CROSS-CULTURAL ADAPTATI ON OF THE BURNS SPECI FI C PAI N ANXI ETY
SCALE - BSPAS TO BE USED W I TH BRAZI LI AN BURNED PATI ENTS
1Mar ía Elen a Ech ev ar r ía- Gu an ilo2 Lídia Apar ecida Rossi3 Rosana Apar ecida Spadot i Dant as4 Cláudia Benedit a dos Sant os4
Echevarría- Guanilo ME, Rossi LA, Dant as RAS, Sant os CB. Cross- cult ural adapt at ion of t he Burns Specific Pain Anx iet y Scale - BSPAS t o be used w it h Br azilian bur ned pat ient s. Rev Lat ino- am Enfer m agem 2006 j ulho-agost o; 14( 4) : 526- 33.
This st udy aim ed at t r anslat ing and adapt ing t he Bur ns Specific Pain Anx iet y Scale - BSPAS and t he I m pact of Event Scale - I ES int o Port uguese; m aking available t wo sim ple, short and easily applicable inst rum ent s and describing t he st udy part icipant s according t o t heir scores on t he Visual Analogue Scale and t he Trait - St at e Anxiet y I nvent ory. The cross- cult ural adapt at ion process involved t he following st eps: t ranslat ion of t he scales; reaching a consensus in Port uguese; evaluat ion by an expert com m it t ee; back- t ranslat ion; obt aining a consensus in Dut ch; com par ing t he or iginal v er sions w it h t he consensus in Dut ch; sem ant ic analy sis and pr et est of t he Por t uguese v er sions. The r esult s show ed t hat bot h scales pr esent high v alues of int er nal consist ency bet w een t he scale it em s. Par t icipant s’ av er age pain scor es w er e higher aft er bat hing and w ound dr essing. Par t icipant s’ av er age anx iet y scor es w er e low or m edium .
DESCRI PTORS: anx iet y ; pain; bur ns
ADAPTACI ÓN TRANSCULTURAL DE LA “BURNS SPECI FI C PAI N ANXI ETY
SCALE - BSPAS” PARA SER APLI CADA EN PACI ENTES QUEMADOS BRASI LEÑOS
Los obj et ivos del est udio fuer on t r aducir y adapt ar la “ Bur ns Specific Pain Anx iet y Scale - SPAS” y la “ I m pact Event Scale - I ES” par a el por t ugués, poner a disposición dos inst r um ent os sim ples, cor t os y de fácil aplicación y describir los part icipant es del est udio, según los scores obt enidos por m edio de la aplicación de la Escala Visual Analógica y del I nv ent ar io de Ansiedad Tr azo- Est ado. El pr oceso de adapt ación de las escalas siguió las siguient es et apas: t r aducción de las escalas; obt ención del consenso en por t ugués; ev aluación por un com it é de j ueces; “ back - t r anslat ion” ; obt ención del consenso en holandés; com par ación de las v er siones originales y en holandés; análisis sem ánt ica y pret est de las versiones en port ugués. Los result ados m ost raron índices elevados de consist encia int erna de los ít em s de la escala. La m edia de los escores de dolor fueron m ás alt os después del baño y cur aciones. Los scor es m edios de ansiedad fuer on clasificados com o baj os o m edios.
DESCRI PTORES: an siedad; dolor ; qu em adu r as
ADAPTAÇÃO TRANSCULTURAL DA “BURNS SPECI FI C PAI N ANXI ETY
SCALE - BSPAS” PARA SER APLI CADA EM PACI ENTES QUEI MADOS BRASI LEI ROS
Est e est udo t eve com o obj et ivos t raduzir e adapt ar a “ Burns Specific Pain Anxiet y Scale - BSPAS” e a “ I m pact of Ev ent Scale - I ES” par a a língua por t uguesa, disponibilizar dois inst r um ent os sim ples, cur t os e de fácil aplicação e descr ev er os par t icipant es do est udo, segundo os escor es obt idos por m eio da aplicação da Escala Visu al An alógica e do I n v en t ár io de An siedade Tr aço- Est ado. O pr ocesso de adapt ação das escalas segu iu as segu in t es et apas: t r adu ção das escalas; obt en ção do con sen so em por t u gu ês; av aliação por u m Com it ê de Juízes; “ back - t r anslat ion” ; obt enção do consenso em holandês; com par ação das v er sões or iginais e consenso em holandês; análise sem ânt ica e pr é- t est e das v er sões em por t uguês. Os r esult ados m ost r ar am que as escalas, em seu pr im eir o est ágio de adapt ação t r anscult ur al par a o por t uguês, apr esent ar am índices elev ados de consist ência int er na dos it ens da escala. For am obt idos m aior es índices de dor após o banho e cur at iv o. Os escor es m édios de ansiedade for am classificados com o baix os ou m édios.
DESCRI TORES: an siedade; dor ; qu eim adu r as
1 Article extracted from the m aster's thesis, funded by the Coordination for the I m provem ent of Higher Education Personnel ( CAPES) ; 2 RN, Doct oral St udent
in Fundam ental Nursing, e- m ail: m aleeg@eerp.usp.br; 3 Associate Professor, e- m ail: rizzardo@eerp.usp.br; 4 Junior Professor, e- m ail: rsdantas@eerp.usp.br,
cbsantos@eerp.usp.br. University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Developm ent
I NTRODUCTI ON
B
urns inj uries are som e of t he m ost painful t ypes of t raum a, even m ore when, besides t he pain of their wounds, burns victim s are subm itted to a great num ber of procedures every day unt il t hey recover, i n cl u d i n g b a t h i n g , w o u n d d r e ssi n g a n d phy siot herapy( 1). Besides pain, anx iet y, depr essionand fear ar e fr equent ly associat ed w it h bur ns( 2). A
pain and anxiet y assessm ent inst rum ent is necessary t o b e u sed w i t h b u r n s v i ct i m s, con si d er i n g l on g h o sp i t a l i za t i o n a n d t h e r e a l i za t i o n o f d i f f e r e n t pr ocedur es w hich, alt hough painful, ar e needed for t he pat ient s’ recovery( 2).
Various inst rum ent s ( scales and invent ories) have been produced, generally in Europe and Nort h Am erica. To be used in Brazil, t hey first need t o go through cross- cultural adaptation( 3). Nowadays, a large
quantity of pain m easurem ent instrum ents is available. Researchers need to select the m ost appropriate one, in view of t he part icularit ies of t he populat ion ( like, for exam ple, cult ure, level of educat ion and physical lim it at ions) , what t hey int end t o m easure ( presence, intensity and/ or characteristics) and the characteristics t hat m ake t he chosen inst r um ent m or e appr opr iat e for the obj ect of study( 4).
Alt h ou g h a w id e r an g e of in st r u m en t s is available to assess anxiety and m easure pain, we did not find any studies in literature that describe the use o f p a i n a n d a n x i et y i n st r u m en t s i n Po r t u g u ese, specifically for Brazilian burn pat ient s.
Li t e r a t u r e sh o w s t h a t Nu m e r i ca l , Ve r b a l Descript or and Visual Analogue Scales are t he m ost f r eq u en t ly u sed m easu r em en t t ools, d u e t o t h eir pr act icalit y and easy under st anding by pat ient s( 5 ).
Mor eov er, in car e f or bu r n s v ict im s, t h e f ollow in g scales are m ost used, alt hough t hey are not specific for pain and/ or anxiety assessm ent in burned patients: Visual Analogue Scale ( VAS)( 6), Num er ical Scale( 6),
Ha m i l t o n ’ s An x i e t y Sca l e( 7 ), McGi l l ’ s Pa i n
Quest ionnaire( 8) and Spielberger ’s St at e-Trait Anxiet y
I nv en t or y ( STAI )( 9 ). As t o specific in st r u m en t s for
b u r n s v i ct i m s, w e f o u n d t h e Vi su a l An a l o g u e Th er m om et er( 1 0 ) ( ad ap t at ion of t h e VAS f or p ain
assessm en t ) an d t h e “ Bu r n s Specific Pain An x iet y Scale” ( BSPAS) , dev eloped by Luc Taal and Ber t us Fab er an d ap p l i ed t o a sam p l e o f Du t ch b u r n ed pat ient s( 10).
Th e “ Bu r n s Sp ecif ic Pain An x iet y Scale -BSPAS” is a unidim ensional scale with nine item s that
descr ibe pat ient s’ feelings r elat ed t o t he healing of t h eir b u r n s, f ear of losin g con t r ol d u r in g w ou n d dressing and ant icipat ory anxiet y about pain during and im m ediately after care ( such as wound cleansing, bathing, wound dressing and skin grafting) . Each item is evaluat ed on a 100- m ilim et er visual analogue line ( without sequential num bering) , with the anchor words “ absolut ely not ” and “ in t he worst form im aginable” as a reference( 10). I n order to assess the reliability of
t h e in st r u m en t , t h e au t h or s of t h e scale( 1 0 ) u sed
Cr on bach ’s Alph a (α 0 . 9 4 , con sider in g coefficien t s > 0 . 7 0 as accep t ab l e) . Th ey al so u sed Pear son ’s correlation coefficient to m easure internal consistency am ong scale item s, with coefficients ranging from 0.71 t o 0. 82 ( p< 0. 0001) . To assess validit y, t hey chose concurrent validit y and t he correspondent correlat ion of dat a obt ain ed t h r ou gh differ en t scales ( BSPAS, STAI - S an d VAS) . Th e au t h or s con clu ded t h at t h e i n st r u m e n t ’ s i n t e r n a l co n si st e n cy m e a su r e s d em o n st r at ed i t s r el i ab i l i t y as a u n i d i m en si o n al inst rum ent ( anxiet y- st at e) . Moreover, t hey highlight t h at t h is is a specif ic, sh or t an d easily applicable inst rum ent for use wit h burned pat ient s( 10).
I n 1 9 9 7 , t h e sa m e a u t h o r s st u d i e d t h e relation between post- traum atic stress, anxiety before m edical procedures and pain percept ion, in a sam ple of 33 adult burned patients. They applied the BSPAS, t h e I m p act o f Ev en t Scal e ( I ES) an d t h e Vi su al Analogue Therm om et er ( VAT) at five different t im es per day. The aut hor s found high associat ion lev els bet w een t he BSPAS ( pain and anx iet y indices) and t h e I ES ( p ost - t r au m at ic st r ess in d ices) an d p ain per cept ion s du r in g t h e f ir st an d secon d w eek s of h ospit alizat ion . Th ey con clu ded t h at pat ien t s w it h st r ess disor der s ar e m or e pr edisposed t o dev elop int ense ant icipat or y anx iet y associat ed w it h painful procedures and that a vicious circle can be established: pain increases anxiet y and anxiet y increases pain( 11).
scores of ordered m eans was applied, based on t he t ot al body surface area burned ( TBSAB) . The result s showed that, j ust like the original scale, psychom etric m easures revealed t he reliabilit y of t he BSPAS short ver sion( 1).
A Nort h- Am erican st udy( 12) invest igat ed t he
capacit y of t he BSPAS ( fiv e- it em shor t v er sion) t o predict pain levels aft er t he burn ( in view of painful procedures) , as well as t o evaluat e pain relief when an al g esi cs ar e ad m i n i st er ed an d t h ese p at i en t s’ physical per for m ance aft er dischar ge fr om hospit al. Besides the BSPAS, the “ Profile of Mood States Short For m - POMS” and t he STAI - S ( evaluat es anx iet y-st at e) were applied t o 27 burns vict im s. The BSPAS cam e out as the best predictor of pain levels in view of painful pr ocedur es and also t he only inst r um ent capable of pr edict in g pat ien t s’ decr eased ph y sical perform ance aft er hospit al discharge, whereas POMS an d STAI - S w er e t h e best pr edict or s of em ot ion al p er f or m an ce. Th ose au t h or s em p h asized t h at t h e BSPAS is t h e on ly v alid in d icat or of p ain - r elat ed anx iet y am ong bur ns v ict im s and can be useful t o ident ify r isk of decr eased funct ional capacit y aft er discharge( 12).
This study aim ed at translating and adapting the Burns Specific Pain Anxiety Scale - BSPAS( 10) and
t he I m pact of Event Scale - I ES( 11) int o Port uguese;
m a k i n g a v a i l a b l e t w o si m p l e , sh o r t a n d e a si l y ap p l i cab l e i n st r u m en t s an d d escr i b i n g t h e st u d y par t icipant s accor ding t o t heir scor es on t he Visual An a l o g u e Sca l e( 6 ) a n d t h e Tr a i t - St a t e An x i e t y
I nv ent or y( 9).
MATERI AL AND METHODS
This study was carried out at the Burns Unit o f t h e Ri b e i r ã o Pr e t o Me d i ca l Sch o o l Ho sp i t a l , University of São Paulo - Brazil, after approval by the Research Et hics Com m it t ee of t hat hospit al.
Th e sam p le con sist ed of b u r n ed p at ien t s hospit alized at t he Burns Unit of t he Medical School Ho sp i t al b et w een May an d Decem b er 2 0 0 4 . Th e inclusion crit eria for t his st udy required t he pat ient s: t o b e old er t h an 1 5 y ear s old ; t o b e Por t u g u ese language speaking; to be in the first or second week after the burn and first or second hospitalization week and cognitively able to participate. During this period, pr ocedu r es lik e bat h in g, w ou n d dr essin g an d sk in gr aft ing ar e car r ied out m or e oft en, and pain and anxiet y m anifest at ions are frequent ly present .
I nst r um ent s
I m p a ct o f Ev e n t Sca l e - I ES. Th i s i n st r u m en t consist s of 15 it em s r elat ed t o t he bur n event and i n d e x e s t w o m o st co m m o n l y r e p o r t e d sp e ci f i c cat egor ies of ex per ien ces in r espon se t o st r essf u l e v e n t s: i n t r u si o n a n d a v o i d a n ce ( d e n i a l o f consequences of m eanings of t he event ) . The scale has been used in different st udies( 11,13). The aut hors
of t he BSPAS used an adapt ed v er sion for bur ned pat ient s( 11). I n t his st udy, we adapt t he version used
by t hese aut hors. Each scale it em is evaluat ed on a visual analogue line with scores ranging from zero to t en and t he t ot al score of t he scale is calculat ed by ad d in g u p t h e scor es of t h e su b scales ( in t r u siv e t hought s and av oidance behav ior ) . Max im um t ot al score is 150 and, the higher the total score, the greater the im pact of the event.
Bu r n s Sp e cif ic Pa in An x ie t y Sca le - Th is scale
was originally proposed in Dutch in a nine- item( 10) and
fiv e- it em v er sion( 1 ). I t ev alu at es pain an d an x iet y
m anifest at ions relat ed t o painful sit uat ions, such as w ou n d d r essin g , b at h in g , d eb r id em en t s an d sk in grafting, which occur while the patient is hospitalized. Each it em is an sw er ed on a v isu al an alog u e lin e r an g i n g f r o m zer o t o t en an d t h e t o t al sco r e i s cal cu l at ed b y ad d i n g u p t h e sco r es o f al l i t em s ( m ax im u m 9 0 p oin t s) . Th e h ig h er t h e scor e, t h e gr eat er t he pat ient s’ lev el of anx iet y about painful pr ocedu r es.
S p i e l b e r g e r ’ s S t a t e - T r a i t A n x i e t y I n v e n t o r y
( STAI ) - I nv ent or y adapt ed t o Por t uguese( 9). This
inst r um ent m easur es unspecific aspect s per m eat ing st r e ssf u l si t u a t i o n s, su ch a s t e n si o n a n d preoccupation, am ong others. I t consists of 40 item s, divided in two 20- item scales that m easure two form s of anxiety: trait anxiety ( 20 item s) and state anxiety ( 20 it em s) respect ively. A choice of four answers is o f f e r e d f o r e a ch i t e m ( n o t a t a l l , so m e w h a t , m oder at ely so, v er y m uch so) w it h scor es r anging from 20 to 80 points. Anxiety scores obtained through this test were ranked as follows: 20- 40 - Low anxiety; 41- 60 - Medium anxiety and 61- 80 - High anxiety. I n this study, we used the State Anxiety inventory, which cont ains 20 it em s.
V isu a l An a log u e Sca le - V AS( 6) - Unidim ensional
“ very severe pain”. The higher t he score, t he higher t he pain int ensit y m anifest ed by pat ient s.
Analysis of psychom et ric propert ies
Re lia b ilit y : analy zed t hr ough int er nal consist ency
between the item s of each scale: BSPAS- VP and I ES-VP, u sin g Cr on bach ’s Alph a an d Pear son ’s Pr odu ct Mom ent Cor r elat ion Coefficient .
V a l i d i t y : co n st r u ct v a l i d i t y w a s a n a l y zed u si n g Sp ear m an ’s co r r el at i o n co ef f i ci en t , st u d y i n g t h e correlat ion bet w een t he BSPAS- VP and t he VAS ( at four different t im es) , t he STAI St at e Anxiety ( applied t oget her wit h t he BSPAS- VP) and t he percent age of t ot al body surface area burned ( TBASB) . The TBSAB variable is direct ly relat ed wit h burned pat ient s’ pain and anxiet y m anifest at ions. TBSAB percent ages were obtained from the patient’s m edical record, considering t he infor m at ion r egist er ed dur ing t he fir st m edical ev aluat ion.
PROCEDURES
First, we obtained the perm ission to translate a n d u se t h e “ Bu r n s Sp eci f i c Pa i n An x i et y Sca l e ( BSPAS) ”. The original docum ent , sent by one of t he aut hors ( FABER, A.W.) , consist ed of t wo scales: t he “ I m pact of Ev ent Scale - I ES” ( 1 5 it em s) and t he “ Bur ns Specific Pain Anx iet y Scale - BSPAS” ( nine it em s) in Dut ch. We decided t o adapt t he nine- it em BSPAS t o g e t h e r w i t h t h e 1 5 - i t e m I ES, a s t h e instructions to fill out the docum ent sent by the authors r efer r ed t o bot h scales. Hence, in t his paper, w hen we discuss the cross- cultural adaptation of the BSPAS, w e ar e also r efer r ing t o t he adapt at ion of t he I ES, specifically for burns vict im s.
The cross- cult ural adapt at ion process of t he BSPAS was carried out according to literature( 3) and a change in the order of the steps, proposed in a study that was presented at a scientific m eeting* . The authors o f t h i s ch a n g e j u st i f y t h a t , b y ca r r y i n g o u t t h e ev alu at ion b y t h e ex p er t com m it t ee b ef or e b ack-t r anslaack-t ion, er r or s or com pr ehension pr oblem s can be det ect ed, which can be m odified in t he t ranslat ed v er si o n . I f t h i s v er si o n h a s a l r ea d y b een b a ck -t ransla-t ed, -t hose m odifica-t ions canno-t be considered
* Dant as R. A. S. , Rossi L. A. Tradução e adapt ação t ranscult ural de inst rum ent os na área da saúde: um a nova propost a. Escola de Enferm agem de Ribeirão Preto. 2004. I n: ENCONTRO Í BERO- AMERI CANO DE QUALI DADE DE VI DA, 2º , 2004, Porto Alegre ( Poster presentation) .
for translation into the instrum ent’s language of origin, so that the obj ective of this step is not reached, which is t o p r eser v e t h e or ig in al id ea con t ain ed in t h e instrum ent as a whole. The sem antic analysis of each in st r u m en t it em bef or e t h e pr et est w as aim ed at verifying the understandability of all item s for the entire inst r um ent , accor ding t o a r epr esent at iv e gr oup of t he t arget populat ion( 14).
T r a n sla t io n o f t h e sca le t o Po r t u g u e se - Th is translation was carried out by two Brazilians who live in the city of Holam bra - SP, Brazil, daughters of Dutch parent s, wit h com prehensive knowledge of t he Dut ch lan gu age an d cu lt u r e. Th is ph ase r esu lt ed in t w o Portuguese versions: Burns Specific Pain Anxiet y Scale - Po r t u g u ese Ve r si o n 1 ( BSPAS- VP 1 ) an d Bu r n s Sp ecif ic Pain An x iet y Scale - Por t u gu ese Ver sion 2
( BSPAS- VP 2) .
A c h i e v e m e n t o f f i r s t c o n s e n s u s v e r s i o n i n P o r t u g u e se - A m eet in g w as h eld w it h t h e t w o t r an slat or s, accor d in g t o t h e f ollow in g st ep s: 1 . Explanat ion about t he obj ect ives of t he m eet ing, t he study and the instrum ent. 2. Distribution of copies of the BSPAS- VP1 and BSPAS- VP2, as well as the original Dut ch version t o t he t ranslat ors. 3. Paused reading of t he inst ruct ions for com plet ion and t he inst rum ent i t e m s, a l l o w i n g f o r a d i scu ssi o n a n d co n se n su s between translators and researchers. 4. Starting from t he obt ained consensus, t he proposed changes were e v a l u a t e d a n d d i scu sse d , se l e ct i n g t h e m o st a p p r o p r i a t e o p t i o n t h a t p r e se r v e d t h e m e a n i n g ex pr essed in t he or iginal inst r um ent . The r esult of t h is ph ase w as t h e: BSPAS- Por t u g u ese Con sen su s Ver sion 1 ( BSPAS- VPC- 1) .
Back - t ranslat ion - I t was carried out by two persons fluent in Dut ch, who lived in Brazil, had full m ast ery of Port uguese and knowledge about Brazilian cult ure. The translators were neither inform ed about the study obj ect ives, nor about t he concept s involved and t he goal of t he inst rum ent . The result of t his phase was the Burns Specific Pain Anxiet y Scale - Dut ch Version 1 ( BSPAS- VH 1) and Burns Specific Pain Anxiet y Scale - Dut ch Ver sion 2 ( BSPAS- VH 2) .
Ach ie v e m e n t o f co n se n su s v e r sio n in D u t ch
-Like in t he previous phases, t he researchers held a m eet in g w it h t h e t r an slat or s. Ch an g es an d t h eir r e sp e ct i v e j u st i f i ca t i o n s w e r e d i scu sse d a n d regist ered. At t he end of t his m eet ing, a consensus version of t he Dut ch back- t ranslat ion was obt ained: t he BSPAS- Final Dut ch Ver sion ( BSPAS- VCFH) .
Co m p a r i s o n b e t w e e n t h e o r i g i n a l a n d
con se n su s v e r sion s in D u t ch - The BSPAS- VCFH
was com pared wit h t he original version of t he scale ( in Dutch) . This step aim ed at verifying cross- cultural e q u i v a l e n ce . Th e se D u t ch v e r si o n s w e r e a l so com par ed w it h t he BSPAS- VPC2 . Few adj ust m ent s w er e m ade in t he BSPAS- VCFH in com par ison w it h the original version, and the sam e happened with the BSPAS- VPC2 . Th e r e su l t o f t h i s p h a se w a s a Por t u gu ese v er sion : BSPAS- Por t u g u ese Con sen su s Version 3 ( BSPAS- VPC- 3) and a new Dut ch ver sion: t he BSPAS- Final Dut ch Ver sion.
Se m a n t ic a n a lysis - The aim of t his phase was t o
f i n d o u t w h e t h e r t h e t a r g e t p o p u l a t i o n co u l d under st and all inst r um ent it em s. Par t icipant s w er e three patients who were hospitalized at the Burns Unit. Af t er t h ey r eceiv ed in f or m at ion ab ou t t h e st u d y obj ectives in general and this phase in particular, the sca l e w a s i n d i v i d u a l l y a p p l i e d b y o n e o f t h e r esear ch er s. Th e f ir st t w o p at ien t s su g g est ed t o i n cl u d e , i n t h o se i t e m s w h e r e t h e w o r d “ ca r e ” appear ed, explanat or y w or ds bet w een par ent heses: w o u n d cl e a n si n g , b a t h i n g , w o u n d d r e ssi n g a n d phy siot herapy. This suggest ion w as pr esent ed and accept ed by t he t hird pat ient and by t he researcher.
Pr e t e st of t h e Por t u gu e se ve r sion : BSPAS- VP
-The final version of t he t ranslat ed scale was now called BSPAS- VP an d su b m i t t ed t o a p r et est w i t h f o u r per sons fr om t he t ar get populat ion. Aft er t hey had filled out t he scale, each part icipant was quest ioned abou t u n der st an dabilit y, per t in en ce, appr oval an d cu lt u r al r elev an ce of t h e in st r u m en t . Du r in g t h is phase, pat ient s did not m eet any difficult ies t o fill out t h e scale an d t h e r esear ch er s obser v ed t h at t h ey
com m ent ed on t he it em s and t he r eason for t heir a n sw e r s ( f o r e x a m p l e : “Th a t i s r e a l l y w h a t w e feel. . .” ) .
Dat a collect ion - The scale was applied to the study
sam ple according t o t he following phases: phase 1: obt aining inform ed consent from pat ient s and filling out t he dat a collect ion inst rum ent wit h ident ificat ion and data on hospitalization, burn and pharm acological t reat m ent . These dat a were obt ained from pat ient s’ m edical files. Ph ase 2 : applicat ion of VAS at fou r different tim es during the day: a. im m ediately before bat hing and w ound dr essing; b. im m ediat ely aft er bathing and wound dressing; c. at 16 hours and d. at 20 hours, for seven days. Phase 3: at the end of the f i r st w eek , b et w een t h e 6 t h an d 1 4 t h d ay af t er hospit alizat ion( 1 1 ) an d at appr ox im at ely 1 6 an d 1 7
hours, t he BSPAS - VP, I ES - VP and t he St at e-Trait I n v en t or y ad ap t ed t o Por t u g u ese ( I DATE)( 9 ) w er e
applied. At this tim e, the m ain care actions had already finished, as w ell as v isit ing hour s. I n all sit uat ions when pat ient s were not able t o fill out t he scale due t o physical ( hand inj uries, visual difficult ies, am ong ot her s) or cognit ive difficult ies ( know how t o r ead/ writ e) , t hey were inform ed of t he possibilit y t hat t he researcher could fill out t he inst rum ent .
RESULTS
Th e “ Bu r n s Sp ecif ic Pain An x iet y Scale BSPAS VPF” and the “ I m pact of Event Scale” I ES -VPF” in Portuguese were j ointly applied to a group of Brazilian burned patients between May and Decem ber 2 0 0 4 . Tw ent y- t hr ee pat ient s r eached t he inclusion cr it er ia, b u t t w o w er e ex clu d ed , on e b ecau se of dischar ge fr om hospit al in less t han 48 hour s and anot her indicat ed insufficient em ot ional condit ions t o fill out t he scales. Hence, t he st udy group consist ed of 21 adult patients: 14 ( 66% ) m en and seven ( 33% ) w om en. Ages r anged fr om 1 5 t o 7 3 y ear s, w it h a m ean of 36.1 and m edian of 34.5 year s ( SD: 16.3 y ear s) . Most par t icipant s w er e up t o 4 5 y ear s old ( 76% ) . Mean TBSAB was 13.2 % ( SD: 10.5) , m edian 9.5% and range from 1 t o 43% .
Concerning the anxiety evaluation, six ( 29% ) pat ient s showed low and 15 ( 71% ) m edium anxiet y. None of t he pat ient s m anifest ed high anxiet y.
As w e m ent ioned befor e, t he docum ent w e r ecei v ed i n D u t ch a n d a d a p t ed i n t o Po r t u g u ese includes bot h t he I ES and t he BSPAS, each of which has different obj ect ives but t he sam e inst ruct ions for com pletion. The first 15 item s ( 1 - 15) are part of the “ I m p act o f Ev en t Scal e” ( i t s v er si o n ad ap t ed t o Por t uguese is called I ES - VP) , w hich assesses t he p sy ch o l o g i cal i m p act o f t h e t r au m a ( b u r n ) . Th e rem aining nine it em s ( 16 - 24) com prise t he “ Burns Specific Pain Anxiet y Scale” ( it s version adapt ed int o Por t uguese is called BSPAS - VP) , w hich ev aluat ed an x iet y an d pain in bu r n s v ict im s. Table 1 sh ow s Pear son ’s Pr odu ct Mom en t Cor r elat ion Coefficien t s ( between scale item s) , Alpha if the item was excluded and t ot al Alpha for I ES- VP.
Tab l e 1 - Pear so n ’s Pr o d u ct Mo m en t Co r r el at i o n Coefficient ( bet ween scale it em s) , Alpha if t he it em w as excluded and t ot al Alpha for I ES- VP, Ribeir ão Pret o, 2005
* p< 0.05 * * p< 0.01
The internal consistency of the I ES - VP was low ( Product Mom ent Correlation Coefficient) for item s 1, 8, 12 and 15; however, no great differences were found when we tested how the exclusion of each item would affect t he t ot al Alpha of t he scale. Tot al Alpha for the item s evaluating int rusive t hought s was 0.746.
Product Mom ent Correlat ion Coefficient s for it em s 1 and 11 w er e low er in com par ison w it h ot her it em s but , again, w e did not find gr eat differ ences w hen t est ing how t he exclusion of each it em would affect the total Alpha of the scale item s. Total Alpha for the it em s relat ed t o avoidance behavior was 0.773 and Product Mom ent Correlat ion Coefficient s for it em s 2, 8 and 12 were lower in com parison with other item s. We did not find great differences when t est ing how the exclusion of each item would affect the total Alpha of t he scale.
Table 2 present s Pearson’s Product Mom ent Correlat ion Coefficient ( bet ween scale it em s) , Alpha if the item was excluded and total Alpha for BSPAS -VP.
Tab l e 2 - Pear so n ’s Pr o d u ct Mo m en t Co r r el at i o n Coefficient ( bet ween scale it em s) , Alpha if t he it em was excluded and total Alpha for BSPAS -VP, Ribeirão Pret o, 2005
s m e t I -t c u d o r P s ' n o s r a e P n o i t a l e r r o C t n e m o M t n e i c i f f e o C α α α α
α(iftheitem ) d e d u l c x e s a w I n e h w n e v e n r u b e h t t u o b a k n i h t I . 1 . o t n a e m t o n o
d 0.312 0.845
t e s p u t e g fl e s y m g n it t e l d i o v a I . 2 m a r o n r u b e h t t u o b a k n i h t I n e h w . t i f o d e d n i m e r 0 0 4 .
0 0.832
y m m o r f n r u b e h t e v o m e r o t y r t I . 3 . y r o m e
m 0.639** 0.821
r o p e e l s a g n il l a f e l b u o r t e v a h I . 4 r o s e r u t c i p e s u a c e b p e e l s a g n i y a t s o t n i e m o c n r u b e h t t u o b a s t h g u o h t . d n i m y m * * 9 2 6 .
0 0.816
s g n il e e f g n o r t s f o s e v a w e v a h I . 5 . n r u b e h t t u o b
a 0.694** 0.822
. n r u b e h t t u o b a s m a e r d e v a h I .
6 0.441* 0.837
e h t f o s r e d n i m e r m o r f y a w a y a t s I . 7 . n r u
b 0.704** 0.816
t' n s a h n r u b e h t f i s a l e e f I . 8 .l a e r t' n s i t i r o d e n e p p a
h 0.143 0.851
. n r u b e h t t u o b a k l a t o t t o n y r t I .
9 0.519* 0.820
p o p n r u b e h t t u o b a s e r u t c i P . 0 1 . d n i m y m o t n
i 0.634** 0.823
e m g n i k a m p e e k s g n i h t r e h t O . 1 1 . n r u b e h t t u o b a k n i h
t 0.276 0.842
t o l a e v a h ll it s I t a h t e r a w a m a I . 2 1 I t u b , n r u b e h t t u o b a s g n il e e f f o . m e h t h t i w l a e d t' n o d 5 5 2 .
0 0.846
. n r u b e h t t u o b a k n i h t o t t o n y r t I . 3
1 0.599** 0.824
k c a b s g n i r b r e d n i m e r y n A . 4 1 . n r u b e h t t u o b a s g n il e e
f 0.602** 0.823
e r a n r u b e h t t u o b a s g n il e e f y M . 5 1 . b m u n f o d n i
k 0.242 0.844
l a t o t a P V -S E
I 0.841
s m e t I -t c u d o r P s ' n o s r a e P n o i t a l e r r o C t n e m o M t n e i c i f f e o C α α α α
α(iftheitem ) d e d u l c x e s a w e r u c e s n i l e e f y l n e d d u s n a c I . 6 1 y m e e s I n e h w g n il a e h y m t u o b a . s n r u b * * 5 3 6 .
0 0.900
g n i k n i h t y lt n a t s n o c m a I , y ll a u t c A . 7 1 . n i a p y m f
o 0.723** 0.888
x a l e r o t e l b i s s o p m i s i t i d n if I . 8 1 , g n i s n a e l c d n u o w ( e r a c g n i r u d d n a s g n i s s e r d , s h t a b . ) y p a r e h t o i s y h p * * 1 0 7 .
0 0.899
s u o v r e n l e e f I , n i a p e h t o t e u D . 9 1 . s s e lt s e r d n
a 0.709** 0.891
t a h t g n o r t s o s n e t f o s i n i a p e h T . 0 2 . s e it i v it c a y m f o ll a p o t s o t e v a h
I 0.750** 0.891
g n it c a r t n o c s e l c s u m y m l e e f I . 1 2 , s h t a b , g n i s n a e l c d n u o w ( e r a c n e h w ) y p a r e h t o i s y h p d n a s g n i s s e r d . s t r a t s y ll a u t c a * * 5 0 6 .
0 0.901
g n i r u d n i a p e h t f o d i a r f a m a I . 2 2 d n u o w ( e r a c r e t f a t h g i r d n a d n a s g n i s s e r d , s h t a b , g n i s n a e l c . ) y p a r e h t o i s y h p * * 6 9 7 .
0 0.893
h g u o r h t o g o t e v a h I e m it h c a E . 3 2 d e i r r o w m a I , e r u d e c o r p ) e r a c ( a .l e e f y a m I n i a p e h t t u o b a * * 4 0 7 .
0 0.891
I t a h t g n o r t s o s e b n a c n i a p e h T . 4 2 f o l o r t n o c g n i s o l f o d i a r f a m a . fl e s y m * * 9 3 6 .
0 0.896
l a t o t a P V -S A P S
B 0.905
The int ernal consist ency of t he BSPAS - VP, u si n g Pe a r so n ’ s Pr o d u ct Mo m e n t Co r r e l a t i o n Coefficient , w as st at ist ically significant for all nine it em s ( 16 - 24) , ranging from 0.605 ( for it em 21 “I
f e e l m y m u scl e s co n t r a ct i n g w h e n ca r e - w o u n d
cl e a n si n g , b a t h s, d r e ssi n g s a n d p h y si o t h e r a p y
-act ually st art s” ) to 0.796 ( for item 22 “I am afraid of t he pain during and right aft er care ( wound cleansing,
bat hs, dressings and physiot herapy” ) and a high total Alpha was found for t he scale ( 0.905) ( Table 2) .
Con cer n in g con st r u ct v alidit y, w e f ou n d a st at ist ically significant correlat ion bet ween t he BSPAS - VP and t he I ES - VP ( 0.594; p< 0.005) and TBSAB ( 0 . 5 3 6 ; p< 0 . 0 5 ) w h ich , accor din g t o lit er at u r e, is direct ly relat ed t o pain m anifest at ions in t his kind of patients. Correlation coefficients were higher between BSPAS - VP sco r e s a n d p a i n e v a l u a t i o n sco r e s im m ediately before and im m ediately after bathing and wound dressing. We also found a statistically significant cor r elat ion bet w een pain scor es im m ediat ely aft er w ound dr essing ( 0.566; p< 0.005) and at 16 hour s ( 0.496; p< 0.05) and TBSAB.
DI SCUSSI ON
Th is st u dy aim ed at adapt in g an d m ak in g a v a i l a b l e t h e Bu r n s Sp eci f i c Pa i n An x i et y Sca l e ( com prising t he I ES and t he BSPAS it self ) t o assess, respectively, stress caused by the im pact of the burn event , pain and anxiet y in Brazilian burns vict im s.
Pat ient s’ ages ranged from 15 t o 73 years, w hich is sim ilar t o ot her st udies( 10,12). Accor ding t o literature, age is an im portant variable in the study of burns vict im s( 15). A st udy about t he charact erist ics of
377 patients hospitalized at a burns unit in Japan found t hat accident s were m ore frequent in t he age range fr om 15 t o 60 y ear s ( 89.2% ) . I n Br azil, st udies( 16)
have dem onst rat ed t hat approxim at ely 50% of burns accident s inv olv e childr en and appr ox im at ely 1 0 % people over 60. Data indicated that, in about 40% of burns accident s, vict im s w ere under 40 ( product ive ag e) . Th is im p lies lost w or k d ay s, f ir st d u e t o a f r eq u en t ly lon g h osp it alizat ion ( acu t e p h ase an d rehabilit at ion phase) and m oving int o t he long- t erm rehabilit at ion phase.
I n term s of gender, 66% of participants were m e n ( 1 4 ) . Th e se d a t a a r e i n l i n e w i t h o t h e r st udies( 10,12).
Th e TBSAB h a s b e e n t h e su b j e ct o f cont roversies about it s relat ion wit h pain percept ion and anxiety in burned patients. I n an analysis of pain e x p e r i e n ce s d u r i n g p a i n f u l p r o ce d u r e s a n d r e st periods, aut hors found t hat t he percent age of TBSAB was associated with increased procedural anxiety. This fact could also influence an increase in these persons’ pain sensat ions( 17). Ot her st udies found t hat pat ient s
w i t h l ar g er b u r n i n j u r i es t en d ed t o r ep o r t m o r e affect ive pain and t ended t o have a pat t ern of high and low reports that differed from patients with severe burn inj uries( 18). Other authors found a low correlation
b e t w e e n TBSAB a n d p a i n m a n i f e st a t i o n s b u t m ent ioned a st at ist ically significant coefficient when pain ev aluat ions dur ing t he fir st w eek post - t r aum a w e r e co r r e l a t e d w i t h TBSAB i n p a t i e n t s w i t h pr edom inant ly super ficial bur ns, as t hese ar e v er y painful( 2).
We f o u n d h i g h e r a v e r a g e p a i n sco r e s im m ediat ely aft er bat hing and w ound dr essing and low and m edium average st at e- anxiet y scores at t he e n d o f t h e f i r st w e e k o f h o sp i t a l i za t i o n . Ot h e r studies( 1,10- 11) evidenced that these pain m anifestations
were relat ed t o painful procedures and t hat anxiet y was frequent in this kind of patients.
I nt ernal consist ency analysis of t he I ES - VP resulted in a wide range of Pearson’s Product Mom ent Correlat ion coefficient s; however, differences in t ot al Alpha of the scale were sm all when each of the item s was excluded. When considering t he t wo sub scales, t hat is, int r usiv e t hought s and av oidance behav ior, result s show ed t hat it em 1 (I t h in k abou t t h e bu r n
even when I do not m ean t o) in the intrusive thoughts part, and item s 8 (I feel as if t he burn hasn’t happened
or it isn’t real) , 12 (I am aware t hat I st ill have a lot of feelings about t he bur n, but I don’t deal w it h t hem) and 15 (My feelings about t he burn are kind of num b) ,
in t he av oidance behav ior par t , st ill pr esent ed low correlat ion coefficient s in com parison w it h t he t ot al scor e of t he 15 scale it em s. Cr onbach’s Alpha w as 0.746 for int rusive t hought s and 0.773 for avoidance
behavior, which is not very different from total Alpha f or t h e scale ( 0 , 8 4 1 ) . Bot h t h ese d at a an d t ot al Cronbach’s Alpha for t he t wo sub scales are sim ilar t o lit erat ure findings( 13).
unidim ensionalit y of t he inst rum ent and t hat int ernal consist ency levels am ong scale it em s are high.
The results of our study suggest that all item s of t he original versions should be m aint ained in t he v e r si o n s a d a p t e d t o Po r t u g u e se . Ba se d o n l i t e r a t u r e( 1 4 , 1 9 ), a l o w l e v e l e r r o r v a r i a t i o n a n d
m easurem ent errors can be inferred for bot h scale, but t his affir m at ion can only be confir m ed t hr ough f a ct o r i a l a n a l y si s( 1 4 ), w h i ch w o u l d r e q u i r e m o r e
par t icipant s.
To assess t he ext ent t o which bot h adapt ed scales ( BSPAS- VP and I ES- VP) m easured the intended co n st r u ct s, w e o b t ai n ed Sp ear m an ’ s Co r r el at i o n Coefficient , w hich r evealed a st at ist ically significant correlation between the BSPAS - VP and the I ES - VP and with the BBS. These data could suggest a relation bet ween pain- relat ed anxiet y m anifest at ions and t he TBSAB in burns vict im s( 11,18).
CONCLUSI ON
This study aim ed at translating and adapting t he Burns Specific Pain Anxiet y Scale - BSPAS as a specific inst rum ent t o assess anxiet y relat ed t o pain m anifest at ions in burns vict im s. We conclude t hat : - Af t er t h e cr oss- cu lt u r al adapt at ion pr ocess, t h e BSPAS- VP an d t h e I ES- VP r each ed t h e cr it er ia of i d i o m a t i c, se m a n t i c, cu l t u r a l a n d co n ce p t u a l equ iv alen ce.
- Participants’ range of average pain scores was wide. High er con cen t r at ion s of pain scor es af t er pain f u l pr ocedu r es lik e bat h in g an d w ou n d dr essin g w er e ob ser v ed .
- We also f ou n d a w ide ran ge of av erage an x iet y scor es. Scor es t en d ed t o con cen t r at e in m ed iu m anx iet y. We did not find any scor es indicat ing high anx iet y lev els.
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