Abstracts

Introduction

As for the feminine gender, since the emergence of the first AIDS cases in the worldwide epidemiologist scenario, the prevention of the HIV transmission among women has been one of the biggest challenges in the control of the disease. This and other questions cause the prominence of the vulnerability of the woman, specifically of the adolescent in relation to the infections through sexually transmissible diseases (STD), human immunodeficiency virus (HIV) and pregnancy, which re-echo negatively in the life quality of his group^{( 1}1. Borges ALV, Nichiata LYI, Schor N. Talking about sex: the social and familial net as a base for sexual and reproducive health promotion among. Rev. Latino-Am. Enfermagem. 2006 maio-junho;14(3):422-7. ⁾.

From the relations that surround the adolescent, the family where that adolescent is inserted plays a basic role in the way how the adolescent grows up, including how that adolescent will interrelate with the future sexual partners. Thus, the family unit has, throughout the years, suffered transformations, mainly in the way of transmitting values on subjects connected to STD/HIV^{( 2}2. Fortuna CM, Matumoto S, Pereira MJB, Mishima SM, Kawata LS, Camargo-Borges C. Nurses and the Collective Care Practices Within the Family Health Strategy. Rev. Latino-Am. Enfermagem. 2011 maio-junho ;19(3):581-8. ⁾.

For the nursing, the family health has become focus of the care in the scope of the work process in health, and this implies the necessity to elaborate educational and care technologies that facilitate this relation, either by means of visits at home, in the school environment, or even during the nursing consultation.

An accomplished integrative revision^{( 3}3. Gubert FA, Vieira NFC, Damasceno MMC, Lima FET, Ximenes LB. Escalas para medida de comportamento preventivo em meninas adolescentes frente às dst/hiv: revisão integrativa. Rev Gaúcha Enferm. 2010 dez;31(4):794-802. ⁾, approaching the use of scales in the area of STD/HIV prevention demonstrates innumerable validated instruments that can be applied with this population. These were in majority developed in other countries, like the USA or the European countries. The focus of these instruments is to identify vulnerabilities with regard to the sexual and reproductive health, and from them, to support the family interaction and the future sexual behavior of the adolescent. Amongst these studies stand out: Partner Communication Scale and Sexual Communication Self-Efficacy, 45 item HIV Knowledge and 18 item HIV Knowledge; Rosemberg´s 10 Scale item; Female Condom Attitude Scale, Sexual Comfort Scale, among others^{( 3}3. Gubert FA, Vieira NFC, Damasceno MMC, Lima FET, Ximenes LB. Escalas para medida de comportamento preventivo em meninas adolescentes frente às dst/hiv: revisão integrativa. Rev Gaúcha Enferm. 2010 dez;31(4):794-802. ⁾.

Amongst the previously stated instruments, the Parent-Adolescent Communication Scale (PACS), object of this study, authorship by DiClemente and Wingood, professors of the School of Public Health of Atlanta University - USA was developed having as referential the communication as promotional tool of the education for healthful experience of the sexuality in the adolescence^{( 4}4. Sales JM, Milhausen RR, Wingood GM, DiClemente RJ, Salazar LF, Crosby RA. Validation of a Parent-Adolescent Communication Scale for Use in STD/HIV Prevention Interventions. Health Educ Behav. June 2006;35(3):332-45. ⁾.

PACS encloses five items, which evaluate the perception of the adolescent concerning the communication frequency with the parents regarding subjects related to sexuality. The questions include the following points: in last the six months, how many times you and your parent(s) spoke about the following subjects: (1) sex (2) how to use condoms, (3) how to protect oneself from sexually transmissible diseases, (4) how to protect oneself from the AIDS virus, and (5) how to protect oneself from pregnancy.

In light of the disclosed, the study aims at translating, validating and applying the PACS in Fortaleza, given that this is today in the state Ceará the city which most concentrates HIV cases among adolescents of the feminine gender. Facing the evidences proceeding from studies in the area of STD/AIDS prevention and development of instruments/scales it is perceivable that studies which comprise this reality in the most different contexts are relevant as they contribute to rethink the educational and preventive practices in the scope of the family health, beyond the (re)creation of adequate technologies for such a reality^{( 5}5. Almeida ACCH, Centa ML. A família e a educação sexual dos filhos: implicações para a enfermagem. Acta Paul Enferm. 2009;22(1):71-6. ⁾. This fact justifies the necessity of validity and precision studies, since its use involves situations in which the nurse, in that case, will evaluate determined aspects that might interfere with the life quality and health of the adolescents^{( 6}6. LoBiondo-Wood G, Haber J. Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice. 6th. ed. New York: Mosby; 2005. 576 p. ⁾.

Methodology

Methodological study of transcultural adaptation, accomplished according to international recommendations^{( 7}7. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine. 2000;25:3186-91. ⁾, carried out in Fortaleza, Ceará, and progressed in three institutions of secondary education, being two public and one private.

Translation procedures

Initially the authorization for translation was requested by means of electronic contact with the authors Wingood and Diclemente, who accepted readily. The initial translation was accomplished by a bilingual nurse with experience in the area and another certified translator, both with knowledge and distinct profiles. The first translator had knowledge about the concepts that were being examined in the PACS and was familiar with translations of materials related to the health area. The second translator was not informed about the objectives of the translation. Afterwards, a synthesis of the two translations was accomplished on the basis of the translated independent versions, originating one report documenting the synthesis of the translations with justification of the final consensus for the later accomplishment of the back-translation ^{( 8}8. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Recommendations for the Cross-Cultural Adaptation of the DASH & QuickDASH Outcome Measures. Institute for Work & Health; 2007. ⁾.

The produced report was submitted to the process of back-translation into English by two other independent bilingual translators. One of the translators was native of the United States and acted in Brazil in the area. This one was not informed about the reason for the translation and the other translator was oriented towards the objective of this stage. After the compilation of the two documents of the back-translation, the final back-translated version was established.

After this stage, it was proceeded with the evaluation of this version by a committee of specialists, which was composed by five nurses with ample experience in the area of sexual and reproductive health of adolescents and methodological studies with doctorate in the area, with the intention to develop the pre-final version of the PACS. The committee evaluated the semantic, cultural, idiomatic and conceptual equivalences, as well as the validity percentage of the content^{( 9}9. Vanable PA, Carey MP, Brown JL, DiClemente RJ, Salazar LF, Brown LK, et al. Test-Reteste Reliability of Self-Reported HIV/STD-Related Measures Among African-American Adolescents in Four U.S. Cities. J Adolesc Health. 2009;44(3):214-21. ⁾, being thus the approved scale to be used in the pre-test. This stage was accomplished by means of two meetings with duration of two hours each, in which the original questionnaire and the further translations and back-translations were provided.

Realization of the pre-test

The version validated by the committee of specialists was applied in October 2010 to 30 adolescents, representatives of the target population of the scale, being 15 from a private school and 15 from a public institution. The completion of the scale was made available online, with the questionnaire constructed by the data base manager Google Docs, whose access occurred in the informatics laboratory of each school. The scales were initially applied in individual form, so that each adolescent would comment on the difficulties/easiness in the completion and at the end they returned to the room in groups of three or four for each item to be discussed again.

Psychometric Properties adopted in the study

Two aspects related to the reliability were distinguished: stability (by means of the test-retest, applying the scale with an interval of five weeks between the first and the second application) and homogeneity (Cronbach's Alpha). The period of five weeks was used following a suggestion of the proper authors of the scale^{( 10}10. Silva FC, Thuler LC. Cross-cultural adaptation and translation of two pain assessment tools in children and adolescents. J Pediatr. (Rio J.) 2008;84:344-9. ⁾.

In relation to the content validity, the consensus among specialists was used^{( 9}9. Vanable PA, Carey MP, Brown JL, DiClemente RJ, Salazar LF, Brown LK, et al. Test-Reteste Reliability of Self-Reported HIV/STD-Related Measures Among African-American Adolescents in Four U.S. Cities. J Adolesc Health. 2009;44(3):214-21. ⁾. And concerning the structure validity, by means of the convergent validity, it was verified by testing the hypothesis: by means of a comparative analysis between the two groups^{( 10}10. Silva FC, Thuler LC. Cross-cultural adaptation and translation of two pain assessment tools in children and adolescents. J Pediatr. (Rio J.) 2008;84:344-9. ⁾ besides the relation between the relevant ones (the homes and the total scale).

Means of information procurement

The application according to PACS was accomplished with 313 adolescents of the feminine gender in the 14 to 18 year age band. From the participants, 171 were from public schools and 142 from private ones in the period October 2010 to February 2011, who counted on the consent of the parent/s or those responsible. Besides PACS the participants answered a questionnaire for the analysis of the sociodemographic variables (age, marital status, years of schooling, income, religion, color/race), beyond the ones regarding behavior and communication on sexual and reproductive health (menarche; first information on menarche, sex, pregnancy, STD, virginity loss).

The study was approved by the Committee for Ethics in Research - COMEPE of the Federal University Ceará, under case file 089/09. It is also to add that the study counted on the support of the National Council for Scientific and Technological Development - CNPq, process number 479111/2010-3.

Results

Figure 1 presents the stages of translation and adaptation, in which the final version of the scale, after the evaluation of the specialists committee and the application of the pre-test, underwent few changes. In relation to the title of the scale in Portuguese, it was titled Escala de Comunicação Pais e Adolescentes (PACS) Brazilian version or PACS-BV.

Escala de Comunicação Pais e Adolescentes (PACS) Brazilian version Application

The time for the completion varied from 7 to 18 minutes (M=8.7; DP=±3.2). It can be inferred that the time of application of the scales was lesser (5 to 8 minutes). In relation to the PACS score, this can vary from 4 to 20 points. From the 313 adolescents, 94 evaluated the scale, 50 from public schools and 44 from private schools, amongst which 86 (91.48%) stated it as being easy to understand and only 10 (8.51%) found the scale difficult to complete.

In the application of the PACS-BV and its stratification per school, the mainly discussed subject between parents and daughters was concerning pregnancy (p: 0.001), and the least approached subject was in relation to STD. Regarding the subject "sex", the parents of youths attending private schools dialogued more with their daughters than the ones from youths attending public schools, showing that in average 48.6% of the parents talked frequently or sometimes about it. Even the preservative one was discussed in a balanced form, once 39% of the participants dialogued with their parents, according to the observations in Table 1.

Psychometric Properties

Scale Reliability Analysis

The Cronbach's Alpha of the scale was 0.86. Still in relation to the internal consistency of the scale, the bipartition coefficient or Guttman Split-Half Coefficient test was used that indicated 0.884. Also, the Wilcoxon test was applied to analyze the differences before and after within the same group which demonstrated for all the item pairs values of p > 0.15, indicating that there was no difference between the two conditions before and after.

Content Validity

The expert nurses, with more than five years of experience in the subject indicated consensus between all the items of the scale, classifying them as equivalent, representing semantic, cultural, idiomatic and conceptual coherence.

Validity of the Convergent Structure

The adolescents divided by school had their scores classified in satisfactory (score > 12) or unsatisfactory (score < 12) communication with the parents, so the students of public schools got as result 12.06 in the PACS-VB whereas the students of private schools got 13.5. The application in five weeks, by means of the Spearman correlation coefficient, showed that all the values of rs were higher than 0.760, whose respective values of p were lower than 0.0001, disclosing that there was a significant correlation between the answers of the two applications within five weeks.

Characterization of the adolescents participating in the study

The average age of the participants of the schools was 16 years. In relation to the marital state, the majority of the adolescents answered that they were single, but as to the status of civil union, the participants from public schools - 23 (13.5%) - related more to this item. In the study, those in civil union still living with the parents and thus it is to consider that still some type of communication within the family should exist.

Regarding the schooling in public schools, the youths presented between 6 and 10 years of study (N:78, 45.6%) and 93 (54.4%) between 11 and 14 years. Already in relation to the monthly family income, in minimum wages, there were variations between the two types of school. However, the question of the predominance of the race/color, according to the participants, was the white race/color with 88(51.5%) in public and 96(67.8%) in private schools. The brown color was identified for 68(39.8%) in the first previously cited institutions and 40(28.2%) in the second one. Yet the youths of black color appeared in a lower ratio with only 15(8.8%) and 6(4.2%), respectively.

In the item "cohabitants" in both scenes, living with the parents predominated. A part of the adolescents also stated to only live with the mother: 44(25.7%) from public schools and 37(26.1%) from private ones. As we can verify in Table 2 below:

As for the sexual and reproductive as well as communication aspects, presented in Table 3, the menarche age is in average 10.96 years in public schools and 11.68 in private ones. Concerning the age of the first sexual relation the average was 15.9 years in public schools and 16.7 years in private ones.

The main source of information on questions related to sex and pregnancy, according to the participants, were the parents. Yet in relation to the knowledge about the subject STD/HIV, the participants named the teachers 61(35.7%) and 38(26.8%) times in public and in private schools, in this order.

Discussion

In this study, regarding the adaptations, there were few modifications in the final version. Those were mainly referring to the use of the word "condom". In relation to item 4 that refers to communication on AIDS, the acronym HIV was added. The suggestion occurred due to the existing doubt among the adolescents which acronym represented the virus and which the disease. This aspect already demonstrated the present gaps concerning this topic. In item 5, related to pregnancy, the expression "avoid" was used for being of better comprehension for the adolescents, since pregnancy is not considered a harm that needs to be prevented, but a specific situation of the feminine life cycle. Moreover, the content validity was strengthened by means of consensus of the specialists committee, demonstrating the relevance of the scale for the use in the nursing practice.

The application of the Escala de Comunicação Pais e Adolescentes (PACS) Brazilian version pointed out that the main topic discussed between parents and children was pregnancy (p: 0.001), and the least approached subject was STD, since only 5% of the parents, from both types of institution, talked frequently with their daughters about it. What the adolescents most look for, comparing the main sources of information on the subject (Table 2), are the professors to dialogue about this topic, with prominence of the public school. This fact draws the importance that public policies, such as the Health at School Program (PSE), have on the sexual education of the adolescents and prove the influence the educators have in the handling of this topic^{( 11}11. Andrade EA, Bógus CM. Public policies targeted at youth and health promotion: how the proposal for youth auxiliaries has been translated into practice. Interface Comunic Saúde Educ. 2010;35(14):853-66. ⁾.

As for the psychometric properties of the PACS, regarding reliability, the convergent structure validity was not approached by means of hypotheses testing since there were no significant differences between the adolescents of the two scenes perceived, however, with respect to the internal consistency, checked through the Cronbach's Alpha (0.86), it was observed and close to the original study 0.88^{( 4}4. Sales JM, Milhausen RR, Wingood GM, DiClemente RJ, Salazar LF, Crosby RA. Validation of a Parent-Adolescent Communication Scale for Use in STD/HIV Prevention Interventions. Health Educ Behav. June 2006;35(3):332-45. ⁾. The fact of proving the testing of the hypotheses does not drop the reliability of the instrument and even emphasizes the absence of the communication of parents and daughters, independent of the socioeconomic situation of the Brazilian families. Studies show that the dialogue absence can be observed in different social classes^{( 3}3. Gubert FA, Vieira NFC, Damasceno MMC, Lima FET, Ximenes LB. Escalas para medida de comportamento preventivo em meninas adolescentes frente às dst/hiv: revisão integrativa. Rev Gaúcha Enferm. 2010 dez;31(4):794-802. ^{, 5}5. Almeida ACCH, Centa ML. A família e a educação sexual dos filhos: implicações para a enfermagem. Acta Paul Enferm. 2009;22(1):71-6. ⁾.

The identified sociodemographic variables illustrate the scene in which the adolescents from the public education are inserted. The economic conditions and the life style are directly related to determinatives of the health-disease process. In analytical terms, the way of life determines certain vital conditions, indirectly guaranteed by means of social policies, and the life styles, corresponding to the set of practices - behaviors, habits, attitudes and perceptions, that in the meaning of the dialogue of parents and daughters can make this practice difficult^{( 12}12. Gomes CN, Horta NC. Promoção de saúde do adolescente em âmbito escolar. Rev APS. [periódico na Internet]. 2010 [acesso 27 jul 2012]; 13(4):486-99. Disponível em: http://www.aps.ufjf.br/index.php/aps/article/viewArticle/897
http://www.aps.ufjf.br/index.php/aps/art... ⁾.

In the study, it was observed that beyond the validation of a scale it is possible to highlight important results in the area of communication parents and children/sexual behavior in this life phase.

The lack of communication between parents and daughters mainly in relation to STD/AIDS restricts the dialogue to pregnancy in the three researched institutions and demonstrates that the parents need support^{( 13}13. Milhausen RR, Sales JM, Wingood GM, DiClemente RJ, Salazar LF, Crosby RA. Validation of a Partner Communication Scale for Use in HIV/AIDS Prevention Interventions. J HIV/Aids Prevent Children Youth. 2008;19(3):14-28. ⁾. In spite of this we cannot deny that many times the parents supply information punctually at the beginning of the adolescence and that in this content predominate the socio-sexual norms, as in the case of pregnancy, besides moral questions and points of view (right and wrong), that are important for the development of the sexual and reproductive health of the adolescent^{( 14}14. Paiva V, Aranha F, Bastos FI. Opiniões e atitudes em relação à sexualidade: pesquisa de âmbito nacional, Brasil, 2005. Rev Saúde Pública. [periódico na Internet] .2008 [acesso 27 jul 2012];42: 54-64. Disponível em: http://www.scielo.br/scielo.php?pid=S0034-891020080008 00008&script=sci_arttext
http://www.scielo.br/scielo.php?pid=S003... ⁾. It is to emphasize that the communication parents/daughters is directly related to the future dialog with the sexual partners^{( 15}15. Alvarez C. Predictors of Condom Use Among Mexican Adolescents. Research and Theory for Nursing Practice. 2010;12(4):34-43. ⁾.

However, through the application of the scales it was possible to observe predictive variables that can be strengthened in the dialogue with the adolescents, fostering the decision taking towards the sexual life, as well as protective factors which are essential for the promotion of self-esteem and empowerment. From the identification of these factors, the nurse can establish a plan for care and health promotion, adequate for the necessities of the adolescents, the parents and the sexual partners^{( 16}16. Guilamo-Ramos V, Bouris A. Working with Parents to Promote Healthy Adolescent Sexual Development. Prevent Res. 2009;16(4):7-11. ⁾. When using the points where the participants showed more self-efficacy in the communication with their parents and sexual partners, the improvement of other aspects in their lives can be stimulated.

These evidences demonstrated the reality of the adolescents in Fortaleza and they also reflect the one of other youths in the country, and cause among the health professionals who act close to this population the necessity to deepen the actions that involve the sexual and reproductive health of adolescents. This activity ought to be made in nursing consultations, home visits, educative groups, participation in associations or youth groups, beyond that educative measures and the strengthening of the relation parents and children as well as between the sexual partners must be prioritized when the subject is adolescence^{( 14}14. Paiva V, Aranha F, Bastos FI. Opiniões e atitudes em relação à sexualidade: pesquisa de âmbito nacional, Brasil, 2005. Rev Saúde Pública. [periódico na Internet] .2008 [acesso 27 jul 2012];42: 54-64. Disponível em: http://www.scielo.br/scielo.php?pid=S0034-891020080008 00008&script=sci_arttext
http://www.scielo.br/scielo.php?pid=S003... ⁾.

Final Considerations

The difficulty of the health professionals in approaching the communication of parents and children during the nursing consultation, as well as subjects related to sexuality in the perspective of family health, motivated the process of transcultural adaptation of this scale.

After the whole process of translation, validation and application of the PACS-VB it is to perceive that it can be applied with easiness both in the scene of the first health attention during the nursing consultations of the adolescent, previous diagnosis for health education activities, as well as in communitarian activities, and also in specialized clinics, since they allow to identify factors that make it difficult or facilitate the communication frequency among the adolescents, their parents and their sexual partners.

When analyzing the two school environments, it was observed that the sociodemographic factors seem to have influence on the communication parents and daughters, however they are not determinatives for the dialog to occur. Beyond the process of the PACS adaptation, validation and application, the study above all allowed to reflect on the dialog within the family, which ought to be promoted from the beginning of infancy, with adequate information on adolescence, STD, HIV, love relationships. All this seems to be above the financial condition or the social class, since in the study it was verified that there were no statistically expressive differences between the public and the private school environment in the study.

The validity of the structure, by means of comparison between the two contrasted groups, that analyzes the initial presupposition that the adolescents of public schools would have a minor frequency of communication with their parents than those of private schools due to possible influence of some social determinatives did not materialize in the study, as what was to perceive was a very close communication in the two scenes.

The fact that the parents, regarding both schools, communicate more about the topic pregnancy and little in relation to STD/HIV deserves emphasis. This finding demonstrates that the parents are having difficulties in approaching this subject and that is linked to the number of new cases of STD/HIV each year in the great urban centers, which means new policies for family health promotion in this area must be reconsidered.

As limitations of the research, we can relate the bias of memory, since many items of the instruments established a reference to events which had taken place several years ago, and as well with the bias of the social desirability on the answers given by the individuals according to the item. However, as the study inquired on distinctive events in the lives of the adolescents (like the sexual initiation) and equally prioritized recent events (like the last sexual relation), it is to expect that this problem has been diminished.

Publication Dates

History