IJCS | Volume 32, Nº5, September/October 2019

439 Gontijo et al. Distress evaluation (stop-d) brazilian version Int J Cardiovasc Sci. 2019;32(5):438-446 Original Article illness, changes in emotional well-being, physical and emotional discomfort, verbal and non-verbal cues of discomfort, in addition to individual damages that may become permanent. 3 Some risk predictors for distress can be found in the literature, including female sex, 4-6 poor social support, 7 lack of access to specialized support (psychologists and/or psychiatrists), 8 and type D personality (negative affectivity), 9 low socioeconomical status and lower educational attainment. 4,7 Distress is recognized as an unpleasant emotional change which, when experienced for a long time, leads to an increase in sympathetic nervous system activity. Increased levels of distress-related hormones can affect the cardiovascular system and worsen the prognosis of the patients. 10 In addition, distress has been associated with fatigue level, 11 increased risk of rehospitalization, 12 higher mortality rate, 7,13,14 and poor cardiac prognosis. 15,16 Thus, distress can potentiate the complications of heart disease. Denollet, Schiffer and Spek 15 describe depression, anxiety, anger and posttraumatic stress as specific markers of distress. Besides, the authors report an association of distress with a poor prognosis and decompensation of heart failure. A strategy to promote a comprehensive support to patients is to perform the screening for distress using specific, sensitive tools. Systematic evaluation and early identification of distress can promote adequate intervention that requires individual’s confrontation that facilitates the whole process. 16 Young et al., 17 developed, in St. Paul’s Hospital, Canada, a screening tool for distress called Screening Tool for Psychological Distress (STOP-D). The instrument provides risk scores for five items – depression, anxiety, stress, anger, and low social support. STOP-D is a brief, free instrument that can be self-administered, and applied in both outpatient and inpatient settings. 17,18 The Brazilian Society of Cardiology recognizes that emotional repercussions of heart diseases as comorbidities of these conditions. It also highlights the importance of a regular psychosocial evaluation and screening of heart disease patients for unfavorable psychosocial conditions. 19,20 However, so far, there is no instrument for distress screening adapted and validated to the Brazilian population, making cultural adaptation and statistical validation of well-established international instruments necessary. 21,22 Therefore, the aim of the present study was to describe the validation process of the Screening Tool for Psychosocial Distress (STOP-D) to the Brazilian population. Methods Study design and ethical aspects This was a cross-sectional, observational study with a quantitative approach performed at Hospital das Clínicas da Universidade Federal de Goiás (HC-UFG), between August and December 2016. After approval by the local ethics committee, data collection was started at the outpatient cardiology department of the Hospital das Clínicas da Universidade de Goiás (HC-UFG), and at the internal medicine ward. Participants Patients older than 18 years attending the outpatient cardiology department and patients hospitalized at the Division of Cardiology of the Hospital das Clínicas da Universidade Federal de Goiás (HC-UFG), regardless of heart disease diagnosis and time of diagnosis were considered eligible for the study. Patients with hearing, oral communication or cognitive impairment that could affect their ability to answer to the assessment tools were not included. A total of 144 patients were included, and all of them signed an informed consent form. Instruments • Sociodemographic questionnaire: developed specifically for the study, for characterization of the study population. The following data were collected – sex, age, place of residence, marital status, number of children, educational attainment, occupational status, income and religion/beliefs. • Clinical questionnaire: developed specifically for the study to gather information about the diagnosis of cardiac disease that was the cause of hospitalization or outpatient follow-up, time of diagnosis, number of hospitalizations due to the cardiac condition, comorbidities and patients’ perception about their health status. • Brazilian version of the STOP-D for heart disease patients (appendix): adapted from the English language version 17 to Portuguese language by evaluation of the target population and back-translation. The cross- cultural adaptation was performed according to the International Test Commission (UTC) guidelines. 22