ABSTRACT

OBJECTIVE

To perform the translation and cross-cultural adaptation from English into Brazilian Portuguese of the Composite Abuse Scale, an instrument that identifies and quantifies intimate partner violence.

METHODS

This study is based on the strict implementation of its previously published protocol, which consists of ten steps: (a) conceptual analysis; (b) double-blind translation; (c) comparison and first reconciled version of the two translations; (d) back-translation; (e) review of the back-translation by the developer and second reconciled version; (f) expert committee review (n = 6); (g) comparison of expert reviews and third reconciled version; (h) cognitive interviews with women from the Casa da Mulher Brasileira in Curitiba (n = 15); (i) assessments of user perceptions and final reconciliation; and (j) submission of the final version of the questionnaire to the developer.

RESULTS

The implementation of the 10 steps of the protocol allowed the idiomatic, semantic, conceptual and experiential equivalences of the Composite Abuse Scale, incorporating suggestions and criticisms from the different participants of the process. Participants included the developer, professional translators, researchers specialized on the subject, women in situation of intimate partner violence, and professionals who provide care to them. Experts and cognitive interviews with women were instrumental in ensuring equivalence, and facilitating the understanding, including: (1) adaptation of the term “intimate relation” to “affective or conjugal relation”; (2) substitution of enclisis for proclisis cases in 20 items; (3) adoption of gender-neutral language, allowing its use in heterosexual, bisexual, and same-sex relations; (4) materialization of an instrument of scientific rigor and self-applicable, which may help women to visualize the situations of abuse in their relations.

CONCLUSIONS

The translation and cross-cultural adaptation process of the Composite Abuse Scale resulted in the Composite Abuse Scale Brazilian Portuguese Version, a 30-item self-applicable instrument, capable to identify and quantify intimate partner violence, its frequency, severity and typologies (physical, emotional, harassment and severe combined violence).

DESCRIPTORS
Violence Against Women; Intimate Partner Violence; Surveys and Questionnaires; Translating; Cross-Cultural Comparison

INTRODUCTION

Intimate partner violence (IPV) is a global public health problem¹1 World Health Organization. Intimate Partner Violence. Understanding and addressing violence against women. Geneva (CH): WHO; 2012 [cited 2022 Jun 3]. Available from: https://apps.who.int/iris/bitstream/handle/10665/77432/WHO_RHR_12.36_eng.pdf?sequence=1&isAllowed=y
https://apps.who.int/iris/bitstream/hand... ,²2 World Health Organization. Health care for women subjected to intimate partner violence or sexual violence: a clinical handbook. Geneva (CH): WHO; 2014 [cited 2022 Jun 3]. Available from: https://apps.who.int/iris/handle/10665/136101
https://apps.who.int/iris/handle/10665/1... . Estimates from the World Health Organization (WHO) indicate that 23% of Brazilian women have experienced IPV³3 World Health Organization. Violence against women prevalence estimates, 2018. Global, regional and national prevalence estimates for intimate partner violence against women and global and regional prevalence estimates for non-partner sexual violence against women. Geneva (CH): WHO; 2021 [cited 2022 Jun 3]. Available from: https://www.who.int/publications/i/item/9789240022256
https://www.who.int/publications/i/item/... . Between 2011 and 2017, most of gender-based violence notifications in the Unified Health System (SUS) were for intimate partner violence⁴4 Mascarenhas MDM, Tomaz GR, Meneses GMS, Rodrigues MTP, Pereira VOM, Corassa RB. Análise das notificações de violência por parceiro íntimo contra mulheres, Brasil, 2011-2017. Rev Bras Epidemiol. 2020;23 Suppl 1:E200007.SUPL.1. https://doi.org/10.1590/1980-549720200007.supl.1
https://doi.org/10.1590/1980-54972020000... –⁶6 Silva MMA, Mascarenhas MDM, Lima CM, Malta DC, Monteiro RA, Freitas MG, et al. Perfil do Inquérito de Violências e Acidentes em Serviços Sentinela de Urgência e Emergência. Epidemiol Serv Saude. 2017;26(1):183-94. https://doi.org/10.5123/S1679-49742017000100019
https://doi.org/10.5123/S1679-4974201700... .

Eliminating IPV is one of the Sustainable Development Goals for 2030⁷7 United Nations. Transforming Our World: the 2030 Agenda for Sustainable Development. New York: UN; 2015 [cited 2022 Jun 3]. Available from: https://sustainabledevelopment.un.org/post2015/transformingourworld/publication
https://sustainabledevelopment.un.org/po... , of which Brazil is a signatory. The country has made efforts⁸8 Brasil. Lei N° 11.340/2006, de 7 de agosto de 2006. Cria mecanismos para coibir a violência doméstica e familiar contra a mulher, nos termos do § 8° do art. 226 da Constituição Federal, da Convenção sobre a Eliminação de Todas as Formas de Discriminação contra as Mulheres e da Convenção Interamericana para Prevenir, Punir e Erradicar a Violência contra a Mulher; dispõe sobre a criação dos Juizados de Violência Doméstica e Familiar contra a Mulher; altera o Código de Processo Penal, o Código Penal e a Lei de Execução Penal; e dá outras providências. Brasilia, DF;2006 [cited 2022 Jun 3]. Available from: http://www.planalto.gov.br/ccivil_03/_ato2004-2006/2006/lei/l11340.htm
http://www.planalto.gov.br/ccivil_03/_at... ,⁹9 Brasil. Lei N° 13.104 de 9 de março de 2015. Altera o art. 121 do Decreto-Lei n° 2.848, de 7 de dezembro de 1940 - Código Penal, para prever o feminicídio como circunstância qualificadora do crime de homicídio, e o art. 1° da Lei n° 8.072, de 25 de julho de 1990, para incluir o feminicídio no rol dos crimes hediondos. Brasília, DF; 2015 [cited 2022 Jun 3] Available from: http://www.planalto.gov.br/ccivil_03/_ato2015-2018/2015/lei/l13104.htm
http://www.planalto.gov.br/ccivil_03/_at... to prevent this type of violence, but challenges remain¹⁰10 Reichenheim ME, Souza ER, Moraes CL, Mello Jorge MHP, Silva CMFP, Minayo MCS. Violence and injuries in Brazil: the effect, progress made, and challenges ahead. Lancet. 2011;377(9781):1962-75. https://doi.org/10.1016/S0140-6736(11)60053-6
https://doi.org/10.1016/S0140-6736(11)60... . In 2021, specific legislation was approved to typify psychological violence against women¹¹11 Brasil. Lei N° 14.188, de 28 de julho de 2021. Define o programa de cooperação Sinal Vermelho contra a Violência Doméstica como uma das medidas de enfrentamento da violência doméstica e familiar contra a mulher previstas na Lei n° 11.340, de 7 de agosto de 2006 (Lei Maria da Penha), e no Decreto-Lei n° 2.848, de 7 de dezembro de 1940 (Código Penal), em todo o território nacional; e altera o Decreto-Lei n° 2.848, de 7 de dezembro de 1940 (Código Penal), para modificar a modalidade da pena da lesão corporal simples cometida contra a mulher por razões da condição do sexo feminino e para criar o tipo penal de violência psicológica contra a mulher. Diário Oficial da União. 29 set 2021 [cited 2022 Jun 3]; Seção 1:1. Available from: https://www.in.gov.br/en/web/dou/-/lei-n-14.188-de-28-de-julho-de-2021-334902612
https://www.in.gov.br/en/web/dou/-/lei-n... , estimated as the most prevalent subtype of intimate partner violence¹²12 Dokkedahl S, Kok RN, Murphy S, Kristensen TR, Bech-Hansen D, Elklit A. The psychological subtype of intimate partner violence and its effect on mental health: protocol for a systematic review and meta-analysis. Syst Rev. 2019;8:198. https://doi.org/10.1186/s13643-019-1118-1
https://doi.org/10.1186/s13643-019-1118-... . This, however, is the most difficult violence to identify when compared to the other subtypes of IPV (physical or sexual), and is described as the most striking to women's health¹²12 Dokkedahl S, Kok RN, Murphy S, Kristensen TR, Bech-Hansen D, Elklit A. The psychological subtype of intimate partner violence and its effect on mental health: protocol for a systematic review and meta-analysis. Syst Rev. 2019;8:198. https://doi.org/10.1186/s13643-019-1118-1
https://doi.org/10.1186/s13643-019-1118-... ,¹³13 Heise L, Pallitto C, García-Moreno C, Clark CJ. Measuring psychological abuse by intimate partners: constructing a cross-cultural indicator for the Sustainable Development Goals. SSM Popul Health. 2019;9:100377. https://doi.org/10.1016/j.ssmph.2019.100377
https://doi.org/10.1016/j.ssmph.2019.100... . Therefore, it is necessary to have reliable instruments¹⁴14 Ware JE Jr, Gandek B. Methods for testing data quality, scaling assumptions, and reliability: the IQOLA Project approach. J Clin Epidemiol. 1998;51(11):945-52. https://doi.org/10.1016/S0895-4356(98)00085-7
https://doi.org/10.1016/S0895-4356(98)00... ,¹⁵15 Nunnally JC, Bernstein IR. Psychometric theory. 3. ed. New York: McGraw-Hill; 1994. to identify and measure this type of issue (psychological violence), not disregarding the other subtypes of IPV.

Identifying and quantifying IPV and its subtypes, using comparable and scientifically rigorous methods contributes to monitoring and supporting decision-making¹⁶16 Bott S, Guedes A, Ruiz-Celis AP, Mendoza JA. Intimate partner violence in the Americas: a systematic review and reanalysis of national prevalence estimates. Rev Panam Salud Publica. 2019;43:e26. https://doi.org/10.26633/RPSP.2019.26
https://doi.org/10.26633/RPSP.2019.26... . The Composite Abuse Scale (CAS) is a scale developed in Australia, internationally validated with the purpose of identifying intimate partner violence, estimating frequency and severity, besides classifying subtypes of IPV¹⁷17 Hegarty K, Sheehan M, Schonfeld C. A multidimensional definition of partner abuse: development and preliminary validation of the Composite Abuse Scale. J Fam Violence. 1999;14:399-415. https://doi.org/10.1023/A:1022834215681
https://doi.org/10.1023/A:1022834215681... ,¹⁸18 Hegarty K, Bush R, Sheehan M. The Composite Abuse Scale: further development and assessment of reliability and validity of a multidimensional partner abuse measure in clinical settings. Violence Vict. 2005;20(5):529-47 https://doi.org/10.1891/0886-6708.2005.20.5.529
https://doi.org/10.1891/0886-6708.2005.2... . It is self-completed by women, comprising four dimensions: emotional abuse, physical abuse, severe combined abuse, and harassment¹⁹19 Hegarty K, Valpied J. Composite Abuse Scale Manual. Melbourne (AU): The University of Melbourne; 2013.. The instrument allows quantifying violence through a Likert-type scale, in which the woman answers how often abusive situations have occurred in the last twelve months (“never”, “once”, “sometimes”, “once a month”, “once a week” or “daily/almost daily”), generating at the end, a score of up to 150 points¹⁷17 Hegarty K, Sheehan M, Schonfeld C. A multidimensional definition of partner abuse: development and preliminary validation of the Composite Abuse Scale. J Fam Violence. 1999;14:399-415. https://doi.org/10.1023/A:1022834215681
https://doi.org/10.1023/A:1022834215681... –¹⁹19 Hegarty K, Valpied J. Composite Abuse Scale Manual. Melbourne (AU): The University of Melbourne; 2013.. In the original instrument, the internal consistency reliability was 0.85 or above, for most subscales greater than 0.90, and the corrected item-total correlations were generally high (more than 0.5)¹⁸18 Hegarty K, Bush R, Sheehan M. The Composite Abuse Scale: further development and assessment of reliability and validity of a multidimensional partner abuse measure in clinical settings. Violence Vict. 2005;20(5):529-47 https://doi.org/10.1891/0886-6708.2005.20.5.529
https://doi.org/10.1891/0886-6708.2005.2... .

The CAS has been used to measure IPV in different contexts, including for case tracking/screening in health services, surveys, and online interventions²⁰20 MacMillan HL, Wathen CN, Jamieson E, Boyle M, McNutt LA, Worster A, et al. Approaches to screening for intimate partner violence in health care settings: a randomized trial. JAMA. 2006;296(5):530-6. https://doi.org/10.1001/jama.296.5.530
https://doi.org/10.1001/jama.296.5.530... –²⁵25 Signorelli M, Taft A, Gartland D, Hooker L, McKee C, MacMillan H, et al. How valid is the question of fear of a partner in identifying intimate partner abuse? A cross-sectional analysis of four studies. J Interpers Violence. 2020 Jul 10:10:886260520934439 https://doi.org/10.1177/0886260520934439. Epub ahead of print.
https://doi.org/10.1177/0886260520934439... . It is considered the gold standard for measuring intimate partner violence²⁶26 Ford-Gilboe M, Wathen CN, Varcoe C, MacMillan HL, Scott-Storey K, Mantler T, et al. Development of a brief measure of intimate partner violence experiences: The Composite Abuse Scale (Revised)-Short Form (CASR-SF). BMJ Open. 2016;6(12):e012824. https://doi.org/10.1136/bmjopen-2016-012824
https://doi.org/10.1136/bmjopen-2016-012... , with content, construct, criterion, and factor validity¹⁸18 Hegarty K, Bush R, Sheehan M. The Composite Abuse Scale: further development and assessment of reliability and validity of a multidimensional partner abuse measure in clinical settings. Violence Vict. 2005;20(5):529-47 https://doi.org/10.1891/0886-6708.2005.20.5.529
https://doi.org/10.1891/0886-6708.2005.2... . It has been translated from English into nine languages (Arabic, German, Spanish, Vietnamese, Dutch, Bengali, Russian, Japanese, and Malay)¹⁹19 Hegarty K, Valpied J. Composite Abuse Scale Manual. Melbourne (AU): The University of Melbourne; 2013.,²⁷27 Alhabib S, Feder G, Horwood J. English to Arabic translation of the Composite Abuse Scale (CAS): a multi-method approach. PLoS One. 2013;8(9):e75244. https://doi.org/10.1371/journal.pone.0075244
https://doi.org/10.1371/journal.pone.007... , but not into Portuguese up to then.

Standardized IPV instruments allow comparability across different cultures, profiles and magnitudes of the problem. Other scales²⁸28 Reichenheim ME, Moraes CL, Hasselmann MH. Equivalência semântica da versão em português do instrumento Abuse Assessment Screen para rastrear a violência contra a mulher grávida. Rev Saude Publica. 2000;34(6):610-6. https://doi.org/10.1590/S0034-89102000000600008
https://doi.org/10.1590/S0034-8910200000... –³¹31 Manders O, Xavier Hall C, Vertamatti M, Evans D, Campbell J. “We need to use words that we'd use in Brazil, right?” A community-based content validation of a translated femicide risk assessment instrument. Violence Against Women. 2021. https://doi.org/10.1177/10778012211051397. Epub ahead of print.
https://doi.org/10.1177/1077801221105139... available in Brazilian Portuguese do not include all the types of intimate partner violence found in the CAS, nor do they generate scores to measure the frequency and severity of the problem. Therefore, we identified the gap in the CAS in Portuguese, and the need to adapt it to the Brazilian cultural context, aiming to measure IPV, its typologies, frequency and severity. The guiding question was: how to make available a version of the CAS that meets the idiomatic and cultural specificities of Brazil and at the same time is faithful to its original English version? This article discusses the translation and cross-cultural adaptation of the CAS into Brazilian Portuguese.

METHODS

The protocol with the detailed methodology of the CAS translation and cross-cultural adaptation was previously published³²32 Rocha RWG, Oliveira DC, Liebel VA, Pallu PHR, Hegarty K, Signorelli MC. Translation and Cross-Cultural Adaptation Protocol of Abuse Questionnaires: The Brazilian Portuguese Version of the Composite Abuse Scale (CAS). Violence Against Women. 2021 Jun1:10778012211013901. https://doi.org/10.1177/10778012211013901. Epub ahead of print.
https://doi.org/10.1177/1077801221101390... , and rigorously followed, and the final results are described in this article. Briefly, the protocol contains ten steps (Figure): (a) conceptual analysis; (b) double-blind translation; (c) comparison and first reconciled version of the two translations (VR1); (d) back-translation; (e) developer's review of the back-translation and second reconciled version (VR2); (f) expert committee review; (g) comparison of expert reviews and third reconciled version (VR3); (h) cognitive interviews with users; (i) assessments of users’ perceptions and final reconciliation (VRF); and (j) presentation of the final version to the creator of the original instrument, in English³²32 Rocha RWG, Oliveira DC, Liebel VA, Pallu PHR, Hegarty K, Signorelli MC. Translation and Cross-Cultural Adaptation Protocol of Abuse Questionnaires: The Brazilian Portuguese Version of the Composite Abuse Scale (CAS). Violence Against Women. 2021 Jun1:10778012211013901. https://doi.org/10.1177/10778012211013901. Epub ahead of print.
https://doi.org/10.1177/1077801221101390... .

This paper is part of the first author's Masters in Collective Health. The developer of the original instrument actively participated in the process and is a co-author. Three translators with fluency in Portuguese and English (also co-authors) participated in steps (b) and (d), being: a PhD expert in gender-based violence; a Bachelor in translation, expert in translation and validation of health questionnaires; and a sworn translator.

To ensure the rigor of the translation and cross-cultural adaptation, invitations were sent to 12 experts in intimate partner and/or gender-based violence. The inclusion criteria for the experts were: Brazilian male and female researchers over 18 years old, with at least a doctoral degree, bound to universities or research centers, with research and scientific publications in the area of violence against women, and/or gender and violence studies. Of the 12 people invited, six agreed to participate in order to support the equivalences³³33 Guillemin F, Bombardier C, Beaton D. Cross-cultural adaptation of health-related quality of life measures: literature review and proposed guidelines. J Clin Epidemiol. 1993;46(12):1417-32. https://doi.org/10.1016/0895-4356(93)90142-n
https://doi.org/10.1016/0895-4356(93)901... ,³⁴34 Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine (Phila Pa 1976). 2000;25(24):3186-91. https://doi.org/10.1097/00007632-200012150-00
https://doi.org/10.1097/00007632-2000121... : 1) semantic-idiomatic (the translation of the item keeps the meaning of the expression in the original version); 2) experiential (the situations evidenced in the items correspond to situations experienced in the Brazilian cultural context); and 3) conceptual (the situations presented in the items are easily understood by what is understood, in different populations of the country, about the concept addressed). The equivalence analysis by experts (Jan/2019-Feb/2019) occurred: quantitatively, comparing the English version with the VR2 and assigning a numerical score (0-100% equivalence); and qualitatively, through comments and suggestions for each item. The average numerical scores and suggestions are shown in Table 1. The number of experts was consistent with other translation and cross-cultural adaptation studies of IPV instruments³⁵35 Vives Cases C, Torrubiano Domínguez J, Carrasco Portiño M, Espinar-Ruiz E, Gil-González D, Goicolea I. Validación de la versión española del cuestionario Physician Readiness to Manage Intimate Partner Violence Survey PREMIS. Rev Esp Salud Publica. 2015;89(2):173-90. https://doi.org/10.4321/S1135-57272015000200006
https://doi.org/10.4321/S1135-5727201500... –³⁷37 Kita S, Haruna M, Hikita N, Matsuzaki M, Kamibeppu K. Development of the Japanese version of the Woman Abuse Screening Tool-Short. Nurs Health Sci. 2017;19(1):35-43. https://doi.org/10.1111/nhs.12298
https://doi.org/10.1111/nhs.12298... .

From June to September 2019, 15 cognitive interviews were conducted with women (users and professionals) from the Casa da Mulher Brasileira (House of the Brazilian Woman - CMB) of Curitiba. The CMB is an institution specialized in providing care to women experiencing violence, integrating all the services of the network in a single location³⁸38 Almeida J, Rocha R, Signorelli M, Silva V, Prado S, Evans D. The House of the Brazilian Woman: impacts of a cross-sectoral public health policy for abused women. Eur J Public Health. 2020;30 Suppl 5:ckaa166.945. https://doi.org/10.1093/eurpub/ckaa166.945
https://doi.org/10.1093/eurpub/ckaa166.9... . The inclusion criteria for this stage were: i) professionals: over 18 years of age, who had been working at the CMB directly with women in situation of IPV for at least a year; ii) women: over 18 years of age, in situations of IPV and assisted by the CMB, who were not in crisis (as previously evaluated by the CMB professionals). Besides investigating what they understood about each item, they were also asked about the acceptability/applicability of the CAS to the Brazilian women. A printed version (VR3) was given to them to evaluate the layout/design of the instrument. The interviews lasted from 11 to 25 minutes, conducted in a private room of the CMB by an interviewer, a Master's student, occupational therapist, with a residency in women's health. Interviews were conducted until saturation was reached. After being recorded, they were transcribed and thematically analyzed according to each item of the instrument, following qualitative data analysis principles³⁹39 Liamputtong P. Qualitative research methods. 5. ed. South Melbourne, Vic: Oxford University Press; 2019.,⁴⁰40 Willis GB. Analysis of the cognitive interview in questionnaire design. New York: Oxford University Press; 2015..

At the end, the Brazilian version of the CAS was presented to the developer and the professionals at the CMB, being made available as an auxiliary tool in the assessment of IPV in women assisted there.

The study was approved by the Research Ethics Committees of the Federal University of Paraná (UFPR) and Curitiba City Hall, CAAE 89411818.4.000.0102. Participants signed the Informed Consent Form and were identified by codes, designated “E” (experts) and “P” (respondents). The study followed the WHO guidelines⁴¹41 Ellsberg M, Heise L. Researching violence against women: a practical guide for researchers and activists. Washington, DC: World Health Organization; PATH; 2005 [cited 2022 Jun 3]. Available from: http://apps.who.int/iris/bitstream/handle/10665/42966/9241546476_eng.pdf?sequence=1
http://apps.who.int/iris/bitstream/handl... –⁴³43 World Health Organization. Ethical and safety recommendations for intervention research on violence against women: building on lessons from the WHO publication ‘Putting women first: ethical and safety recommendations for research on domestic violence against women’ Geneva (CH): WHO; 2016 [cited 2022 Jun 3]. Available from: https://apps.who.int/iris/bitstream/handle/10665/251759/9789241510189-eng.pdf
https://apps.who.int/iris/bitstream/hand... for research with women in violence. Only CMB users who were not in crisis, previously evaluated by the psychosocial department, participated.

RESULTS

Chart 1 summarizes the process of translation and cross-cultural adaptation. In the first stage - conceptual analysis - the developer provided additional materials on the CAS development, including her thesis⁴⁴44 Hegarty K. Measuring a multidimensional definition of domestic violence: prevalence of partner abuse in women attending general practice [tese]. Brisbane (AU): The University of Queensland;1998. and the CAS handbook¹⁹19 Hegarty K, Valpied J. Composite Abuse Scale Manual. Melbourne (AU): The University of Melbourne; 2013.. She also explained cultural differences found in translations into other languages, such as the Arabic translation, where one of the items (Item 25 - “Put foreign objects in my vagina”) did not match the standards of that culture, which would cause embarrassment to the respondents²⁷27 Alhabib S, Feder G, Horwood J. English to Arabic translation of the Composite Abuse Scale (CAS): a multi-method approach. PLoS One. 2013;8(9):e75244. https://doi.org/10.1371/journal.pone.0075244
https://doi.org/10.1371/journal.pone.007... .

In step (b), some divergences between the two translators (T1 and T2) were discussed between the research team (masters student and advisors) in meetings for comparison, analysis, and summary between the two translated versions and the original instrument. Translators have also contributed to clarify doubts, thus obtaining the VR1 (c), presented in Chart 1.

In step (d) VR1 was back-translated in a blinded way, without the back-translator knowing the original instrument, nor communicating with the translators. The back-translator sent some questions to the research coordinating team about words that had no literal translation in Portuguese, but had a different connotation of intensity in the English language (e.g. item 17 - “Pushed, grabbed or shoved me”) or gender neutrality in the English instrument (e.g. “partner”), which implies a gender inflection in Portuguese (“parceiro”/”parceira”).

The back-translated version was sent to the developer for analysis (step e). Doubts arising in the previous steps were also pointed out to the developer, in a meeting to seek consensus. The developer's opinion was crucial to maintain the reliability of the original instrument, but at the same time keeping the language updated and contextualized to the Brazilian scenario. One of the adjustments at this stage included the adaptation of item 7, “Raped me” for “Forced me to have sex against my will”, since many married women (or in a relation) do not perceive forced sexual intercourses within marriage/relationship as rape. Another adaptation was in item 25 (“Put foreign objects in my vagina”) which became “Put foreign objects in my vagina against my will” to differentiate from consensual relations. The developer also suggested updating some items based on a recent revision of CAS²⁶26 Ford-Gilboe M, Wathen CN, Varcoe C, MacMillan HL, Scott-Storey K, Mantler T, et al. Development of a brief measure of intimate partner violence experiences: The Composite Abuse Scale (Revised)-Short Form (CASR-SF). BMJ Open. 2016;6(12):e012824. https://doi.org/10.1136/bmjopen-2016-012824
https://doi.org/10.1136/bmjopen-2016-012... , as in item 13, “Harassed me over the telephone”, which now also includes Internet and social media. At the end of step (e), we got to VR2, detailed in Chart 1.

Six specialists (S), professors at universities in different regions of the country, whose profiles are shown in Table 2, participated in step (f). The areas of training were quite diverse, including Health, Psychology, Human and Exact Sciences, enabling multidisciplinary views on the translation and cross-cultural adaptation of the CAS.

Four out of six experts problematized the term “adult intimate relations” and why we did not use “sexual intercourses” or “affective-sexual relations”. Regarding the term “adult intimate relations”, the instrument itself explains its meaning, as can be seen in Table 1 (VR2): “By adult intimate relations, we refer to spouse, male or female partner, or boyfriend/girlfriend for a period longer than one month”. The committee drew attention to the fact that in Brazil, unlike in other countries, 16-year-old women are not considered adults, since the instrument can be completed by people as young as 16. Thus, we removed the word “adult”, but kept the term “intimate relations” because of the explanation of this term, which comes right after in the instrument.

Experts have also showed concern with the understanding of the items and commands for proper completion, reinforcing that the language should be more colloquial than academic. They signaled the need to exchange enclisis for proclisis cases (e.g.: “me derrubou” instead of “derrubou-me”); and need for gender inflection, as in item 24 - “Did not want me to socialise with my female friends” for “Did not want me to meet with my female/male friends”, since it is common in Brazilian society for women to also have male friends.

Based on the experts’ considerations and conciliation meetings among the team, we reached VR3, which was then submitted to the cognitive interviews with women from the CMB, in order to assess whether the items were understood as expected. Of the 15 participants in this stage, seven identified themselves as white, four as black, and four did not know; 11 identified themselves as heterosexual, two as bisexual, and two as lesbian, all of them cis women. As for income, three participants had family incomes of up to one minimum wage, two between one and two minimum wages, one between two and three minimum wages, and nine had three or more minimum wages. Eight participants were the main responsible for the family income. As for education, two had a high school degree, four had a college degree, and nine had a graduate degree.

After providing a hardcopy (VR3), we asked them what they understood by each item. Some doubts emerged, shown in Chart 1 (column “Cognitive interviews”). The most problematic term was “intimate relation”, which had already been problematized in the expert stage. The women's understanding of intimate relations generally disagreed with the original concept, stating that “intimate relation” was understood as “sexual intercourse”. The interviewer noticed that even after reading the explanatory excerpt from the CAS describing what is considered an intimate relation, participants continued to associate the term with sexual intercourse. Even the participants who, after reading the concept, understood it as referring to a dating, marriage, or intimate partner relation, throughout the interview again associated the intimate relation with sexual intercourse. This interpretation occurred in all the questions that contained this term. Participant P3, when asked about her understanding of the question “Have you had any intimate relations in the last twelve months?”, immediately responded: “Do you want to know if I have had sex in the last 12 months?”

The participants’ criticisms converged with the experts’ notes and, considering their suggestions, the interviewer inquired if the question should be rephrased to “Have you had any affective or conjugal relations…?” Participants then understood that yes, the question would be related to dating, marriage, or affective partnership. They also unanimously agreed that the new wording improved understanding, as exemplified by P4: “In this question it's in a, like, different tone, you know, I can't see the sexual aspect like in the others. I can see it as something like, there's a dating”.

Another question raised by participants was about the language of the instrument and its experiential equivalence. Most recommended a more colloquial language, without the use of the enclisis case, as already pointed out by the experts. P4 exemplifies: “…slapped me, it's popular language…it's the language that most people use…” When P15 was asked if it would be more intelligible “Me jogou e me derrubou” instead of “Jogou-me e derrubou-me” (Threw me and knocked me down), the participant replied: “If you're talking about an assault it's…me jogou e me derrubou.” Based on this, all the enclisis cases were replaced by proclisis cases, as stated in the final version of the instrument, aware that they do not correspond to the correct grammar of the Portuguese language, but paying attention to the needs of understanding and interpretation by the population at large.

Some participants also challenged item 3 (“Followed me”), because they considered that it did not convey the idea of violence or could generate double meaning, thinking in the context of social media (“followed me on Facebook”). Some suggested that “stalked me” would be more appropriate. Even those who did not suggest changing the term, when explaining what they understood about it they used the word “stalk”: “The partner stalked me” (P10); “Someone is stalking me” (P11). The item was then changed to “Stalked me”.

In item 14 (“Chacoalhou-me”), 11 out of 15 participants felt that it would be better to replace it with “Me sacudiu” (shook me). Even though they understood the meaning of the term “Chacoalhou-me”, the word “Sacudir” would sound better, as exemplified by (P6): “I think ‘me sacudiu’ sounds better…”. P14 adds that: “‘Me sacudiu’, I think anyone can get it”. She considers, therefore, more accessible to the understanding of people with different schooling levels.

In the other items, there were no discordant notes, with a consensual understanding. Some participants highlighted the instrument's relevance for the Brazilian women, saying that the CAS is compatible with the Brazilian scenario, it is practical, useful, and may even be necessary. One of the professionals’ comments in this sense:

She, then, supports the compatibility of the CAS with the reality of the women who seek the CMB, and that the instrument can even help them to visualize and understand the situations of violence to which they are subjected in their relationships.

Some items drew the researchers’ attention, such as “2 - Prevented me from getting medical treatment”, according to P5, “This is very common, partners don't allow them to attend or follow up”. This signals challenges for the health field in caring for these women considering comments from professionals who work every day with women in situations of violence. Thus, the research team considers this a relevant finding for the compatibility of the instrument with the Brazilian cultural context, even though it was created in another country.

As for the design of the instrument and completion of the items, some participants praised it for its objectivity and ease of understanding, such as P6: “I think it looks great like that. Much better than those evaluations, scales, which I think are terrible, choose partially, partially agree. Here it is very clear and objective”. The participant refers to some instruments that use Likert scales⁴⁵45 Sullivan GM, Artino AR Jr. Analyzing and interpreting data from Likert-Type Scales. J Grad Med Educ. 2013;5(4):541-2. https://doi.org/10.4300/JGME-5-4-18
https://doi.org/10.4300/JGME-5-4-18... as a method of completing. On the other hand, two participants made criticisms of the instrument's design, which should be incorporated into the final version. These were the need for greater spacing between items to facilitate visualization, as well as the use of lines or different shading to separate one question from another.

DISCUSSION

The implementation of the protocol³²32 Rocha RWG, Oliveira DC, Liebel VA, Pallu PHR, Hegarty K, Signorelli MC. Translation and Cross-Cultural Adaptation Protocol of Abuse Questionnaires: The Brazilian Portuguese Version of the Composite Abuse Scale (CAS). Violence Against Women. 2021 Jun1:10778012211013901. https://doi.org/10.1177/10778012211013901. Epub ahead of print.
https://doi.org/10.1177/1077801221101390... for translation and cross-cultural adaptation of the CAS resulted in the “CAS Brazilian Portuguese Version”, adapted to the context of the Brazilian women and with idiomatic, semantic, conceptual, and experiential equivalence³³33 Guillemin F, Bombardier C, Beaton D. Cross-cultural adaptation of health-related quality of life measures: literature review and proposed guidelines. J Clin Epidemiol. 1993;46(12):1417-32. https://doi.org/10.1016/0895-4356(93)90142-n
https://doi.org/10.1016/0895-4356(93)901... ,³⁴34 Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine (Phila Pa 1976). 2000;25(24):3186-91. https://doi.org/10.1097/00007632-200012150-00
https://doi.org/10.1097/00007632-2000121... . The instrument may be self-applied, generating a score that allows classifying the woman as living in a situation of intimate partner violence (score ≥ 7 points), in a score range that varies from 0 to 150 points¹⁸18 Hegarty K, Bush R, Sheehan M. The Composite Abuse Scale: further development and assessment of reliability and validity of a multidimensional partner abuse measure in clinical settings. Violence Vict. 2005;20(5):529-47 https://doi.org/10.1891/0886-6708.2005.20.5.529
https://doi.org/10.1891/0886-6708.2005.2... ,¹⁹19 Hegarty K, Valpied J. Composite Abuse Scale Manual. Melbourne (AU): The University of Melbourne; 2013.. The field research highlighted that the scale may help women visualize situations of abuse experienced in their relationships, helping them to perceive IPV.

The main adaptations made throughout the process consisted of changing some terms, such as replacing “intimate relations” for “affective or conjugal relationships” because they have a better equivalence to the original construct, which refers to affective relationships with partners of at least one month duration, and not only sexual intercourses. A meaningful adaptation was the exchange of enclisis for proclisis cases in 20 items, aware that this change does not contemplate the grammar according to the Portuguese language norms, but meets a demand of the potential users, facilitating their understanding. Another significant adaptation was the incorporation of neutral language, such as partner, allowing the instrument to be used by women in heterosexual, bisexual, or same-sex relationships.

Another aspect was the replacement of the term “Rape me” for “Forced me to have sex against my will”, taking into account findings in literature showing that women do not believe they can be raped within affective/conjugal relationships and, therefore, do not associate this type of sexual relation with intimate partner violence⁴⁶46 Dantas-Berger SM, Giffin K. A violência nas relações de conjugalidade: invisibilidade e banalização da violência sexual? Cad Saude Publica. 2005;21(2):417-25. https://doi.org/10.1590/S0102-311X2005000200008
https://doi.org/10.1590/S0102-311X200500... –⁴⁸48 Acosta DF, Gomes VLO, Fonseca AD, Gomes GC. Violence against women commited by intimate partners: (in)visibility of the problem. Texto Contexto Enferm. 2015;24(1):121-7. https://doi.org/10.1590/0104-07072015001770013
https://doi.org/10.1590/0104-07072015001... . Similarly, we also adapted item 15 “Tried to rape me” to “Tried to force me to have sex against my will”.

Additional questions problematized by the expert committee related to the types of relationships, suggesting to include other intimate bonds and practices (such as polyamory, for example), as well as friendship relationships. However, concerned to maintain the reliability of the original instrument, the research team believes that the CAS presents this limitation for not including these other types of relationships. However, this is a gap that cannot be solved in this study, being necessary another type of research or the creation of a new instrument that specifically addresses these issues. Even considering as important to think over the many types of bonds existing in intimate relations, one of the purposes of the translation and cross-cultural adaptation of a scale into another language/culture is the possibility of comparing the results obtained from its application in other countries/languages/cultures. Therefore, the instrument cannot undergo substantial changes that would not allow comparability of responses between languages. In the case of the CAS, instructions are explicit with regard to the instrument completion, which should consider the person who perpetrated the violence and who has been for at least one month in a relationship (affective or conjugal) with the person who is completing the scale.

The cognitive interview stage was crucial in the translation and cross-cultural adaptation process to investigate the understanding of the women who will be the potential users of the CAS. Collins⁴⁹49 Collins D. Pretesting survey instruments: an overview of cognitive methods. Qual Life Res. 2003;12(3):229-38. https://doi.org/10.1023/A:1023254226592
https://doi.org/10.1023/A:1023254226592... explains that the questions in this step, particularly when applied in the context of the instrument, allow us to determine whether respondents can understand the concept or task of the question, and whether they do so consistently and in the manner intended by the researcher. Thus, conducting this step at CMB which exclusively serves women in situations of violence, proved to be an effective strategy for adapting the CAS to the needs of the Brazilian women. The content, meanings, and presentation format of the instrument were evaluated by potential users and by the professionals who assist them daily.

Regarding the layout, even though only two of the 15 participants in this stage criticized the design, one can see in their statements the importance of absorbing the criticism to make the instrument completion as intuitive and easy as possible, since the CAS was designed to be self-completed by women.

The study had as main limitations the fact that cognitive interviews were conducted in one single place, in the Southern Region of Brazil, and with no participation of women with low education. Women with a lower level of education may have some difficulty in completing the questionnaire, and regional idiomatic nuances from other areas of the country may not have been sufficiently incorporated into the instrument. Therefore, it is recommended in future studies that the Brazilian CAS be applied to a larger number of women, with more diversified education levels. On the other hand, the stage with experts included researchers from different regions of the country, who were invited to carry out their analysis having in mind the diverse public of Brazilian women (regionalisms, levels of education, age group, etc.). And, in fact, notes were made in this direction, such as the simplification of the language to facilitate the respondents’ understanding.

In brief, participants gave a verdict of pertinence to the CAS Brazilian Portuguese Version. Besides the positive evaluation regarding linguistic comprehension, for them the instrument incorporated aspects about intimate partner violence that also concern the Brazilian reality and, therefore, should be monitored. Thus, the process of translation and cross-cultural adaptation was successfully completed, and the CAS Brazilian Portuguese version is available for use by the Brazilian academic community. It is worth pointing out the need for the instrument to have its psychometric properties evaluated in future studies. Thus, it may be made available according to the highest methodological standards and scientific rigor for wide use in Brazil.

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