ABC | Volume 112, Nº1, January 2019

Original Article Santos et al Validation of CADE-Q II in portuguese Arq Bras Cardiol. 2019; 112(1):78-84 private CR program and knowledge level about the disease, reinforcing the influence of socioeconomic disparities on education in health. 21 These data make clear the need for developing strategies aiming at overcoming the obstacles between health knowledge and patients of different social classes. In this regard, these proposals should be grounded in simple models, with high population coverage, since less educated patients are the ones who would benefit most from educational interventions. 22 In addition, we found that patients withmore comorbidities, risk factors, previous procedures and acute events did not show higher knowledge level about the disease compared with patients without these conditions. These results contrast with those found in validation of the original version, since those patients with more risk factors showed higher knowledge about the disease. 17 These findings may be related to differences in the health education approach to the patients by the healthcare members and in patients’ ability to understand the information received in different contexts. 23 These findings should be interpreted with caution. First, our results cannot be generalized, since our sample was selected by convenience and recruited from four CR programs only, which may limit the extrapolation of the results. Second, CADE-QII is based on education curriculum of Canadian CR programs, which are based on more rigorous educational processes than the Brazilian programs. Third, although all patients were recruited from CR programs, these were conducted at distinct centers (public and private), located in different regions of the country. Therefore, the type of educational approach and variability between the investigators may have influenced the results. Fourth, reliability analysis was performed with 49 patients enrolled in only two of the four programs. The occurrence of a response trend, hence, may not be ruled out, since data in the literature consider that a sample size of at least 50 patients is adequate for this analysis. 19 In addition, it is possible that participants gained additional education during the 15 minute-interval between questionnaire applications, which could have also influenced the results. Fifth, CADE-QII was not developed using plain (or simple) language techniques, which may have had a negative impact on interpretation of the questions and consequently on the responses. 23 Sixth, as previously mentioned, during validation of its original version, CADE-QII was self-administered, in contrast to the adapted version, that was administered by means of a questionnaire. Even though the interviewers have been trained, bias intrinsic to questionnaire-based methods may have influenced the answers to the instrument. To address this, further studies are needed to validate and use the short version of the CADE-Q, 24 as an alternative. Also, some questions were excluded during the construction of this adapted version, since they did not meet minimum standards of ICC; new validation studies proposing reformulation and inclusion of these questions are also encouraged. Also, future studies are needed to evaluate whether the Brazilian version is sensitive to longitudinal changes in assessment of patients’ knowledge before and after their participation in CR programs. Conclusions This study showed that CADE-Q II version in Brazilian Portuguese version has enough reliability, consistency and validity, supporting its use in future studies to evaluate the level of knowledge of CAD patients enrolled in CR programs. This instrument could support the evaluation of the educational component in CR programs and identify knowledge domains compatible with patients’ need for information. Author contributions Conception and design of the research: Santos RZ, Ghisi GLM, Britto R; acquisition of data: Bonin CDB, Chaves G, Haase CM; analysis and interpretation of the data: Santos RZ, Bonin CDB; statistical analysis: Santos RZ, Chaves G, Benetti M; writing of the manuscript: Santos RZ, Ghisi GLM, Bonin CDB, Chaves G, Haase CM, Britto R, Benetti M; critical revision of the manuscript for intellectual contente: Santos RZ, Ghisi GLM, Britto R, Benetti M. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This study is not associatedwith any thesis or dissertationwork. Ethics approval and consent to participate This study was approved by the Ethics Committee of the Universidade Federal de Minas Gerais under the protocol number 1.350.973. All the procedures in this study were in accordance with the 1975 Helsinki Declaration, updated in 2013. Informed consent was obtained from all participants included in the study. 83