Translation and cross-cultural adaptation of the Cardiff Wound Impact Schedule to Brazilian Portuguese

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Journal of Tissue Viability xxx (2016) 1e6
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Journal of Tissue Viability
journal homepage: www.elsevier .com/locate/ j tv
Translation and cross-cultural adaptation of the Cardiff Wound Impact
Schedule to Brazilian Portuguese
Fabiana da Silva Augusto a, *, Leila Blanes b, Denise Nicodemo c, Lydia Masako Ferreira d
a Graduate Program in Translational Surgery, Federal University of S~ao Paulo (UNIFESP), S~ao Paulo, Brazil
b Graduate Program in Translational Surgery and Professional Master's Degree Program, UNIFESP, S~ao Paulo, Brazil
c S~ao Paulo State University, UNESP, S~ao Paulo, Brazil
d Division of Plastic Surgery, Department of Surgery, UNIFESP, S~ao Paulo, Brazil
a r t i c l e i n f o
Article history:
Received 21 April 2016
Received in revised form
7 November 2016
Accepted 9 December 2016
Keywords:
Quality of life
Wounds and injuries
Validation studies
Reproducibility of results
Evaluation
* Corresponding author. Division of Plastic Surgery
Barros 715, 4� andar, CEP 04024-002, S~ao Paulo, SP, B
E-mail address: fabianasaugusto@gmail.com (F.S. A
http://dx.doi.org/10.1016/j.jtv.2016.12.002
0965-206X/© 2016 Tissue Viability Society. Published
Please cite this article in press as: Augusto
Brazilian Portuguese, Journal of Tissue Viab
a b s t r a c t
Aim: To translate into Brazilian Portuguese and cross-culturally adapt the Cardiff Wound Impact
Schedule, a specific measure of health-related quality of life (HRQoL) for patients with chronic wounds.
Chronic wounds have a relevant impact on the HRQoL of patients. However, there are few instruments
cross-culturally adapted and validated in Brazil to assess HRQoL in patients with wounds.
Methods: A descriptive cross-sectional study was conducted following six steps: (1) translation of the
original instrument into Brazilian-Portuguese by two independent translators; (2) construction of a
consensus version based on both translations; (3) two independent back-translations into English of the
consensus version; (4) review by an expert committee and construction of the pre-final version; (5)
testing of the pre-final version on patients with chronic wounds; and (6) construction of the final version.
The psychometric properties of the instrument were tested on 30 patients with chronic wounds of the
lower limb; 76.7% were men, 70.0% had traumatic wounds, and 43.3% had the wound for more than 1
year. Participants were recruited from an outpatient wound care clinic in S~ao Paulo, Brazil.
Results: The final version approved by the expert committee was well understood by all patients who
participate in the study and had satisfactory face validity, content validity, and internal consistency, with
Cronbach's alpha coefficients ranging from 0.681 to 0.920.
Conclusion: The cross-culturally adapted Brazilian-Portuguese version of the instrument showed satis-
factory face and content validity, good internal consistency, and was named Cardiff Wound Impact
Schedule-Federal University of S~ao Paulo School of Medicine or CWIS-UNIFESP/EPM.
© 2016 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.
1. Introduction
Wounds may be direct or indirect consequences of various
diseases and affect people of all ages. Wound healing involves a
number of complex, biological and anatomical processes, which in
favourable clinical condition, can occur in an acceptable period of
time [1]. In the case of chronic wounds, the treatment may be quite
complex, leading to significant social and economic impact [2].
Chronic wounds affect about 6 million people in the United States
for an estimated annual cost of treatment of US$25 billion [3]. This
condition also causes changes in the quality of life of these patients.
Studies on quality of life in people with chronic wounds have
, UNIFESP, Rua Napole~ao de
razil.
ugusto).
by Elsevier Ltd. All rights reserved
FdS, et al., Translation and
ility (2016), http://dx.doi.org/
helped researchers gain a better understanding of the challenges of
having a wound, adaptive strategies used by patients, and factors
related to their quality of life. The presence of a wound has a
negative impact on the quality of life of this population [4e8],
because wounds are commonly associated with pain, exudate, foul
odour, impaired mobility, sleep problems, difficulty in performing
functional activities, impaired body image, low self-esteem, social
isolation, and changes in mood [4,5,7e14].
Various generic and specific questionnaires are available
worldwide to assess health-related quality of life (HRQoL) in pa-
tients with wounds, including in people with venous ulcers,
wounds caused by diabetic complications, burns, chronic wounds,
and pressure ulcers [15e26]. Several studies have addressed the
quality of life of patients with wounds in Brazil, but there are few
specific tools validated in Brazilian Portuguese [25e32].
The Cardiff Wound Impact Schedule (CWIS) is a British
.
cross-cultural adaptation of the Cardiff Wound Impact Schedule to
10.1016/j.jtv.2016.12.002
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http://dx.doi.org/10.1016/j.jtv.2016.12.002
Abbreviations
CVI Content Validity Index
CWIS Cardiff Wound Impact Schedule
CWIS-UNIFESP/EPM Cardiff Wound Impact Schedule-Federal
University of S~ao Paulo School of
Medicine
CXVUQ Charing Cross Venous Ulcer Questionnaire
HRQoL Health-related quality of life
MMSE Mini-Mental State Examination
SPSS Statistical Package for the Social Sciences
VAS Visual analog scale
F.S. Augusto et al. / Journal of Tissue Viability xxx (2016) 1e62
questionnaire used worldwide to assess HRQoL in patients with
wounds. It is available in several languages, including French,
German, American English, European Portuguese, Swedish, and
Chinese [20,33e36]. The work presented here is the first of three
stages necessary for the development of an instrument for use in a
different culture and language. The second and third stages involve
tests of construct validity, criterion-related validity, and reproduc-
ibility (test-retest reliability) of the instrument.
The aim of this study was to translate, cross-culturally adapt the
CWIS to Brazilian Portuguese and assess face and content validity
and internal consistency of the instrument for assessing HRQoL in
patients with chronic wounds on the legs.
Translation 2
Original
Translation 1
Version 1
Back-translation 1
Expert
Committee
Version 2
Back-translation 2
2. Materials and methods
This clinical, primary, observational, cross-sectional study
approved by the Institutional Research Ethics Committee (approval
no. 02143/08) was conducted between 2014 and 2015 in a
university-affiliated outpatient wound care clinic in S~ao Paulo,
Brazil. The present study was performed after the authors of the
original version of the CWIS [20], represented by Dr Patricia Price,
granted permission to translate, cross-culturally adapt and validate
the instrument to Brazilian Portuguese. Written informed consent
was obtained from all patients prior to their inclusion in the study;
anonymity was assured.
The size of the sample was determined based on the guidelines
of Beaton et al. [37], which recommend a sample size ranging from
30 to 40 patients from the target population. A non-probability,
convenience sample of 30 patients with chronic wounds of the
lower limb who met study criteria were selected for the study.
Inclusion criteria were age of 18 and over, having awound of the
lower limb for 12 weeks or more, and agreeing to participate in the
study.
Patients who had cognitive impairment according to the Mini-
Mental State Examination (MMSE), any type of cancer or burn
injury, and those without physical conditions to answer the ques-
tions were not included in the study [38,39].
Four instruments were used for data collection: (1) the MMSE to
detect cognitive impairment, (2) a questionnaireassessing socio-
demographic and clinical characteristics of patients, (3) a visual
analogue scale (VAS) for pain assessment, and (4) the CWIS. The
questionnaires were administered as a structured interview by the
same investigator.
Assessment
N = 30
Final Version
Fig. 1. Translation and cross-cultural adaptation steps according to Beaton et al. [37].
2.1. The instrument
CWIS is a specific self-report instrument with 47 items assessing
HRQoL in patients with chronic wounds. The items are grouped into
Please cite this article in press as: Augusto FdS, et al., Translation and
Brazilian Portuguese, Journal of Tissue Viability (2016), http://dx.doi.org/
three scales. Scale 1 assesses demographic and clinical character-
istics of patients. Scale 2 measures the impact of the wound on
lifestyle and is divided into three domains: well-being (7 items),
physical symptoms and daily living (24 items), and social life (14
items). The items are rated on a 5-point Likert-type scale to mea-
sure the frequency or intensity of each response. Scale 3 proposes a
self-assessment of HRQoL and has two items rated from 1 to 10. All
three scales are then transformed onto a 0e100 scale, where a high
score indicates a positive rating of HRQoL. There is no single overall
score for the CWIS and no cut-off values [20].
The tool was translated and adapted to the Brazilian culture
based on the guidelines of Beaton et al. [37], according to the
following steps: (1) translation of the original questionnaire into
Brazilian-Portuguese by two independent translators; (2) con-
struction of a consensus version based on both translations; (3)
back-translation of the consensus version into English by two
different independent translators; (4) review by an expert com-
mittee and construction of the pre-final version; (5) testing of the
pre-final version on patients with chronic wounds; and (6) con-
struction of the final version of the instrument (Fig. 1).
The translators were native Brazilian-Portuguese speakers. Only
one of the translators who performed the forward translation was
experienced in translating specialized texts containing the tech-
nical terminology used in the questionnaire, whereas the other
translators did not have such experience [37].
Six experts with extensive experience in the management of
patients with wounds and scientific research participated in the
expert committee. A document containing the text of the original
questionnaire and forward translations was provided to the expert
committee, who evaluated the understanding of the items. The
experts considered semantic, idiomatic, cultural and conceptual
equivalences in the construction of a pre-final version, which was
obtained by combining elements from both translations [30]. The
expert committee also assessed face and content validity of the
instrument.
Face validity, which evaluates whether the instrument appears
to measure what it was designed to measure [40], was assessed by
the experts based on the answers given by the 30 participants and
their own clinical experience in the management of patients with
wounds combined with their knowledge of the concept of quality
of life. The expert committee evaluated whether patients were able
to understand the purpose of the instrument and its measurement
procedure. The minimum level of agreement among experts and
cross-cultural adaptation of the Cardiff Wound Impact Schedule to
10.1016/j.jtv.2016.12.002
Table 1
Sociodemographic and clinical characteristics of patients.
Variables Subjects
N %
Gender
Men 23 76.7
Women 7 23.3
Age group (years)
21e39 11 36.7
40e59 12 40.0
60e79 7 23.3
Ethnicity
Not Caucasian 23 76.7
Caucasian 7 23.3
Religion
Catholic 19 63.3
Other 9 30
Not informed 2 6.7
Practice of religion
Yes 19 63.3
No 9 30
Not informed 2 6.7
Marital status
With a partner 15 50.0
Without a partner 15 50.0
Education level
Illiterate 2 6.6
Primary education 9 30.0
High school education 14 46.7
College degree 5 16.7
Household
Live alone 5 16.7
Live with others 25 83.3
Employment status
Unemployed 5 16.7
Employed 2 6.6
Retired/retired on disability 23 76.7
Type of wound
Traumatic 21 70.0
Non-traumatic 9 30.0
Wound duration (months)
� 6 13 43.3
7e12 4 13.4
> 12 13 43.3
Wound size (cm2)
< 25 19 63.3
25e50 7 23.3
> 100 4 13.4
Amount of exudate
Scant 8 26.6
Small 14 46.7
Moderate 5 16.7
Large 3 10.0
Presence of odour
F.S. Augusto et al. / Journal of Tissue Viability xxx (2016) 1e6 3
researchers was set at 80%.
Content validity is defined by the degree to which each item of a
measuring instrument is relevant to and representative of the
target construct [41,42]. Content validity was measured by calcu-
lating the content validity index (CVI), using ratings of item rele-
vance and clarity by content experts [43]. Members of the expert
committee rated each item of the instrument as: (1) “not impor-
tant”, (2) “slightly important”, (3) “important”, and (4) “very
important.” Items rated “1” or “2” were revised by experts and
researchers, according to principles of equivalence and their clinical
experience, and could be removed from the instrument if consid-
ered irrelevant [37,41]. Items rated “3” and “4” were used for
determining the CVI (Equation (1)) [43]. The minimum level of
agreement among experts and researchers was set at 80%
(CVI � 0.80) [44].
CVI ¼ Number of items rated “3” þ Number of items rated “4”
Total number of items
(1)
The pre-final version was tested in patients with chronic
wounds of the lower limb who met study criteria. During the
application of the adapted instrument, each patient was probed
about what he or she thought was meant by each questionnaire
item and the chosen response, and was asked to suggest any
changes he or she considered necessary to improve the under-
standing of the items and response choices. The patients were also
asked to rate the items for relevance according to the same 1e4
scale used by the experts. The comments of the patients were
evaluated by the expert committee together with the authors of the
study, and the final Brazilian-Portuguese version was obtained by
consensus. The final version was then back-translated into English
and sent to Dr Price for approval by the original authors.
The internal consistency of all items of the cross-culturally
adapted instrument was measured using the Cronbach's alpha co-
efficient. Cronbach's alpha indicates the degree to which a set of
items measures a single construct, determining the internal con-
sistency or average correlation of items in a survey instrument and
estimating its reliability [45,46]. It ranges from 0 to 1, with higher
values indicating greater consistency among items of a scale or
subscale. Cronbach's alpha values over 0.70 are considered
acceptable [45].
Data were entered into an Excel spreadsheet (Microsoft Cor-
poration, Redwood, WA, USA) and analysed using the IBM Statis-
tical Package for the Social Sciences (IBM SPSS Statistics) 20.0 for
Windows (IBM Corp., Armonk, NY, USA).
Absent 23 76.7
Slight 4 13.3
Moderate 2 6.7
Strong 1 3.3
3. Results
The pre-final version of the instrument was tested in 30 patients
with chronic wounds of the lower limb, of whom 23 (76.7%) were
men, the mean age was 47.7 years (range, 21e77), 15 (50.0%) pa-
tients had a partner, 14 (46.7%) had high school education, and 23
(76.7%) were retired or receiving a government benefit at the time
of interview. Among the patients, 21 (70.0%) had traumatic wounds,
13 (43.3%) had the wound for more than 1 year, 19 (63.3%) had
wounds of less than 25 cm2; 14 (46.7%) showed small amount of
wound exudate, and the wound of 23 (76.7%) patients had no
strong odour (Table 1).
The mean VAS pain scores was 2.74 ± 3.48 (range, 0e10), cor-
responding to a mild pain; 12 (40.0%) patients reported no pain
(VAS score¼ 0) and 13 (46.6%) were using analgesics regularly or as
needed.
During the analysis of semantic, idiomatic, experiential and
conceptual equivalence, the word ‘schedule’ in the name of the
Please cite this article in press as:Augusto FdS, et al., Translation and
Brazilian Portuguese, Journal of Tissue Viability (2016), http://dx.doi.org/
instrument was translated as ‘questionnaire’, because, for Brazil-
ians, theword ‘schedule’ has a time connotation (e.g., time schedule
or timetable). The original instrument uses an ‘(s)’ to indicate
possible plural forms after a few singular nouns, as in the example ‘I
feel anxious about my wound(s)’. Initially, this was maintained in
the translated version of the instrument, including the possible
inflections of nouns, pronouns, adjectives, and articles related to
grammatical gender and declensional classes, according to Brazil-
ian Portuguese [e.g., ‘Eu me sinto preocupado(a) com a(s) minha(s)
ferida(s)’]. However, such additions may hinder the reading and
contribute little to an understanding of the item content. Thus, all
markers of plural, gender and declensional classes were removed
and the final translation of the above example was ‘Eu me sinto
cross-cultural adaptation of the Cardiff Wound Impact Schedule to
10.1016/j.jtv.2016.12.002
F.S. Augusto et al. / Journal of Tissue Viability xxx (2016) 1e64
preocupado com a minha ferida’. In addition, when the sentence ‘To
what extent do you agree/disagree with the following statements?’
was literally translated into Brazilian Portuguese (i.e., ‘At�e que ponto
você concorda/discorda com as seguintes afirmaç~oes?’), the patients
had difficulty during the pretesting to understand that the subse-
quent items were related to their own feelings and not to the
opinion of a health professional. So, the sentence was replaced with
‘To what extent the following statements are consistent with what
you feel’. Also, the categorical response options of the Likert-type
scale related to the physical symptoms, daily living, and social life
domains were initially translated as ‘no/not applicable’, ‘rarely’,
‘sometimes’, ‘often’, and ‘always’. However, the patients understood
that there were two questions to be answered in a single item, the
first being if the symptom/situation had occurred, and the second
being how often the symptom/situation occurred in last week.
Thus, the word ‘yes’was added before positive response options, as
follows: ‘no/not applicable’, ‘yes, rarely’, ‘yes, sometimes’, ‘yes,
often’, ‘yes, always’. The participants had a good understanding of
the adapted instrument, had few questions and made few sug-
gestions about items and form filling, which were all addressed by
the expert committee. There was no need for deletion of items.
Face validity achieved 100% consensus among the expert com-
mittee, who concluded that the instrument assesses HRQoL in
people with chronic wounds satisfactorily addressing relevant
factors that underlie the problem.
As for content validity, the 47 items of the adapted instrument
were assessed by the 6 members of the expert committee, for a
total of 282 evaluations, of which 271 (96%) were rated as “very
important” (n ¼ 206; 73%) or “important” (n ¼ 65; 23%). Thus, CVI
for the adapted instrument was 0.96.
The overall Cronbach's alpha for the instrument was 0.920,
corresponding to an excellent internal consistency, and ranged
from 0.681 to 0.846 for the domains, as seen in Table 2.
The back-translated version was approved by Dr Price after few
adjustments, such as the replacement of the word ‘disappointed’
with ‘upset’ in the item 2 of the well-being domain (i.e., I feel upset
with the time to healing of my wound).
The cross-culturally adapted CWIS preserved the main features
of the original instrument in English. The final cross-culturally
adapted, Brazilian-Portuguese version of the CWIS for assessing
HRQoL in patients with wounds was then named Cardiff Wound
Impact Schedule-Federal University of Sao Paulo/School of Medi-
cine (CWIS-UNIFESP/EPM).
4. Discussion
The concept of HRQoL involves aspects of quality of life that are
affected or influenced by changes in health [47]. Despite its
subjectivity, researchers recognize that HRQOL provides a more
accurate measure of the impact of a disease on the patient than the
evaluation of strictly clinical results, such as estimates of mortality
rates [47]. The assessment of patient HRQoL, especially when using
disease-specific instruments, may contribute to the development of
management strategies and interventions for improving quality of
care for the target population.
Table 2
Cronbach's alpha coefficient values for the Brazilian version of the Cardiff Wound
Impact Schedule (CWIS-UNIFESP/EPM).
CWIS domains Cronbach's alpha coefficient
Well-being 0.681
Physical symptoms and daily living 0.786
Social life 0.846
Overall Cronbach's alpha (CWIS-UNIFESP/EPM) 0.920
Please cite this article in press as: Augusto FdS, et al., Translation and
Brazilian Portuguese, Journal of Tissue Viability (2016), http://dx.doi.org/
Several studies have been conducted over the years evaluating
the impact of wounds on quality of life. The Charing Cross Venous
Ulcer Questionnaire (CXVUQ) was one of the first validated specific
measures of quality of live for patients with wounds [15]. Currently,
there are many wound-specific measures of quality of life world-
wide [15e32], but few are available in Brazilian-Portuguese
[27e32], resulting in a small number of investigations on this
topic in our country.
The cross-cultural adaptation of an already developed instru-
ment has the advantage of producing a measure whose results can
be compared with those of international studies. In addition, it is
less expensive and requires less time to create a tool with indicators
already internationally validated. However, the cross-cultural
adaptation of a quality-of-life measure also requires a rigorous
research before the validation of the resulting instrument
[37,48e50]. Every culture sees the world in a unique way and this
view is reflected in its language. This uniqueness permeates all
aspects of life, including the way in which patients see their health
and its effects on their physical well-being [33]. A valid translation
of a measure is not achieved by the literal translation of terms, but
by expressing complex concepts of a foreign culture [33]. In this
study, some terms have been adapted to the Brazilian culture, such
as the replacement of the word ‘schedule’ with ‘questionnaire’,
similarly to previous cross-cultural adaptations to French and
German, in which the name of the CWIS was translated as ‘Cardiff
Wound Impact Questionnaire’ [33].
With regard to the psychometric analysis, face validity is a
relevant measure that determines whether the instrument mea-
sures what it was designed to measure [40]. The expert committee
established by consensus that the Brazilian version of the CWIS had
face validity for measuring HRQoL in patients with chronic wounds.
Similarly, a previous study on the cross-cultural adaptation and
validation of the CWIS to Swedish also found that the final version
of the instrument had face validity after testing it in patients with
chronic wounds [35]. The CWIS-UNIFESP/EPM has also good con-
tent validity, according to the ratings of experts and patients with
chronic wounds of the lower limb. This is in agreement with the
findings for the original instrument, as well as for other versions of
this measure [20,35,36]. In this study, the overall Cronbach's alpha
was 0.920, indicating an excellent internal consistency for the in-
strument; the Cronbach's alpha was acceptable for the well-being
domain (alpha ¼ 0.681) and good for both the physical symptoms
and daily living (alpha ¼ 0.746) and social life (alpha ¼ 0.846) do-
mains. These results are similar to those of the original instrument
(alpha range, 0.770e0.960), and those obtained in validation
studies of the CWIS conducted in Canada (alpha range,
0.562e0.809), Sweden (alpha range, 0.690e0.920), and China
(alpha range, 0.789e0.915) [20,35,36,51]. However, the validation
study conducted in Portugal showed a Cronbach's alpha ranging
from 0.805 to 0.956, indicating good to excellent internal consis-
tency forall domains [34].
In this study, only the validation tests (i.e., face validity, content
validity and internal consistency) directly related to the cross-
cultural adaptation of the questionnaire to Brazilian Portuguese
were performed. Additional studies will be conducted to test other
psychometric properties of the CWIS-UNIFESP/EPM, including
construct validity, criterion-related validity, and test-retest reli-
ability (reproducibility).
The study was conducted only in patients with chronic wounds
on the legs. This is a limitation on the generalization of the results.
Further studies are necessary to test the performance of the CWIS-
UNIFESP/EPM in patients with different types of wounds.
The use of quality of life as an indicator of treatment response in
health care is an international trend that can also be applied to the
Brazilian reality. Although there are still few studies evaluating
cross-cultural adaptation of the Cardiff Wound Impact Schedule to
10.1016/j.jtv.2016.12.002
F.S. Augusto et al. / Journal of Tissue Viability xxx (2016) 1e6 5
quality of life in patients with wounds in Brazil, the practical
application of assessment results (especially those obtained with
specific tools) contributes to the implementation of interventions
and evaluation of their effectiveness in improving quality of life
among patients with wounds.
5. Conclusion
The cross-culturally adapted Brazilian-Portuguese version of the
instrument showed satisfactory face and content validity, good
internal consistency, and was named Cardiff Wound Impact
Schedule-Federal University of S~ao Paulo School of Medicine or
CWIS-UNIFESP/EPM.
Conflicts of interest statement
The authors have no conflicts of interest, financial interest or
commercial association with any of the subject matter or products
mentioned in the manuscript.
Funding
There was no external funding for this study.
References
[1] Lazarus GS, Cooper DM, Knighton DR, Percoraro RE, Rodeheaver G,
Robson MC. Definitions and guidelines for assessment of wounds and evalu-
ation of healing. Wound Rep Regen 1994;2:165e70. http://dx.doi.org/
10.1046/j.1524-475X.1994.20305.x.
[2] Moffatt CJ, Franks PJ, Doherty DC, Martin R, Blewett R, Ross F. Prevalence of leg
ulceration in a London population. QJM 2004;97:431e7. http://dx.doi.org/
10.1093/qjmed/hch075.
[3] Sen CK, Gordillo GM, Roy S, Kirsner R, Lambert L, Hunt TK, et al. Human skin
wounds: a major and snowballing threat to public health and the economy.
Wound Repair Regen 2009;17:763e71. http://dx.doi.org/10.1111/j.1524-
475X.2009.00543.x.
[4] Gorecki C, Brown JM, Nelson EA, Briggs M, Schoonhoven L, Dealey C, et al.
Impact of pressure ulcers on quality of life in older patients: a systematic
review. J Am Geriatr Soc 2009;57:1175e83. http://dx.doi.org/10.1111/j.1532-
5415.2009.02307.x.
[5] Gonz�alez-Consuegra RV, Verdú J. Quality of life in people with venous leg
ulcers: an integrative review. J Adv Nurs 2011;67:926e44. http://dx.doi.org/
10.1111/j.1365-2648.2010.05568.x.
[6] de Meneses LC, Blanes L, Francescato Veiga D, Carvalho Gomes H, Masako
Ferreira L. Health-related quality of life and self-esteem in patients with
diabetic foot ulcers: results of a cross-sectional comparative study. Ostomy
Wound Manag 2011;57:36e43.
[7] Salom�e GM, de Souza Pellegrino DM, Vieira TF, Blanes L, Ferreira LM. Sleep
quality among patients with venous ulcers: a cross-sectional study in a health
care setting in S~ao Paulo, Brazil. Wounds 2012;24:124e31.
[8] Salom�e GM, Blanes L, Ferreira LM. The impact of skin grafting on the quality of
life and self-esteem of patients with venous leg ulcers. World J Surg 2014;38:
233e40. http://dx.doi.org/10.1007/s00268-013-2228-x.
[9] Goodridge D, Trepman E, Embil JM. Health-related quality of life in diabetic
patients with foot ulcers: literature review. J Wound Ostomy Cont Nurs
2005;32:368e77.
[10] Galhardo VA, Garroni Magalh~aes M, Blanes L, Juliano Y, Masako Ferreira L.
Health-related quality of life and depression in older patients with pressure
ulcers. Wounds 2010;22:20e6.
[11] Faria E, Blanes L, Hochman B, Mesquita Filho M, Ferreira LM. Health-related
quality of life, self-esteem, and functional status of patients with leg ulcers.
Wounds 2011;23:4e10.
[12] Gorecki C, Nixon J, Madill A, Firth J, Brown JM. What influences the impact of
pressure ulcers on health-related quality of life? A qualitative patient-focused
exploration of contributory factors. J Tissue Viability 2012;21:3e12. http://
dx.doi.org/10.1016/j.jtv.2011.11.001.
[13] Salom�e GM, Blanes L, Ferreira LM. Avaliaç~ao de sintomas depressivos em
pessoas com úlcera venosa. Rev Bras Cir Plast 2012;27:124e9.
[14] Salom�e GM, de Almeida SA, Ferreira LM. Evaluation of pain in patients with
venous ulcers after skin grafting. J Tissue Viability 2014;23:115e20. http://
dx.doi.org/10.1016/j.jtv.2014.04.004.
[15] Smith JJ, Guest MG, Greenhalgh RM, Davies AH. Measuring the quality of life
in patients with venous ulcers. J Vasc Surg 2000;31:642e9. http://dx.doi.org/
10.1067/mva.2000.104103.
[16] Kildal M, Andersson G, Fugl-Meyer AR, Lannerstam K, Gerdin B. Development
of a brief version of the burn specific health scale (BSHS-B). J Trauma 2001;51:
Please cite this article in press as: Augusto FdS, et al., Translation and
Brazilian Portuguese, Journal of Tissue Viability (2016), http://dx.doi.org/
740e6.
[17] Abetz A, Sutton M, Brady L, McNulty P, Gagnon DD. The Diabetic Foot Ulcer
Scale (DFS): a quality of life instrument for use in clinical trials. Pract Diabetes
Int 2002;19:167e75.
[18] Lamping DL, Schroter S, Kurz X, Kahn SR, Abenhaim L. Evaluation of outcomes
in chronic venous disorders of the leg: development of a scientifically
rigorous, patient-reported measure of symptoms and quality of life. J Vasc
Surg 2003;37:410e9. http://dx.doi.org/10.1067/mva.2003.152.
[19] Vileikyte L, Peyrot M, Bundy C, Rubin RR, Leventhal H, Mora P, et al. The
development and validation of a neuropathy- and foot ulcer-specific quality of
life instrument. Diabetes Care 2003;26:2549e55.
[20] Price P, Harding K. The Cardiff Wound Impact Schedule: the development of a
condition specific questionnaire to assess health-related quality of life in
patients with chronic wounds of the lower limb. Int Wound J 2004;1:10e7.
[21] Hareendran A, Doll H, Wild DJ, Moffatt CJ, Musgrove E, Wheatley C, et al. The
venous leg ulcer quality of life (VLU-QoL) questionnaire: development and
psychometric validation. Wound Repair Regen 2007;15:465e73. http://
dx.doi.org/10.1111/j.1524-475X.2007.00253.x.
[22] Palfreyman S. Assessing the impact of venous ulceration on quality of life.
Nurs Times 2008;104:34e7.
[23] Augustin M, Herberger K, Rustenbach SJ, Sch€afer I, Zschocke I, Blome C.
Quality of life evaluation in wounds: validation of the Freiburg Life Quality
Assessment-wound module, a disease-specific instrument. Int Wound J
2010;7:493e501. http://dx.doi.org/10.1111/j.1742-481X.2010.00732.x.
[24] Augustin M, Blome C, Zschocke I, Sch€afer I, Koenig S, Rustenbach SJ, et al.
Benefit evaluation in the therapy of chronic wounds from the patients'
perspective-development and validation of a new method. Wound Repair
Regen 2012;20:8e14. http://dx.doi.org/10.1111/j.1524-475X.2011.00751.x.
[25] Gorecki C, Brown JM, Cano S, Lamping DL, Briggs M, Coleman S, et al.
Development and validation of a new patient-reported outcome measure for
patients with pressure ulcers: the PU-QOL instrument. Health Qual Life Out-
comes 2013;11:95. http://dx.doi.org/10.1186/1477-7525-11-95.
[26] Blome C, Baade K, Debus ES, Price P, Augustin M. The “Wound-QoL”: a short
questionnaire measuring quality of life in patients with chronic wounds based
on three established disease-specific instruments. Wound Repair Regen
2014;22:504e14. http://dx.doi.org/10.1111/wrr.12193.
[27] Ferreira E, Dantas RAS, Rossi LA, Ciol MA. The cultural adaptation and vali-
dation of the ‘‘Burn Specific Health Scale-Revised’’ (BSHS-R): version for
Brazilian burn victims. Burns 2008;34:994e1001. http://dx.doi.org/10.1016/j.burns.2007.12.006.
[28] Yamada BFA, Santos VLCG. Development and validation of Ferrans & powers
quality of life index: wound version. Rev Esc Enferm USP 2009;43:1105e13.
[29] Xavier AT, Foss MC, Marques Junior W, dos Santos CB, Onofre PT, Pace AE.
Cultural adaptation and validation of the neuropathy - and foot ulcer - specific
quality of life instrument (NeuroQol) for Brazilian portuguese - phase 1. Rev
Lat Am Enferm 2011;19:1352e61.
[30] Couto RC, Leal FJ, Pitta GBB, Bezerra RCB, Segundo WSS, Porto TM. Translation
and cultural adaptation of charing cross venous ulcer questionnaire. J Vasc
Bras 2012;11:102e7.
[31] Araujo RB, Fortes MR, Abbade LP, Miot HA. Translation, cultural adaptation to
Brazil and validation of the venous leg ulcer quality of life questionnaire (VLU-
QoL-Br). Rev Assoc Med Bras 2014;60:249e54.
[32] Piccolo MS, Gragnani A, Daher RP, Scanavino Mde T, de Brito MJ, Ferreira LM.
Validation of the Brazilian version of the burn specific health scale-brief
(BSHS-B-Br). Burns 2015;41:1579e86.
[33] Acquadro C, Price P, Wollina U. Linguistic validation of the Cardiff wound
impact schedule into French, German and US English. J Wound Care 2005;14:
14e7.
[34] Ferreira PL, Migu�ens C, Gouveia J, Furtado K. Mediç~ao da qualidade de vida em
doentes com feridas cr�onicas: a Escala de Cicatrizaç~ao da Úlcera de Press~ao e o
Esquema Cardiff de Impacto da Ferida. Nursing 2007;17:32e41.
[35] Fagerdahl AM, Bostr€om L, Ulfvarson J, Bergstr€om G, Ottosson C. Translation
and validation of the wound-specific quality of life instrument Cardiff Wound
Impact Schedule in a Swedish population. Scand J Caring Sci 2014;28:
398e404. http://dx.doi.org/10.1111/scs.12050.
[36] Huang Y, Wu M, Xing P, Xie T, Cao Y, Qian P, et al. Translation and validation of
the Chinese Cardiff wound impact schedule. Int J Low Extrem Wounds
2014;13:5e11. http://dx.doi.org/10.1177/1534734614521233.
[37] 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):3186e91.
[38] Folstein MF, Folstein SE, McHugh PR. Mini-Mental State”: a practical method
for grading the cognitive state of patients for the clinician. J Psychiatr Res
1975;12:189e98.
[39] Bertolucci PH, Brucki SM, Campacci SR, Juliano Y. The Mini-Mental State Ex-
amination in a general population: impact of educational status. Arq Neuro-
psiquiatr 1994;52:1e7.
[40] Nunnally JC, Bernstein IH. Psychometric theory. third ed. Ventura: Cram101
Incorporated; 2006.
[41] Haynes SN, Richard DCS, Kubany ES. Content validity in psychological
assessment: a functional approach to concepts and methods. Psychol Assess
1995;7:238e47.
[42] Terwee CB, Bot SD, de Boer MR, van der Windt DA, Knol DL, Dekker J, et al.
Quality criteria were proposed for measurement properties of health status
questionnaires. J Clin Epidemiol 2007;60:34e42.
cross-cultural adaptation of the Cardiff Wound Impact Schedule to
10.1016/j.jtv.2016.12.002
http://dx.doi.org/10.1046/j.1524-475X.1994.20305.x
http://dx.doi.org/10.1046/j.1524-475X.1994.20305.x
http://dx.doi.org/10.1093/qjmed/hch075
http://dx.doi.org/10.1093/qjmed/hch075
http://dx.doi.org/10.1111/j.1524-475X.2009.00543.x
http://dx.doi.org/10.1111/j.1524-475X.2009.00543.x
http://dx.doi.org/10.1111/j.1532-5415.2009.02307.x
http://dx.doi.org/10.1111/j.1532-5415.2009.02307.x
http://dx.doi.org/10.1111/j.1365-2648.2010.05568.x
http://dx.doi.org/10.1111/j.1365-2648.2010.05568.x
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref6
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref6
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref6
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref6
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref6
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref7
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref7
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref7
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref7
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref7
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref7
http://dx.doi.org/10.1007/s00268-013-2228-x
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref9
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref9
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref9
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref9
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref10
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref10
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref10
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref10
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref10
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref11
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref11
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref11
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref11
http://dx.doi.org/10.1016/j.jtv.2011.11.001
http://dx.doi.org/10.1016/j.jtv.2011.11.001
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref13
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref13
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref13
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref13
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref13
http://dx.doi.org/10.1016/j.jtv.2014.04.004
http://dx.doi.org/10.1016/j.jtv.2014.04.004
http://dx.doi.org/10.1067/mva.2000.104103
http://dx.doi.org/10.1067/mva.2000.104103
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref16
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref16
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref16
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref16
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref17
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref17
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref17
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref17
http://dx.doi.org/10.1067/mva.2003.152
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref19
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref19
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref19
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref19
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref20
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref20
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref20
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref20
http://dx.doi.org/10.1111/j.1524-475X.2007.00253.x
http://dx.doi.org/10.1111/j.1524-475X.2007.00253.x
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref22
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref22
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref22
http://dx.doi.org/10.1111/j.1742-481X.2010.00732.x
http://dx.doi.org/10.1111/j.1524-475X.2011.00751.x
http://dx.doi.org/10.1186/1477-7525-11-95
http://dx.doi.org/10.1111/wrr.12193
http://dx.doi.org/10.1016/j.burns.2007.12.006
http://dx.doi.org/10.1016/j.burns.2007.12.006
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref28
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref28
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref28
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref28
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref29
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref29
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref29
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref29
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref29
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref30
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref30
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref30
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref30
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref31
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref31
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref31
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref31
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref32
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref32
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref32
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref32http://refhub.elsevier.com/S0965-206X(16)30085-7/sref33
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref33
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref33
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref33
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref34
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref34
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref34
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref34
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref34
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref34
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref34
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref34
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref34
http://dx.doi.org/10.1111/scs.12050
http://dx.doi.org/10.1177/1534734614521233
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref37
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref37
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref37
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref37
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref38
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref38
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref38
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref38
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref39
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref39
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref39
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref39
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref40
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref40
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref41
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref41
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref41
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref41
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref42
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref42
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref42
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref42
F.S. Augusto et al. / Journal of Tissue Viability xxx (2016) 1e66
[43] Alexandre NM, Coluci MZ. Content validity in the development and adapta-
tion processes of measurement instruments. Cien Saude Colet 2011;16:
3061e8.
[44] Grant JS, Davis LL. Selection and use of content experts for instrument
development. Res Nurs Health 1997;20:269e74.
[45] Gliem JA, Gliem RR. Calculating, interpreting and reporting Cronback's alpha
reliability coefficient for Likert-type scales. In: 2003 Midwest research to
practice conference in adult, continuing, and community education. Colum-
bus, OH: Ohio State University; 2003. p. 82e8.
[46] Martins GA, The�ophilo CR. Metodologia da investigaç~ao científica para ciên-
cias sociais aplicadas [Methodology of scientific research to applied social
sciences]. 2009. S~ao Paulo: Atlas.
[47] Litvoc J, Kimura M, Santos VLCG. Qualidade de Vida e Avaliaç~ao em Saúde. In:
Cianciarullo TI, Silva GTV, Cunha ICKO, editors. Uma nova estrat�egia em foco:
Please cite this article in press as: Augusto FdS, et al., Translation and
Brazilian Portuguese, Journal of Tissue Viability (2016), http://dx.doi.org/
O programa de saúde da família e identificando as suas características no
cen�ario do SUS. S~ao Paulo: �Icone Editora; 2005. p. 287e318.
[48] 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;46:1417e32.
[49] World Health Organization (WHO). Process of translation and adaptation of
instruments. 2016. Available at: http://www.who.int/substance_abuse/
research_tools/translation/en/#. Accessed 25 June 2016.
[50] MAPI Institute. Linguistic validation manual for health outcome assessments.
second ed. Lyon: MAPI Research Trust; 2012.
[51] Jaksa PJ, Mahoney JL. Quality of life in patients with diabetic foot ulcers:
validation of the Cardiff Wound Impact Schedule in a Canadian population. Int
Wound J 2010;7:502e7. http://dx.doi.org/10.1111/j.1742-481X.2010.00733.x.
cross-cultural adaptation of the Cardiff Wound Impact Schedule to
10.1016/j.jtv.2016.12.002
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref43
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref43
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref43
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref43
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref44
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref44
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref44
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref45
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref45
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref45
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref45
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref45
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref46
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref46
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref46
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref46
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref46
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref46
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref46
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref47
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref47
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref47
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref47
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref47
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref47
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref47
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref47
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref47
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref47
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref47
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref48
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref48
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref48
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref48
http://www.who.int/substance_abuse/research_tools/translation/en/#
http://www.who.int/substance_abuse/research_tools/translation/en/#
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref50
http://refhub.elsevier.com/S0965-206X(16)30085-7/sref50
http://dx.doi.org/10.1111/j.1742-481X.2010.00733.x
	Translation and cross-cultural adaptation of the Cardiff Wound Impact Schedule to Brazilian Portuguese
	1. Introduction
	2. Materials and methods
	2.1. The instrument
	3. Results
	4. Discussion
	5. Conclusion
	Conflicts of interest statement
	Funding
	References