We need to use words that we’d use in Brazil,right ? A Community-Based Content Validation of a Translated Femicide Risk Assessment Instrument

Abstract

The Danger Assessment (DA) is a widely-used risk assessment instrument designed to help women understand their risk of femicide. Currently, no validated tool exists in Brazilian Portuguese. The purpose of this study was to conduct a cross-cultural adaptation of the DA for use in the Brazilian context as a precursor to validation and broader testing among women in Brazil. This study describes a community participatory approach for translation and cultural adaptation of the DA from European to Brazilian Portuguese that engages the target population in the process. Using a three-step process, a final version of the DA-Brazil instrument was developed.

Keywords

femicide violence against women intimate partner violence Brazil qualitative research

Introduction

Intimate femicide is the intentional homicide of a woman by a past or current intimate partner (Stöckl et al., 2013). Considering that intimate partner violence (IPV) is the primary known risk factor for intimate femicide (Stöckl et al., 2013; World Health Organization & Pan American Health Organization, 2012), the ability to identify women at risk of intimate femicide and provide them with timely protective support is critical to saving lives. In countries that report data where the perpetrator has been identified, male intimate partners commit approximately 47.4% of all femicides (Stöckl et al., 2013). Men are more likely to kill their partners out of jealousy (Hotton, 2001) or possessiveness after the relationship has ended (Johnson & Hotton, 2003; World Health Organization & Pan American Health Organization, 2012). As a result, women are at particular risk for intimate femicide within the 12 months after leaving an abusive relationship (Campbell et al., 2003; Dobash & Dobash, 2012; Lewandowski et al., 2004), and when they enter into a new relationship following estrangement from an abusive partner. Other risk factors for intimate femicide perpetration include unemployment (Campbell et al., 2003; Dobash & Dobash, 2012; Lewandowski et al., 2004) and mental health issues, especially suicidality (Campbell et al., 2007; Campbell et al., 2008).

In Brazil, up to a quarter of women have experienced IPV in their lifetime (World Health Organization, 2021). In 2015, the country ranked fifth in the world for femicide with a rate of 4.5 homicides per 100,000 women (Waiselfisz, 2015), which was at that time 2.5 times higher than the global average (Racovita, 2015). Regionally, rates have fluctuated, femicide has been steadily increasing since 2012, and disproportionately affects Black women. In 2019, there were 1,326 femicides in Brazil of which 89.9% were committed by a current or former intimate partner, and 66.6% of the victims were Black (Forum Brasileiro de Segurança Pública [FBSP] & Instituto de Pesquisa Económica Aplicada [IPEA], 2020). This represents a 7.2% increase from 2018, and a 5.5% increase in the murder of Black women alone.

Brazil has instituted protective laws and a network of services to assist and support women experiencing violence, including police stations for women, family and domestic violence courts, shelters, and counseling centers among others; however, there are often barriers to accessing criminal justice and health providers (Evans et al., 2019). The National Justice Council (Conselho Nacional de Justiça—CNJ) reports that women across Brazil are accessing services for assistance in increasing numbers. In 2019, courts processed 563,698 applications for protective measures, awarded 403,646 cases and there were 1,036,746 cases in process in the legal system; these numbers represented increases of 9.9%, 19.9%, and 5.9%, respectively, over 2018 (Bandeira, 2020).

Internationally recognized screening tools for domestic and IPV have been translated and modified for use in Brazil to quantify and describe the prevalence of IPV and in the development and testing of other instruments. However, most of this work has been done among pregnant women. Macedo Piosiadlo and Godoy Serpa da Fonseca (2016) used a validated Portuguese version of the Abuse Assessment Screen (AAS) and an instrument comprised of gender subordination indicators to test if their questionnaire could identify women that were vulnerable to domestic violence, and found that it could. The AAS and the Conflict Tactics Scale (CTS) have been modified and used at the regional and state levels to estimate the prevalence and factors associated with IPV (Lopes et al., 2016; Mathias et al., 2013; Silva et al., 2010). Reichenheim and Moraes (2004) compared and tested the accuracy of the AAS against the Revised CTS to measure violence against pregnant women. Alone, the AAS missed nearly two-thirds of women experiencing minor abuse and one-third of women experiencing severe abuse in pregnancy. The authors suggested the AAS not be used on its own without further evidence. Santos et al. (2017) used the AAS and the Tolerance, Annoyed, Cut down and Eye-opener (T-ACE) questionnaires to identify and describe pregnant women experiencing abuse. To estimate the prevalence of violence and factors that contribute to depression in pregnancy, Manzolli et al. (2010) used a modified version of the AAS with the primary care evaluation of mental disorders screen. Mattar et al. (2007) used the Portuguese version of the AAS with the Edinburgh Postnatal Depression Scale to assess the prevalence of post-partum depression and associated factors, such as partner violence. While these studies have addressed the use of translated and modified validated instruments to quantify the prevalence of violence and related factors, there is currently no rigorously designed and validated instrument to identify women at the highest risk of intimate femicide at the hands of an intimate partner in Brazil. In 2019, in partnership with the Brazilian Ministry of Human Rights, the CNJ launched the Formulário de Avaliação de Risco (FRIDA), a national risk assessment form for IPV. FRIDA is based on the Danger Assessment (DA), Domestic Violence Screening Inventory Revised, and the Spousal Assault Risk Assessment (Brambilla & Pereira, 2020) and is intended for use by specialized and non-specialized professionals to help them determine how best to help women that seek protective services for abuse (Conselho Nacional do Ministério Público [CNMP] & Ministério da Mulher Família e dos Direitos Humanos, 2019). As it is relatively new, FRIDA is not widely used, and there is no available peer-reviewed literature on testing and formal validation for use among Brazilian populations.

One of the foundations of FRIDA is the DA, an instrument developed, refined, and validated over almost two decades for use with women experiencing IPV (Campbell, 2003). The DA may be used to assess risk of repeat assault (Weisz et al., 2000) but is more accurate when used to measure a woman's immediate risk of both attempted and completed intimate femicide (Campbell et al., 2009). Given the high rates of IPV and intimate femicide in Brazil, a validated instrument such as the DA is needed to assist criminal justice and health professionals in identifying Brazilian women who are at imminent risk of intimate femicide. The DA has already been translated into several languages (Campbell, 2003). In the absence of an existing validated and proven instrument to measure a woman's risk of intimate femicide in Brazil, we identified the DA as a needed resource to help women understand their risk of being killed by their partner, as well as a resource for health and justice system professionals providing support to women.

The purpose of the study was to conduct a cross-cultural adaptation of the DA as a precursor to validation and broader testing among women in Brazil for use in the Brazilian context. As a first step in validating the instrument, we describe a community participatory approach engaging women who are representative of the target population to ensure that instrument translation and adaptation would be applicable to the diversity of Brazilian women.

Language and cultural beliefs influence people's ability to understand and respond to surveys and instruments (Warnecke et al., 1997). The existence of a concept in both source and target cultures, its meaning, and its interpretation are all factors that comprise conceptual equivalence (Sidani et al., 2010). When using or adapting instruments not originally developed for use with a target population, understanding how people use and understand terms and concepts, particularly where perspectives on meaning may differ, is essential (Stewart & Nápoles-Springer, 2000). Cultural adaptation of health-related measures and instruments to reflect the views of the target population and to avoid attributing meaning is crucial (Givens et al., 2007; Killoran & Moyer, 2006; Sidani et al., 2010; Stewart & Nápoles-Springer, 2000). Considerations include modification of adaptations to achieve idiomatic equivalence through translation relative to the population's socioeconomic status (SES) and culture (Beaton et al., 2000; Crawford et al., 2017; Epstein et al., 2015; Guillemin et al., 1993; Pellegrino et al., 2014).

Several studies have evaluated translated versions of violence screening tools. Reichenheim et al. (2000) evaluated and compared two Portuguese versions of the AAS for Violence in Pregnant Women for semantic equivalence. The team followed a four-phase process of translation, back translation, formal review of equivalence, and assessment by family violence experts as recommended by Beaton et al. (2000). Their results suggested the importance of including an additional step evaluating the target population's understanding of the tool as well as using two different translations in the target language for comparison and synthesis. Paixão Júnior et al. (2007) described the cross-cultural adaptation of the Caregiver Abuse Screen (CASE), in which they followed up using a multidimensional questionnaire. Reichenheim et al. (2009) then carried out a psychometric analysis to test the construct validity of the CASE, finding it, too, required additional refinement. We describe a direct approach that actively engages the target population in the first phases of the translation, and thereby reduces the need for significant modifications in the final phases of development and testing.

Methods

Study Site

This study was conducted in March 2018 at the Department of Obstetrics and Gynecology at the Faculdade de Medicina do ABC (FMABC) in Santo André, Brazil. This site previously acted as a partner on a mixed-methods study conducted to understand the nature of violence against women locally, a public health priority for the municipality (Evans et al., 2017; Evans et al., 2018; Evans et al., 2019; Gattegno et al., 2016).

Study Participants, Recruitment, and Sampling

In keeping with the goal of the study to conduct a cross-cultural adaptation of the DA for use in the Brazilian context and given that this work did not include obtaining individual experiences with partner violence or attempted intimate femicide, we did not specifically seek to recruit women that had experienced either for the instrument validation. Rather, following the guidance of the senior author we sought a heterogeneous cohort of adult women, characteristic of the socio-economic diversity of Brazil that could provide an adaptation of the language for the Brazilian context.

An FMABC human resources manager with access to departmental employee records assisted with the purposive selection of participants and recruitment. We asked this manager to identify a socio-demographically diverse cohort of staff aged 18 years and over who self-identify as women from among all functional sectors of the department and invite them to participate in the study. FMABC provided participants with paid time away from their duties so that none of the participants incurred loss in compensation, which would have disproportionately affected the custodial and administrative staff. No other incentives were provided for participation in the study. All invited individuals (N = 24) participated in one of three cognitive focus group discussions which were held over 2 days in March 2018.

Instrument

The DA consists of two parts: a calendar exercise designed to help women remember events and provide a visual of the frequency and severity of abuse; and a 20-item yes/no weighted questionnaire. The calendar module has a scale of abuse and a list of resulting injuries that ranges along a five-point scale. Working with someone trained to administer the DA, women write the number corresponding to the severity of abusive events on or around the respective calendar date of the violent interaction. The calendar helps women to visualize changes in the severity and frequency of violence, and aids in providing a realistic picture of the abuse they experience. The second section consists of questions related to specific intimate femicide risk indicators such as threat types (i.e., with a lethal weapon; harm to her children; to kill her; to kill himself), the abuser's history of drug and alcohol abuse, employment status, and controlling, jealous, and violent behaviors.

The DA has been used with women experiencing abuse from their partners, in violence research, and to validate other instruments for almost two decades (Pearce et al., 2003). At the time of this study, the DA was translated into both European and Brazilian Portuguese. The study team elected to use the European Portuguese version because it was known to have been formally translated and back-translated, and the team understood it to have been previously validated for research purposes.

Following oral and written guidance provided by the senior author for translation of the DA, we developed a semi-structured focus group discussion guide to test the translated language and cultural applicability of the validated DA among women who were representative of possible end-users of the risk assessment. The guide consisted of a short introduction to the DA and the purpose of the activity followed by two sections corresponding to the modules of the DA. Each section included a brief description of the module, its intended use, and procedures victim advocates follow when they use the instrument with a woman experiencing violence. The guidance from the senior author was to read the calendar abuse scale items individually and ask participants to describe what the words meant to them, and where necessary or useful, to have them describe or enact the action. For the questionnaire, the guidance suggested reading the questions aloud and allowing time to reflect upon them, but not reframing questions for participants. The senior author also suggested probes designed to elicit an individual's lived experience, such as “What does this make you think of?,” “If you were in this situation, are these the words you would use to describe what was happening to your sister?” and “What does this mean to you?”

Data Collection Procedures

Participants provided verbal consent to participate and to be audio-recorded. A facilitator fluent in European Portuguese, Brazilian Portuguese, and English conducted the focus groups in Brazilian Portuguese together with a local study team member with expertise in violence research. Each participant received a copy of the European Portuguese translation of the DA (EP-DA) to follow during the discussion if they desired. The facilitators explained the purpose of the instrument and its structure (calendar and questionnaire), and the reason they were being asked to help adapt its language. Participants asked questions about how the DA might be used in Brazil, and discussed what they thought about it. This allowed the facilitators to observe some of the normative language women used to talk about abuse as well as to establish group rapport.

The facilitator asked participants to listen as she read the sections line by line and to decide as a group if the wording in the EP-DA was what they would use in Brazil to describe a similar situation and if not, to decide what they would suggest in its place. When opinions differed, the facilitator asked participants to provide examples or describe the action they associated with the word or phrase, and come to a consensus as a group as to the most common language used in Brazil to describe the action or situation.

The facilitator noted each group's discussion, comments, changes, and resolutions for each question, phrase, or term directly onto a paper copy of the EP-DA. Throughout the discussions, the facilitator cross-referenced the suggested changes or modifications to the EP-DA with the original English version to review consistency in meaning. Where the facilitator noticed a suspected diversion in meaning between the English source document and the EP-DA and/or the Brazilian Portuguese modifications made to the EP-DA, the facilitator asked probing questions to ensure the item in the Brazilian Portuguese adaptation aligned in meaning with the item in the English DA source document. The facilitator made field notes of the proceedings in each session, and debriefed with the Brazilian team member about modifications to the document suggested by participants following the first two focus groups. These were incorporated into a clean version of the document.

Cross-Cultural Adaptation: Focus Group Discussion

The study team used an iterative process throughout the cross-cultural adaptation process. The first two focus groups each made one pass through the document, and were asked to accept the wording as it was, or make suggestions to adapt it to the Brazilian context. After the first two focus groups, the facilitator synthesized the wording modifications into a clean document.

The third focus group followed a three-step process. The first step was the same as that of the prior groups, with the facilitator following the same procedures reviewing the EP-DA and noting the discussion and proposed changes on a clean version of the source document. Then, the facilitator read the synthesized document from the previous focus groups to the third group, and made note of participant comments and suggestions. Finally, the facilitator led the group through a third step that compared the modifications their group had made to the original EP-DA alongside the ones they had just made to the synthesized document from the previous focus groups. The third group then discussed the differences in the suggestions they made and came to a consensus on the wording in the document. The extra steps for the third focus group were designed to test the reliability of the adaptations made by each group. Following the third focus group, the research team synthesized the feedback from the third group's document comparison and incorporated it into a draft version of the DA in Brazilian Portuguese.

Content Validation: Expert Reviewers

The study team further endeavored to establish content validity through a two-stage process of refinement in collaboration with three psychologists working in the Rio de Janeiro court system of domestic and family violence. The study team developed instructions based on the guidance provided by the senior author for the expert review of the document created in the focus groups. This included retaining the meaning of the phrases and based on their experience, to evaluate if the language and wording in the synthesized adaptation were ones the women they served would use and understand. Two psychosocial workers independently reviewed the draft version of the instrument created via the focus group discussions and made suggested revisions in writing. Following the structure of the earlier focus group reviews, the facilitator then synthesized their written feedback and presented the senior psychologist with a clean draft. After receiving the feedback from this third and final expert reviewer, we synthesized the suggested changes into a final draft. The final expert reviewer exceeded the scope of the exercise, making extensive recommendations for simplification of the document's language that substantially changed the meaning of the wording. These suggestions were excluded from the revisions to the final instrument. The resulting document is a final version of the DA in Brazilian Portuguese (DA-Brazil) ready for validation among speakers of Brazilian Portuguese.

Ethical and Participant Considerations

This study was approved by Emory University's Institutional Review Board (IRB) as well as the IRB of the Santo André municipal government and Plataforma Brasil (CAAE 57344616.0.000Aft.5485). In the introduction to the activity, we forewarned participants that while we would not ask them about personal experiences with violent partners, as a group we would discuss situations women might experience or be at risk for violence as well as the associated terms that describe them. We advised participants that if at any time they did not want to discuss a situation, they could take a break or choose not to join in the discussion around that particular subject. Likewise, if anyone wanted to seek help in addressing a personal experience or situation of violence, or seeking advice for someone else, a trained clinician and study team member would be available after the session to counsel them. Finally, we explained to participants that they were not study subjects and that no identifiable personal data would be collected or used. We explained we were asking their help as members of the community to translate the instrument for use among speakers of Brazilian Portuguese.

Results

Participant Demographics

The study team wanted the words and phrases the women decided upon to be the ones that would reflect the lived experience of women of all ages and socioeconomic backgrounds. Our participants ranged in age from 18 to 54 years, with an average age of 34 years (see Table 1).

Table 1.

Age Distribution of Focus Group Participants.

Age group (yrs.)	N
18–29	10
30–39	9
40–49	2
50 <	2
No response	1
Total	24

Following our guidance to achieve diversity in the population, a human resources manager purposively selected participants from among their functional roles and assigned women agreeing to participate to one of three groups. Each eight-member group was composed of a similar mix of administrative and clinical staff, and matched by department (custodial, administration, reception, nursing, psychosocial, laboratory, physicians, and fertility specialists). Within each department, the manager selected different hierarchical roles, including supervisors, aides, assistants, and technicians (see Table 2). This composition provided three similarly diverse groups representing a range of SES, age, and education that provided us with the desired heterogeneity for discussion in the groups (see Table 2).

Table 2.

Distribution of Focus Group Participants by Department and Role.

Department	Total by department	Supervisory/mid-level role	Assistant/aide role
Administration	8	2	6
Clinicians/specialists	2	1	1
Housekeeping	3	1	2
Laboratorians	1	1	0
Nursing	6	3	3
Pharmacy	2	1	1
Patient support	2	2	0
Total	24	11	13

Semantic, Cultural and Content Equivalence

In adapting the DA from European to Brazilian Portuguese, the study team sought to ensure that the new DA-Brazil would be the semantic, cultural, and content equivalent of the English source document so that our adaptation was as close to the original validated version as possible. Semantic equivalents are items that retain the same or similar meaning following translation; semantic meaning may vary somewhat in expression, but the meaning of the expression remains the same. Cultural equivalence is when the translation reflects lived experience, and content equivalence ensures that each item is relevant for the culture (Flaherty et al., 1988). Typically, homogeneity in age and background is desired for focus group discussions to facilitate group rapport (Hennink et al., 2011). However, in this case, it was important to have heterogeneity in the groups because we sought diversity in perspective and understanding in order to ensure that the DA-Brazil would reflect language that is accessible and appropriate to a wide range of speakers of that language. One interaction between the facilitator and participants exemplifies this: Facilitator:

Let's start with the words in the calendar that describe forms of aggression. The first word is “bofetadas” (slaps, open-handed blows).

Juliana:

I’d put “porrada” (slang for a violent strike, slapping or beating). We need to use words that we’d use in Brazil, right? Is “bofetadas” a word a 15-year old girl would use? Nobody uses “bofetão” to say he slapped me hard! He gave me a “porrada.” “Bofetão” no way! Who still says “bofetão”?

Ana Maria:

(laughing) “Bofetão” is from my grandmother's generation!

Juliana:

Exactly! What you hear now is “porrada”!

Achieving Semantic Equivalence: Expressions May Vary, but the Meaning is the Same

One of the key issues in translating a validated assessment such as the DA is ensuring that the translation retains the time frames and verb tenses as well as the meaning of the words that describe the events in the items in the source document. This is important because the DA items are derived from extensive research that identified specific temporal aspects of risk that contribute to overall risk of intimate femicide. In translation, the meaning of the time frames must be retained; however, a challenge is that colloquial Brazilian Portuguese often uses less-formal simplified verb tenses as opposed to the more formal, complex tenses that express a more precise temporal meaning in European Portuguese. The questions in the English source document may be primarily grouped as simple present tense that describe a current action, and simple past perfect which describes an action that occurred and finished in the past; this relates to one or more occasional occurrences that are not habitual. The progressive tenses indicate incomplete action. Past perfect progressive describes an action that was ongoing and then interrupted in the past, and the present perfect progressive describes an action started in the past and that continues into the present. To respect the nuance of temporality of each risk in the context of the validated instrument, it was important to maintain the sense of temporality in the translation, even if the expression was different (see Table 3).

Table 3.

Verb Tenses and Time Frames in the English Danger Assessment.

Simple present (current action)	Present perfect (occurred, experienced in the past)	Past perfect progressive (on-going action in the past interrupted)	Present perfect progressive (started in the past and on-going in the present)
Does he own a gun? Does threaten to kill you? Does he spy on you? Does he follow you? Does he control you? Does he use illegal drugs? Do you have a child that is not his? Is he an alcoholic or problem drinker? Is he violently and constantly jealous of you? Does he threaten to harm your children? Do you believe he is capable of killing you? Does he ever try to choke you?	Has he ever used a weapon against you or threatened you with a lethal weapon? Has he ever forced you to have sex with him when you did not wish to do so? Have you ever been beaten by him while pregnant? Has he ever threatened or tried to commit suicide? Have you ever threatened or tried to commit suicide?¹	Have you left him after living together in the past year?	Has the violence increased over the past year?² Has he avoided being arrested for domestic violence?
¹To identify women at risk of suicide ²Used with calendar abuse severity scale

Achieving Cultural Equivalence: Ensuring the Language “Reflects the Lived Experiences of Survivors”

In the first section of the DA, women list abusive events on a 12-month calendar using a scale from one to five that corresponds to a list of types of physical abuse that ranges in severity and duration, from one (slapping, pushing; no injuries or lasting pain) to five (use of weapon; wounds from weapon). The suggested changes among the three groups were more frequent when describing actions such as slapping, hitting, punching, and beating, than among terms that indicated specific types of injury. Specific forms of physical abuse that left lasting marks or pain such as cuts (cortes), burns (queimaduras), broken bones (ossos quebrados) were understood in the same way across the three focus groups, while those that described less specific types of injuries to the head, internal, or permanent injuries differed among the discussion groups as did the use of terms for “bruises/bruising” and “contusions.” For the verb strangle/strangled, suggestions varied from “estrangulamento,” “esganamento,” “enforcamento,” and “estrangulada.”

The second section of the DA describes known risk factors of intimate femicide phrased as yes/no statements. As mentioned previously, these questions have an element of temporality that needed to be aligned with the English source DA. To adapt the more formal EP-DA version into a less formal and more colloquial DA-Brazil version, both grammatical and lexical changes were identified to maintain equivalences in meaning. In the Brazilian version, this included substituting the subject pronoun “você” (“you”) for direct object pronouns (“la”) as in “to choke you” (“estrangulá-la” for “estrangular você”) and for indirect object pronouns (“lhe”) as in “to call you” (“telefone-lhe” for “telefonar você”). Words were replaced with more colloquial terms such as “to call” (ligar) for “to telephone” (telefonar), “quebra as suas coisas” (break your things) for “destrói a sua casa” (destroy your house), and “vigia” (watch) for “espia” (spy on).

Content Equivalence: Indicators of Intimate Femicide Risk

For many of the key indicators of risk, participant feedback revolved around terminology and reflected the difficulties that translating validated instruments can present. One of the primary risk factors for intimate femicide is strangulation, and as described above, there was great variation in the use of different terms to describe it. This ranged from accepting the EP-DA version of choking as “sufocá-la, por exemplo estrangulando-a” (“suffocate you, for example strangling you”), to “enforcar” (to hang or strangle), “esganar” or “estrangular”; the last two terms were both offered by the third focus group after rich discussion. These words are distinguished by the use of an object such as a strap or belt (estrangular) as opposed to only using the hands to strangle or choke someone (esganar). Interestingly, more colloquial references—such as the use of the term “mata-leão,” or “lion-killer,” which is a Brazilian Jiu-Jitsu martial-art term for a chokehold made from behind a person with the arm around the neck—were not mentioned. In another example, there was extensive discussion of whether to use “weapon” (“arma”), “firearm” (“arma de fogo”), “revolver,” or “pistol” to describe a gun.

Suggestions and Resulting Items

The first two focus groups had very similar suggestions for refining words and definitions, and changed few words and phrases in the EP-DA. The third group made many suggestions and engaged in lively discussion; however, when they were asked to compare their modifications and comment on the synthesized version from the previous groups, they made little deviation from the synthesized version, even when asked about differences they had previously discussed, suggesting a degree of saturation.

Fidelity to the Source Document

The DA has undergone extensive validation and refinement in the United States over almost two decades to ensure the risks it measures are indicative of an individual's risk of intimate femicide. Thus, it is important for translations of this document to preserve and convey the original intent of each risk factor in the English source document. Errors in translation that do not capture nuance or that change the meaning of the indicator can lead to an inaccurate representation of an individual's risk. While all risk factors may not be contextually equivalent across cultures, many are universal and others may be similar. Thus, it is important to maintain semantic and cultural equivalency while working to validate contextual equivalency. Examples of decreased fidelity to the source document that can change the intention of the indicator include errors in translation and colloquialisms such as choices of verb tense and/or vocabulary that can alter the meaning of the risk factor. Prior versions of the EP-DA translation and an un-back translated and un-validated Brazilian Portuguese translation provide examples of such errors.

One such example appears in the abuse scale in the calendar section (see Table 4). In this section, each level of abuse in the scale has a descriptor for the type of abuse and sequelae. The first level in the English source document is “slapping, pushing; no injuries and/or lasting pain” (Campbell, 2013). The EP-DA source document uses “slapping, pushing, absence of injury, with or without lasting pain.” The Brazilian translation used as a reference for this activity, listed “slapping, pushing, without injury and/or pain present.” In this case, the terms for the types of abuse, slapping, and pushing, are translational and semantic equivalents. The word choice in the two translations are the same for pushing “empurrões,” and while different for slapping—“bofetadas” and “tapas”—they share the same meaning.

Table 4.

English Danger Assessment (DA) Calendar Abuse Scale (Updated 2017).

Scale	English DA Source Document	Translation: EP-DA	Translation: Unvalidated Brazilian Portuguese
1	Slapping, pushing; no injuries and/or lasting pain	Slaps, shoves, absence of wounds, with or without lasting pain	Slaps, shoves, without injury and/or pain present
2	Punching, kicking; bruises, cuts, and/or continuing pain	Punches, kicks, bruises, cuts, with or without continuous pain	Perforations, kicks, punches, cuts, and/or pain present
3	“Beating up”; severe contusions, burns, broken bones	Beating or “thrashing,” severe bruising, burns, broken bones	“Beating,” severe bruising, burns, broken bones
4	Threat to use weapon; head injury, internal injury, permanent injury, choking or miscarriage	Threat to use a weapon, head wounds, internal wounds, consequences of the injuries	Threat to use weapons, head injuries, internal injuries, permanent injuries
5	Use of weapon; wounds from weapon	Use of weapons, gunshot wounds	Use of weapons, injury resulting from the use of weapons

The description of pain, however, is different. The English DA source document indicates that the individual has not experienced injury or lasting pain (no injury and/or lasting pain). The EP-DA version changes the meaning to include the possibility of lasting pain; present pain and lasting pain are slightly different. The prior un-validated, un-back translated Brazilian Portuguese is closer in meaning to the English DA than the EP-DA in this instance. This is further complicated by the elimination of the punctuation in the EP-DA. In the English source document, there is a semi-colon that serves to separate the act of violence from the injury it causes. These two aspects of the item may be very different, and the instructions indicate noting the more severe of the two on the calendar. Someone could be pushed and sustain a head injury (a “4” on the scale), or be pushed yet have no wounds and experience no pain (a “1” on the scale). Likewise, a current or former intimate partner could threaten to use a weapon on a woman but not physically harm her, and it would be considered a “4” on the scale (see Table 4).

Another example is the key intimate femicide risk factor of “violent and continuous jealousy.” Translation errors from English into European Portuguese led to confusion in responses within the first two focus groups. The translation into European Portuguese was, “he is violent and is constantly jealous.” The first two focus groups accepted this translation; the third offered, “he gets violent because of jealousy.” Yet, neither translation is close to the original sentiment, which is the combination of “violently jealous” and “constantly jealous.” This is important because individually, violence and jealousy are not necessarily precursors to intimate femicide, but the combination of violent jealousy and constant jealousy is. In this case, validation of the adaptations made by the first two focus groups and that the meaning of the translation aligned with the intent of the original English source document were the important outcomes. We reached saturation with the first two focus groups; the third group had little to add that was new and didn’t define the actions differently.

Discussion

There are two primary considerations in approaching the translation of a survey or instrument for intervention or research into another language: semantic and cultural equivalency (Givens et al., 2007; Killoran & Moyer, 2006; Sidani et al., 2010; Stewart & Nápoles-Springer, 2000). Addressing the first assures that the intended meaning and intent of the risk factor or scale item is preserved. This is particularly important for a document such as the DA in which the instrument helps abused women make informed decisions based on their risk for intimate femicide, including formulating appropriate safety plans, and securing appropriate protective measures. Cultural equivalency ensures that the risk factors relate to lived experiences in context as well as how individuals describe them in their own words. The challenge lies in melding the two to achieve contextual equivalency: translating an assessment that has been validated and refined in one language, so that it both retains the significance of the risk described as well as resonating with the lived experiences of a socioeconomically and geographically diverse group of individuals in a novel context. In order for individuals to be able to respond to survey questions or assessment items accurately, it is important for them to be able to understand and relate to the concepts. The items must reflect their reality in a way that expresses what is happening to them in language they would use and understand, as well as conceptually (Pearce et al., 2003). In this way, engaging the target community as experts to convert the document into their own language helped advance the translation.

Limitations

Factors that limit the study primarily relate to the study site and participant sampling, including the small number of focus groups (N = 3). Since the primary objective of the focus groups was to gain input in wording and not to obtain saturation in meaning, the small number of focus groups was appropriate, especially given that we reached saturation.

While all three groups contributed to changes to the EP-DA, the third group served a dual role as arbiter, deciding differences between the previous groups’ consolidated version and its own. As such, it could have influenced the phrasing of the final version. However, the third group was just as likely to accept the changes in the consolidated version over their own. Further, the final changes suggested by the independent experts confirmed contextual equivalency.

One site in metropolitan São Paulo hosted the focus groups, and on behalf of the study team recruited from among its staff and assigned participants to groups; inclusion criteria did not specify recruitment based on demographics. While the study team did not collect extensive demographic data on participants, it sought heterogeneity in the sample by inviting staff members from each division (custodial, administrative, clinical, and laboratory) to participate. This method of recruitment within the same professional environment served as a proxy for demographic information on SES and provided some diversity in age, income level, and educational background. Participants were not recruited based on race and ethnicity nor employment status. Thus, Afro-Brazilian, Asian, and Indigenous women may be under-represented, and under- and unemployed women did not participate.

Participants were colleagues with existing rapport and seemed comfortable interacting with each other, despite differences in social status and education. At the start of the discussions, some of the women deferred to the study team—one was a senior faculty member and the other not Brazilian—however, they did not defer to one another based on any observable differences such as departmental role. Learning about the purpose of the DA and the purpose of the study during the warm-up engaged participants and most readily joined in the discussion.

A fixed-room set-up complicated the establishment of group rapport. Spatially, the room was not conducive to focus group dynamics. It had fixed, conference-style seating facing a raised dais with a head table and chairs for the research team. The participants had to turn to face each other, and the dais established distance between the study team and participants. To “level” herself, the non-Brazilian facilitator sat on the edge of the dais facing the group in very close proximity and positioned to look up at the participants.

Finally, the team recognizes that linguistic regionalisms may influence word choice, as well as how women understand the significance and meaning of the questions. We accounted for differences within the Southeast region of Brazil by asking subject matter experts from another metropolitan area, Rio de Janeiro, to provide feedback in the second phase of the study. Review by the expert team from Rio de Janeiro did not yield significant differences from the sessions in São Paulo; both locations were in Southeastern Brazil and additional regional differences were not accounted for. This work reflects the first step in translation of the DA-Brazil, and the team recommends a face validation assessment and pilot testing among women for language appropriateness prior to use nationally or in regions other than Southeastern Brazil.

Conclusion

We present a model for community involvement in the cross-cultural adaptation and content validation of an intimate femicide risk assessment instrument used for intervention and research. This model is useful for testing usage and meaning of language across countries. Involving members of the target population in the process of translating a scale or assessment for use among that population is a means of ensuring the cultural relativity of a concept as well as gaining an understanding of how the target population expresses experienced phenomena. In translating interventions or scales for use in a different language and culture, combining the perspectives of members of the community (emic) with those of experts in the field (etic) in the process of translating and adapting instruments can tease out differences in the way individuals understand and express concepts relating to emotionally charged issues. In addition to its use to identify women at immediate risk of intimate femicide, the translated DA-Brazil may be used by women themselves as well as by first responders, health professionals, police, lawyers, and judges to identify women at risk as an aid in decision making around provision of protective and social services. The newly translated and culturally adapted version of the DA has the potential to save women's lives in Brazil. To facilitate this end goal, our next steps are to test the DA-Brazil among women experiencing violence within their intimate relationships.

Supplemental Material

sj-pdf-1-vaw-10.1177_10778012211051397 - Supplemental material for We need to use words that we’d use in Brazil, right? A Community-Based Content Validation of a Translated Femicide Risk Assessment Instrument

Supplemental material, sj-pdf-1-vaw-10.1177_10778012211051397 for We need to use words that we’d use in Brazil, right? A Community-Based Content Validation of a Translated Femicide Risk Assessment Instrument by Olivia C. Manders and Casey D. Xavier Hall, Maria A. F. Vertamatti, Dabney P. Evans, Jacquelyn C. Campbell in Violence Against Women

Footnotes

Acknowledgments

The authors thank the women who participated in the focus groups for their enthusiastic contribution to the project; our research partner and site, the Faculdade de Medicina do ABC, Santo André, Brazil, for providing technical support, recruiting participants, time off for staff members to participate, and hosting the discussions. Special thanks to Ms. Richelle Bolyard for her support and guidance; Dr. Juliana Corrêa, and Judge Adriana Ramos de Mello of the 1st Court of Family and Domestic Violence of Rio de Janeiro, Brazil, and her team, for providing expert review of the draft instrument version. Thanks to Drs. Ana Teixeira and Catherine Ostrom of the Emory University Department of Spanish and Portuguese, and Emory University graduate students Ana Paula Pohl Duarte, MPH, Natalia Souza JD (c), and Shaiana Oliveira, MPH, for translating and back translating the different versions of the instrument into Brazilian Portuguese and back to English for comparison purposes. The authors are very grateful to the Emory University Research Committee and the Emory Global Health Institute for funding this project.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by funding from the Emory University Global Health Institute and the Emory University Research Committee.

ORCID iDs

Olivia C. Manders

Dabney P. Evans

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Olivia C. Manders, MPH, MA, is a program manager in the Hubert Department of Global Health at Emory University. Her research interests include gender-based violence, social norms, and social support. She is currently managing qualitative studies focusing on women's perceptions of Zika virus infection in pregnancy in Latin America and trauma-informed care in Ryan White Region IV primary care clinics.

Casey D. Xavier Hall, PhD, MPH, is a postdoctoral scholar at the Institute for Sexual and Gender Minority Health and Wellbeing at Northwestern University. His work focuses on mixed-methods, intersectional approaches to sexual health disparity, and violence research.

Maria A. F. Vertamatti, MD, PhD, is a gynecologist and an associate professor in the Faculdade de Medicina do ABC, in Metropolitan São Paulo, Brazil. Since 2000, she has coordinated the Program for Integrated Care for Survivors of Sexual Violence—the main focus for her research and publications.

Dabney P. Evans, PhD, MPH, is an associate professor in the Hubert Department of Global Health at Emory University. Her research focuses on gender-based violence and sexual and reproductive health and rights. Dr. Evans is the author of over 45 peer-reviewed manuscripts. Her public scholarship has appeared in The Pacific Standard, Ms. Magazine, and The Hill.

Jacquelyn C. Campbell, PhD, MSN, RN, is a national leader in research and advocacy in the field of domestic and intimate partner violence (IPV). She has authored or co-authored more than 230 publications and seven books on violence and health outcomes. She was a member of the congressionally appointed U.S. Department of Defense Task Force on Domestic Violence.

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