Cross-cultural adaptation and validity of the Questionnaire on Handwashing Knowledge and Behavior (QHKB)
Adaptación transcultural y validación del Questionnaire on Handwashing Knowledge and Behavior (QHKB)
Adaptação transcultural e validação do Questionnaire on Handwashing Knowledge and Behavior (QHKB)
Rafaela Aparecida Prata; Tamara Barros Bicudo; Juliana Bastoni da Silva; Fernanda Maria Alves Lima; Sidiany Mendes Pimentel; Graziela Maria Ferraz de Almeida; Marla Andréia Garcia de Avila
Abstract
Objective to perform the cross-cultural adaptation and validity of the Questionnaire on Handwashing Knowledge and Behavior (QHKB) into Brazilian Portuguese.
Method a methodological study conducted in two phases: cross-cultural adaptation according to the COnsensus-based Standards for the selection of health Measurement INstruments guidelines; and psychometric assessment. A total of 49 adolescents participated in the pretest stage and 618 in the validity phase. Content validity, factorial structure, and internal reliability were assessed.
Results the Brazilian version of the instrument (QHKB-Br) achieved an overall Content Validity Index higher than 0.95. In the pretest, the agreement rate among adolescents was 98.7%. Factor analysis indicated a better fit for the unidimensional model compared with the original bidimensional model, with explained variance of 61.5%. Reliability of the total instrument showed α=0.67 and Ω=0.76, which were considered adequate for instruments with few items.
Conclusion and implications for the practice QHKB-Br is a brief, self-administered, and easy-to-use instrument that demonstrated better fit to a unidimensional model in the studied sample. Its use by healthcare professionals may support educational actions and strategies to promote health literacy, contributing to the health promotion of Brazilian adolescents in different school and community settings.
Keywords
Resumen
Palabras clave
Resumo
Objetivo: realizar a adaptação transcultural e a validação do Questionnaire on Handwashing Knowledge and Behavior (QHKB) para o português do Brasil.
Método: estudo metodológico, realizado em duas fases: adaptação transcultural segundo diretrizes COnsensus-based Standards for the selection of health Measurement INstruments; e avaliação psicométrica. Participaram 49 adolescentes na etapa de pré-teste e 618 na fase de validação. Foram avaliadas a validade de conteúdo, a estrutura fatorial e a confiabilidade interna.
Resultados: a versão brasileira do instrumento (QHKB-Br) obteve Índice de Validade de Conteúdo global superior a 0,95. No pré-teste, a taxa de concordância entre adolescentes foi de 98,7%. A análise fatorial indicou melhor ajuste do modelo unidimensional, em comparação ao modelo bidimensional original, com variância explicada de 61,5%. A confiabilidade do instrumento total apresentou α=0,67 e Ω=0,76 — considerados adequados para instrumentos de poucos itens.
Conclusão e implicações para a prática: o QHKB-Br é um instrumento breve, de fácil aplicação, autoadministrado e que apresentou melhor ajuste ao modelo unidimensional na amostra estudada. Sua utilização por profissionais de saúde pode subsidiar ações educativas e estratégias de promoção do letramento em saúde, contribuindo para a promoção da saúde de adolescentes brasileiros em diferentes contextos escolares e comunitários.
Palavras-chave
References
1 Talic S, Shah S, Wild H, Gasevic D, Maharaj A, Ademi Z et al. Effectiveness of public health measures in reducing the incidence of covid-19, SARS-CoV-2 transmission, and covid-19 mortality: systematic review and meta-analysis. BMJ. 2021;375:e068302.
2 Toney-Butler TJ, Gasner A, Carver N. Hand hygiene [Internet]. Treasure Island: StatPearls Publishing; 2026 [citado 2026 abr 17]. Disponível em:
3 Mieth L, Mayer MM, Hoffmann A, Buchner A, Bell R. Do they really wash their hands? Prevalence estimates for personal hygiene behaviour during the COVID-19 pandemic based on indirect questions. BMC Public Health. 2021;21(1):12.
4 Brodin P. SARS-CoV-2 infections in children: understanding diverse outcomes. Immunity. 2022;55(2):201-9.
5 Dardas L, Khalaf I, Nabolsi M, Nassar O, Halasa S. Developing an understanding of adolescents’ knowledge, attitudes, and practices toward COVID-19. J Sch Nurs. 2020;36(6):430-41.
6 Choi S, Bang KS, Shin DA. eHealth literacy, awareness of pandemic infectious diseases, and healthy lifestyle in middle school students. Children. 2021;8(8):699.
7 Skolmowska D, Głąbska D, Guzek D. Hand hygiene behaviors in a representative sample of Polish adolescents in regions stratified by COVID-19 morbidity and by confounding variables (PLACE-19 Study): is there any association? Pathogens. 2020;9(12):1011.
8 Bazaid AS, Aldarhami A, Binsaleh NK, Sherwani S, Althomali OW. Knowledge and practice of personal protective measures during the COVID-19 pandemic: a cross-sectional study in Saudi Arabia. PLoS One. 2020;15(12):e0243695.
9 Chen X, Chen H. Differences in preventive behaviors of COVID-19 between urban and rural residents: lessons learned from a cross-sectional study in China. Int J Environ Res Public Health. 2020;17(12):4437.
10 Riiser K, Helseth S, Haraldstad K, Torbjørnsen A, Richardsen KR. Adolescents’ health literacy, health protective measures, and health-related quality of life during the COVID-19 pandemic. PLoS One. 2020;15(8):e0238161.
11 Ismail SR, Radzi R, Megat Kamaruddin PSN, Lokman EF, Lim HY, Abdul Rahim N et al. The effects of school-based hygiene intervention programme: systematic review and meta-analysis. PLoS One. 2024;19(10):e0308390.
12 Pradhan NA, Hashmi M, Mazhar L, Uzair M, Hussain L, Naseem M et al. Intervention to improve children’s hygiene in urban squatter settlement schools in Pakistan: an implementation research. Environ Health Insights. 2025;19:11786302241306288.
13 Abrinq F. Um retrato da infância e adolescência no Brasil 2024 [Internet]. São Paulo: Fundação Abrinq; 2024 [citado 2025 maio 9]. Disponível em:
14 Ministério da Saúde (BR), Secretaria de Vigilância em Saúde, Departamento de Análise de Situação em Saúde. Pesquisa Nacional de Saúde do Escolar: 2019 [Internet]. Brasília: Ministério da Saúde; 2019 [citado 2025 out 22]. Disponível em:
15 Praxedes RCS, Gubert FDA, Sousa GB, Castro Jr AR, Martins MC, Alves RS et al. Saúde bucal na infância: construção e validação de instrumento sobre conhecimento, atitude e prática de cuidadores. Cien Saude Colet. 2023;28(8):2203-14.
16 Prihanto JB, Nurhayati F, Wahjuni ES, Matsuyama R, Tsunematsu M, Kakehashi M. Health literacy and health behavior: associated factors in Surabaya high school students, Indonesia. Int J Environ Res Public Health. 2021;18(15):8111.
17 Andrade C, Menon V, Ameen S, Praharaj SK. Designing and conducting knowledge, attitude, and practice surveys in psychiatry: practical guidance. Indian J Psychol Med. 2020;42(5):478-81.
18 Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine. 2000;25(24):3186-91.
19 Epstein J, Santo RM, Guillemin F. A review of guidelines for crosscultural adaptation of questionnaires could not bring out a consensus. J Clin Epidemiol. 2015;68(4):435-41.
20 Mokkink LB, Prinsen CA, Bouter LM, Vet HC, Terwee CB. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) and how to select an outcome measurement instrument. Braz J Phys Ther. 2016;20(2):105-13.
21 Souza AC, Alexandre NMC, Guirardello EB. Psychometric properties in instruments evaluation of reliability and validity. Epidemiol Serv Saude. 2017;26(3):649-59.
22 World Health Organization. Adolescent health [Internet]. Geneva: WHO; 2026 [citado 2026 abr 17]. Disponível em:
23 Ministério da Saúde (BR), Secretaria de Vigilância em Saúde. Marco legal da saúde de adolescentes [Internet]. Brasília: Ministério da Saúde; 2007 [citado 2025 out 22]. Disponível em:
24 Polit DF, Beck CT. The content validity index: are you sure you know what’s being reported? Critique and recommendations. Res Nurs Health. 2006;29(5):489-97.
25 Schreiber JB. Issues and recommendations for exploratory factor analysis and principal component analysis. Res Social Adm Pharm. 2021;17(5):1004-11.
26 Echevarría-Guanilo ME, Gonçalves N, Romanoski PJ. Psychometric properties of measurement instruments: conceptual basis and evaluation methods – Part II. Texto Contexto Enferm. 2019;28:e20170311.
27 Sellbom M, Tellegen A. Factor analysis in psychological assessment research: common pitfalls and recommendations. Psychol Assess. 2019;31(12):1428-41.
28 Ferrando PJ, Lorenzo-Seva U. On the added value of multiple factor score estimates in essentially unidimensional models. Educ Psychol Meas. 2019;79(2):249-71.
29 Vocci MC, Fontes CMB, Abbade LPF. Cultural adaptation of the Glamorgan Scale to Brazilian Portuguese: pressure injury in pediatrics. Rev Lat Am Enfermagem. 2021;29:e3424.
30 Hair JF, Black WC, Babin BJ, Anderson RE, Tatham RL. Multivariate data analysis. 8th ed. Upper Saddle River: Thomson Business; 2018.
31 Lorenzo-Seva U, Ferrando PJ. MSA: the forgotten index for identifying inappropriate items before computing exploratory item factor analysis. Methodology (Gött). 2021;17(4):296-306.
32 Oliveira F, Kuznier TP, Souza CC, Chianca TCM. Theoretical and methodological aspects for the cultural adaptation and validation of instruments in nursing. Texto Contexto Enferm. 2018;27(2):e4900016.
33 Shapiro J, Donaldson S. The Leader Vitality Scale: development, psychometric assessment, and validation. Front Psychol. 2022;13:884672.
34 Sijtsma K. On the use, the misuse, and the very limited usefulness of Cronbach’s alpha. Psychometrika. 2009;74(1):107-20.
35 Grama MM, Fonseca DL, Lovisi GM, Lima LA. CONNECT – uma medida de continuidade do cuidado em serviços de saúde mental: adaptação transcultural e confiabilidade da escala. J Bras Psiquiatr. 2016;65(2):140-8.
36 Campo-Arias A, Oviedo H. Psychometric properties of a scale: internal consistency. Rev Salud Publica. 2008;10(5):831-9. PMid:19360231.
37 Prata RA, Silva JB, Pimentel SM, Nunes HRC, Avila MAG. Digital health literacy, behavior and knowledge of adolescents for hand hygiene during the COVID-19 pandemic. Rev Lat Am Enfermagem. 2024;32:e4308.
38 Schulenkorf T, Sørensen K, Okan O. International understandings of health literacy in childhood and adolescence a qualitative-explorative analysis of global expert interviews. Int J Environ Res Public Health. 2022;19(3):1591.
Accepted date:
04/23/2026
Facebook
Google+
Twitter
LinkedIn
Mendeley
StumbleUpon
CiteULike
Reddit
Email