www.jped.com.br
ORIGINAL ARTICLE
Brazilian Portuguese translation, cross-cultural adaptation and reproducibility assessment of the modified Bristol Stool Form Scale for children 夽
Debora Rodrigues Jozala
a, Isabelle Stefan de Faria Oliveira
b, Erika Veruska Paiva Ortolan
c, Wilson Elias de Oliveira Junior
d, Giovana Tuccille Comes
d, Vanessa Mello Granado Cassettari
d, Mariella Marie Self
e, Pedro Luiz Toledo de Arruda Lourenc ¸ão
c,∗aUniversidadeEstadualPaulista‘‘JúliodeMesquitaFilho’’(UNESP),FaculdadedeMedicinadeBotucatu,Programade Pós-graduac¸ãoemMedicina,Botucatu,SP,Brazil
bUniversidadeEstadualPaulista‘‘JuliodeMesquitaFilho’’(UNESP),FaculdadedeMedicinadeBotucatu,Botucatu,SP,Brazil
cUniversidadeEstadualPaulista‘‘JúliodeMesquitaFilho’’(UNESP),FaculdadedeMedicinadeBotucatu,Departamentode CirurgiaeOrtopedia,DisciplinadeCirurgiaPediátrica,Botucatu,SP,Brazil
dUniversidadeEstadualPaulista‘‘JúliodeMesquitaFilho’’(UNESP),FaculdadedeMedicinadeBotucatu,Programade Pós-graduac¸ãoemBasesGeraisdaCirurgia,Botucatu,SP,Brazil
eBaylorCollegeofMedicine,DepartmentofPediatrics,Houston,UnitedStates
Received2December2017;accepted30January2018 Availableonline15March2018
KEYWORDS Translations;
Reproducibilityof results;
Defecation;
Constipation;
Child
Abstract
Objective: TotranslateandculturallyadaptthemodifiedBristolStoolFormScaleforchildren intoBrazilianPortuguese,andtoevaluatethereproducibilityofthetranslatedversion.
Methods: Thestageoftranslationandcross-culturaladaptationwasperformedaccordingtoan internationallyacceptedmethodology,includingthetranslation,back-translation,andpretest application ofthetranslated versionto asample of74 children to evaluatethe degree of understanding.Thereproducibilityofthetranslatedscalewasassessedbyapplyingthefinal versionofBrazilianPortuguesemodifiedBristolStoolFormScaleforchildren toasampleof 64childrenand25healthcareprofessionals,whowereaskedtocorrelatearandomlyselected descriptionfromthetranslatedscalewiththecorrespondingrepresentativeillustrationofthe stooltype.
夽 Pleasecitethisarticleas:JozalaDR,OliveiraIS,OrtolanEV,OliveiraJuniorWE,ComesGT,CassettariVM,etal.BrazilianPortuguese translation,cross-culturaladaptationandreproducibilityassessmentofthemodifiedBristolStoolFormScaleforchildren.JPediatr(RioJ).
2019;95:321---7.
∗Correspondingauthor.
E-mail:lourencao@fmb.unesp.br(P.L.Lourenc¸ão).
https://doi.org/10.1016/j.jped.2018.01.006
0021-7557/©2018SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Results: ThefinalversionofBrazilianPortuguesemodifiedBristolStoolFormScaleforchildren wereevidentlyreproducible,sincealmostcompleteagreement(k>0,8)wasobtainedamong thetranslateddescriptionsandillustrations ofthestooltypes,bothamongthechildrenand thegroupofspecialists.TheBrazilianPortuguesemodifiedBristolStoolFormScaleforchildren wasshowntobereliableinprovidingverysimilarresultsforthesamerespondentsatdifferent timesandfordifferentexaminers.
Conclusion: TheBrazilianPortuguesemodified BristolStoolFormScaleforchildrenisrepro- ducible;itcanbeappliedinclinicalpracticeandinscientificresearchinBrazil.
©2018SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/
4.0/).
PALAVRAS-CHAVE Traduc¸ões;
Reprodutibilidadedos resultados;
Defecac¸ão;
Constipac¸ão;
Crianc¸a
Traduc¸ãoparaoportuguês(Brasil),adaptac¸ãotransculturaleavaliac¸ãoda reprodutibilidadedaEscaladeBristolparaConsistênciadeFezesmodificadapara crianc¸as
Resumo
Objetivo: Traduzir e adaptar culturalmente a Escala de Bristol para Consistênciade Fezes modificada para crianc¸as para o português (Brasil) e avaliara reprodutibilidade da versão traduzida.
Métodos: O estágio de traduc¸ão e adaptac¸ão intercultural foi feito de acordo com uma metodologiainternacionalmenteaceita,incluiuatraduc¸ão,retrotraduc¸ãoeaplicac¸ãodepré- testedaversãotraduzidaaumaamostrade74crianc¸asparaavaliaroníveldeentendimento.
Aavaliac¸ãodareprodutibilidadedaescalatraduzidafoifeitacomaaplicac¸ãodaversãofinal daEscaladeBristolparaConsistênciadeFezesmodificadaemportuguês(Brasil)paracrianc¸as aumaamostrade64crianc¸ase25profissionaisdesaúde,quetiveramdecorrelacionaruma descric¸ãoaleatoriamenteselecionadadaescalatraduzidacomailustrac¸ãorepresentativacor- respondentedotipodefezes.
Resultados: A versão finalda Escala deBristol para Consistência deFezes modificada para crianc¸asemportuguês(Brasil)foicomprovadamentereproduzível,poisfoiobtidaquaseuma concordânciatotal (k>0,8)entreasdescric¸õeseilustrac¸õestraduzidas dostiposdefezes, entreascrianc¸as eogrupodeespecialistas.A EscaladeBristol paraConsistênciadeFezes modificadaparacrianc¸asemportuguês(Brasil)mostrou-seconfiávelemproporcionarresultados muitosemelhantesparaosmesmosentrevistadosemdiferentesmomentoseparadiferentes examinadores.
Conclusão: AEscaladeBristol paraConsistênciadeFezesmodificadaparacrianc¸asempor- tuguês(Brasil)éreproduzívelepodeseraplicadanapráticaclínicaeempesquisacientíficano Brasil.
©2018SociedadeBrasileiradePediatria.PublicadoporElsevierEditoraLtda.Este ´eumartigo OpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/licenses/by-nc-nd/4.
0/).
Introduction
Characterizing stool consistency is of fundamental impor- tancefordiagnosis, therapeuticmonitoring, andscientific researchonintestinaldiseases.1,2Theuseofgraphicscales isaneffectivetoolduringthisworkup.3---6TheBristolscale forstool consistency(BristolStoolFormScale [BSFS]) was developedandvalidatedinthecityofBristol,UnitedKing- dom, about two decades ago.7---11 This scale is composed ofpicturesrepresentingsevenstooltypes,associatedwith accuratedescriptionsoftheirshapeandconsistency,using recognizableillustrations.11 In adults,theuse ofthe BSFS todeterminestoolconsistencyiswellestablishedinclinical practice,epidemiologicalstudies,andclinicaltrials.11---13
TheBSFSforchildren(mBSFS-C)wasrecentlymodified.4 This scale proposed reducing the number of stool types fromseventofive,andadapting thelanguageusedinthe descriptions to allow children to fully understand the
depictionsofeachstooltype.Theuseofthisscalehasbeen validatedintheUnitedStatesforchildrenaged6---8years, when thedescriptionsareread aloud,andfor thoseaged over8years,whoreadthedescriptionsthemselves.5
Thesetwoscaleswerecreatedandhavebeenvalidatedin theEnglishlanguage.However,toallowtheiruseinclinical practiceand inscientific researchin countrieswithother officiallanguages,thetranslationandculturaladaptationis fundamental.6,14---16Toachievethis,theprocessmustfollow internationallyacceptedstandards,i.e.,theitemsmustnot onlybetranslatedproperlyfromalinguisticpointofview, butmustalsobeculturallyadapted,whilemaintainingthe validityoftheoriginalinstrument.15,16
In Brazil, the BSFS has been translated and cross- culturally adapted for Brazilian Portuguese for adult populations (>18 years).6 However, the mBSFS-C still has notundergone thisprocess,toallowitsapplication inthe Brazilian pediatric population. Thus, the authors decided
toundertakethetranslationandculturaladaptationofthe mBSFS-CintoBrazilianPortugueseandtoevaluatetherepro- ducibilityofthetranslatedversion.
Methods
This wasasingle-centerstudy,conductedat theBotucatu Medical School, São Paulo State University (UNESP), São Paulo,Brazil,betweenJune2015andJuly2017.Thestudy included 138 children aged between 6 and 18 years who hadnocognitiveimpairmentandwhowerebeingtreatedat theGeneralPediatricOutpatientsClinicduetootherhealth problems,notrelatedtointestinalcomplaints.Agroupof 25 healthcare professionals, composed of physicians and nurses with experience in the areas of gastroenterology andpediatrics, have participatedduring the reproducibil- ity assessment stage. Participants and/or their guardians wereinformed ofthe purposeof the researchandsigned atermoffree,informedconsent.Thisstudywasapproved bythelocalResearchEthicsCommittee,underprotocolNo.
28104614.8.0000.5411.
Stage1:Translationandcross-culturaladaptation
Toensure thequalityof theadaptationprocess,thescale wastranslatedandadaptedaccordingtoaninternationally acceptedandrecommendedmethodology,consistingofsix phases.6,14---18
Phase1:TranslationintoBrazilianportuguese
TwoindependenttranslationsofthemBSFS-Cweremadeby twobilingualtranslatorswhosemotherlanguageisBrazilian Portuguese.
Phase2:Producingasynthesizedforwardtranslation Ameetingwasheldbetweenthetwotranslatorswhopar- ticipated in Phase 1 and a team of specialists, composed of professionals with experience in child healthcare (two doctors, one nurse, one psychologist, and one nutrition- ist), and a universityprofessor withextensive experience in cross-cultural adaptation of health assessment tools. A synthesizedforwardtranslationwasproducedbasedonthe evaluation,reflection,anddiscussionofthisgroup ofpro- fessionals.
Phase3:Back-translation
The synthesizedtranslation wasthen back-translatedinto English,independently,bytwobilingualtranslatorswhose motherlanguageisEnglish;thesetranslatorsdidnotpartic- ipateinthefirstphaseandarenothealthcareprofessionals.
These translators were not informed of the concepts explored by the instrument, and both translations were madewithoutpriorknowledgeoftheoriginalversionofthe scale.
Phase4:Preparingthepre-finalversionofthetranslated scale
Thepre-finalversionofthetranslatedscale wasproduced after joint discussion and assessment between the four translatorsandthe teamof specialists.At this stage,the back-translationswerecomparedwiththeoriginalversionof themBSFS-Candallfourforward-translatedversionswere analyzed,edited,andconsolidatedinthejointdevelopment ofthepre-finalversionoftheBrazilianPortuguesescale.
Phase5:Pretestandevaluationofthedegreeof understanding
The pretest was applied to a sample of 74 children (21 aged6---8yearsand53aged8---18years).Afive-pointverbal numericalscalewasappliedtoassessthedegreeofunder- standingofthetranslatedversionofthemBSFS-Casawhole andeachofitscomponents,inreferencetothetranslated descriptionsofeachofthefivestooltypes.Theguidingques- tionforevaluatingthetranslatedscaleasawholewas‘‘Did youunderstandwhatwasaskedandthedifferencesbetween thesetypesofstools?’’and,forevaluatingeachoftheindi- vidualitemsofthescale,‘‘Doyouunderstandwhatthistype ofstoolis?’’Theminimumvaluewas0(‘‘Idon’tunderstand anything’’)andthemaximumwas5(‘‘Iunderstandperfectly andhavenodoubts’’).Valueslessthan3wereconsideredto indicateinsufficientunderstanding.17,19 In conformitywith thevalidation conducted in the United States, the trans- lated scale descriptions were read aloud to the group of childrenaged6---8years,whilethegroupofchildrenover8 yearsreadthedescriptionsbythemselves.5
Phase6:Evaluatingtheresultsandproducingthefinal version
This phase consisted of analyzing the results obtained in the pretest by the team of specialists and making minor modificationstothe pre-finalversion basedondifficulties inunderstanding observedinthe populationevaluated, in ordertoproducethefinalversionoftheBrazilianPortuguese mBSFS-C(Fig.1).
Stage2:Reproducibilityassessmentofthe translatedscale
This stagewas conductedby fivedifferent examiners, all doctors,workingintheareaofpediatrics.Theparticipants inthisstagewere64children(28aged6---8years,and36over 8years),anda groupof25 healthcareprofessionals with expertisein the areasof gastroenterology and pediatrics.
The scale’s descriptionswere only read aloud tochildren agedbetweentheagesof6and8years.5
Instrumentreproducibilitywasinvestigatedby applying the final version of Brazilian Portuguese mBSFS-C for the 64childrenandfor the25healthprofessionals, whowere askedtocorrelatearandomlyselecteddescriptionfromthe translatedscalewiththecorrespondingrepresentativeillus- trationofthestooltype.Withthistest,itwaspossibleto comparethecorrelationsobtainedbythegroupofchildren withthoseobtainedbyhealthcareprofessionalsgroup.
Furthermore,theauthorsevaluatedthepotentialinflu- ence of scale interpretation by different individuals (inter-observer reliability), by the same individual in
1) BOLINHAS BEM DURAS,SEPARADAS UMAS DAS OUTRAS E DIFÍCEIS DE SAIR UMA MASSA DURA COM PELOTAS
UMA BANANA MACIA E SUAVE
PEDAÇOS MOLES E IRREGULARES,UM COCÔ MOLE
COCÔ SEM PEDAÇOS SÓLIDOS,TIPO ÁGUA
2) 3)
4)
5)
Figure1 FinalversionoftheBrazilianPortuguesemBSFS-C.
differentmoments(intra-observerreliability),bydifferent examiners (inter-examiners reliability), and by the same examinerindifferentmoments(intra-examinerreliability).
To evaluate inter-observer reliability, a test waselab- orated in which each of the five examiners applied the scale,witheachaskingfivedifferentchildrentocorrelatea randomlyselecteddescriptionandthecorrespondingrepre- sentativeillustrationofthestooltype;25ofthe64children participated,tenaged6---8yearsand15agedover8years.
Toevaluateintra-observerreliability,oneoftheseexamin- ersappliedthescalefivetimestothesamechild,requesting thattheycorrelatearandomlyselecteddescriptionwiththe correspondingrepresentativeillustrationofthestooltype, at60-minintervals;tenofthe64childrenparticipated,five aged6---8yearsandfiveover8years.Inter-examinerreliabil- itywasassessedbyatestinwhichfivedifferentexaminers askedthequestion‘‘Whichof thesetypes ofstoolismost likeyoursmostof thetime’’tothesamechild, at60-min intervals;11ofthe64childrenparticipated,fiveaged6---8 yearsandsixagedover8years.Toevaluateintra-examiner reliability,anexaminerposedthissamequestionfivetimes tothesamechild,at60-minintervals;tenofthe64children participated,fiveaged6---8yearsandfiveagedover8years.
Statisticalanalysis
Thereproducibilityofthetranslatedscalewasassessedby theagreementbetween the randomlyselected translated descriptionsandthecorrespondingillustrationsofthestool types.Thesamplesizewasestimatedin73agreementtests, whichconsideredtheexpecteddiscriminantcapacityofthe scaleof95%,4with95%confidenceintervaland5%error.The agreementvaluesweredeterminedbyKappawithquadratic weights(Fleiss-Cohen),consideringtheordinalcharacterof themBSFS-C.Thetestsconductedtoevaluatethereliabil- ityof the translatedscale in differenttimes or occasions wereanalyzedbypercentageratesofagreementbetween the descriptions and illustrations of the stool types and amongtheresponsesgivenbychildrenwhenaskedonmore thanoneoccasion.Theinfluenceofageinthesescenarios wasdeterminedusingasimplelogisticregressionmodel.To assessinter-examiner reliability,Cohen’skappa indexwas usedtodetermine the agreement between the children’s responseswithdifferentexaminers,asthisisadichotomous variable.Comparative analyses between twogroups were performedusingFisher’sexacttestforcategoricalvariables
andMann---Whitneytestfornumericalvariableswithabnor- mal distribution.The level ofsignificance considered was 5%, andtheanalyses wereperformed usingSPSSsoftware (IBMSPSSStatisticsforWindows,Version22.0.NY,USA).
Results
Stage1:Translationandcross-culturaladaptation
The synthesizedforward-translation wasbasedonthetwo previoustranslationsofthescalefromthesourcelanguage to thetarget language, Brazilian Portuguese, followed by theassessment,reflectionanddiscussionoftheteamofspe- cialists,togetherwiththePhase1bilingualtranslators.This versionwasindependently back-translatedintothesource languageofthequestionnairebytwotranslatorswhodidnot participate inthe first phaseand whoare nothealthcare professionals. These translators are native English speak- erswhowerenotinformedoftheconceptsexploredbythe instrument.Thepre-finalversionwascreatedfollowingthe assessmentanddiscussionoftheteamofspecialists,incon- junctionwiththefourtranslatorsinvolved.Atthisstage,the back-translationswerecomparedwiththeoriginalversionof thescale.Thepurposeoftheteamwastoconsolidatethe translatedversions andcreatethepre-finalversionof the BrazilianPortuguesemBSFS-C,havingreviewedalltransla- tionstoreachaconsensusonanydisagreementobserved.
Thispre-finalversionwasassessedbyapretest(Table1).
Thetranslateddescriptionsachievedamaximumof15%of the valuesconsidered toindicateinsufficient understand- ing,withmedianvaluesofunderstandinghigherthan3.00 obtainedonthenumericalverbalscale.Nosignificant dif- ferenceswereobservedwhencomparingthetwoagegroups regarding the values of understanding obtained for the translated pre-final version and each of its descriptions.
These results were discussed at a subsequentmeeting of theteamofspecialists,whencertainitemsthatcontinued topresentcomprehensiondifficultiesamongthepopulation testedwerereviewed.ThefinalversionoftheBrazilianPor- tuguesemBSFS-CisshowninFig.1.
Stage2:Reproducibilityassessmentofthe translatedscale
Agreements betweenrandomly selecteddescriptionsfrom the translated scale and corresponding representative
Table1 Pretestresults:degreeofunderstandingofthetranslatedversionofthemBSFS-Casawholeandeachofitscomponents, inreferencetothetranslateddescriptionsofeachofthefivestooltypes.
6---7years(n=21) >8years(n=53) pb
%Ofindividualswith insufficientunderstanding
Mediana %Ofindividualswith insufficientunderstanding
Mediana
Pre-finalversion 10% 5(1---5) 0% 5(3---5) 0.52
Description1 15% 5(1---5) 11% 4(1---5) 0.83
Description2 15% 4(1---5) 11% 4(1---5) 0.85
Description3 5% 5(2---5) 7.5% 5(1---5) 0.98
Description4 15% 4(1---5) 15% 4(1---5) 0.61
Description5 5% 5(2---5) 5.6% 5(1---5) 0.91
a Median(min/max)valuesbasedontheresultsobtainedthroughtheapplicationofthenumericalverbalscale.
b p-ValueontheMann---Whitneytest.
Table2 Numberofagreementsbetweenrandomlyselecteddescriptionsfromthetranslatedscaleandillustrationsofthestool types:children’sresponses.a
Randomlyselecteddescriptions Illustrationsofthestooltypes
Type1 Type2 Type3 Type4 Type5
Description1 15 2 0 0 0
Description2 1 12 0 3 0
Description3 0 1 16 0 0
Description4 0 0 2 14 5
Description5 0 0 0 0 16
a n=87agreements,determinedby64children.
Table3 Numberofagreementsbetweenrandomlyselecteddescriptionsfromthetranslatedscaleandillustrationsofthestool types:healthcareprofessionals’responses.a
Randomlyselecteddescriptions Illustrationsofthestooltypes
Type1 Type2 Type3 Type4 Type5
Description1 7 0 0 0 0
Description2 0 6 0 0 0
Description3 0 0 4 0 0
Description4 0 0 0 3 0
Description5 0 0 0 1 4
a n=25agreements,determinedby25healthprofessionals.
illustrations ofthe stooltypes, asdeterminedbychildren andhealthprofessionals,arepresented inTables2 and3.
Almost complete agreement (k>0.8)20 was observed for both the children (k=0.933) and the healthcare profes- sionals(k=0.990).Thedescriptorsthatpresentedtheleast numberoferrorsinthecorrespondencesperformedbythe childrenweretypes1(twoerrors),3(oneerrors),and5(no errors).Stratification according toage groupshowed that significantvaluesof agreementwereachievedbychildren agedbetween6and8years(k=0.950),andthoseagedover 8years(k=0.975).
When assessing the reliability among the observers, it was observed that, on average, 88% (95% CI=69---100%) of the children correctly matched the randomly selected translateddescription tothecorrespondingrepresentative illustration of the stool type, when applied by the same
examiner.Asimplelogisticregressionmodelshowednosig- nificantassociationbetweenthechild’sageandthechance oferror in matching thetranslateddescriptions andstool types(OR=1.31,95%CI=0.86---1.99;p=0.200).
The test conducted to assess intra-observer reliability showed that 80% of the children correctly matched the translateddescriptionstothecorrespondingrepresentative illustrationofthestooltypeinatleastfouroutoffiveappli- cationsperformedbythesameexaminerforthesamechild, at60-minintervals.Halfofthechildrencorrectlymatched theitemsinallfiveapplications.Inthistest,nosignificant associationwasobservedbetween thechild’sageandthe chanceofcorrectlymatchingthetranslateddescriptionsand stooltypes(OR=0.47,95%CI=0.15---1.51;p=0.206).
Inthetestconductedtoassessinter-examinerreliability (Table4),agreementwasatleastsubstantial(0.60---0.79)20
Table4 Inter-examiner reliability: agreement between the children’s responses to the questions asked by five different examiners.
Comparisonbetweentheresponses obtainedbydifferentexaminers
%Ofagreement Kappaindex pa
E1-E2 91 0.89 <0.001
E1-E3 91 0.89 <0.001
E1-E4 82 0.74 <0.001
E1-E5 82 0.74 <0.001
E2-E3 100 1.00 <0.001
E2-E4 91 0.89 <0.001
E2-E5 91 0.89 <0.001
E3-E4 91 0.89 <0.001
E3-E5 91 0.89 <0.001
E4-E5 100 1.00 <0.001
E1,Examiner1;E2,Examiner2;E3,Examiner3;E4,Examiner4;E5,Examiner5.
ap-valueonkappaindex.
amongthechildren’s responsesto thequestionsasked by fivedifferentexaminers;thechildrenwereaskedtopointto themostcommonstooltypetheyevacuatedafterseeingthe illustrations and interpreting the translated descriptions.
Comparing the percentage of perfect agreement (100%
agreement) among the responses obtained by five exam- iners, nostatistically significant differences were verified betweenthegroupofchildrenover 8yearsandthegroup aged6---8years(66% vs.100%,p=0.454, byFisher’sexact test).
Thetestusedtoassessintra-examinerreliabilityshowed variation in the response in three of the ten children (30%, 95% CI=1.5---58%) who indicated the most common stool type they evacuated, after seeing the illustrations andinterpreting thetranslateddescriptionsfivetimes for the same examiner, at 60-min intervals. In these three cases of variation in the response, the maximum varia- tion was between two stool types (types 2 and 4 twice, and types 1 and 3, once). The simple logistic regression modelshowednosignificantassociationbetweenthechild’s ageandthechanceofvariationintheresponsesobtained by the same examiner (OR=0.47, 95% CI=0.15---1.51;
p=0.206).
Discussion
The present study was the first to translate and cross- culturally adapt the mBSFS-C into a language other than Englishandtoevaluatethereproducibilityofthistranslated version. The translation and cultural adaptation are key steps.6Inadditiontolanguage,culturalaspectsconsiderably influencetheunderstandingofaninstrument;therefore,the culturaladaptationoftheoriginalcomponentsisrequired.14 Thesequentialphasesoftranslation,back-translation,and themeetingsbetweenthetranslatorsandtheteamofspe- cialistsledtothedevelopmentof descriptionsadapted to theunderstanding of Brazilian children. Forexample,the fooditems‘‘nuts’’and‘‘sausage’’donotformpartofthe dailylivesofthemajorityofBrazilianchildrenandtherefore wereadapted to‘‘marbles’’ and‘‘banana’’, respectively.
The satisfactory values of understanding achieved during thepretest applicationsofthe translatedmBSFS-Camong
children in both age groups indicate that the trans- lated scale has been properly adapted to Brazilian culture.
TheBrazilian PortuguesemBSFS-Cwasevidentlyrepro- ducible, since almost complete agreement was obtained amongthe translateddescriptionsand illustrations of the stooltypes,bothamongthechildrenandthegroupofspe- cialistsfromthefieldsofgastroenterology andpediatrics.
Allthestooltypesshowedpercentagesofcorrectmatches considered appropriate. This was true for children aged 6---8 yearsandthoseover8 years.Asin theoriginal study of mBSFS-C,5the types ofstool withthehighest percent- ageof correctresponses weretypes 1,3,and5.Although types2and4presentedagreaternumberofdisagreements, themajorityof childrenwhohadtheserandomlyselected descriptorswereabletocorrelatethemappropriately.The authors believe that this findingcan be explained by the ordinalcharacterofthescale,justifyingthegreatereasiness inidentifyingextremesandgreaterdifficultyinidentifying intervals.
Moreover, the Brazilian Portuguese mBSFS-C produced very similarresultsfor the samerespondents at different times, characterizing stability, and for different examin- ers, characterizingequivalence, which constitute thetwo axesofexternal reliability.21 Thepresent resultsaresimi- lartothosereportedintheoriginalvalidationstudyofthe mBSFS-C,5whichobtainedvaluesofintra-classcorrelation coefficient greater than0.70 for inter-observerreliability in the correlations made by children between stool pho- tographsandthedescriptorsofthescale.
The tests for reliability focused on the examiner (betweendifferentexaminersandbetweenthesameexam- ineratdifferenttimes) werebasedonclinical application of the scale, and asked the children point to the most common type of stool they evacuated. In these scenar- ios, thewaytheexaminerasksthequestioncan influence the results obtained; however, the children’s responses wereconsistent.Internalreliabilitywasnottestedbecause the instrument is a scale, rather than a questionnaire with numerous questions.21 The reliability of the trans- lated scale was maintained regardless of the children’s age.
Two mainlimitations ofthisstudymustbehighlighted.
Thefirstisthatitwasconductedinasinglecenter,which limitsthegeneralizationsandmaybringstrongbiasrelated to the social, economic, and cultural background of the sample. The second limitation is related to the fact that children who participated in the study were waiting for consultationinthegeneralpediatricsoutpatientclinic.For thisreason,thetimeintervalforapplyingteststothesame individualhad tobelimitedto60min.However,although this time interval can be considered limited, it can be emphasizedthatitwasthesameinallsituationsanalyzed, minimizingpotentiallyrelatedmemorybias.
Thus,thetranslationandadaptationofthemBSFS-Cfor Brazilian Portuguese is reliable for use when reading the descriptionsforchildrenagedbetween 6and8years,and withoutassistanceforchildrenover8yearsold.Theauthors hopethisversionwillbeusefulbothinclinicalpracticeand inscientificresearchinBrazil.
Funding
Fundac¸ãodeAmparo àPesquisadoEstadodeSãoPaulo --- FAPESP.Processosn◦2014/04271-1e2015/03649-3.
Conflicts of interest
Theauthorsdeclarenoconflictsofinterest.
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