The Constitution in Chinese Medicine Questionnaire [CCMQ] organizes 9 body constitutions according to Traditional Chinese Medicine [TCM]. The translation was realized by a Medical Doctor [MD] specialized in TCM and the back translation by an english-speaking MD. Comprehensibility assessment was performed (N = 40, main scores ranged from 4.20 to 4.95). On the test-retest reliability Cronbach’s alpha was 0.920 in the first application and 0.943 in the second, the intraclass correlation scores ranged between good and excellent (0.6 - >0.80). The results show that the adaptation of the CCMQ is valid and ready to be used.
The Chinese concept of body constitution is a model that comprehends many aspects of one individual’s health [
Since its development, CCMQ was translated and validated to different languages and communities [
Recent data show that TCM plays an important role on treatment and disease prevention [
For the validation of the CCMQ for Brazilian Portuguese, we adopted a six- step procedure, following the proposals of Conti et al. [
The first translation of the English version into Brazilian Portuguese was provided by the first author (CBSR) based on a previously validated English version from Jing and colleagues [
The translated version was back-translated into English by a native English- speaking doctor (FB), familiar with the TCM concepts.
The first and the senior author of the current report (CBSR and HT, respectively) reviewed the semantic equivalence between versions, having correct conceptual equivalence between versions as the main goal.
The second version of the translated questionnaire was then presented to 40 medical students from the School of Medicine of the University of São Paulo (Faculdade de Medicina da Universidade de São Paulo) for the comprehensibility evaluation via an online platform. The students were aware of the study’s goal, and could only access the questionnaire after accepting an informed consent form. Also, the principal of the School of Medicine of the University of São Paulo signed a consent form for the students to be accessed by the researchers. An adapted verbal-numeric questionnaire was used [
The internal consistency of the translated version was assessed by calculating Cronbach’s alpha applied to the responses obtained with the second application of the questionnaire. The test-retest reliability assessment was performed with another 40 medical students from the same institution, contacted to answer the questionnaire twice via the same online platform, with an interval of two weeks.
For this final step, the questionnaire was answered twice by the same group of students, with an interval of two weeks between each assessment. The assessment of test-retest reliability was made using the intraclass correlation analysis method (ICC), which is best indicated for continuous variables [
A total of 6 items presented discrepancies between the original and the back- translated version, but only two of those were considered important by the authors (CBSR and HT) designated to compare and evaluate the back-translated version in relation to the original version. For one of these items, the authors suggested a specific adaptation regarding the expression “hot flashes”, because a direct translation into the corresponding wording did not describe the symptom in its usual wording for Brazilian Portuguese. The translation for the other item analyzed added the expression “breathe deeply” to clarify the meaning of “sigh”, but this change was considered misleading, as this expression can be related not only to emotional questions (as originally intended) but also to respiratory problems. The suggestions made by these authors were discussed with and approved by the others.
The comprehensibility mean scores of the CCMQ items ranged from 4.20 to 4.95. The Wilcoxon signed-rank test identified three levels or blocks of comprehensibility. The first block comprised 43 items, headed by item #1.6, with a mean score of 4.88. Then, there was a second block of 20 items, headed by item #6.5, they all differed from the leading comprehensibility score, with a mean score of 4.67. Finally, there was a third block comprising items #4.1, #4.2, #5.2 and #5.7 with the lowest comprehensibility scores, all differing from level two highest score, with a mean score of 4.33.
Only two items scored below the previously established cutoff for comprehension scores. Both (Items 4.1 and 5.2) had an average of 77.5% of good or excellent rating. In fact, both items were just one score 4 or 5 short to achieve the required cutoff. These items were reviewed and discussed by the researchers, but it was concluded that there was no safe way to make the text clearer, at the risk of important conceptual changes.
| Comprehensibility | Item ranking | Comprehensibility | Wilcoxon’s test | ||
|---|---|---|---|---|---|
| Excellent (%) | Good (%) | Z | p | ||
| Best ranked item within level 1a | Item #1.6d | 95 | 5 | - | - |
| Worst ranked item within level 1 | Item #7.2 | 85 | 7.5 | −1.890 | 0.059 |
| Best ranked item within level 2b | Item #6.5e | 82.5 | 10 | −2.530 | 0.011 |
| Worst ranked item within level 2 | Item #4.7 | 75 | 17.5 | −0.884 | 0.376 |
| Best ranked item within level 3c | Item #5.7f | 62.5 | 22.5 | −2.360 | 0.018 |
| Worst ranked item within level 3 | Item #4.1 | 57.5 | 20 | −1.049 | 0.294 |
aLevel 1 items in ranking order: #1.6, #2.2, #3.6, #3.5, #8.7, #7.4, #1.7, #9.1, #2.6, #2.3, #7.5, #1.1, #3.7, #1.5, #1.3, #9.8, #9.3, #9.2, #8.2, #7.7, #5.3, #4.5, #8.4, #7.6, #6.2, #5.6, #5.4, #3.8, #9.7, #4.4, #6.7, #4.3, #3.4, #3.2, #5.1, #8.3, #2.7, #3.3, #1.2, #8.1, #6.1, #2.8, #7.2; bLevel 2 items in ranking order: #6.5, #2.5, #9.6, #6.3, #2.4, #8.5, #2.1, #9.5, #4.6, #3.1, #9.4, #6.6, #7.1, #1.4, #5.5, #6.4, #4.8, #7.3, #8.6, #4.7; cLevel 3 items in ranking order: #5.7, #5.2, #4.2, #4.1; dReference score for comparison with remaining items from level 1 and first item from level 2; eReference score for comparison with remaining items from level 2 and first item from level 3; fReference score for comparison with the remaining items from level 3.
The mean completion time for the first application was 12 minutes and 48 seconds.
Cronbach’s alpha for the entire instrument was 0.920 in the first application and 0.943 in the second application. The alpha coefficients for each subscale from the CCMQ were considerably lower ranging from 0.53 to 0.88. The majority were slightly above 0.60 (moderate); three fell below 0.60 (low): Stagnant blood, Yin-deficiency and Neutral; and only Stagnant-qui alpha was above 0.80 (very good). The intraclass correlation scores for all CCMQ subscores ranged between good and excellent (0.6 - >0.80).
The results show that the adaptation of the CCMQ to Brazilian Portuguese performed in this study is valid and ready to be used. The analyzes of the comprehensibility scores allowed a very careful assessment of the potentially confusing items. There was no item with a mean comprehensibility score below 4. The two items with less than 80% of “good” or “excellent” ratings would be above this cutoff with the change of a single evaluation, thus a decision was made to keep the actual item versions. However, in a posterior reflection, we could not discard the possibility that maybe the translation of these items deserved a review. Our best guesses would be the word “stuffiness” from item #4.1 was misinterpreted and deserved another translation to better indicate constipation of the chest and stomach as originally intended; whereas with item #5.2 a more subtle problem may have happened regarding the concept of “having acne or sore easily”, perhaps a more connotative translation could better imply the original concept of experiencing acnes and sores as a passive process rather than something actively sought. In both cases, these adaptations can be provided with slight language adjustments in Portuguese, and they must be tested in the ensuing works of the CCMQ in Brazil.
The value of Cronbach’s alpha for the entire questionnaire was very high in both applications, what suggests great reliability of the instrument. In the case of the coefficients for the subscales, however, the values were considerably lower, with only one of these being classified as very good, which suggests that our adapted version may have a structure more complex than a one-factor model, as it happens with its original version. Nonetheless, the study was not designed for the assessment of its domains or underlying dimensions, which requires a factorial analysis and a bigger sample. In fact, testing the underlying structure of the symptoms listed in the CCMQ, according to the theoretical TCM framework, in a larger community sample from a diverse sociocultural milieu would be the natural following step, as it may yield precious insights into theoretical model of the TCM itself, i.e., how much of it can be automatically transposed to a different cultural milieu.
| CCMQ Subscales | Cronbach’s alpha a | Test-retest intraclass Correlation Coefficient (ICC) b |
|---|---|---|
| Yang-deficiency | 0.692 | 0.619 |
| Yin-deficiency | 0.580 | 0.781 |
| Qi-deficiency | 0.623 | 0.888 |
| Phlegm-damp | 0.624 | 0.721 |
| Damp-heat | 0.630 | 0.827 |
| Stagnant-blood | 0.531 | 0.836 |
| Inherited-special | 0.758 | 0.861 |
| Stagnant-qi | 0.884 | 0.814 |
| Neutral | 0.532 | 0.798 |
aInterpretation of Cronbach Alpha values [
The analysis of the ICC coefficients shows that our version of the CCMQ has good to excellent test-retest reliability. Indeed, two out of nine subscores had ICCs within the “Good” range, and the other ICCs for the remaining scores were within the “Excellent” range.
LimitationsBoth samples used in this study for comprehension and reliability analyzes were small and participation was on a voluntary basis, which may increase sample skewness. Besides, the subjects constituted a very specific subgroup of, i.e., Medicine School students, which could lead to further bias due to their peculiar profile and soon-to-be professional gaze upon symptom experience and appraisal.
The Brazilian Portuguese version of the CCMQ is the only one of its kind validated and ready to be used in future research endeavors, as well as to support the clinical practice of acupuncture and TCM in our country. Overall, the items translation was quite direct, but a continuous validation effort of instruments of the CCMQ, e.g., exploring its factorial structure, is necessary to further investigate the strengths and limitations of tradition-based medical models. So far, the evidence from the current report speaks in favor of the cross-cultural validity of the CCMQ.
Impulse Control Disorders and Behavioral Addictions Outpatient Unit, Institute and Department of Psychiatry, University of São Paulo, São Paulo, Brazil.
The authors declare no conflicts of interest regarding the publication of this paper.
dos Santos Rohde, C.B., Blumrich, L., Martins, P.O.D., Babler, F., Hsing, W.T. and Tavares, H. (2021) Translation, Adaptation and Validation of a Chinese Medicine Questionnaire to Brazilian Portuguese. Open Journal of Applied Sciences, 11, 1149-1156. https://doi.org/10.4236/ojapps.2021.1110086