Adaptation of the Attitudes toward Alcohol Scale for the Portuguese Population ^†

Abstract

Social alcohol consumption in Portugal is highly accepted despite its risks and consequences. Health professionals’ attitudes toward alcohol may influence care for people with alcohol-related problems. The aim of this study is to adapt linguistically and culturally the attitudes toward alcohol scale for the Portuguese population (EAFAA). This study was conducted according to international guidelines. Changes made between the original instrument and the adapted version were based on cultural differences and the use of different technical terminologies. EAFAA-PT presented a robust construct validity index.

1. Introduction

According to the World Health Organization, Europe is the region of the world with the highest levels of alcohol consumption. [1]. Recent data report that 69% of the Portuguese population consumed alcohol in the last 12 months, 21% consumed alcohol daily, and 3.5% have abusive consumption or dependence [2]. In 2020, there were 35,390 hospitalizations in Portugal related to primary or secondary diagnoses attributable to alcohol consumption, representing 3% of all hospitalizations [2].

A comprehensive approach to alcohol-related problems should include identifying health professionals’ attitudes toward alcohol, alcohol users, and alcohol-related disorders. [3]. Negative attitudes, which are sometimes observed in health professionals, have been documented as one of the obstacles to the treatment of people with alcohol consumption disorders. Adequate knowledge and positive feelings and attitudes of health professionals are essential prerequisites for the effectiveness of alcohol-related disorders’ treatment and educational interventions [3].

The Attitudes toward Alcohol, Alcoholism and People with Alcohol-related Disorders Scale (EAFAA) was originally developed in Brazil to evaluate health professionals’ attitudes [3]. The EAFAA has already been adapted and validated for Spanish [4,5] and American English [6,7]. Based on our previous research, it was not possible to identify any instrument that allowed us to evaluate these attitudes in Portuguese samples. Only instruments for assessing personal expectations and beliefs about alcohol [8], adolescents’ expectations about alcohol [9], and mental health literacy about alcohol abuse in adolescents [10] have been identified.

The aim of this study is to adapt the EAFAA linguistically and culturally to Portuguese health professionals.

2. Methods

Between January and February 2021, a methodological study was carried out for the linguistic and cultural adaptation of the EAFAA, from Brazilian Portuguese (BR) to Portuguese (PT). We used the guidelines from Beaton et al. [11], which include translation, synthesis, back-translation, review by an expert committee, and a pre-test.

Translation was done independently by two Portuguese native speakers. One of them had knowledge of the topic and the other one had a degree in Languages. Two translated versions of the EAFAA-Translation, 1 (T1) and 2 (T2), were obtained.

For synthesis, T1 and T2 were analyzed by three persons with postgraduate training. Two of them were experts in addictive behaviors. The objective of this phase was to identify and analyze divergences and reach a consensus on a synthesized version (S1).

Back-translation of S1 to the original language (BR) was carried out independently by two Brazilian researchers. Both had postgraduate training in mental health and addictive behaviors and experience in scientific writing in both languages (PT and BR). The two back-translations (BT1 and BT2) were then synthesized into Synthesis 2 (S2). This version was presented to the original author to determine whether it was coherent with the original objectives and meanings.

Review by an expert committee was conducted by a group of experts with clinical experience in alcohol-use disorders. The committee included a psychologist, a psychiatrist, a general practice nurse, and a nurse who specialized in mental health and psychiatric nursing who also had experience in the development and cross-cultural adaptation of instruments. The experts were provided with a questionnaire, sent to them by e-mail, to assess S2. They were asked to consider aspects such as relevance, clarity, semantic equivalence, and conceptual equivalence. They were also asked to make suggestions for each item and for the title and to give feedback on the overall instrument. The assessment was made using a 5-point Likert-type scale, from ‘1- Strongly Disagree’ to ‘5- Strongly Agree’. Agreement analysis was conducted, based on the calculation of the Content Validity Index (CVI), which had to be above 0.80 to be considered acceptable. Only items scored with 3 or more points on the Likert scale were considered valid for agreement.

A pre-test of the pre-final version was made to assess the comprehensibility and proper functioning of the online questionnaire. We used a convenience sample of 34 participants, which included final-year nursing-degree students and nurses studying for a master’s degree in nursing at a nursing school in Portugal.

All data were transferred to the computers of three researchers and protected by a password.

3. Results

The adaptation process required some changes to the original instrument. There were discrepancies both in the translation (T1 and T2) and back-translation (BT1 and BT2) phases.

The expression ‘alcoholism’ was replaced with ‘alcohol-related problems’. This change occurred in all items and in the instrument’s title. This expression allowed for a much broader perspective that considered not only the substance itself but also its multidimensional impact.

The need to adapt the expression ‘alcohol-related disorders’ to ‘alcohol consumption disorder’ was also considered, given that this is the technical expression used in Portugal. For the same reason, the expression ‘alcohol use’ was adapted to ‘alcohol consumption’.

The personal pronouns at the beginning of each item were omitted to improve fluidity in reading.

We chose to use the expression ‘person’ instead of the original expressions ‘individual’, ‘patient’, and ‘user’. Whenever it was essential to characterize the person in a health organizational context, the term ‘user(s)’ was chosen (items 1, 37, 41).

The expression ‘family maladjustment’ was changed to ‘family problem’ (item 3) and ‘when not intoxicated’ was changed to ‘when they are not under the influence of alcohol’ (item 21). In item 25, the expression ‘I feel angry’ was changed to ‘I get very irritated’ and in item 29 the expression ‘problems with drinking’ was changed to ‘problems with alcohol’. In item 30, the expression ‘they are to blame for their health problems’ was replaced with ‘they are responsible for their health problems’. Concerning this specific item, equivalence was not confirmed in the back-translation, but both the researchers, the Brazilian native speakers involved, and the author of the original instrument considered this last one to be the most appropriate expression.

The expression ‘psychologically disturbed people’ (item 35) was replaced with ‘people who suffer psychologically’. The back-translation confirmed the equivalence of this expression in relation to the original version, despite conveying a more positive orientation. The same occurred in item 42, where we replaced the original expression ‘difficult to relate to’ with ‘difficult to deal with’.

The S2 version, which resulted from the back-translations, was sent to the author of the original instrument. His only suggestion was to keep the term ‘user’ instead of ‘person’ in specific items of factor 1, as it specifically refers to professional interactions in healthcare contexts.

After the expert committee’s review, the concordance analysis showed an average of 4.80 (min 3.67–max 5) and the calculated CVI for each subsection was greater than 0.80: F1 = 0.95/F2 = 0.96/F3 = 0.95/F4 = 1.0 with a total scale value = 0.96 (S-CVI-scale content validity index). Experts made only minor suggestions that were included in the final version after being analyzed, and a consensus was reached by three researchers.

According to the pre-test, there was no need to change any questions, as clarity and comprehensibility were confirmed. Measures of central tendency and dispersion were analyzed to address variability in the responses and sensitivity of the items.

4. Discussion

This study aimed to adapt the EAFAA from Brazilian Portuguese to Portuguese from Portugal (EAFAA-PT). Although the language is the same, there are phonetic, vocabulary, and syntax differences between the Brazilian and Portuguese variants. Furthermore, cultural differences between these countries require an adaptation that must be as rigorous as it would be for two completely different languages [10,12]. The same happened when this instrument was adapted to Spanish [4,5] and American English [6,13].

The cross-cultural adaptation process led mainly to the reformulation of technical designations to those currently used in Portugal. Semantic equivalence (grammatical consistency of the terms used throughout the scale) and conceptual equivalence (adequacy of the concepts used in the Portuguese cultural context) were taken into consideration.

Representativeness, clarity, semantic equivalence, and conceptual equivalence were assessed for each item. In contrast to what was observed in previous validation studies of the EAFAA [4,13], no suggestions for moving items to different factors or for their elimination were observed. This may be the result of the cultural and linguistic similarities between Portugal and Brazil.

5. Conclusions

The linguistic and cultural adaptation of the EAFAA was performed for the population of health professionals in Portugal. The EAFAA-PT achieved consensus regarding acceptability, comprehensibility, ease of completion, semantic equivalence, and content equivalence compared to the original version. We recommend a study on the psychometric properties of the EAFAA-PT.