Cross-cultural adaptation of Dimensions of Corporate Well-Being Scorecard to the Brazilian Portuguese language

| Background: The integration of occupational risk management initiatives and health promotion and well-being in the workplace poses a challenge to organizations from different sectors. Objective: Cross-cultural adaptation of the Dimensions of Corporate Well-Being Scorecard (DCWS) to the Brazilian Portuguese language. Method: The process of cross-cultural adaptation of the Dimensions of Corporate Well-Being Scorecard to the Brazilian Portuguese language evolved along six steps: translation, reconciliation, back-translation, revision by internal expert committee, revision by expert panel (pretest) and final revision. Results: The stringent protocols adopted in the present study resulted in a satisfactory and adequate instrument to analyze programs which target workers’ health, safety and well-being at organizations operating in Brazil. Conclusion: The Brazilian version of DCWS, entitled Questionário sobre as Dimensões do Bem-Estar Corporativo (QDBC) represents an advance in the evaluation of the effectiveness of integrated actions for health promotion and workers’ well-being in different work environments.


INTRODUCTION
The concern with occupational health is increasing among organizations from several sectors 1 .Such organizations have acknowledged the impacts of work environments and conditions on the health and well-being of workers, which sometimes contribute to the development of physical and mental disorders, with consequent impairment of the productivity of organizations [2][3][4] .
To eliminate or control hazards in organizational environments, institutions seek to develop and implement actions to improve health and safety at work and promote the well-being of workers.
However, to accomplish consistent results, such actions should replace dispersed and fragmented measures merely aiming at attenuating negative effects by articulated policies, programs and practices which integrate the elimination or control of existing occupational hazards with measures aiming at promoting health in the workplace and the well-being of workers 5 .
To contribute to such integration, national and international centers are developing instruments to help organizations assess their own programs, as well as their degree of success in the integration of measures previously implemented separately into a broad-scoped program focusing on the health, safety and well-being of workers 6,7 .
Within this context, the Harvard T.H. Chan School of Public Health Center for Work, Health and Well-being has an active role in the development of instruments to support the implementation of approaches aiming at reducing or eliminating occupational hazards and promoting health in the workplace in an integrated manner.
With the support of HealthPartners, the aforementioned school developed a set of three instruments to evaluate several variables related to workers' health, safety, and well-being in an integrated manner.These instruments were grouped in a document entitled the Dimensions of Corporate Integration (DCI) measurement tool. 8.
To make it available to Brazilian organizations, healthcare professionals and in particular to occupational physicians involved in integrated management of health and safety at work, the National Association of Occupational Medicine (Associação Nacional de Medicina do Trabalho-ANAMT) performed the translation and cross-cultural adaptation of the instruments contained in DCI, to wit: Dimensions of Corporate Safety Scorecard (DCSS), Dimensions of Corporate Well-Being Scorecard (DCWS) and Indicators of Integration Scorecard (in progress).
DCSS is already available for use in Brazil, where it is known as Questionário sobre as Dimensões de Segurança Corporativa (QDSC) 7 .
The translation and cross-cultural adaptation of DCWS were concluded recently, and represent the focus of the present article, which describes the process undertaken by the group of investigators responsible for the project to make a version adapted to the Brazilian context available.
DCWS comprises five sections entitled "Organizational culture and leadership," "Program design," "Program implementation and resources", " Program evaluation, " and "Scoring summary".Items are scored on a Likert scale which ranges from "Does not apply at all" (0) to "Fully applies" (5); the total score ranges from 0 to 100.
The first four sections were developed based on the document entitled The Essential Elements of Effective Workplace Programs and Policies for Improving Worker Health and Well-being, formulated by the National Institute for Occupational Safety and Health (NIOSH) which concepts were adapted for use in an assessment instrument 8 .
DCWS was intentionally validated with a sample of employees of small and medium-sized enterprises, together with two other instruments developed by the Harvard T.H. Chan School of Public Health Center for Work, Health and Well-being.The internal consistency (α=0.94) and item-total correlation (0.17˜0.19) obtained for construct validation were adequate.Other studies were performed with construction and health workers in the attempt to better understand the behavior of the analyzed instrument in different occupational contexts 5,6,9,10 .

METHOD
The process of cross-cultural adaptation of DCWS to the Brazilian Portuguese language was organized in six steps according to international recommendations for cross-cultural adaptation of instruments, to wit: translation, reconciliation of translations, back-translation to the original language, revision of the Portuguese version by an internal expert committee, pretest involving application to an expert panel, and final revision [11][12][13] .
First ANAMT entered in a partnership with Harvard T.H. Chan School of Public Health and Well-being, and obtained formal authorization to start the translation and adaptation of the original instrument 11.Next, two translators independently translated DCWS to the Brazilian Portuguese language.Both translators were native Portuguese speakers, and were given orientation on the aims of the present study to perform a conceptual translation and ensure semantic, idiomatic, experiential and conceptual equivalence.The result of this step was DCWS Portuguese versions 01 and 02.
These versions were analyzed by the project scientific coordinator for the purpose of reconciling them into one single version and remove possible bias.This step resulted in a third Portuguese version of DCWS 14 .
This third version was delivered to two bilingual translators, who independently performed back-translation into the original language.Both translators were fluent in English (a Scottish nurse with experience in mental health, and a Brazilian psychologist with proven English proficiency), did not participate in the earlier steps of the study, and were oriented to perform a literal translation of the version received 13 .
The aim of this step was to ensure high quality to the adapted version, as it allowed identifying inconsistencies in the earlier translations from the original into the Brazilian Portuguese language, resulting in ambiguity and problems in the understanding of idioms uncommon in definite contexts.
Next the two back-translations and the Portuguese versions 01, 02, and 03 were delivered to an internal expert committee specifically called for the present project.This panel comprised five professionals in psychology, social work and management from Laboratory of Mental Health and Quality of Work Life (Laboratório de Saúde Mental e Qualidade de Vida no Trabalho-LSMQVT), Dom Bosco Catholic University (Universidade Católica Dom Bosco-UCDB) with large experience in occupational health psychology, occupational health, and instrument validation.
Together with the professionals who performed back-translation, this committee analyzed the compatibility of versions with the original instrument.They also suggested adjustments in the Portuguese version whenever needed to ensure the equivalence and adequacy of statements as a function of the intended responders.This step resulted in a fourth Portuguese version of DCWS.This version was assessed through application (pretest) to an expert panel composed of 20 professionals from different fields related to workers' health, safety, and well-being, to wit: labor appellate judges, lawyers, managers, psychologists, occupational nurses, social workers, human resources managers, occupational physicians and psychiatrists, and university nursing and psychology professors.The study scientific coordinator oriented the panel members as to the study aims and methods.The participants were informed about the procedure for the pretest, and were instructed to identify the items and statements with problems in their formulation, were difficult to understand, or somehow disagreed with the legislation in force in Brazil.
The recommendations made by the expert panel were communicated to the internal expert committee for analysis and, when accepted, to be included in the instrument.Inclusion of suggestions rated valid allowed adjusting statements difficult to understand or with problems in their formulation without any change in their meaning.
A final revision, including typographic and grammatical aspects, was performed by the group of investigators responsible for the study.The aim here was to rule out any flaw in the final Portuguese version of DCWS.This step resulted in the fifth version of DCWS, now renamed Questionário sobre as Dimensões do Bem-Estar Corporativo (QDBC) -to wit, the adapted version semantically adequate for application in Brazil.

DEVELOPMENT OF THE VERSION FOR ADMINISTRATION TO THE EXPERT PANEL
To ensure the semantic, idiomatic, empirical and conceptual equivalence of the Brazilian version of DCWS 15 , the investigators responsible for this project performed a systematic process of translation and cross-cultural adaptation in compliance with international standards [11][12][13] .
The two first Portuguese versions were obtained through independent translation of the original instruments by two translators.But for some small differences in the translation of some terms, these two versions were considered similar in regard to the structure of statements.
The differences found in the translation of some terms between these two versions (for instance, "effective programs" was translated as "programas efetivos" and "programas eficazes"; "encourage" as "encorajam" and "incentivam"; "commitment" as "compromisso" and "comprometimento," among others) did not change the meaning of the statements included in the original instrument.
To develop the synthetic version to be applied to the expert panel, the project scientific coordinator reconciled the two translations into a single one.We cannot say that the characteristics of this synthesized version derived from any of the two translations given the similarity between both.Whenever divergences were found, the criterion for selection was the adequacy of terms to the language spoken by the targeted population of responders.The result of this step was a third Portuguese version of DCWS.
To ensure high quality to the process of translation and cross-cultural adaptation, the internal expert committee analyzed the two back-translations having the third Portuguese version as basis, and compared them to the original instrument.Inconsistencies were found, for which reason some items were revised to ensure equivalence between the original and translated versions.
For instance, section 1-entitled in the original "1.Organizational culture and leadership"-was reconciled as "Cultura e Liderança Organizacional." Following the revision by the internal expert committee, it was changed to "Cultura Organizacional e Liderança." Relative to item "1.2 Demonstrate leadership, " the explanatory section "In some notable examples, corporate Boards of Directors have recognized the value of workforce health and well-being" was reconciled as "Em alguns exemplos emblemáticos, os Conselhos Administrativos Corporativos reconheceram o valor da saúde e bem-estar da força de trabalho." This section was rewritten by the internal expert committee as "Em alguns exemplos notórios, os Conselhos de Administração Corporativos reconheceram o valor da saúde e bem-estar da força de trabalho." For item "2.2.Integrate relevant systems," changes were made to the translation of section "Integrate separately managed programs into a comprehensive health-focused system and coordinate them with an overall health and safety management system." In the reconciled version this section was translated as "Devem-se integrar e coordenar separadamente os programas gerenciados em um sistema abrangente centrado na saúde com um sistema geral de gerenciamento de saúde e segurança." Following the internal expert committee revision, the version applied to the expert panel read "Deve-se integrar os programas, gerenciados separadamente, em um amplo sistema centrado na saúde e coordená-los com um sistema geral de gerenciamento de saúde e segurança." Similar changes were made in sections "3.Program design," "4.Program implementation and resources", and "5.Program Evaluation" to ensure not only equivalence between versions, but also to make items easier to understand by rewriting statements rated by the internal expert committee as difficult to understand.
The revision performed by the internal expert committee resulted in the fourth Portuguese version of DCWS.The equivalence of this to the original version is shown in Table 1, which summarizes the steps of the process of translation and cross-cultural adaptation of DCWS until the version administered to the expert panel was obtained.
The experts required about 35 minutes to respond and evaluate the Portuguese version of DCWS.Once all the participants had finished making suggestions, the project scientific coordinator led the analysis of all 20 items in the

Engage midlevel management
Supervisors and managers at all levels should be involved in promoting health-supportive programs.They are the direct links between the workers and upper management and will determine if the program succeeds or fails.Mid level supervisors are the key to integrating, motivating and communicating with employees.

Program design 2.1. Establish clear principles
Effective programs have clear principles to focus priorities, guide program design, and direct resource allocation.Prevention of disease and injury supports worker health and well-being.

Integrate relevant systems
Program design involves an initial inventory and evaluation of existing programs and policies relevant to health and well-being and a determination of their potential connections.
In general, better integrated systems perform more effectively.Programs should reflect a comprehensive view of health: behavioral health/mental health/physical health are all part of total health.No single vendor or provider offers programs that fully address all of these dimensions of health.Integrate separately managed programs into a comprehensive health-focused system and coordinate them with an overall health and safety management system.Integration of diverse data systems can be particularly important and challenging.

Be consistent
Workers' willingness to engage in worksite health-directed programs may depend on perceptions of whether the work environment is truly health supportive.Individual interventions can be linked to specific work experience.Change the physical and organizational work environment to align with health goals.For example, blue collar workers who smoke are more likely to quit and stay quit after a worksite tobacco cessation program if workplace dusts, fumes, and vapors are controlled, and workplace smoking policies are in place.

Promote employee participation
Ensure that employees are not just recipients of services but are engaged actively to identify relevant health and safety issues and contribute to program design and implementation.Barriers are often best overcome through involving the participants in coming up with solutions.Participation in the development, implementation, and evaluation of programs is usually the most effective strategy for changing culture, behavior, and systems.

Adjust the program as needed
Successful programs reflect an understanding that the interrelationships between work and health are complex.New workplace programs and policies modify complex systems.Uncertainty is inevitable; consequences of change may be unforeseen.Interventions in one part of a complex system are likely to have predictable and unpredictable effects elsewhere.Programs must be evaluated to detect unanticipated effects and adjusted based on analysis of experience.

Make sure the program lasts
Design programs with a long-term outlook to assure sustainability.Short-term approaches have short-term value.Programs aligned with the core product/values of the enterprise endure.There should be sufficient flexibility to assure responsiveness to changing workforce and market conditions.

Ensure confidentiality
Be sure that the program meets regulatory requirements (e.g., HIPAA, State Law, ADA) and that the communication to employees is clear on this issue.If workers believe their information is not kept confidential, the program is less likely to succeed.

Build accountability
Build accountability into program implementation.Accountability reflects leadership commitment to improved programs and outcomes and should cascade through an organization starting at the highest levels of leadership.Reward success.

Construindo responsabilidade
Construa responsabilidade na implantação do programa.A responsabilidade reflete o compromisso da liderança para a melhoria dos programas e resultados e deve ter efeito cascata por meio dos mais altos níveis de liderança.Recompense o sucesso.instrument, and asked the panel members to report any problem found in their structure, or any flaw likely to impair an adequate understanding of the items.Many panel members (65%) reported difficulty to understand how to respond the instrument in general.In their view, the statements seemed to correspond to recommendations to organizations of practices likely to improve the well-being of workers, and it was not clear to them what respondents should assess.
The main issue was whether respondents ought to opine on the existence of such good, often ideal practices, or on the availability of initiatives or programs compatible with the items described in column "Essential element." The study scientific coordinator explained that assessment concerned the items described in column "Essential element." She also observed that the difficulties in understanding could be related to how the original instrument was formulated, to wit, based on an adaptation of NIOSH document The Essential Elements of Effective Workplace Programs and Policies for Improving Worker Health and Well-being 8.
To facilitate the understanding of items, the expert panel suggested rewriting the headings of the four first sections and 20 items in a way to make what should be effectively assessed clear.
The changes suggested by the expert panel to adequate the descriptions of items in section "1.Organizational culture and leadership" are described in Table 2.The changes made to section "2.Program design" are listed in Table 3. Table 4 summarizes the changes made to items in section "3.Program Implementation."Finally, Table 5 shows the adjustments in section "4.Program evaluation" suggested by the expert panel and accepted by the study investigators.
Still in regard to section "Organizational culture and leadership", term workforce, initially translated as "força de trabalho, " was changed to "trabalhadores", and "mid-level supervisors," from "supervisores de nível médio" to "supervisores de nível intermediário." These changes sought to adapt the statements to the way the target population of respondents usually speaks (Table 2).
In section "Program design" (Table 3), statement "Programs should reflect a comprehensive view of health: behavioral health/mental health/physical health are all part of total health.No single vendor or provider offers programs that fully address all of these dimensions of health.Integrate separately managed programs into a comprehensive health-focused system and coordinate them with an overall health and safety management system" was initially translated as "Os programas devem refletir uma visão abrangente da saúde: saúde comportamental/saúde mental/saúde física são todas partes da saúde geral.Nenhum vendedor ou fornecedor oferece programas que abordam completamente todas essas dimensões da saúde.Deve-se integrar os programas, gerenciados separadamente, em um amplo sistema centrado na saúde e coordená-los com um sistema geral de gerenciamento de saúde e segurança" [our emphasis].
Still in regard to section "Program design" (Table 3) the panel suggested rewriting statement "Design programs with a long-term outlook to assure sustainability." Initially translated as "Elabore programas com perspectiva de longo prazo para assegurar sua sustentabilidade" (our emphasis), in the

Engage midlevel management
Supervisors and managers at all levels should be involved in promoting health-supportive programs.They are the direct links between the workers and upper management and will determine if the program succeeds or fails.Mid level supervisors are the key to integrating, motivating and communicating with employees.

Original version
Expert panel version (5 th Portuguese version)

Establish clear principles
Effective programs have clear principles to focus priorities, guide program design, and direct resource allocation.Prevention of disease and injury supports worker health and well-being.

Integrate relevant systems
Program design involves an initial inventory and evaluation of existing programs and policies relevant to health and well-being and a determination of their potential connections.In general, better integrated systems perform more effectively.Programs should reflect a comprehensive view of health: behavioral health/mental health/physical health are all part of total health.No single vendor or provider offers programs that fully address all of these dimensions of health.Integrate separately managed programs into a comprehensive health-focused system and coordinate them with an overall health and safety management system.Integration of diverse data systems can be particularly important and challenging.

Eliminate recognized occupational hazards
Changes in the work environment (such as reduction in toxic exposures or improvement in work station design and flexibility) benefit all workers.Eliminating recognized hazards in the workplace is foundational to WorkLife principles.

Be consistent
Workers' willingness to engage in worksite healthdirected programs may depend on perceptions of whether the work environment is truly health supportive.Individual interventions can be linked to specific work experience.Change the physical and organizational work environment to align with health goals.For example, blue collar workers who smoke are more likely to quit and stay quit after a worksite tobacco cessation program if workplace dusts, fumes, and vapors are controlled, and workplace smoking policies are in place.

Promote employee participation
Ensure that employees are not just recipients of services but are engaged actively to identify relevant health and safety issues and contribute to program design and implementation.Barriers are often best overcome through involving the participants in coming up with solutions.Participation in the development, implementation, and evaluation of programs is usually the most effective strategy for changing culture, behavior, and systems.

Adjust the program as needed
Successful programs reflect an understanding that the interrelationships between work and health are complex.New workplace programs and policies modify complex systems.Uncertainty is inevitable; consequences of change may be unforeseen.Interventions in one part of a complex system are likely to have predictable and unpredictable effects elsewhere.Programs must be evaluated to detect unanticipated effects and adjusted based on analysis of experience.

Make sure the program lasts
Design programs with a long-term outlook to assure sustainability.Short-term approaches have shortterm value.Programs aligned with the core product/values of the enterprise endure.There should be sufficient flexibility to assure responsiveness to changing workforce and market conditions.

Ensure confidentiality
Be sure that the program meets regulatory requirements (e.g., HIPAA, State Law, ADA) and that the communication to employees is clear on this issue.If workers believe their information is not kept confidential, the program is less likely to succeed.

O programa garante a confidencialidade
Certifique-se que o programa atenda aos requisitos legais (Código de Ética Médica) e que a comunicação com os trabalhadores seja clara nesse aspecto.Se os trabalhadores acreditam que suas informações não são confidenciais, o programa terá menos chances de sucesso.final version it says: "Programas com perspectiva de longo prazo devem ser elaborados para assegurar sua sustentabilidade" (our emphasis).Once again, the idea was to facilitate the reading and understanding of the instrument without changing the meaning of statements.
Further narrow-scoped changes seeking to standardize the terms used as a function of the target respondents, and update legal aspects to the norms in force in Brazil (as e.g., the Medical Ethics Code) were suggested by the expert panel and included in the instrument.These changes are described in Tables 2, 3, 4, and 5.
Similar procedures were used in the translation and cross-cultural adaptation of the instructions to respond the instrument and scoring to ensure the semantic, idiomatic, experiential and conceptual equivalence of statements.
Once the process of translation and cross-cultural adaptation was over, the instrument was named QDBC which is the adapted, semantically adequate Brazilian Portuguese version.

DISCUSSION
Adapting instruments for use in different countries and cultures is a complex task, and demands complying with internationally accepted protocols to ensure the high quality of the work done, achieve equity in assessment, and comparability between the scores obtained with the original and adapted versions [16][17][18] .
The procedures adopted in the present study (translation, reconciliation, back-translation, revision by internal expert committee, assessment by expert committee, and final revision by the project investigators) were designed to ensure high quality to the final Portuguese version of DCWS, by following internationally acknowledged recommendations for translation and cross-cultural adaptation of instruments.
The steps of translation and reconciliation resulted in the earliest Portuguese version of the instrument of interest.Back-translation detected semantic or conceptual differences likely to impair the equivalence of the Portuguese to the original version.The revision performed by the internal expert committee sought to solve such discrepancies and develop the version to be administered to the expert panel as pretest.
The recommendations made by the expert panelcomposed of professionals with large experience in health and safety in the workplace -allowed adjusting the instrument to the Brazilian reality, without interfering with the semantic, idiomatic, experiential, and conceptual equivalence of the instrument.
A relevant contribution made by the expert panel, which was accepted and included by the internal expert committee and the project investigators, was the suggestion to rewrite the description of the 20 items to be assessed in the first four sections in a way respondents might see what they should consider upon scoring these items.
This procedure made the statements easy to understand by the expert panel without impairing their equivalence to the ones in the original instrument.
The description of items was indeed modified, however, this change was necessary to adapt the Brazilian version of DCWS to how the target respondents do speak.Differently from a mere translation, cross-cultural adaptation often demands changes in the instrument's layout, or adjustments in examples and statements to ensure not only the semantic and idiomatic, but also the experiential and conceptual equivalence of the translated and adapted versions 14 .
The present study contributes to enlarge the set of available validated instruments to assess workers' health, safety and well-being under different working conditions.
The adaptation of DCWS to the Brazilian Portuguese language, together with the translation of DCSS into Portuguese 7 , and the future translation of Indicators of Integration Scorecard will thus make available in Brazil all three instruments composing DCI, developed by Harvard T.H. Chan School of Public Health -Center for Work, Health and Well-being 8 .This initiative increases the arsenal of instruments available to achieve more accurate diagnoses, and also allows improving existing practices aiming at creating safer and healthier work environments in Brazilian organizations 7,17,19 .
The sampling method used should be considered a limitation of the present study, because it did not allow representing the Brazilian diversity.However, the qualitative and quantitative composition of the expert panel called for pretesting the adapted version complied with recommendations in the literature (number and professional diversity) for expert panels to evaluate the quality of adaptations of instruments 20 .
Although semantic, idiomatic, experiential and conceptual equivalence was ensured, new studies to measure validity and psychometric properties, following the methods used in the present study for validation of instruments to different cultures and contexts, are needed to guarantee the high quality of the Portuguese version of DCWS 21 .

CONCLUSIONS
The Brazilian Portuguese version of DCWS obtained in the present study represents a considerable advance in occupational health.
The cross-cultural adaptation of DCWS to the Brazilian context increases the number of instruments available to assess the effectiveness of actions and programs to promote workers' health and well-being in different work contexts.
Quantitative studies are needed to assess the validity and psychometric properties of the translated and cross-cultural adapted instrument vis-à-vis its original version.Such procedure will afford a better understanding of the performance of QDBC within the Brazilian context, and will enable the creation of benchmark repositories available for consultation by all types of organizations interested in developing increasingly healthier and more productive work environments.

Table 1 .
Original version and following adjustments by the internal expert committee of instrument Dimensions of Corporate Well-Being Scorecard, Campo Grande, 2017.

Table 2 .
Original version and following contributions by the expert panel of instrument Dimensions of Corporate Well-Being Scorecard, Campo Grande, 2017.

Table 3 .
Original version and following contributions by the expert panel of instrument Dimensions of Corporate Well-Being Scorecard, Campo Grande, 2017.

Table 4 .
Original version and following contributions by the expert panel of instrument Dimensions of Corporate Well-Being Scorecard, Campo Grande, 2017.

Table 5 .
Original version and following contributions by the expert panel of instrument Dimensions of Corporate Well-Being Scorecard, Campo Grande, 2017.Cross-cultural adaptation of Dimensions of Corporate Well-being Scorecard for Brazil Rev Bras Med Trab.2018;16(4):466-81