, standard deviation and median). To evaluate the construct that the instrument proposes to measure and the quality of translation, we used: : 1) the average, being considered adequate a value above 80% of the Likert scale (ideal value ≥ 4.0) and; 2) the Content Validity Coefficient (CVC), which aims to quantify, examine and interpret the clarity and consistency of each item of the instrument that was proposed by the final version of the expert committee10. The CVC was calculated for each of the aspects judged in the adaptation (semantic, idiomatic, cultural and conceptual) and the CVC for each item of the scale. To consider the quality of the aspect or item judged, a CVC value ≥ 0.8010 was accepted as criteria.

The verification of the degree of internal consistency of the questions was performed by Cronbach's alpha coefficient, considering very low (≤ 0.30), low (0.30 ≤ 0.60), moderate (0.60 ≤ 0.75), high (0.75 ≤ 0.90) and very high (> 0.90) 11. To assess IFIS discriminant ability between boys and girls physical fitness, we used the Mann-Whitney U Test and the effect size, represented by Pearson's correlation coefficient r, considering as: small effect (r = 0.10) ), medium effect (r = 0.30) and high effect (r = 0.50) 12.


RESULTS

Translation and cultural adaptation

The synthesis of the translation was elaborated according to the cultural context and the consensus of the translators with the researchers, being suggested the following adaptations: in the title - "Self-reported physical preparation"; in the statement - translation of the word "fitness" as "preparation" and not as "conditioning"; in the grading of the answers - "very poor, poor and average" were translated, respectively, as "very bad, bad and medium"; Question 02 - The term "cardiorespiratory fitness" was translated as "cardiorespiratory fitness", but the translation for "cardiorespiratory fitness" was considered more appropriate in the study area.

The synthesis of back translation followed the same patterns of the previous step, suggesting the following changes: statement - the expression "very important" was translated as "very important"; the word "questionnaire" was translated as "questionnaire"; "by yourself" has been replaced by "on your own"; the word "check" was translated as "check"; and the expression "try to" was taken from back translation. In the statement and the first question, the word "fitness" was translated as "fitness"; In question 02, the word "capacity" appears twice and was translated as "capacity" and "ability" respectively; In question 03, the word "muscular" became "muscular"; in question 04, the word "is" was translated as "is"; In the grading of the answers, the options "very bad", "bad" and "regular" were, respectively, as "very poor", "poor" and "average". The original version and the versions of the translation and back translation syntheses are presented in Table 1.




In possession of the original versions, syntheses of translation and back-translation, there was an evaluation of semantic, idiomatic, cultural and conceptual equivalence by the expert committee, in which only the idiomatic and conceptual equivalences related to the title presented results below 80% of the Likert scale (Table 1). For the final version, it was accepted the alteration of the expression "physical fitness" that was translated as "fitness", being suggested the expression "physical fitness" as representing the literal meaning of the proposal, and understanding "fitness" as a process and not as a product.




Content Validation

The total Content Validity Coefficient, considering the CVC average for each of the four judged aspects (semantic, idiomatic, cultural and conceptual) was 0.94, above the established cutoff point. After reviewing the expert committee, adapting some expressions and the CVCi value for each aspect evaluated, the final version of the instrument was prepared (Table 2).




Clarity and degree of understanding

Regarding the degree of clarity and verbal comprehension of the final version of the questionnaire evaluated by health professionals, the average value obtained was 4.74, above 80% of the Likert scale. Considering the total CVC of the instrument (CVCt = 0.95) and for each item evaluated (CVCi), all scores were above the established cutoff point (Table 3).




Regarding the professional areas (physical education, nursing, physiotherapy, nutrition and psychology), it was found that the evaluation of all obtained CVCt and CVCi greater than or equal to the established cutoff point, ranging from 0.80 to 1, 00 (Figure 2).


Figure 2. Evaluation of the degree of clarity and verbal comprehension of the final translated Portuguese version of the IFIS questionnaire, evaluated by health professionals
Sutitle: A - Title; B - Enunciation; C - question 01; D - question 02; E - question 03; F - question 04; G - question 05; H - final; I - CVCt and J - CVCi (n = 5). The dashed line indicates the cutoff point of the Likert scale, (80% of 5.0 points - totaling the ideal value ≥ 4.0) and CVC (value ≥ 0.80). Data are presented as average and standard deviation.



For the pretest, the final version of the IFIS questionnaire translated into Brazilian Portuguese was applied to 40 adolescents, 21 females (52.5%) and 19 males (47.5%). whose average age was 16.33 + 0.69 years.

The internal consistency of IFIS assessed by the total Cronbach's alpha coefficient was 0.88, which is equivalent to a high internal consistency. If any items were excluded, Cronbach's alpha would range from 0.84 to 0.88. But even if this occurred, regardless of the item, internal consistency would remain high (Table 4).




Regarding the IFIS responses of adolescents according to gender, we found that there was a significant difference between them and in all variables (p <0.05), which shows that the instrument has the ability to discriminate between different sexes (Table 5 and Figure 3).




Figure 3. IFIS ability to discriminate between sexes of adolescents



In addition to statistical significance, the results obtained from the adolescents' IFIS responses obtained the mean effect size (r) for all items, as follows: overall physical fitness = 0.35; cardiorespiratory capacity = 0.42; muscle strength = 0.42; speed / agility = 0.40 e; flexibility = 0.36.


DISCUSSION

This is the first study that translated into Brazilian Portuguese an instrument capable of assessing general physical fitness and its components, and which strongly correlates with adiposity and risk of cardiovascular disease in children and adolescents1. Therefore, the results of this study enable researchers and health professionals to use this tool, whether or not associated with complementary physical tests, and may propose national reference scales according to age, gender and level of trainability, and stimulate the development of government programs that promote quality of life of this population.

Studies addressing the physical fitness assessment of adolescents are scarce in Brazil due to the need for specialized laboratories, high funding and qualified professionals. Therefore, it is essential to look for easy-to-use, low-cost tools that allow for their evaluation. Thus, the use of the IFIS questionnaire, originally validated in the English language, followed by the translation into nine languages (German, Austrian German, Greek, Flemish, French, Hungarian, Italian, Spanish and Swedish)2, is a viable alternative for the application in Brazil.

The essence of the present study ensures the veracity and quality of the instrument, ensuring that the cross-cultural validation process followed the guidelines recommended by Beaton et al. (2000)7, seeking to meet the psychometric properties, respecting the cultural context and linguistic particularities of the country of origin.

In the translation and back-translation stages, discrepancies were observed in the translators' versions, and it was necessary to discuss some items, adapting to the target audience. In the synthesis of the translation, in the title and utterance, the word "fitness" was translated as "preparation" and not as "conditioning", as it is a term of greater understanding; in the grading of the answers - "very poor, poor and average" were translated as "very bad, bad and medium", seeking a language more accessible to respondents; In question 02, the term "cardiorespiratory fitness" was translated as "cardiorespiratory fitness" and "cardiorespiratory fitness", but it was discussed that "cardiorespiratory fitness" is more appropriate in the study area.

In the synthesis of back-translation, in the statement, the expression "very important" was translated as "very important" and "crucial", but it was argued that "crucial" is an term "extreme"; the word "questionnaire" was translated as "survey" and "questionnaire", the latter being selected for being more specific to an instrument; "by yourself" has been replaced by "on your own" because it better portrays the idea of the individual performing the task individually; the word "mark" was translated as "check" and "mark", the first being selected by the sense of "ticking" and marking the alternative, the phrase "try to" was taken from back translation, due to the possible implicit idea that The individual does not know how to think or that there is a doubt in his ability to reflect.

In the statement and the first question, the word "fitness" was translated as "fitness"; In question 02, the word "capacity" appears twice and was translated as "capacity" and "ability" due to their sense of ability; in question 03, the word "muscular" was translated as "muscular" as it is more suitable to qualify the successive word "strength"; In question 04, the word "is" was translated as "is" because the term preceding it (speed / agility) refers to the same context. Finally, in the response scale, "very poor, poor and fair" were translated, respectively, as "very poor, poor and average", because the term "poor" is more pertinent when it comes to health conditions and "average"as it is more appropriate for the proposal.

After the synthesis, the instrument was evaluated by the expert committee, followed by the evaluation of health professionals. The results regarding semantic, idiomatic, cultural, conceptual, clarity and understanding equivalence evaluated by the experts (CVCt = 0.94 - Tables 1 and 2) and health professionals (average = 4.14; standard deviation = 0.38 and CVCt). = 0.95 - Table 3), in addition to the suggestions adopted with the screening and consent of all evaluators, demonstrate that the final version of IFIS for the Brazilian Portuguese language were pertinent and well adapted to the process of translation and cultural adaptation, considering the qualitative and quantitative analysis, since the instrument quality criterion was considered above the value (CVC ≥ 0.80) and 80% of the Likert scale cutoff10. Moreover, these results are corroborated by the different health areas (physical education, nursing, physiotherapy, nutrition and psychology), since they obtained CVCt above 0.90 (Figure 2).

In the analysis of internal consistency, the instrument presented value equivalent to high internal consistency. Therefore, the instrument responded satisfactorily, preserving the coherence and integration of the items that compose it. The ability to discriminate physical fitness between sexes corroborates the literature, as changes due to puberty hormones responsible for the growth and differentiation of physical characteristics of boys and girls make boys show better physical performance compared to girls13.

Although several instruments measure the level of physical activity in adolescents, such as the Physical Activity Questionnaire for Adolescents (PAQ-A)14, this study is the first to validate in the Brazilian Portuguese language a questionnaire of good reliability, reproducibility and easy interpretation, capable of to evaluate physical fitness.

Limitations and future prospects

Although the final translated version of IFIS is adequate and coherent within the cultural context of Brazil, it still needs to go through some steps to consolidate itself as a new alternative instrument for measuring the physical fitness of Brazilian adolescents. Therefore, to ensure the connection between theoretical content and empirical data that expresses our reality, psychometric studies are required to test reproducibility, discriminating ability, predictive ability and applicability in large-scale epidemiological studies.


CONCLUSION

It is concluded that the process of translation and cross-cultural adaptation was coherent and appropriate according to the judgment of the committee of experts and health professionals, and from the application of IFIS in adolescents.

Thus, it is possible to affirm that the final version of IFIS for the Brazilian Portuguese language (Attachment 1) proved to be valid, according to the content quality, clarity, comprehension and internal consistency, presenting adequate conditions to be submitted to the next psychometric analyzes, allowing recommendations of its application in adolescents in Brazil.


ACKNOWLEDGMENTS

The authors thank the translators, expert committee, and health professionals who contributed to the writing of this job.


Attachment 1

SELF-RELATED PHYSICAL FITNESS

It is very important that you answer this questionnaire yourself, regardless of the answers given by your classmates. Your answer will be helpful to the progress of science and medicine. Please answer all questions and do not leave any blank. Check only one answer per question and, most importantly, be honest. Thanks for your cooperation.

Please try to think about your fitness level (compared to your friends) and choose the right one.

Your overall physical fitness is:

(  ) Too bad

(  ) Bad

(  ) Average

(  ) Good

(  ) Very good

Your cardiorespiratory capacity (ability to exercise, for example, running for a long time) is:

(  ) Too bad

(  ) Bad

(  ) Average

(  ) Good

(  ) Very good

Your muscle strength is:

(  ) Too bad

(  ) Bad

(  ) Average

(  ) Good

(  ) Very good

Your speed / agility is:

(  ) Too bad

(  ) Bad

(  ) Average

(  ) Good

(  ) Very good

Its flexibility is:

(  ) Too bad

(  ) Bad

(  ) Average

(  ) Good

(   ) Very good

THANK YOU FOR YOUR TIME AND PARTICIPATION


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6. Ortega FB, Sánchez-López M, Solera-Martínez M, Fernández-Sánchez A, Sjöström M, Martínez-Vizcaino V. Self-reported and measured cardiorespiratory fitness similarly predict cardiovascular disease risk in young adults. Scand J Med Sci Spor 2012;23(6):749-757.

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10. Hernandez-Nieto RA. Contributions to Statistical Analysis. Merida: Universidad de Los Andes; 2002. p. 119.

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12. Cohen J. Statistical Power Analysis. Curr Dir Psychol Sci [Internet] 1992 jun;1(3):98-101.

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14. Kowlaski KC, Crocker PRE, Kowalski NP. Convergent validity of the physical activity questionnaire for adolescents. Pediatr. Exerc. Sci. 1997;9:342-352.
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