Cross-Cultural Equivalence and Psychometric Properties of the Portuguese Version of the Depressive Cognition Scale

Transcription

1 SOUZA,V.D..;ZAUSZNIEWSKI,J.A.;MENDES,I.A.C.,ZANETTI,M. Cross-cultural equivalence and psychometric properties of the portuguese version of depressive cognition scale. Journal of nursing measurement, v.13, n.2, p.87-99, 2005 Cross-Cultural Equivalence and Psychometric Properties of the Portuguese Version of the Depressive Cognition Scale Valmi D. Sousa 1, Jaclene A. Zauszniewski 2, Isabel A. C. Mendes 3, Maria L. Zanetti 4, ABSTRACT There is a great need for researchers to have access to reliable and valid research instruments in their own language to measure a concept of interest or concern. Therefore, the purpose of this study was to determine semantic equivalency and psychometric properties of the Depressive Cognition Scale (DCS) in a Brazilian sample of diabetics, Back-translation and field testing methodology was used to determine the DCS semantic equivalency and psychometric properties- A convenience sample of 40 bilingual Brazilian adults was used to conduct the field testing of the scale. The findings suggested that the translation of the DCS was adequate and initial estimates of internal consistency and construct validity were adequate for both the DCS and its Portuguese version. Psychometric testing of the Portuguese language version of the DCS in this small sample appears to have sufficient reliability and validity for use in examining depressive cognitions in Brazilian adults. Further psychometric testing of the Portuguese version of the DCS in a larger Portuguese-speaking sample with diabetes is recommended. KEY WORDS: cross-cultural equivalency; semantic equivalency, psychometric properties; back-translation, Depressive Cognition Scale; Escala Cognitiva de Depressão 1 PhD, APRN, BC University of Iowa Iowa City, IA.. 2 PhD, RNC, FAAN Case Western Reserve University Cleveland, OH.. 3 PhD, RN.. 4 PhD, RN University of SSo Paulo at Riberao Prein Riberao Prelo. Brazil.

2 INTRODUCTION A growing number of publications in the scientific literature show a great need for clinicians and researchers to have access to reliable and valid research instruments in their own language to measure a concept of interest or concern. Depression is a universal phenomenon that may coexist with other health conditions, such as diabetes. Accurate measurement of depression in diabetics is necessary if it is to be effectively addressed, since it also has implications for self-care and diabetic outcomes. Having interest in depression, diabetes, and self-care, the Depressive Cognition Scale (DCS). which had been developed by one of the researchers and tested in various samples of subjects with diabetes in the United States (Zauszniewski, 1995, 1997; Zauszniewski, Chung, Krafcik. & Sousa,20;Zausziewski, Picot, Debanne, Roberts. & Wykle. 2002), was selected to conduct an initial methodological study on Brazilian individuals. To that end. the purpose of this study was to translate the DCS from English into Portuguese and to conduct a pilot test in bilingual Brazilian adults to determine its semantic equivalence and psychometric properties. Thus, the following research questions were posed for investigation: 1. Is there evidence of cross-cultural equivalence between the original version of the Depressive Cognition Scale (DCS) and a translated Portuguese version? 2. Is the Portuguese version of the DCS a reliable and valid tool to measure symptoms of depression in the Brazilian population? This initial study was an important step in preparing for future studies that will focus on detecting cognitive processes that predispose or contribute to depression in Brazilian people with diabetes. Background and significance Depression in Diabetics Depression is a mental disorder characterized by persistent sadness, loss of interest in normal daily living activities, and decreased energy. Individuals suffering from depression feel hopeless, worthless, and helpless, and have difficulty concentrating, remembering, and making decisions. They may experience loss of appetite or overeat, leading to weight loss or gain. Changes in mood and thought processes are common; restlessness, irritability, and suicidal ideation can also occur. This mental condition affects 21 million people and it is among the leading causes of disabilities in people worldwide (World Health Organization, 20). Research shows that there is an association between depression and diabetes. The prevalence of depression is more common in people with diabetes than in the general population, ranging from 15% to 40% (Carney, 1998; Hanninen. Takala, & Keinanen-Kiukaanniemi, 1999; Harris, 2003). Individuals suffering from depression are at greater risk for the onset of diabetes (Eaton. Armenian, Gallo, Prall, & Ford, 1996), On the other hand, people with diabetes are also at risk of depression, which is thought to be related to the burden of their financial situation, responsibility for self-management of the disease, and diabetes-related complications (Bailey, 1996; Connell, Davis, Gallant, & Sharp, 1994; Leedom, Meehan, Procci, & Ziedler, 1991). Because depression contributes to a decrease in physical and mental functioning, it may lead to a decrease in compliance and

3 adherence to self-care activities in diabetics, which in turn may lead to worse glycemic control and greater risk for disease-related complications (Ciechanowski. Katon, & Russo, 2000). Thus, these findings suggest that individuals with diabetes who are also depressed are less likely to monitor their blood glucose levels, adhere to an exercise program and a healthy diet, or comply with medication needs. Moreover, detecting and treating depression in people with diabetes improves their glycemic control and decreases or delays the risks for diabetes-related complications (Lustman, Griffith, Freedland. Kissel, & Clouse. 199B). Therefore, a reliable and valid measure of depression that is available in the language of diabetics is needed. Instrument Translation and Assessment of Language Equivalence The process of translation starts with a bilingual individual translating an original version of a research instrument into a target language (language into which the translation is made). The validation of the translated instrument starts with back-translation of the target language version into the original language, which is considered to be the most reliable method in determining cultural equivalence of an instrument. When both language versions of the instruments are identical in meaning, they are more likely to be equivalent (Jones & Kay. 1992; McDemott & Palchanes, 1994; Yu, Lee, & Woo, 2004). Two categories of translation have been identified in the literature: symmetrical and asymmetrical translations. Symmetrical translation refers to loyalty of meaning and colloquialness in both original and target languages and is considered essential when the goal is to compare responses from one culture against another culture to determine semantic equivalence. A symmetrical translation refers to loyalty to one language and its use being more appropriate when the study goal is operational, not comparative (Jones & Kay, 1992). Psychometric properties of both language versions of a research instrument provide additional evidence of their equivalence. This evidence is seen when there are statistically significant correlations between total scores and between paired items of both versions. In addition, adequate reliability coefficients of both versions demonstrate internal consistency of the scale (Jones &. Kay, 1992). To ensure a reliable and valid translated tool, this study followed the recommendations of Bracken and Barona(1991), Jones and Kay (1992), McDennott and Palchanes (1994), andyu et al. (2004) to translate, back-translate, and test the DCS scale in bilingual subjects. The DCS was chosen for translation into Portuguese because it has been found to be a short, valid, and reliable research instrument for measuring depressive cognitions in persons with diabetes. The Depressive Cognition Scale (DCS) The DCS was originally developed by Zauszniewski (1995) to measure cognitive symptoms consistent with depression in individuals not yet considered clinically depressed. This scale allows the identification of patients with diabetes who may be at risk for the development of clinical depression (Zauszniewski ). Two psychological theories, Beck's theory of depression and Erikson's theory of psychosocial development, served as conceptual frameworks for the development of the scale (Zauszniewski, 1995). Erikson's theory of psychosocial development is believed to be universally applicable (Douvan. 1997) and, therefore, appropriate for people worldwide, including Brazilians. The

4 DCS consists of eight items scored on a 6-point Likert-type scale ranging from 0 = strongly disagree to 5 = strongly agree. Each iten measures one of the following depressive cognitions; hopelessness, helplessness, purposelessness. powerlessness, worthlessness, loneliness, emptiness, and meaninglessness. However, all items are phrased in a positive direction. Sample items are: "I am hopeful about my future" and "I am a worthwhile human being," Therefore, strong disagreement with a specific DCS item indicates the presence of a specific depressive cognition. Scores range from 0 to 40. and when scoring is reversed, a higher score indicates a higher level of cogniiive symptoms consistent with depression (Zauszniewski, 1995), The scale. a papcr - based, self-administered research instrument, has been tested with various populations in the United Stales, including individuals with diabetes. The validity of the scale has been empirically documented (Zauszniewski. 1995, 1997; Zauszniewski et al., 20,2002) and its internal consistency reliability ranged from.78 through.87 (Zauszniewski, 1995, 1997; Zauszniewski el al., 20,2002). Methods Design The study used a traditional and widely accepted approach for determining cultural equivalence (Bracken & Barona, 1991; Jones &Kay, 1992; McDemiott & Palchanes, 1994; Yu et al ). which begins with translation of the instrument into the target language, in this case, Portuguese. It is generally recommended that the translator be fluent in both languages and able to make recommendations for altering the original items to make them more meaningful in the target language (Brislin, 1986; Yu et al., 2004). Following the translation of the measure, a blind backtranslation should be completed, during which a bilingual person converts the translated instrument into the original language, without having seen the original instrument (Brislin, 1986; Yu et al., 2004). Discrepancies between the original and translated instruments can then be examined and decisions made about the equivalence of the two forms. If necessary, revisions are made in the translated measure until the two forms appear to be equivalent or use of a variation of Brislin's process by conducting translation and back-translation repetitions of the scale (Bracken & Barona, 1991: Hansen & Fouad. 1984; Lee, Kim, & Song. 2002; Marín & Marín, 1991). The final step in determining cultural equivalence involves initial psychometric testing. Brislin (1986) suggests bilingual field testing, which involves administration of both the original and translated instruments to a group of subjects fluent in both languages. Items are then analyzed statistically by comparing reliability coefficients and examining paired t tests for mean score differences on items. Following this approach, the study reported here consisted of two phases. The first phase involved the translation of the DCS measure of depressive cognitions (Zauszniewski, ) from English into Portuguese and back-translation into English by persons who were fluent in both languages. The second phase was a cross-sectional survey of a convenience sample of bilingual persons to obtain data on both measures so that comparisons could be made and cultural equivalence determined for persons who speak Portuguese. The study was dually approved by the Human Subjects Boards/Ethics Committees of Case Western Reserve University in the United Stales and the University of Sao Paulo at Riberao Preto in Brazil.

5 Coinvestigators in Brazil distributed pamphlets throughout the community to invite bilingual individuals to participate in the Study. In addition, a verbal invitation was also made to known bilingual individuals. Each subject received verbal and written information about the purpose, benefits, and risks of the study. Subjects who agreed to participate signed a consent form and received assurances of confidentiality and privacy. Phase One: Translation and Back-Translation Procedures. English-Portuguese semantic equivalence was determined with translation and backtranslation by two independent translators. The DCS was translated from English into Portuguese and back-translated to English using a three-step process. In the first step, one translator produced a Portuguese version of the scale. In the second step, the Portuguese version of the scale was backtranslated into English by the second translator who had not seen the instrument before. In the final step. translation and back-translation repetition was conducted by new translators, using the same procedures in the first and second steps, to reduce discrepancies and produce a more accurate translated scale (Bracken & Barona, 1991; Marín & Marín, 1991). yielding two new English and Portuguese versions of the DCS. A panel of three Brazilian bilingual nursing faculty (two living in Brazil and one living in the United States for 9 years) reviewed the consistency of the translations, grammar. and structure of the Portuguese language. Then this Brazilian panel plus one American monolingual nursing faculty reviewed the consistency of the back-translations of the scale into English. This panel compared the English and Portuguese versions, examining item by item. After reaching a consensus in relation to the consistency of the translations and back-translations of the scale as well as corrections of the Portuguese language grammar and structure, a Portuguese version of the scale was produced: Escala Cognitiva de Depressão (ECD). This final Portuguese version of the scale was considered to have semantic equivalence and was used in (he field lest with the Brazilian bilingual population to determine its psychometric properties and empirical evidence of equivalence. Cross-Cultural Equivalence Analysis. Examination of the symmetrical translations and backtranslations of the DCS revealed that there was inconsistency on the scale itens measuring emptiness and purposelessness. One translator translated the item. "I think my life is pretty full" into "Acho que a minha vida é bem cheia" and a second translator into "Estou satisfeito com a minha vida." Backtranslations of this item were "I am happy about my life" and "I think my life is totally complete." The item reflecting purposelessness. "I feel useful and needed," was translated by one translator as "sintome util e necessário" and by the other into "sinto-me util e precioso." Back-translations of his item were "I feel I am useful and necessary" and "I feel I am useful and valuable." respectively. The panel of three Brazilian bilingual nursing faculty members compared the original scale and two translated versions into Portuguese to validate the translation. In addition, one American nursing faculty who speaks only English also analyzed the two back-translations of the Portuguese versions into English to determine which version was the closest to the original scale in English. The panel agreed that one of the back-translations /as almost identical to the original version. The Portuguese version of the scale that Brazilian members of the panel agreed upon as having the best semantic equivalence was further reviewed and edited to meet the requirements of Portuguese grammar and

6 structure. The final items on emptiness and purposelessness became "Estou salisfeito(a) com minha vida" and "sinto-me util e necessário(a)" respectively, in the final version of the ;scale in Portuguese; Escala Cognitiva de Depressão (ECD). Phase Two: Field Testing Sample and Characteristics. For the field testing of the DCS and its Portuguese ver-on, the ECD. a convenience sample of 40 bilingual adults was recruited in a major brazilian city in the southern region of Sao Paulo State. The sample size was determined by rule of thumb, which suggests a minimum of five subjects per item to evaluate the psychometric properties of a measurement instrument (Nunnally & Bernstein, 1994; Tinsley & Tinsley, 1987). Inclusion criteria were age (18 years old and over) and ability to understand, read, and write in both Portuguese and English. Sample characteristics are shown in Table 1, Data Collection Procedure. All study participants completed a demographic questionnaire and the English version of die DCS. Immediately after completion of the English version, participants completed the Portuguese version of the scale (ECD). Data were collected from March , to July 20,2004, The participants' names were not written in the demographic questionnaire neither on the English nor Portuguese versions of the DCS; each participant received a code number. Data. without personal identifiable information, were mailed to researchers in the United Stales via Global Express Mail, Data were entered into a computer database. The data file was double-checked for accuracy and few randomly missing data. 5% or less, were replaced with the mean of the group on the particular missing item. One subject did not report his or her age and two subjects did not report monthly family income. These values were replaced with the group mean as indicated (Polit & Beck. 2004; Tabachnik & Fidell. 20). Psychometric Analysis. Psychometric testing of the DCS and ECD measures involved determining initial estimates of reliability (internal consistency and homogeneity) and construct validity. The Statistical Package for the Social Sciences (SPSS) version 12-0 was used to analyze the data- Characteristics of the sample were determined by computing frequencies for categorical variables and descriptive statistics (i.e., means and standard deviations) for continuous variables. Reliability analyses involved examination of Cronbach's alphas, inter-item correlations, and item-to-total scale correlations. Validity testing involved the use of paired t tests and Pearson's correlations between the English and Portuguese item scores and total scale scores. Results of Descriptive Analysis. Examination of the means and standard deviations for the English and Portuguese versions of the DCS showed that the study participants scored similarly on the measure (Table 2), Although the possible range of scores is 0 to 40, participants scored between 1 and 14 on the English version and between 0 and 14 on the Portuguese version. There was no significant difference between the mean scores on the two measures (t[1,39 ] =0,76, p =.45). Nearly half of the participants had identical scores on the English and Portuguese versions of the DCS (n = 19), Forty percent (n = 16) had scores that only differed by 1 point. Three participants had a discrepancy of 2 points, one had a 3-point difference, and one had a 5-point difference between the

7 total scores on the two measures. Among those participants who had discrepant scores on the two versions (n = 21), 57% (n = 9) scored higher on the English version of the DCS and 43% (n = 12) scored higher on the Portuguese translation. Results of Item Analysis. Subjects' responses on each of the eight items on the English version of the DCS scale were compared to their responses on the same items of the Portuguese version. There were strong similarities in participants" responses on both versions of the scale. Almost all subjects who chose to answer "strongly agree." "mostly agree," "slightly agree." "slightly disagree." "mostly disagree." and strongly disagree" on the English version of the DCS also had similar choices on the scale's Portuguese version (ECD). Identical responses on the eight items ranged between 78% and 98%. When identical responses were added to responses that deviated by only 1 Likert scale point, it was found that for all eight DCS items, 95% of the participants (n = 38) responded either identically on both versions or selected the next closest response alternative on the scale.

8 TABLE 1. Sample Characteristics (N = 40) Variable n % Mean SD Gender Male Female Marital status Single Married Separeted/divorced Race/ethnicity White Black Hispanic Asian/Pacifc Islander Education in years 8 years or less 12 years years 16 years Place of residence Ribeirão Preto Other cities Occupation Student Not specified Registered nurse Nutritionist Nursing faculty System analyst Housekeeper Plastic artist Schoolteacher Physical therapist Hours of work/study per week Less than 10 hours hours hours More than 40 hours Age Family income , , Note. Family income was converted to American dollars on September 24, 2004 (exchange rate from Central Bank of Brazil). On two items, reflecting the depressive cognitions of helplessness (four cases) and hopelessness (one case), respondents selected either identical responses on both versions or the next closest alternative. On five items, respondents selected alternatives that were two responses

9 apart. These items reflected emptiness (one case), meaninglessness (two cases), powerlessness (one case), purposelessness (one case), and worthlessness (one case). On the item measuring loneliness, one respondent selected responses that deviated by 3 response categories points. This was the only one case in which a respondent selected a response alternative that reflected agreement with the item on one version (English. DCS4) and slight disagreement on the other version (Portuguese. ECD4). Reliability of the Scales. Initial estimates of reliability were determined using Cronbach's alpha (as shown In Table 2), Coefficient alpha for the Portuguese version was.79 and coefficient alpha for the English version of the same measure was.78. Further analysis indicated that deletion of the item measuring loneliness from either of the two versions of the measures would increase the alpha coefficient to.80. which is considered a reasonable goal (Gliem & Gliem, 2003), though alpha coefficients between.70 and.80 are acceptable (DeVellis. 1991; George & Mallery, 2005), especially for newly developed measures (George & Mallery. 2005; Nunnally & Bernstein, 1994) and for measures with fewer than 10 items (Iacobucci & Duhachek, 2003). Reliability of the DCS measure was also evaluated by examining inter-item correlations. For the English and Portuguese versions of the DCS. the mean interitem correlations were.30 and.32, respectively. In the English version, the inter-item correlations ranged from -.17 to.60 while in the Portuguese version ranged from -.05 to.63. According to Nunnally and Bernstein (1994), inter-item correlations mean should average between.30 and.70. Thus, the average inter-item correlations for both measures of the DCS met the minimal criterion for internal consistency. The patterns of correlations among the items constituting the English (DCS) and Portuguese (ECD) versions of the measure are found in Tables 3 and 4. To determine the homogeneity of the English and Portuguese version of the DCS, item-to-total scale correlations were examined using Pearson's correlation. According to Ferketich (1991), homogeneity exists when large percentages of the scale items have item-to-total scale correlations between.30 and.70. In this analysis, one item on the English TABLE 2.Internal Consistency of English and Portuguese Versions of the DCS Interitem Correlations Scale Mean SD Mean Itens Means Cronbach's English version Portuguese version

10 TABLE 3. Correlation Matrix of the English Version of the DCS Items DCS2 DCS3 DCS4 DCS5 DCS6 DCS7 DCS8 DCS1 DCS2 DCS3 DCS4 DCS5 DCS6 DCS *.60** *.36*.14.45**.43** *.19.41**.40**.18.45** **.48**.10.59**.37.57** Note.DCS = Depressive Cognition Scale *p <.05. ** <.. TABLE 4. Correlation Matrix of the Portuguese Version of the ECD Items ECD2 ECD3 ECD4 ECD5 ECD6 ECD7 ECD8 ECD1 ECD2 ECD3 ECD4 ECD5 ECD6 ECD ** **.51** **.47**.03.48**.10.55**.56**.10.39* **.63**.00.60**.32*.51** Note. ECD = Escala Cognitive de Depressão *p <.05. **p <.. TABLE 5. Item-to-total Scale Correlations Item Description Correlation With DCS DCS1-ECD1 DCS2-ECD2 DCS3-ECD3 DCS4-ECD4 DCS5-ECD5 DCS6-ECD6 DCS7-ECD7 DCS8-ECD8 Emptiness Helplessness Hopelessness Meaninglessness Powerlessness Purposelessness Worthlessness P Value Note.DCS = Depressive Cognition Scale; ECD = Escla Cognitive de Depressão. Correlation With ECD P Value version, the item measuring loneliness, had an item-total scale correlation that was not sig-nificant al the.05 level (r =.29, p =,07), but all other items had significant correlations (as shown in Table 5). In the Portuguese version, all of the item-total scale correlations were significant (also shown in Table 5). However, these findings must be interpreted giv ing consideration to the fact that multiple tests were conducted. Application of the Bonferroni correction statistic, which would restrict the acceptable alpha level for inter pretation to p <.005 (i.e., alpha of,05 divided by nine tests =.005). suggests that a few of the correlations may have been due to chance. Construct Validity. Paired I tests and correlations between the original eight DCS items (English) and the Portuguese (ECD) translation of these items were examined to estimate construct validity (Polit & Beck, 2004; Son, Zauszniewski. Wykle, & Picot. 2000; Zauszniewski & Harman, 1996), A significant difference was found between the mean of the English DCS item measuring helplessness and the Portuguese translation of that item at the.05 level (t []1.39] = 2.08,p=.04). On this item. the mean score on the English Item exceeded that of the Portuguese version (as shown in Table 6). Again, application of the Bonferroni correction statistic, which would

11 restrict the acceptable alpha level for inter pretation to p<.005 (i.e..alpha of.05 divided by nine lests =.005). suggests that is mean difference may have been due to chance. There was no significant difference in mean scores between the other items or between the English and Portuguese versions total score. These findings also must be interpreted with caution since multiple tests were conducted. TABLE 6. Paired t Test for Paired Items and Total Scores of Both English and Portuguese Vesions Variables(items/total Scores) Pair1 DCS 1 and ECD 1 Pair 2 DCS 2 and ECD2 Pair 3 DCS 3 and ECD3 Pair 4 DCS 4 and ECD4 Pair 5 DCS 5 and ECD5 Pair 6 DCS 6 and ECD6 Pair 7 DCS 7 and ECD7 Pair 8 DCS 8 and ECD8 Pair 9 DCST and ECDT Englis h Portugues e (N=40) (N=40) t p Mean SD Mean SD Value Valu e Emptiness Helplessness *.04 Hopelessness Loneliness Meaninglessnes s Powerlessness Purposelessnes s Worthlessness Depressive Cognitions Note. DCS = Depressive Cognition Scale; ECD = Escala Cognitive de Depressão; DCST = Depressive Cognitive Scale Total Score; ECDT = Escala Cognitiva de Depressão Total Score. *p <.05.

12 TABLE 7. Pearson's Correlation for Paired Items and Total Scores of Both English and Portuguese Versions Variable (Items/Total Scores) Pair 1 DCS1 and ECD1 Pair 2 DCS2 and ECD2 Pair 3 DCS3 and ECD3 Pair4 DCS4 and ECD4 Pair 5 DCS5 and ECD5 Pair 6 DCS6 and ECD6 Pair 7 DCS7 and ECD7 Pair 8 DCS8 and ECD8 Pair 9 DCST and ECDT Person's Correlation p Value Emptiness.79 < Helplessness.92 < Hopelessness.96 < Loneliness.68 < Meaninglessness.63 < Powerlessness.92 < Purposelessness.74 < Worthlessness.77 < Depressive Cognitions.94 < Note. DCST = English Version Scale Total Score; ECDT = Escala Cognitiva de Depressão Total Score. As shown in Table 7, Pearson's correlations indicated highly significant correlations (p < ) between all eight of the original English DCS items and the Portuguese (ECD) translations of these items as well as between the English and Portuguese versions total score. Discussion The most common and highly recommended procedure for determining cultural equivalence of an instrument translated from one language to another is known as back-translation (Bracken & Barona, 1991; Jones & Kay, 1992; McDermott & Palchanes, 1994;Yu et al., 2004), In this study, a few differences were found between the original English version of the DCS and its Portuguese translation. The differences were identified on items that measured emptiness and purposelessness. In both cases, one of the translators appeared to provide more than a literal translation of the item while the other expanded on the item's interpretation, perhaps illustrating the distinction between linguistic and conceptual equiv alence of the measures (Bracken & Barona, 1991; Brislin, 1986; Marín & Marín, 1991). To achieve cross-cultural equivalence of scale items, five criteria are often examined: content, meaning, method of assessment, interpretation, and conceptualization (Flaherty et al., 1988). In this study, using these criteria, the cross-cultural equivalence of the DCS meas ure was evaluated by members of an expert panel before it was psychometric ally tested in the field. The panel accepted the version most equivalent to the original. Administering two versions of a measurement instrument (i.e., in both the English lan guage and the translated version) to bilingual persons is considered the best way to exam ine equivalence and the psychometric properties of a translated instrument (Bracken & Barona, 1991; Brislin, 1986; Jones & Kay, 1992; McDermoit &Palchanes, 1994; Yu et al., 2004). The findings from this analysis

13 revealed potential differences between the mean scores on the English and Portuguese measures on the item reflecting helplessness. How ever. the application of the Bonferroni correction statistic, which makes the acceptable alpha level more stringent, suggests that these differences may have been due to chance. Since this occurred only on one item, it appears that the potential differences lie with either the content of the item, the translation of the item, or cultural differences on some underlying belief conveyed with the item, rather than a problem with the Likert scaling. If there was truly a problem with the scaling, more discrepant or extreme responses would occur. Item analysis revealed that the bilingual participants responded similarly on most of the items on the English and Portuguese versions of the DCS, which suggests that the trans lation of the DCS was adequate for this sample of bilingual participants, who were pre dominantly highly educated, professional, unmarried, and nondepressed Brazilian women. Further evaluation of the cross-cultural equivalence of the DCS measure is needed using a larger, more diverse group of Brazilian persons. In addition, further psychometric prop erties of the Portuguese version of the scale must be evaluated in methodological studies prior to using the scale to measure depression cognitions in Brazilian adults with diabetes. The Portuguese language version of the DCS appears to have sufficient reliability and validity for use in examining depressive cognitions in Brazilian adults without diabetes. Initial estimates of internal consistency and construct validity were adequate for both the DCS and its Portuguese version. Although the applicability of Erikson's developmental framework is believed to be universal (Douvan, 1997) and therefore appropriate for people of all nations, including Brazil, one item of the scale measuring loneliness emerged as being problematic. It appears that there are cultural distinctions in regard to loneliness that sets it apart from the other seven depressive cognitions. Further analysis of this item may also be needed. Within the unique culture and mindset of the Brazilian people, the strength of the family and personal relationships provide stability and affect the Brazilian perspective on the world in every way. Loneliness or the lack of emotional ties, which may or may not be associated with being single, have been identified as explanatory factors for committing suicide, while female gender is associated with more frequent suicide attempts (Souza, Minayo, & Malaquias, 2002). Thus, further development and testing of measures of loneliness, which may reflect a distinctively different concept from other depressive cognitions and are appropriate for Brazilian peoples, should be an important focus for future research. In addition, further psychometric properties of the scale must be evaluated prior lo using it as a measure of depressive cognitions in Brazilian adults with diabetes. REFERÊNCIAS BIBLIOGRÁFICAS Bailey, B. J. (1996). Mediators of depression In adult:. with diabetes. Clinical Nursing Research, 5(1), Bracki'n, B.A., &Barona, A. (1991) State of the art procedures for translating, validating and using

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