ORIGINAL ARTICLE
http://dx.doi.org/10.7322/jhgd.145001

 

Cross-cultural adaptation of the child development surveillance instrument "Survey of Wellbeing of Young Children (SWYC)" in the Brazilian context

 

 

Rafaela Silva Moreira^I; Lívia de Castro Magalhães^II; Cláudia Machado Siqueira^III; Cláudia Regina Lindgren Alves^IV

^IFisioterapeuta, Doutora em Ciências da Saúde. Professora do Departamento em Ciências da Saúde da Universidade Federal de Santa Catarina (UFSC) - Araranguá (SC), Brasil
^IITerapeuta Ocupacional, Pós doutorado em Terapia Ocupacional. Professora do Departamento de Terapia Ocupacional da Universidade Federal de Minas Gerais (UFMG) - Belo Horizonte (MG), Brasil
^IIINeurologista Pediátrica, Mestre em Ciências da Saúde. Professora do Departamento de Pediatria da Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG) - Belo Horizonte (MG), Brasil
^IVPediatra, Doutora em Ciências da Saúde. Professora do Departamento de Pediatria da Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG) - Belo Horizonte (MG), Brasil

Correspondence

 

 

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ABSTRACT

INTRODUCION: Due to the scarcity of culturally adapted, validated and feasible instruments for assessing child development for use in clinical practice in Brazil, more investment is needed to provide resources with good psychometric properties for clinical and scientific use.
OBJECTIVE: To analyze the cross-cultural adaptation process of the Child Development Surveillance Instrument "Survey of Wellbeing of Young Children (SWYC)" in the Brazilian context.
METHODS: SWYC is an instrument for monitoring development, behavior and risk factors for children younger than 65 months, consisting of questionnaires - Developmental Milestones, Parent's Observations of Social Interactions (POSI), Baby Pediatric Symptom Checklist (BPSC), Preschool Pediatric Symptom Checklist (PPSC) e Family Questions. The cross-cultural adaptation followed the steps recommended in the literature and 45 parents from the first pre-test and 27 from the second pre-test participated. For the analysis of the properties of measurement was used factor analysis (Kaiser-Meyer-Olkin-KMO), calculation of convergent validity (Average Variance Extracted - AVE) and reliability (Internal consistency - Cronbach's Alpha - CA.
RESULTS: In the first pre-test, parents comprised only 31% of the items. The panel of experts reviewed and modified the questionnaires. In the second pre-test, the comprehension index was 77%, giving rise to the final version. The questionnaires Developmental Milestones, BPSC and PPSC were considered unidimensional (KMO = 0.62 to 0.95) and had AVE of 0.52 to 0.73 and CA = 0.55 to 0.97.
CONCLUSION: Analysis of the quality of the items, the convergent validity and the Internal consistency of the Brazilian version of the SWYC revealed satisfactory measurement properties, showing a promising instrument for clinical use and in research with children in Brazil.

Keywords: Psychometry, translation, child development.

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Why was this study done?

The cross-cultural adaptation of the "Survey of Wellbeing of Young Children (SWYC)" to Brazilian Portuguese was made due to the scarcity of culturally adapted, validated and feasible instruments to identify signs of developmental delay in clinical practice in Brazil. As the SWYC is free of charge, it could be a valuable tool to be used for developmental surveillance in public health care.

What did the researchers do and find?

We conducted the translation and cross-cultural adaptation of the SWYC to Brazilian Portuguese and analyzed its measurement properties. The cross-cultural adaptation followed the steps recommended internationally, with 45 parents participating in the first pre-test and 27 on the second pre-test. The comprehension index of the final version of the SWYC was 77%. The results indicated the SWYC questionnaires - Developmental Milestones, Baby Pediatric Symptom Checklist (BPSC) and Preschool Pediatric Symptom Checklist (PPSC) - were considered unidimensional (KMO = 0.62 to 0.95), had an Average Variance Extracted (AVE) of 0.52 to 0.73 and a reliability of CA = 0.55 to 0.97.

What do these findings mean?

The analysis of item quality, convergent validity, and internal consistency of the Brazilian version of the SWYC revealed satisfactory measurement properties, showing it is a promising instrument to be used clinically and in research with Brazilian children.

 

INTRODUCTION

Child health indicators reflect the living conditions of contemporary societies. Despite enormous regional disparities, challenges such as high infant mortality rates, child malnutrition and morbimortality due to immunopreventable diseases are being overcome worldwide, ensuring the survival of an increasing number of children. For low- and middle-income countries, however, offering living and health conditions to these children requires a radical paradigm shift, placing early childhood development as an absolute priority.

Achieving full development has positive repercussions throughout the life of the individual and for all society¹. It is mainly in the first years of life that the development of sensory-motor, social-emotional and cognitive skills essential for success in the next stages of life occurs^1,2.

Ensuring full child development is a pressing need in countries where children are exposed to risk factors such as malnutrition, poverty, violence, and poorly stimulating environments¹. Considering that less than a third of children with developmental disorders are diagnosed before school age and that less than 30% of developmental disorders are detected by clinical impression³, it is necessary to use reliable scales that allow timely intervention. The American Academy of Pediatrics recommends the routine use of standardized instruments for monitoring infant development in routine consultations aimed at promoting integral health^2,4.

In many countries, including Brazil, there is a gap with regard to culturally adapted, validated, accessible and feasible child development assessment tools for use in primary care⁵. Considering these aspects, tests such as the Bayley Scales of Infant and Toddler Development-III (Bayley-III), Denver Developmental Screening Test-II (Denver-II) and the Age and Stages Questionnaire (ASQ-3 and ASQ-SE) have important limitations.

Bayley-III, despite having been adapted for Brazil⁶, requires high financial investment, specific training, and its application is time-consuming. Denver-II is shorter and less expensive, but the kit of materials also needs to be imported⁷, and there are no standards for Brazilian children. Although ASQ-3 has been adapted for the Brazilian population⁸ and widely used in research in the country^9,10, its use in primary care is still restricted, due to the costs for the acquisition of the forms and kits. It is emphasized that cross-cultural adaptation and instrument validation is a necessity in Brazil, aiming to overcome the scientific, clinical and epidemiological gaps reported^11,12.

The Survey of Wellbeing of Young Children (SWYC) was developed in 2011 and validated for the US population in 2013¹³. It is a screening questionnaire that aims to screen/surveillance of child development for children under 65 months. The items were based on instruments recognized in the literature, such as ASQ-3 and ASQ-SE, Patient Health Questionnaire-2 and Pediatric Symptom Checklist^13,14. It is a simple instrument, easy to apply and interpret. Its application requires, in average, 10 minutes and does not need a kit with specific materials, because it is based on the information provided by the caregivers¹³.

SWYC has the advantages of presenting good psychrometric properties in the original version, being free access, being able to be used by education and health professionals^13,15, and having the application and interpretation manuals available online¹⁶. The validity and reliability of the original SWYC version are similar to those of other screening instruments recognized in the literature. The psychometric properties of original SWYC were considered adequate (sensitivity from 0.7 to 0.89, specificity from 0.54 to 0.9, test-retest from 0.70 to 0.81)^13,14,17-19.

The SWYC is a structured interview with about 40 questions that address the domains development, emotions/behavior, and family risk factors^13,14. There is a questionnaire with 10 questions for each age group to evaluate cognitive, motor, social and language skills (Developmental Milestones) and another for specific screening of autism spectrum disorders (Parent's Observations of Social Interactions - POSI)¹³. POSI is indicated for children between 18 and 36 months and contains seven questions¹⁷.

The emotions/behavior domain is analyzed in the Baby Pediatric Symptom Checklist (BPSC) and Preschool Pediatric Symptom Checklist (PPSC), which contains 12 and 18 items, respectively. BPSC was developed for children under 18 months and PPSC for children aged 18 to 65 months^18,19. There are also two questions about parents' concerns about child behavior and learning/development. The Family Questions domain contains nine items, addressing risk factors such as maternal depression, alcohol and drug abuse, and parental conflicts¹³.

Considering the characteristics described and the scarcity of validated, culturally adapted, accessible and feasible instruments for evaluating child development in Brazil, it becomes important to cross-culturally adapt instruments that can be used in a large scale in our country. Thus, the objective is to analyze the cross-cultural adaptation process of the child development surveillance tool Survey of Wellbeing of Young Children (SWYC) in the Brazilian context.

 

METHODS

The Portuguese version of the SWYC was developed according to the recommendations of Beaton et al.²⁰ and Reichenheim & Moraes²¹. The steps in this process are described in Flowchart (Figure 1).

The first step was to obtain authorization for cross-cultural adaptation of the SWYC, given by Perrin et al.¹⁴. The translation into Portuguese of Brazil was carried out by three independent translators from different health areas with a teaching role and clinical experience in child development. These professionals had Portuguese as their native language and were fluent in the English language.

These translations were discussed by a committee of experts, originating a consensual version of the translations^21,22. The expert committee consisted of six professionals (Physiotherapists, Occupational Therapists, Pediatrician and Pediatric Neurologist), with four professors of public higher education institutions and two postgraduate students with clinical experience.

The consensual version was discussed by the expert committee and sent to back-translation, in order to verify the semantic similarity between the translation and the original document. The back-translation was carried out by three translators, two natives of the English language and a Brazilian psychologist graduated in the United States. Native translators had no relation to the knowledge area of the questionnaire. These back-translations were also discussed by the committee of experts, originating a consensual version²³.

The evaluation of referential equivalence stage²² was carried out by the committee of experts, which evaluated the correspondence between the original version and the back-translated version, verifying if the expressions were identical, similar or different and making the necessary adjustments.

This first version of SWYC was tested by two physiotherapists and a neuropediatrician in two states of the country. The questionnaire was tested with 12 parents in a follow-up outpatient clinic and with 15 parents in a public hospital in Minas Gerais, and also with 18 parents in Basic Health Units and a public university in Santa Catarina. Subjects eligible for this stage should be responsible for children under 65 months of age and have Portuguese as their native language.

In the interview, the researcher read the questions and, when necessary, the content was explained. In questions where clarification was required, parents were asked to explain what they had understood and to give suggestions on how to rewrite this phrase, as recommended in the cognitive interview technique²⁴. The items not understood were discussed in the committee of experts and made semantic adjustments. This second version of the questionnaires was again tested with 27 other parents in Minas Gerais and Santa Catarina using the same procedures of the first application. From the cognitive interviews, the final version of the questionnaires was elaborated. In both stages, we included children in all age groups of the SWYC.

The measurement properties of the Developmental Milestones, BPSC, and PPSC questionnaires were analyzed following the recommendations of the original instrument^18,19. A factor analysis was performed with all items, and then a Scree Plot graph was constructed to verify the unidimensionality based on the Acceleration Factor (AF) criterion²⁵. Factor loadings were measured to assess whether all items were contributing to the construct measurement (RV > 0.50). To determine if the use of the analysis factor would be adequate for these questionnaires, the Kaiser-Meyer-Olkin (KMO) sample adequacy measure (RV > 0.50) was used. In order to verify the convergent validity, the Average Variance Extracted (AVE) (RV> 50)²⁶ was used and to verify the reliability, the Cronbach's Alpha (CA) (RV> 0.70) was calculated²⁷.

In the Developmental Milestones, BPSC, and PPSC questionnaires, the parents answered items about the development of the child on an ordinal scale with three alternatives: not yet, little and a lot. In this way, the factor analysis was adjusted to ordinal scales.

For the evaluation of the quality and validity of the PPSC items, we used the Bifactor model adjusted for gradual responses. We decided to fit a new model for the Brazilian version of PPSC that could present a better structure within each domain since the proposed model had some negative loadings factor. The adjustment of the models was analyzed by the Root Mean Square Error of Approximation (RMSEA) (RV <0.10) and Comparative Fit Index (CFI) (RV> 0.90) indicators, the first being a general index and the second a normalized incremental index²⁸. Data processing and analysis were made on software R (version 3.2.2).

This study received funding from the Grand Challenges Canada initiative and the Fundação de Apoio à Pesquisa e Inovação do Estado de Santa Catarina (FAPESC) and is part of a larger project called "Avaliação do desenvolvimento infantil e intervenção precoce em crianças de alto risco e suas famílias no Brasil", approved by the Research Ethics Committee (CAAE 29437514.1.0000.5149). The participants signed a free and informed consent form before the interviews began.

 

RESULTS

● Evaluation of referential equivalence

This step was based on the comparison of the original and backward versions. The questions were classified as identical when the translations were completely equal, similar when the versions were written differently but the content was similar, and different when there was no agreement between the versions²². Of the 123 questions analyzed, 32.5% were considered identical, 65.1% similar and 2.4% different. Items considered different were modified to achieve semantic, idiomatic, experimental, and conceptual cross-cultural equivalence^a. These items were two questions from BPSC ("Does your child have a hard time being with new people?" and "Does your child have a hard time in new places?") and one from POSI ("Please check all that apply"). These items were modified by the committee of experts.

● Pretest 1

The sample of parents who participated in Pretest 1 was from different states of Brazil and had different socioeconomic levels. In Pretest 1, the parents' understanding was considered unsatisfactory, since only 31% of the 45 respondents comprised 100% of the questions.

• Evaluation of general equivalence

Based on the results of the Pretest 1, all SWYC questions were re-analyzed. The committee of experts made adjustments in all questionnaires, using terms more commonly used by the Brazilian population^b.

The cognitive interviews showed that parents did not understand the meaning of the items "Is it hard to comfort your child?" And "Is it hard to put your child to sleep?" from BPSC. These items involve very different behaviors in Brazilian and North American cultures, which may have made it difficult to understand the semantic meaning of the translation. This situation was discussed with the authors, who suggested testing alternative questions for these items. Thus, a new version of the instrument containing the two alternative questions and those translated literally from the original English version of the BPSC.

• Pretest 2

A new version of the instrument was tested again. Of the 27 parents interviewed, 77% comprised 100% of SWYC items, which was considered satisfactory.

● Elaboration of the final version

After the second pretest, in the Family Questions questionnaire, the word spouse was replaced by husband/partner, which are most commonly used in Brazil. In the Developmental Milestones questionnaire, we included "without help" after the item "Run".

Based on preliminary data from 114 mothers from the larger study, it was found that the degree of agreement between first version responses and alternative questions added to BPSC was very low. After discussion with the SWYC authors, we decided to keep only the alternative questions in the final version.

• Quality and validity analysis of SWYC items

Table 1 presents the factor loadings of the 54 items of the Developmental Milestones questionnaire. Items 2, 3, 4, 7 and 54 presented factor loadings below 0.50, indicating that only these items did not contribute in a relevant way to the composition of the latent variable level of development of the child. We chose not to exclude these items because their convergent validity was considered adequate. The factor analysis was appropriate for this set of items (KMO = 0.97), confirming the unidimensionality of the items (first autovalor = 39,65; second autovalor = 8.95), satisfying the AF criterion. The set of items of the Brazilian version presented AVE = 0.73 and CA = 0.97 (Table 1).

Table 2 shows the factor loadings of BPSC items by domain. All items had a high load factor, except for item 8 of the inflexibility construct (Does your child have a hard time with change?). Since the convergent validity of the inflexibility construct proved to be satisfactory, we chose not to exclude this item. The KMO values of each domain were higher than 0.62. According to the Kaiser criterion, all the BPSC constructs were unidimensional and presented AVE between 0.52 and 0.57; CA between 0.55 and 0.63 and CC between 0.68 and 0.71.

In the PPSC analysis, all items presented positive loadings factor in the Bifactor model. In General Factor, all loads were greater than 0.35 and factors related to Externalizing, Attaining and Attention Problems behaviors were greater than 0.20. The values of RMSEA = 0.02 and CFI = 0.98 indicate that the model is well adjusted for the Brazilian version. Considering that General Factor presented, in most cases, the largest Factor Loadings and the highest proportion of explained variance, we concluded that it is appropriate to interpret only the General Factor of the Bifactor model (Table 3).

 

DISCUSSION

The cross-cultural adaptation of SWYC to Brazilian Portuguese was carried out in accordance with internationally recognized procedures. The properties of initial measures were analyzed and suggested that the Brazilian version of the SWYC, after adjustments, was well understood by the target public, maintained the internal consistency and the validity of the items similar to the original version.

Expert opinion combined with cognitive interviews at the pretest stage proved to be critical, as respondents explicitly stated unexpected interpretations of SWYC items. Several changes were made in the SWYC aiming at a better understanding of the items and adaptation to the life context and cultural habits of Brazilians²². All modifications were analyzed together and accepted by the authors of the original instrument.

Epstein et al.¹¹ also demonstrated in their study the importance of the multidisciplinary committee of experts to ensure the accuracy of the content. These authors questioned the need to perform back-translation, as this step showed results of moderate impact. However, we highlight the relevance of the back-translation step, since the comparison with the original instrument allowed to identify important semantic differences and to make adjustments to preserve the construct.

When analyzing the referential equivalence, it was verified that only two items of the BPSC and one of the POSI were considered different from the original questionnaire. This may have occurred because behavioral issues are strongly influenced by cultural aspects. SWYC can be self-filled, and there will not always be a professional to assist the caregivers. Adaptation in the wording of the statement was necessary to facilitate parents' understanding.

As in the study by Losapio & Pondé²², two pretests were performed, since in the first pretest, the parents' understanding was unsatisfactory. Based on this result, the committee of experts analyzed again and modified the questionnaires. In the second pretest, the comprehension index increased, giving rise to the final version. The first pretest was intended to verify the understanding of the items and the second was to ensure that the modifications made were sufficient. Only in the second pretest a satisfactory understanding was achieved, confirming the importance of double testing in the target population. To ensure greater consistency of the results, the sample selected for the pretests was diversified, the committee of experts was multidisciplinary, and the interviews were conducted in two regions of Brazil, including participants from the rural and lower socioeconomic classes.

The final version in Brazilian Portuguese was also tested with Brazilian immigrants residing in the United States of America and was considered adequate for the target population by the authors of the original instrument. The questionnaires produced in this research are available on the SWYC¹⁶ website.

The Portuguese version sought to remain faithful to the original version of SWYC and reproduced the statistical analyses used in the creation of the instrument. The psychometric parameters found in all SWYC questionnaires in the Brazilian version were similar to the original version^13,14,18,19. The analysis of the quality and validity of the items of the Developmental Milestones, BPSC, and PPSC questionnaires showed that most of the items contributed significantly to the assessment of the child development and presented convergence validity and reliability parameters considered adequate for the use of the instrument in Brazil.

Thus, the properties analyzed suggest that the "Survey of Wellbeing of Young Children (SWYC)" in the Brazilian context may prove to be a useful tool for screening for changes in neuropsychomotor development and behavior. It is a questionnaire that is easy and quick to apply, with free access and, therefore, a promising option to be used in the context of primary care in Brazil, especially for aggregating aspects related to development, behavior and risk factors in the same instrument relatives²⁹. This holistic view of child development is innovative and quite appropriate for family and community approaches by multi-professional team, which guide the care of children in primary care.

The availability of a screening instrument with these characteristics will favor the inclusion of child development surveillance in the daily life of health and education professionals, enabling timely intervention in cases suspected of alterations. The use of a standardized instrument will also allow the generation of epidemiological information for the promotion of public policies and comparison with studies conducted in other countries.

 

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Correspondence:
rafaela.moreira@ufsc.br

Manuscript received: October 2018
Manuscript accepted: December 2018
Version of record online: April 2019

 

 

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