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Transcultural adaptation of the Refugee Health Screener - 15 to Brazilian Portuguese
Adaptação transcultural do instrumento Refugee Health Screener - 15 para o português brasileiro

Dienifer Katrine Chierici - Universidade Federal do Paraná
E-mail: dienifer.chierici@gmail.com
ORCID: https://orcid.org/0000-0002-6462-4627

Amer Cavalheiro Hamdan - Universidade Federal do Paraná
E-mail: amerc.hamdan@gmail.com
ORCID: https://orcid.org/0000-0003-0198-7401

Abstract
The forced migration process exposes the individual to different situations of vulnerability before, during and after arrival in the country of destination. In this context, the prevalence of anxiety, depression and post-traumatic stress disorder is double when compared to the non-refugee population. Brazil receives approximately 30,000 refugee requests annually, but it lacks mental health screening instruments adapted for this public. Thus, the objective of this research was to perform the translation and cross-cultural adaptation of the Refugee Health Screener - 15 (RHS-15) instrument from Spanish to Brazilian Portuguese. The aim was to create a bilingual instrument that would enable Brazilian professionals to assist Hispanic refugee populations in Brazil. This study involved the stages of translation and back-translation, evaluation by expert judges and the target audience. Statistical analysis was based on the assessment of agreement between translations and the measurement of the reliability of the results by the kappa coefficient. The RHS-15 was adapted to Brazilian Portuguese, giving rise to the Escala de Saúde para Refugiados - 15, which presents evidence of validity based on indicators of semantic and conceptual equivalence.
Keywords: Refugees; Psychometrics; Transcultural Studies; Ethnopsychology.

Resumo
O processo de migração forçada expõe o indivíduo a diversas situações de vulnerabilidade antes, durante e depois da chegada ao país de destino. Neste contexto, a prevalência de ansiedade, depressão e transtorno do estresse pós-traumático se apresenta em dobro quando comparada à população não refugiada. O Brasil recebe cerca de 30 mil pedidos de refúgio anualmente, mas carece de instrumentos de triagem em saúde mental adaptados para esse público. Assim, o objetivo desta pesquisa foi realizar a tradução e adaptação transcultural do instrumento Refugee Health Screener - 15 (RHS-15) do espanhol para o português brasileiro. Visou-se a criação de um instrumento bilíngue que viabilize o atendimento, por profissionais brasileiros, de populações hispânicas refugiadas no Brasil. Trata-se de um estudo que envolveu as etapas de tradução e retrotradução, avaliação por juízes especialistas e público-alvo. A análise estatística se baseou na avaliação de concordância entre traduções e na medida de confiabilidade dos resultados pelo coeficiente kappa. O RHS-15 foi adaptado para o Português brasileiro dando origem à Escala de Saúde para Refugiados - 15, que apresenta evidência de validade baseada em indicadores de equivalência semântica e conceitual.
Palavras-chave: Refugiados; Psicometria; Estudos Transculturais; Etnopsicologia.

Introduction
Over the past few years, Brazil has received an average of 30,000 requests for refugee status annually¹. In 2021, 80.3% of these requests originated from Cuba and Venezuela. Currently, the country hosts more than 65,000 individuals recognized as refugees and residing within its borders, with 70.6% being Venezuelans and another 3.3% originating from other Spanish-speaking countries¹. Brazil\'s strategic location vis-à-vis conflict zones in Latin and Central America partly explains the significant presence of Spanish-speaking refugees in the country. Furthermore, in 2019, the National Committee for Refugees (CONARE) recognized the situation in Venezuela as involving serious and widespread human rights violations, which facilitates the assessment of refugee status applications.
Given a migratory history marked by serious threats and violations, refugees are exposed to various risk factors for developing psychopathological conditions related to stress. There is nearly double the prevalence compared to non-refugee populations for disorders such as anxiety, depression, and post-traumatic stress disorder²⁻⁵. Due to prevalent symptoms of psychopathological conditions, refugees are also subject to greater cognitive impairments related to attention and memory⁶. Moreover, factors such as adaptation, quality of life, and professional integration have been directly linked to pre- and post-migration mental health conditions⁷⁻¹¹. Therefore, it can be concluded that refugees whose mental health needs are not addressed during the reception process tend to develop worse outcomes in adaptation, social integration, health, and quality of life in subsequent years.
In this context, the application of structured tools for mental health screening is necessary, providing a swift and reliable option for identifying symptoms and subsequent professional monitoring. Gadeberg and Norredam¹² emphasized the importance of using linguistically and culturally adapted instruments for migrant populations. The authors highlight the risks of non-standardized assessment, which may under-diagnose those in need of care and pathologize healthy individuals.
Hollifield and colleagues¹³⁻¹⁴ developed a screening instrument for common disorders among refugees called the Refugee Health Screener - 15 (RHS-15). This tool consists of 15 self-report items on a Likert scale, providing a culturally comprehensive and quickly applicable approach aimed at facilitating initial assessment and diagnostic support. Results are obtained through simple summation, with scores equal to or greater than 12 considered positive. Positive results indicate the presence of a mental disorder or a strong risk of its development, suggesting the need for more thorough interventions.
Officially translated into 17 languages, the Refugee Health Screener - 15 has become a benchmark instrument in the mental health screening process for refugees. Several studies ¹⁵⁻¹⁸ have focused on validating the psychometric properties of the instrument across different cultural contexts. Overall, these studies demonstrate strong validity and reliability of the instrument, capable of reliably identifying clinically relevant psychological symptoms.
Given the absence of a Brazilian Portuguese version of the instrument, coupled with high demand for psychological screening of refugees in the country, this study aimed to culturally adapt the Refugee Health Screener - 15 to Brazilian Portuguese. The Spanish version of the instrument, already published and validated by the same research institution responsible for the original in English¹⁸, served as the basis. The original sentences in Spanish were retained alongside the final Portuguese version of the instrument, creating a bilingual material that can be administered by Brazilian professionals or self-administered by participants in Portuguese or Spanish.

Method
Participants
The study involved voluntary participation from three translators: two undergraduate students majoring in Spanish Literature - one Brazilian and one from Equatorial Guinea - and one Brazilian psychologist with a master\'s degree in languages. The panel of expert judges consisted of four professionals specializing in migration: two Brazilians with master\'s degrees in Sociology and Law respectively, a Cuban psychologist, and a public servant from Venezuela. Finally, non-expert judges were selected from adults residing in Curitiba and its metropolitan area, including one Venezuelan man, one Cuban woman, and two Cuban men.

Instruments
The Refugee Health Screener - 15¹³⁻¹⁴ was developed as a rapid and comprehensive option for mental health screening of refugees. Its construction was based on items originating from three other tests: the New Mexico Refugee Symptom Checklist¹⁹; Posttraumatic Stress Symptoms-Self-Report²⁰; and Hopkins Symptom Checklist²¹.
The original validation study involved 251 refugees from three nationalities (Bhutan, Myanmar, and Iraq), demonstrating sensitivity and specificity of 0.81 and 0.87 for Posttraumatic Stress Disorder; 0.94 and 0.86 for Anxiety; and 0.95 and 0.89 for Depression¹³. Additionally, the instrument has been validated for Cuban Spanish¹⁸, which is highly relevant for the Brazilian migration context. Given the possibility of formulating a bilingual instrument applicable in Portuguese and Spanish, the version by Bosson et al.¹⁸ was adopted as the basis for this study.
As noted in a systematic review²², the methodological procedure for cross-cultural adaptation of psychological instruments is not universally agreed upon within the scientific community. Different methodologies can produce reliable results depending on the specific needs of each study²². However, certain guidelines are widely validated and can be adopted to ensure rigorous adaptation, such as those developed by Guillemin²³, Wild²⁴, and Beaton²⁵⁻²⁶.
This study follows the protocol proposed by Wild²⁴ and incorporates methodological contributions from Paiano²⁷. Furthermore, methodological innovations were necessary to better address the research\'s specificities, as it involves interaction between Brazilian professionals and Spanish-speaking individuals. The analysis of results based on feedback from four expert judges was divided into pairs: one consisting of Brazilians and the other of Spanish speakers, allowing for the identification of potential divergences between the two groups. Additionally, an evaluation step by non-experts (Spanish-speaking refugees) was added to assess the clarity of the instrument among the target audience.

Procedures
Table 1 shows the cross-cultural adaptation of the instrument, which followed 13 steps based on the proposed model and necessary adjustments.
[Insert Table 1 here]

Statistical Analysis
Item adequacy analysis was conducted using two methods: evaluation of percentage agreement between translations²⁸ and reliability measurement using the kappa coefficient²⁹⁻³⁰. This coefficient compares the observed proportion of agreement between judges to the maximum possible agreement, correcting for chance³¹.
Data were initially produced through analysis of literal and semantic agreement of translations obtained. Subsequently, items were presented to expert and non-expert judges for evaluation using two assessment options (Clear/Not clear), along with opportunities for comments. Agreement among evaluators was assessed using the kappa coefficient based on these data.

Ethical Considerations
The study was approved by the Ethics Committee of the Federal University of Paraná as part of a project aimed at developing and applying a culturally appropriate cognitive assessment battery for use with Latin Hispanic refugees (CAAE 71822723.7.0000.0214.). It is emphasized that validation of the material produced through a pilot study will be conducted in a subsequent study.

Results
Table 2 shows the initial version, discrepancies between items, and the synthesized version. Comparison of the back-translated version with the original version (step 4) showed that 10 sentences (33%) were satisfactorily translated with minimal differences in construction. The remaining 20 sentences (67%) exhibited discrepancies and were forwarded for further consideration. Thirteen (65%) of the forwarded items were deemed semantically identical and thus accepted. The remaining seven items progressed to Step 6 (development of a new synthesized version).

[Insert Table 2]

Results
Table 3 shows the evaluation by expert judges. Of the items presented, 25 (83%) were deemed clear. Five other items received comments. Agreement among Brazilian judges yielded a kappa coefficient of 0.73, indicating a moderate level of agreement. Conversely, among Hispanic judges, the instrument achieved a coefficient of 0.93, considered nearly perfect. This discrepancy was expected, as the base material for Portuguese adaptation originated from the Spanish language. Therefore, particular attention was given in the next step to grammatical and cultural observations specific to Portuguese.

[Insert Table 3]

Based on the feedback received, the items in question progressed to Step 8 (author analysis based on the presented observations). The decisions included adopting the suggestions for items 16, 23, and 24, which did not conflict with each other. For items 17 and 20, the suggestions of judges 2 and 4 respectively were incorporated, aiming to maintain the closest possible correlation with the original instrument and linguistic adequacy to Brazilian reality.
Subsequently, the new version of the material was reviewed by four non-expert judges, considered representative of the instrument\'s target audience. The clarity assessment received full approval without new comments or reservations. Thus, no further modifications were made, and the material was returned to the same panel of expert judges for another review (step 11). At this stage, only two sentences (6.6%) received minor suggestions from Brazilian judges regarding grammatical construction. The kappa coefficient for the final version was 0.87, indicating a strong level of agreement. Given the validity evidence of the material, it was decided not to make any additional changes. Thus, the cross-cultural translation process of the instrument was concluded.
The adaptation of the Refugee Health Screener - 15 into Brazilian Portuguese was developed through rigorous methods of translation and cross-cultural adaptation. The instrument can be fully accessed at this link.


Discussion
The cross-cultural adaptation process employed in this article aimed to create a Brazilian Portuguese version of the RHS-15. This adaptation will enable Brazilian healthcare professionals to assess predominant symptoms of major psychological disorders in refugees²⁻⁵, thereby facilitating diagnosis and treatment.
With the opening of borders and recognition of the humanitarian crisis in Latin American and Central American countries, Brazil has become a major destination for migration flows in the Americas¹. However, this emergency reception lacks the necessary technical and scientific preparation, as observed in the cross-cultural adaptation of psychological instruments. Therefore, efforts are needed to align Brazilian mental health practices with those already in the country, as well as to facilitate the reception and adaptation of those yet to come. The development of culturally adapted instruments is directly related to the reliability and validity of the results obtained³³. Without the adoption of a substantial and rigorous cross-cultural adaptation protocol, the validity of any data obtained cannot be guaranteed, rendering psychological assessment instruments less usable in the psychodiagnostic process of refugee populations.
Several studies have emphasized the impact of psychological conditions on refugees\' adaptation ability, quality of life, and professional integration in their destination countries⁷⁻¹¹. Using the RHS-15, Vukčević and colleagues² identified the need for additional psychological support in eight out of ten evaluated refugees, highlighting the high vulnerability of this population. The high incidence of mental health disorders requires rapid and precise interventions, as refugees with psychological disorders face greater difficulties in overcoming common adaptation barriers⁷⁻¹¹, leading to worsening symptoms and a cycle of health deterioration. Lack of social and familial support, language difficulties, and financial problems are the main post-migration barriers⁷, demanding ample psychological resources to overcome them.
The translation and cross-cultural adaptation of the RHS-15 described in this article are expected to enable early diagnosis, improve clinical prognosis, and contribute to better adaptation conditions for refugees in Brazilian society. Moreover, maintaining the test in a bilingual format (as in its Spanish/English version) extends access to individuals who do not yet have proficiency in Portuguese. As noted by Gadeberg et al.³³, the ideal application of psychological instruments for refugee populations should include the presence of a translator or written instructions in both languages, ensuring better understanding of what is being assessed.
The findings of this study showed a high level of agreement between the original and back-translated versions. Clarity assessment based on feedback from expert judges indicated high agreement with the original material. Evaluation by non-expert judges showed complete agreement, indicating excellent acceptance of the material by the target audience. Thus, the Brazilian Portuguese version demonstrated good indicators of semantic and conceptual equivalence in all described stages, aligning with standards in the field²⁷,³².
Finally, some limitations should be noted. Firstly, the term "refugee" is broad and encompasses many groups not covered in the adaptation study. Despite including representatives from major Hispanic migration flows to Brazil (Venezuela, Cuba, and Equatorial Guinea), Spanish has regional variants, making it impossible to guarantee a unified interpretation. However, efforts were made to avoid regionalisms, aiming for maximum core understanding in both Portuguese and Spanish.
Secondly, regarding the cross-cultural adaptation protocol, it would be beneficial to include a second group of non-expert judges composed of Brazilian healthcare professionals. Indeed, this instrument\'s adaptation involves two distinct target audiences: refugees undergoing assessment and Brazilian healthcare professionals applying the instrument. The exclusion of this group was a methodological choice, based on the understanding that observations provided by Brazilian expert judges would be sufficiently representative, given their educational level comparable to professionals who will use the instrument. This is not the case among Spanish-speaking expert judges, thus necessitating validation with the target audience.
With the satisfactory results of this adaptation, the next step will be evaluating the psychometric properties of the instrument. Future research should determine whether the Brazilian Portuguese version of the Refugee Health Screener - 15 is a valid and reliable instrument for collecting indicators of anxiety, depression, and post-traumatic stress disorder among different migrant populations.

Final Considerations
This study presented unprecedented evidence regarding the applicability of the RHS-15 instrument in Brazilian Portuguese, demonstrating high agreement and semantic equivalence. It is concluded that the instrument was translated and adapted to maintain its original meaning and intent, making it suitable and relevant for screening anxiety, depression, and post-traumatic stress disorder in Spanish-speaking refugees. The development of a valid and reliable instrument implies better understanding and treatment of the mental health of refugees in Brazil. It is hoped to contribute to improving screening and diagnosis, social inclusion of refugees, and promotion of culturally sensitive professional practices.

Funding
This study was partially funded by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Financial Code 001.
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