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Psicologia: teoria e prática

versão impressa ISSN 1516-3687

Psicol. teor. prat. vol.19 no.3 São Paulo dez. 2017 



Transcultural adaptation of the "Everybody's Different" program to self-esteem promotion among adolescents: translation process to Brazilian Portuguese



Gabriela Salim Xavier MoreiraI; Carmem Beatriz NeufeldII; Sebastião Sousa AlmeidaIII

IUniversity of São Paulo, SP, Brazil
IIUniversity of São Paulo, SP, Brazil
IIIUniversity of São Paulo, SP, Brazil

Mailing address




Eating Disorders and Obesity share the same health risk factors as dissatisfaction with body image, low self-esteem, and poor eating behaviors. Self-esteem promotion programs lead to a positive body image, which is associated with physical and mental health among adolescents. The objective of this study was to do the transcultural adaptation of the "Everybody's Different" program to the Brazilian context, aiming its application among adolescents between 10 and 14 years old. This program aims at promoting a positive body image by raising general self-esteem. We followed the main international recommendations for instruments adaptation (translations, synthesis of translations, back-translations, synthesis of back-translations, and a committee of judges). Some terms were not translated literally, respecting the cultural equivalence between the original version and the Brazilian context. We selected a vocabulary that could be easily understood by the age group and with national comprising. The "Todos São Diferentes" program is available for use and evaluation in the Brazilian population, with the purpose of investigating its effectiveness in preventing health risk behaviors.

Keywords: primary prevention; health promotion; self-esteem; body image; adolescent.




Eating Disorders (EDs) are severe disturbances in eating behaviors and body image (American Psychiatric Association, [APA], 2013). Its prevalence has increased worldwide, and it occurs more frequently among female adolescents or young adult women, affecting up to 1.8% of them (APA, 2013). Although the prevalence of classic EDs is low compared to other chronic degenerative diseases, there is a much higher incidence of children and adolescents presenting risk behaviors for EDs; the presence of some of the classic symptoms of these disorders, such as food restriction and/or binge eating, and purging behaviors aimed at losing weight, characterized it According to Leal, Philippi, Polacow, Cordás, & Alvarenga's review (2013), the frequency of risk behaviors for EDs ranged from 1.1% to 39.04% in national studies.

EDs have a multifactorial etiology; that is, different elements interact for the disorder's development and perpetuation (APA, 2013). With certain similar etiological aspects, obesity is the accumulation of abnormal or excessive fat that can result in health damage (World Health Organization [WHO], 2016). It is neither a type of ED nor a psychiatric disease: obesity is treated as a general medical condition and is a chronic non-communicable disease according to the World Health Organization. Obesity is currently a serious worldwide public health problem due to its increasing prevalence and associated comorbidities (WHO, 2016).

Despite the differences between EDs and obesity cases, both are results of changes in eating patterns and body weight, and they can associate with confusing and conflicting media messages (Evans, Tovée, Boothroyd & Drewett, 2013). There is a common perception of body image dissatisfaction in overweight and obese individuals of all ages, including children and adolescents. It associates with low self-esteem and health risk behaviors such as eating restrictive diets, binge eating episodes, and "skipping" meals, as well as the use of weight loss medication and purgative methods (Bibiloni, Pich, Pons, & Tur 2013; Mendes, Araújo, Lopes, & Ramos 2014).

The difficulties and costs involved in the treatment and remission of these conditions justify the development and application of prevention strategies (Dunker, 2009; Oliveira, 2013). Prevention programs for both EDs and obesity reduce costs and eliminate contradictory messages about eating and body image, common in separate programs (Neumark-Sztainer, 2012). Among the preventive strategies available in the international context, programs that increase self-esteem and educate people to question social standards related to dissatisfaction by decreasing the internalization of beauty ideals and social comparison deserve special mention (Grogan, 2010).

These guidelines have a direct or indirect base on the promotion of positive body image due to the characteristics that constitute it and associate with it. There is also a connection between the construct of a positive body image and several positive aspects, such as body appreciation and acceptance, broad conceptualization of beauty, spirituality, internal positivity, confidence, self-care, and filtering information that could bring harm to the body. Acquiring characteristics and behaviors associated with positive body image protects the individual against stressors and difficulties related to body dissatisfaction and abnormal eating behaviors (Tylka, 2012).

In this panorama, the program "Everybody's Different" is worth notice for the good results obtained by the combination of positive body image development and general self-esteem with education through media. According to a review published by Watson et al. (2016), every universal prevention program that seeks to recover self-esteem used the "Everybody's Different" manual. The program focuses on increasing self-esteem, embracing various aspects of oneself while reducing the emphasis and importance of physical appearance, rejecting social body stereotypes and ideals propagated by the media, and accepting diversity in oneself and others. The program's core message is to value and recognize singularity: everyone is different, and no one is perfect. It is worth mentioning that the intervention avoids any mention of food, EDs, diets, or body shapes (O'Dea, 2007).

Developed in Australia, it is a primary and universal preventive approach, since its purpose is to universally reduce or eliminate risk factors in healthy individuals, reaching the population in general (Dunker, 2009). There was an initial implementation in schools by pre-trained teachers (O'Dea & Abraham, 2000). In comparison to those who composed a control group, there was a significant improvement in the body image of students between 11 and 14 years who participated in the "Everybody's Different" program. Students with risk behavior for EDs and those with overweight or obesity benefited from the program, showing improved body satisfaction, decreased intention to go on diets, and minimized unhealthy behaviors for weight control. Several of these results remained the same after a one-year follow-up (O'Dea & Abraham, 2000).

The program is also in agreement with the main recommendations of literature for the development of prevention strategies for EDs and obesity. It includes male students, presenting good results; its protocol has a higher number of sessions (nine weekly meetings of 50 to 80 minutes) when compared to other programs; it has an interactive methodology and presents good results in long-term follow-up, following the main recommendations with a minimum interval of one year; it involves parents and the school environment (Dunker, 2009; O'Dea, 2007, 2012).

Canada (McVey, Davis, Tweed, & Shaw, 2004) and Sweden (Ghaderi, Martensson, & Schwan, 2005) already implemented the program in some studies, with changes in content structure and time. Also, United States (Phelps, Sapia, Nathanson, & Nelson 2000) and England (Stewart, Carter, Drinkwater, Hainsworth, & Faiburn, 2001) integrated some of the program's activities, obtaining good results in most cases.

The development of intervention cultural adaptations from one country to another is a time-consuming process that requires a careful assessment of the local context, especially concerning cultural norms and family practices. After evaluating the relevance of the preventive program to the local population, it is necessary to translate its activities to organize the protocol and the subsequent application in pilot studies (Kumpfer, Pinyuchon, & Whiteside, 2008).

Regarding specifically the translation procedures, its systematization we based it on the guidelines used for instruments' cross-cultural adaptation. According to the international guidelines proposed by Beaton, Bombardier, Guillemin, and Ferraz (2002), these steps begin with two translations of the original material into the target language to ensure the identification of possible discrepancies could be identified. Then it is necessary to create a synthesis of those readings based on the likely differences in the translated versions. The next stage consists of the back-translation of the synthesis-version, which, entirely blindly, is poured into the original language to test whether the contents reflect the original version, thus verifying its validity. A committee of experts, composed of research team members and the translators involved, evaluate the equivalence between the translations.

Considering the many risk factors to which Brazilian children and adolescents are exposed, including those related to EDs development, obesity, and at-risk eating behaviors, it is imperative to implement preventive programs. Thus, the present study aims at describing the translation process of the activities included in the protocol of the "Everybody's Different" program (O'Dea, 2007) to the Brazilian context as part of the first stage of the transcultural adaptation procedure.



The project was approved by the School of Philosophy, Sciences and Literature of Ribeirão Preto Ethics Committee, of the University of São Paulo (protocol no. 35025514.7.0000.5407).

The process of cross-cultural adaptation of the program activities was carried out similarly to the translation procedures used in the cross-cultural adaptation of evaluation instruments, based on the recommendations of Beaton, Bombardier, Guillemin, and Ferraz (2002) (translation, synthesis of translation, back translation, synthesis of back translations, and expert committee). To maintain the content of the program activities, we prioritized the evaluation of semantic (reciprocity of words meaning), idiomatic (preservation of meaning in colloquial expressions), cultural (coherence of described situations), and conceptual (preservation of the construct's meaning) equivalence. Likewise, we considered linguistic variations, differences in virtues and customs (Beaton et al., 2002; Hambleton, 2005).

We extracted the activities from the version published by O'Dea (2007), following the protocol described in O'Dea and Abraham (2000). Thus, we included in the Brazilian protocol, that we described in the present study, the activities that contemplate the objectives of the program sessions initially described by O'Dea and Abraham (2000). It consists of nine consecutive weekly meetings with 50 to 80 minutes long.

The author of the Program (Jennifer O'Dea) granted permission to the first author of this study to adapt it to the Brazilian context. Guidelines for conducting activities were submitted to simple translation only. Thus, we introduced just the content of activities directed at students to all stages of the cross-cultural adaptation procedure described below.

The first stage (Initial translation) consisted of two independent translations of the original language into Portuguese, by two bilingual translators who have the target language as their mother tongue, one of whom had knowledge of the subject of study, while the other did not know the subject at all. In the second stage (Synthesis of translations), the two translators who participated in the previous stage evaluated the differences between the two translations. We produced a synthesis of translations based on the original version of the activities.

The third stage (Back translation) aimed at verifying the translation validity, ensuring that the translated activities accurately reproduce the content of the originals. In this stage, two bilingual translators who were not aware of the subject addressed and whose mother tongue is the source language of the material translated elaborated two back translations. Next, we created a synthesis of the two back translations.

The fourth stage consisted of submitting the previous translations to an Expert Committee, composed by one of the translators who supervised all previous translations and by a researcher with experience in the field. At this stage, we aimed at consolidating all the produced versions of the activities, making changes when needed, until obtaining a consensus among those involved about the equivalence between the versions for the generation of the final version. The translation aimed at achieving semantic, idiomatic, cultural, and conceptual equivalences, enabling the target population to understand the activities.



The first part of the "Todos São Diferentes" ("Everybody's Different") program is about stress management. There are two sessions on this stage, the first involves group discussions to talk about healthy ways of dealing with stress, and the second includes relaxation techniques.

The primary goal of Activity 1 is to psychoeducate students about healthy ways of dealing with stress, that is, to teach them about the benefits of adopting appropriate behaviors when identifying signs of stress. The main alteration in this activity consisted of turning the first question into an affirmative sentence. The affirmative "Make a list of some things that make you feel 'stressed'" was more evocative of stressful situations than the question "What are the things that make you feel 'stressed'?" This change did not alter the content proposed by the activity. The contents of the original version and the synthesis of translations and back translations of this activity are in Table 1:

In Table 1 and the following tables, the contents referring to the synthesis of translations consist of the final versions of each activity, that is, the result of the translation synthesis carried out after the Expert Committee evaluation. The main alterations discussed by the experts are available in the descriptions of each activity.

The second part of the program is composed of 10 activities aimed at constructing a positive sense of oneself, exploring the individuality of the adolescent and their classmates. With these activities, adolescents are expected to base their self-esteem in different aspects, not only on the body size, identifying the many different elements that make people different and unique; develop respect and tolerance with others by learning to appreciate diversity; and develop a positive sense of themselves, recognizing their own and others' qualities.

Thus, Activity 2 of "Todos São Diferentes" program aims to broaden the possibilities of characterizing the individual beyond their physical attributes, praising the several different aspects that make up a person and decreasing the importance of physical appearance. There was no need to make changes in sentence structure to ensure equivalence between versions. The contents of the original version, synthesis of translations and back translations of this activity are in Table 1.

The third activity recapitulates content from the previous one, summarizing and reinforcing that singularity and diversity are normal and acceptable. Translated as "Bingo na sala de aula" (classroom bingo), this ludic activity consists of matching classmates with personal features, by filling out their names into a printed table containing these characteristics. The student who fills out all the squares first wins. This activity required substantial changes in content due to cultural differences. The following examples highlight these changes. "Simpsons" became "Malhação," which is a TV show people in this age group usually watch, and "know how to spell" was changed to "is great at math" meaning a problematic task for local students. Table 2 shows the final version of Activity 3.

The program's fourth activity is a task in which the students trace an outline of their hand on a piece of paper and fills in three of the drawn fingers with three of their qualities. Students then fill in the missing fingers with positive characteristics of each other and then discuss in the group what they have obtained. The instruction for this activity went according to teacher's instructions, described in the "Everybody's Different" program since the student must develop its contents and there are no systematized questions as in most of the program activities.

Consistent with the objectives of the sessions proposed by O'Dea and Abraham (2000), we included another activity that addresses criticism to the media from the book "Everybody's Different" (O'Dea, 2007). We chose an activity that addresses male and female stereotypes, as this theme is also on the schedule published by O'Dea and Abraham (2000). This activity aims to explore the male and female stereotypes of Western society and convey the idea that we do not have to follow them; understanding that each and every one is an individual with a unique appearance, reinforcing the idea of uniqueness and that everybody is different.

Hence, in Activity 5 of the "Todos São Diferentes" program, translated as "Censurando os estereótipos" (censoring stereotypes), the professional or facilitator explains to students what stereotypes are, and explores examples of male and female stereotypes. Next, in a group, students cut out stereotypical images from magazines and verbally criticize them to the class. The contents of the original version, synthesis of translations and back translations of this activity are in Table 1.

The sixth activity that composes the program is performed in pairs, in which one participant must introduce a student to the class. Students discuss their characteristics and decide what makes the student interesting, different, cool, and what features make the student a good friend. Once again, the focus is on the fact that "everyone is different" and that everyone has something different, unique, and valuable to offer. The biggest alteration in Activity 5 regards the title, aiming to ensure cultural equivalence. The contents of the original version and of the synthesis of translations and back translations of this activity are in Table 1.

Next, in the seventh activity, students must make a "self-advertisement" of themselves, and are oriented to write down their main qualities. Once everyone has finished, the "advertises" are shuffled by the facilitator, who redistributes them, making sure no one has picked up its advertisement. Students take turns reading the information and try to guess who wrote what. This activity focuses on each one's strengths and weaknesses, and in embracing them. No changes in sentence structure were needed. The contents of the original version, synthesis of translations and back translations of Activity 6 are in Table 3.

The eighth activity that composes "Todos São Diferentes" program involves exploring admirable qualities in others. Students are encouraged to think of someone they admire and then articulate the admirable traits of that person. They must also be oriented to choose from historical people, people from their community, and their cultural environment. On the other hand, they are discouraged from choosing celebrities, unless they can confidently describe something that is admirable in that person beyond their physical aspect, such as their talents, achievements, etc. The contents of the original version and the synthesis of translations and back translations of Activity 7 are in Table 3.

The ninth activity of "Todos São Diferentes" program is an extension of the previous activity, in which students identify positive traits in themselves and others. In the original program, the teacher provides a list of qualities and asks students to create cards with those qualities or others they wish, choosing cards for themselves and their classmates. The guidelines for this activity were elaborated based on the orientations to the teacher, described in the "Everybody's Different" program. Following the instructions, some qualities were listed, although not translated from the original list.

The tenth activity from the original "Everybody's Different" program refers to the individual's social support network. The purpose of this activity is that students observe the people they have in their life and social environment, recognizing those who care about them, who are their friends, etc. The participant is instructed to draw a large circle, one smaller inside this one and another even smaller, in the center. The center point of the three circles is the student. In the smallest of them, he must write the names of the people with whom he is most close. In the middle circle, he has to register the people with whom he has more contact and, in the largest, his wider social network. The instruction for this activity was elaborated based on the teacher's instructions, described in the "Everybody's Different" program since its contents must be developed by the student and there are no systematized questions as in most of the program activities.

Hence, the last activity of the "Todos São Diferentes" program presents tasks related to communication, listening and conflict resolution, presented in the original program as the tenth activity. This activity includes two tasks that focus on identifying and expressing emotions, enhancing social skills and interpersonal relationships. In the first one, students are expected to team up in pairs, with classmates with whom they seldom talk, to practice their communication skills in "The Listening Game". Afterward, they fill in the "Quick quiz: Are you a good listener?" in order to evaluate their listening ability, based on the previous task. In both activities, no changes were made to the sentence structure and no other changes were necessary to ensure equivalence between versions. The contents of the original version and of the synthesis of translations and back translations of Activity 11 are in Tables 3 and 4.

There was a workbook with all printed and bound activities in the same order presented here. A cover for this activities book was also provided, designed by a computing design professional. This professional was asked to draw some characters with distinct physical features in a way that each character would be visibly representing some skill or preference.



The process of cross-cultural adaptation of the activities of the "Everyone is Different" program was adequately carried out similarly to the translation procedures employed in the cross-cultural adaptation of evaluation instruments, based on the guidelines of Beaton et al. (2002). The translators were carefully selected, respecting their origin and knowledge of the subject under study, both for the translation and the back translation of the activities.

We prioritized the equivalence between the versions to maintain the content of the program's activities, with emphasis on cultural equivalence since some activities address different habits, virtues, and customs of Australian and Brazilian cultures (Beaton et al., 2002; Hambleton, 2005). The literal meaning of a word does not necessarily imply the same understanding of its content for different cultures. We carefully selected the vocabulary so the age group could fully understand it. Straightforward words and of universal use were preferred rather than those of local application.

The guidelines and discussions regarding the cultural adaptation of interventions, both concerning treatment and prevention, do not focus on the procedures involved in the translation of these interventions (Barrera & Castro, 2006; Castro, Barrera, & Holleran Steiker, 2010; Kumpfer et al., 2008). The systematized procedures for the activities translation adopted in the present study, thus, add methodological rigor to the cross-cultural adaptation of the "Everybody's Different" program to the Brazilian context. Cultural adaptations of interventions from one country to another require a careful assessment of the local context, in particular as regards cultural and family patterns. The translation and back-translation procedures carried out, together with the evaluation of the equivalences between the original and Brazilian versions, aimed at ensuring that the original structure and content are maintained in another sociocultural context (Kumpfer et al., 2008).

In this way, the "Todos São Diferentes" program, resulting from the cross-cultural adaptation of the Australian program "Everybody's Different," is available to be applied and evaluated in the Brazilian adolescent population, to evaluate evidence of its effectiveness, concluding the process of cross-cultural adaptation. Originally, it was evaluated in adolescents aged 11 to 14 years (O'Dea & Abraham, 2000), while other studies delineate the target sample as very young adolescents (Ghaderi et al., 2005; McVey et al., 2004). It was decided to consider the reference to the United Nations (UN) and the United Nations Children's Fund (Unicef) (2011) that distinguish the initial phase of adolescence as the corresponding age of 10 to 14 years as a target population of the "Todos São Diferentes" program.

It is important to note that only the strict content that makes up the activities was translated according to the cross-cultural adaptation procedures. The remaining instructions for managing the activities were simply translated into Portuguese by the main researcher who is proficient in both languages and the subject of study. Thus, the guidelines presented by O'Dea (2007) are paramount for any professional who wishes to use the "Todos São Diferentes" program.

Faced with the need for more effective and broader strategies for the prevention of dissatisfaction with body image, low self-esteem and risk eating behaviors, the "Todos São Diferentes" program becomes a potentially promising strategy, due to the excellent results pointed out in the international studies mentioned above.

The present study, therefore, provides researchers with a universal primary preventive approach to be tested in future studies as to its efficacy in preventing, in the short and long term, negative indicators for adolescent health, so that it can be applied in Brazilian schools. Health professionals, including psychologists, nutritionists, nurses, physical educators, and elementary and junior high school teachers, should consider the "Todos São Diferentes" program as an information source and guidance to deal with these issues of their patients and students.



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Mailing address:
Sebastião Sousa Almeida
Av. Bandeirantes, 3900 - Monte Alegre
Ribeirão Preto - SP - 14049-900

Submission: 16.6.2017
Acceptance: 22.8.2017

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