C
ross
-
cultural
adaptation
of
the
CDC W
orksite
H
ealth
S
core
C
ard
questionnaire
into
P
ortuguese
R
ev
A
ssoc
M
ed
B
ras
2016; 62(3):236-242
239
ly literary translation was emphasized. We therefore
obtained versions no. 1 and no. 2 in Portuguese.
Reconciliation
The researcher responsible for conducting the entire pro-
cess, who prepared one of the initial versions of the trans-
lations (no. 1 in Portuguese), carried out the reconcilia-
tion between versions no. 1 and no. 2 in Portuguese,
producing version no. 3 in Portuguese. The decisions
made during the reconciliation process were reviewed by
the Expert Committee, ensuring consistency and harmo-
nization with the translated versions.
Some questions were modified to ensure experiential
equivalence. For example, in the personal information
section question 2e related to color/race, the categories
available in the original instrument (Non-Hispanic White,
Non-Hispanic Black/African American, Hispanic/Latino,
Asian/Asian American, American Indian/Alaska Native,
Native Hawaiian/Pacific Islander, Others) were replaced
by the categories used by the Brazilian Census Bureau,
IBGE (white, black, yellow, brown, native, others).
In question 4, concerning the type of economic ac-
tivity of the organization, the categories were replaced by
the Brazilian National Classification of Economic Activ-
ities (CNAE).
The following phrase appears in the explanation of
question 22 in the Tobacco Control topic: “refer tobacco
users to 1-800-QUIT-NOW or smokefree.gov”. These terms
were replaced by the “Dial Health” Quit Smoking service:
0800 61 1997 or the National Program for Tobacco Con-
trol
(http://www1.inca.gov.br/tabagismo/).
In question 24, in the phrase “nicotine replacement
products approved by the FDA,” the term FDA was re-
placed by Anvisa.
In the Nutrition topic, question 32, the phrase consult
the “Dietary Guidelines for Americans, 2010, or GSA/HHS
Health and Sustainability Guidelines for Federal Conces-
sions and Vending Operations” was replaced by the Dietary
Guide for the Brazilian Population or the Guidelines for
Federal Operations of Points of Sale.
In question 44, the basketball court was replaced by
a sports court. This is because the practice of basketball
is not as common in Brazil as in the United States.
Back-translation
The initial versions of the translations (no. 1 and no. 2 in
Portuguese) were translated into English by two indepen-
dent English teachers, American nationals, who did not
participate in the previous stage and were unaware of
both the goals and concepts presented in the question-
naire. For practical reasons we recommended more liter-
als back-translations in order to facilitate comparisons
with the original instrument. Only in more subjective
items more conceptual back-translations were indicated.
Revision by the Expert Committee
Next, a comparison was made of the original instrument
with the 3 versions produced in Portuguese and the 2 ver-
sions in English. The expert panel composed of six health
professionals (three physicians, two public health profes-
sionals with experience in translation of questionnaires,
and a psychologist) documented and analyzed the dis-
crepancies found. Some verb tenses and sentences in Por-
tuguese were rewritten until a consensus was reached.
Version no. 4 in Portuguese was thereby created.
Cultural adaptation
Evaluation of cultural adaptation (Pretesting 1)
This step is designed to assess the degree of understand-
ing of the questions, and to identify and explain problems
related to the formulation or content of the questions.
The participants received an explanation of the ob-
jectives and methodology of the study. We asked for per-
mission to use their responses, assuring that the data
would be always displayed in aggregated form and that
the confidentiality of the individuals would be maintained.
Version no. 4 of the questionnaire, in Portuguese, was
answered by a group of 14 individuals responsible for
health promotion programs in health operators. A paper
copy of version no. 4 was delivered, as well as a paper form,
which asked if each of the questions in the questionnaire
had been understood. If not, the participant was asked
to write the word or phrase that had not been understood
and how they would rewrite this question to make it more
understandable.
The participants took approximately 60 minutes to an-
swer the questionnaire and fill out the form. After comple-
tion, one of the researchers asked the participants if they
had generally understood the questions in the questionnaire,
if they were able to answer the questions easily, and if these
questions could be applied to the health promotion pro-
grams at their workplaces. At the end, they were asked wheth-
er they found the HSC a useful and relevant questionnaire
that could be implemented in their workplace.
One of the researchers discussed all of the queries,
comments and suggestions from the participants, and
another researcher noted the emerging points in detail
using a specific form.
Before the start of the study, a minimum level of un-
derstanding of 90% was determined, that is, each ques-