Abstract
Objective
to cross-culturally adapt the Rosenbaum Concussion Knowledge and Attitudes Survey - Student Version (RoCKAS-ST) into Arabic (RoCKAS-ST-A), and to evaluate its psychometric properties (i.e., face validity, internal consistency and test-retest reliability) of the Arabic version 16 of the RoCKAS-ST (RoCKAS-ST-A).
Design
cross-cultural and preliminary validation of the of the Arabic version of the Rosenbaum Concussion Knowledge and Attitudes Survey - Student Version (RoCKAS-ST-A).
Setting
youth clubs and after-school activities centers around Kuwait.
Participants
Adolescent and young adults, aged 13–20 years old, both sexes.
Independent Variables
age, sex, and type of sport (if any).
Main Outcome measure
RoCKAS-ST-A questionnaire answers and demographics of participants.
Results
Two hundred and thirty-four adolescent and young adults (n = 234) participated in this study (mean age = 15.95, SD = 1.92). More than half of the participants were males (n = 163, 69.66%). The internal consistency for the concussion knowledge index (CKI) and concussion attitude index (CAI) ranged between fair and good (α = 0.31 & 0.97, respectively). The test-retest reliability of CKI score was 0.79 (95% CI = 0.42–0.92, P < 0.05) and of CAI was 0.86 (95% CI =0.66–0.94, P < 0.05). The average time between the 2 tests was 9.35 ± 2.44 days.
Conclusion
RoCKAS-ST-A is a reliable, valid, and feasible tool to examine the knowledge about and attitudes toward sport-related concussions (SRC) in adolescents and young adults with Arabic as their first language. Decreased knowledge and unsafe attitudes toward SRC was exhibited among adolescents and young adults in Kuwait.
Introduction
Concussion is the most frequent type of traumatic brain injury (TBI) and is often defined as a mild TBI (mTBI) with disruption in brain function not caused by a penetrating head injury, but is caused by a blow to the head, face, or neck region. 1 Sport-related concussions (SRCs) are known to have short-term effects on cerebral processes, which can result in diverse clinical presentations. 2 Concussions can present with a variety of somatic, cognitive, and behavioral symptoms. Somatic symptoms can include headache, vertigo, nausea, and fatigue. Mental “fogginess”, memory and concentration struggles, and word finding difficulties are some of the cognitive symptoms associated with SRCs. It can also be associated with behavioral symptoms like irritability, anxiety, and depression.3,4
Although cases of individuals with SRCs are documented in the literature, concussion is still considered to be underdiagnosed and manifested as non-specific symptoms, with variable timeframe for their onset . Despite that, the recovery of most of these athletes can take up to 3 weeks; and up to 20% of them disclose prolonged symptoms. Sport concussion assessment tool (SCAT) was created as an educational and clinical tool to assess SRC in a standardized manner. SCAT6 is the most recent version of the tool. 5
In Kuwait, the only study that included an assessment of concussion was a study done by Marwan and team 6 that examined the prevalence and associated factors of sport injuries among professional male athletes. Athletes that practiced for the past 12 months and were 15 years and older were included (n = 450). Of these athletes, 5.2% reported injuries of the head/ neck regions, whereas only 0.9% reported concussion as their type of injury. For all injuries, most athletes reported taking 1–10 days off after the injury. 6 The low percentage reported could be due to the lack of knowledge of this condition among athletes and physicians, which was documented in western communities.5,7,8
To assess the knowledge and attitudes toward SRC, Rosenbaum Concussion Knowledge and Attitudes Survey - Student Version (RoCKAS-ST) was widely implemented in the literature. 9 The RoCKAS-ST questionnaire was developed in order to examine these domains in adolescents (i.e., 13–20 years old individuals). It is divided into three parts with five sections. First, second and fifth sections are part of the concussion knowledge index (CKI) that examine the participants’ knowledge of concussion, which include a 16 - symptom checklist. Third and fourth are part of the concussion attitude index (CAI) that examine the participants’ views on concussion among athletes. Each participant would receive a score out of 25 and out of 15, for CKI and CAI domains of the questionnaire, respectively. 9 RoCKAS-ST survey was translated to Malay language. 10 Fairus and colleague 10 found that the reliability of the Malay version of the survey (RoCKAS-ST-M) for athletes under 18 years of age (n = 32) reliability for both CKI and CAI, intraclass correlation value exceed 0.60. It was also translated into Urdu which was validated by Mahfooz and colleagues. 11 They reported that more than 75% of their sample answered CKI section incorrectly.
The definition of the cross-cultural adaptation of any tool is to acclimate this tool in term of language and cultural issues to be used in a new community.12–14 To better present this new version of the tool, psychometric properties should be established; some of these properties are validity (e.g., face validities) and reliability (e.g., test-retest reliability).12,13 Cross-cultural adaptation process include several stages including forward translation, translation synthesis, back translation, expert committee review process and pre-final administration. The first stage starts with a translation of the tool by 2 independent translators (forward translation), then, after both translators compared their versions and reach consensus (translation synthesis), back translation to the original language is done to ensure the accuracy of the translated tool (back translation). Afterwards, a committee of experts would review the translated tool in terms of linguistic accuracy and cultural relevance (expert committee review process). Following the approval of the expert committee reviewers of the final approved translated tool, the last stage within the cross-cultural adaptation process (pre-final administration) comes in place; in this last stage, the translated tool is then distribute among a sub-group of targeted audience to ensure that the tool is clearly written, linguistically understandable and culturally relevant. After receiving the participants’ feedback, the committee would convene again to address any issue raised by the participants and resolve them to produce the final version of the new tool.12–14
To our knowledge, despite having a well-documented effect on adolescents’ and children's physical, emotional health, and academic performance, the prevalence of concussion among adolescent and young adults in Kuwait has never been tested. Hence, the knowledge and attitude toward SRC should be examine first. Therefore, the aims of this study were: 1) to cross-culturally adapt RoCKAS-ST into Arabic, and 2) to address the psychometric properties of the Arabic version of the RoCKAS-ST (RoCKAS-ST-A) including face validity, internal consistency and retest reliability among adolescent and young adults between the age of 13–20 years.
Methods
Study design
The scientific design utilized for this study was cross-cultural and preliminary validation of the of the Arabic version of the Rosenbaum Concussion Knowledge and Attitudes Survey - Student Version (RoCKAS-ST-A). The protocol was approved by the research ethical committee at Kuwait University (#106).
Participants
Adolescent and young adults aged between 13–20 years, both males and females were asked to participant in the study. High schools and youth centers were approached as recruitment centers. Flyer about the study were sent to legal guardians of these centers to inform them about the study. For participants under the age of 18 years, the consent form was obtained by the parents ahead of participation. Participants were recruited if they were within the included age range and able to speak and read Arabic fluently. Participants were excluded if they reported being diagnosed with any neurological (beside SRC), psychiatric condition, or had any previous head/ neck surgeries.
Procedure
Participants were asked to fill in the RoCKAS-ST-A. Participants were recruited from after-school activities center and youth sport clubs around the state of Kuwait. Parents of participants were sent the consent form along with the demographic information survey that included information on age, sex. Upon approval of the parents, participants were given the assent form to be assigned as well. After a minimum of 5 days, a subgroup of the participants were asked to respond to the questionnaire again to establish test-retest reliability. A reliability value of >0.6 was considered as good test-retest reliability. 10
Instrument
RoCKAS-ST is a questionnaire that include 5 sections. 9 Section 1 consists of 18 true/false questions that assess the participants’ knowledge about SRC. Section 2 also assess knowledge about SRC through 3 true/false scenario-based questions. Sections 3 and 4 are scenario-based questions that examine the attitudes adolescents and young adults have toward SRC through 5-points Likert scale, ranging between strongly agree and strongly disagree (1 = strongly disagree & 5 = strongly agree). Section 5 is a 16-items symptoms list, in which participants are asked to identify the correct symptoms associated with concussion. CKI is an index representing the participant's knowledge about concussions and calculated based on participants correctly responding to sections 1, 2, and 5, with a possible maximum score of 25 points. This is based on scoring the participants’ responses as correct versus incorrect (0 = incorrect & 1 = correct); scoring was done based on a scoring scale provided by Rosenbaum & Arnett. 9 CAI is an index representing the participant's attitude toward concussions and calculated based on participants correctly responding to sections 3, and 4, with a possible maximum score of 15 points, which was scored as safe attitude versus unsafe attitude (0 = unsafe & 1 = safe) based on the scoring grade provided with the original tool. 9 CAI can also be presented using the sum of the raw score on sections 3 and 4 (range = 15–75).
Procedure of cross-cultural and preliminary RoCKAS-ST-A validation
RoCKAS-ST-A questionnaire was developed following the recommendation of the published guidelines of the American Academy of orthopedic surgeons outcomes committee12,15 (Figure 1). The stages were:
Forward Translation: forward translation was conducted by 2 independent translators that were fluent in both Arabic and English. Both translators had medical backgrounds (physical therapists) Translation Synthesis: both Arabic versions were compared and discrepancies were resolved to reach a final version. Back Translation: back translation of the Arabic version into English was conducted by a third translator. Translator 3 was proficient in both Arabic and English with medical background (PhD candidate). Expert committee review process: All versions were discussed by a group of experts to produce the pre-final version (physical therapist = 2, physiologist = 1, neuroscientist = 1). All committee members had more than 5 years of experience working with athletes. Pre-final administration: the pre-final version was distributed among a sub-group of adolescents and young adults to be appraised for assessing the knowledge of and attitudes toward concussions. The final version: The finalized version was formed and distributed among the participants to establish the psychometric properties of the new version of RoCKAS-ST.
The cross-cutltural process of the RoCKAS-ST for arabic-language speakers.
Finally, the committee of experts gathered again to resolve any issues raised by the participants, which produced the final Arabic version of the RoCKAS-ST-A. Afterwards, and to establish the psychometric properties of the newly established tool, the final version was distributed among adolescent and young adults all around Kuwait.
Data analysis
Demographic information, CKI score, and CAI score were summarized using measures of central tendency (sample means, medians) and variation (sample variance, standard deviation, and range). Internal consistency for CAI was calculated using Cronbach's alpha, whereas CKI would be examined using Kuder-Richardson Formula 20 (KR-20) because of the binary nature of the variables. 16 Test-retest reliability was established using two-way random-effects intraclass correlations (ICC), for both CKI and CAI, with a p value at 0.05. All statistical analysis was preformed using Statistical Package for the Social Sciences (SPSS v26, IBM, Armonk, NY).
Results
Two hundred seventy-seven potential participants were approached to join this study from around Kuwait (n = 277); Two hundred thirty-four participants returned the questionnaire (n = 234, mean age = 15.95, SD = 1.92). More than half of the participants were males (n = 163, 69.66%). Out of the 234 participants, 12 participants (5.13%) reported sustaining a previous concussion and 175 completed forms (74.79%) were collected (See Table 1). On average, the participants had a CKI score of 13.85 (SD = 2.77, Range = 6–21) out of 25. For the CAI score, participant had a mean score of 8.84 (SD = 3.15, Range = 0–15) out of 15 (Table 2). The mean raw score for CAI was 45.44 (SD = 6.71, Range = 16–61) out of 75. Participants were sub-grouped into participants aged between 13–16 and 17–20 years and the average CKI and CAI scores were presented for each age group (Table 2).
Characteristics of participating sample.
CKI and CAI scores.
CKI: Concussion Knowledge Index; CAI: Concussion Attitude Index; SD: standard deviation
A sub-group of the participants (n = 156, mean age = 15.50, SD = 1.76) were athletes. Participants were identified as athletes if they were part of organized sports teams and have been involved in that sport for ≥ 12 months. More than half of them played football (n = 94, 60.26%). Other sports were basketball, ice hockey, martial arts, swimming, and handball (Table 1).
Cross-cultural adaptation and translation process of RoCKAS-ST-A
The translation and cross-cultural adaption process used to produce the final version of RoCKAS-ST-A started with a forward translation by two independent translator (Translator 1 & Translator 2) (Figure 1). During the comparison between the generated versions, there was a discrepancy among them in section 1, question 4 & 15 (S1Q4 & S1Q15, respectively), and section 5 (symptoms: Hives & feeling in a “Fog”) (S5S1 & S5S9, respectively). For S1Q4, translator 1 used a lay language to describe cleats whereas, translator 2 used a formal terminology for them. For S1Q15, translator 2 reverse the order between ‘college freshman’ and ‘high school freshman’ whereas, translator 1 used the same order depicted in the original questionnaire. Both discrepancies were resolved. For S1Q4, the formal terminology was used and for S1Q15, the original order was used. For S5S1, translator 1 used a medical terminology to translate ‘Hives’ (i.e., حساسية) whereas, translator 2 used a different translation (i.e., قشعريرة). Both translators reach the conclusion that the terminology used by translator 1 was the most accurate and it was used in the final version. Lastly, both translators reach a different translation for S5S9 (إرهاق عقلي vs. ضبابية التفكير). The consensus was reached to include both translations to better explain the symptom. Then, a final Arabic version was moved to the following stage. The back translation was done by a third translator (Translator 3). Afterwards, a committee of experts was formed (physical therapist = 2, physiologist = 1, neuroscientist = 1) and was presented all the versions developed (i.e., original questionnaire, 2 Arabic versions, final Arabic version, back translation English version). The committee discussed all the versions and agreed on a pre-final version to be administration on a small group of participants and get their feedback on it. This stage was conducted on 11 participants (mean age = 15.8, SD = 1.316, Range = 13–17, Athletes [n = 6] vs. non-athletes [n = 5]). The feedback received about the questionnaire was: 1) the length of the questionnaire and 2) the participants’ lack of knowledge about SRC which made it difficult to answer the questions correctly. The final version was formed and it was distributed about the participants to establish the psychometric properties of the new version of RoCKAS-ST.
Psychometric properties of RoCKAS-ST-A
The internal consistency for the CKI was fair (α = 0.31). On the other hand, the internal consistency for the CAI was good (α = 0.69) (Table 2). Complete forms upon retest were obtained for the CKI (n = 17) and the CAI (n = 21). The test-retest reliability of CKI score was 0.79 (95% CI = - 0.42- 0.92, P < 0.05). The CAI score test-retest reliability was 0.86 (95% CI = 0.66- 0.94, P < 0.05) (Table 3). The average time between the 2 tests was 9.35 ± 2.44 days.17,18 The result of test-retest reliability revealed that the tool is reliable and consistent. As previously mentioned, face validity was established by a sub-group of participants that agreed on the relevance and suitability of the items of the RoCKAS-ST-A.
Psychometric properties of the CKI & CAI.
CKI: Concussion Knowledge Index; CAI: Concussion Attitude Index; SD: standard deviation; ICC: interclass correlation; IC: confidence interval
Discussion
The purpose of this study was to cross-culturally adapt the Rosenbaum Concussion Knowledge and Attitudes Survey - Student Version (RoCKAS-ST) into Arabic (RoCKAS-ST-A), and evaluate its psychometric properties (i.e., face validity, internal consistency and test-retest reliability) among adolescent and young adults between the age of 13–20 years. According to our findings, the Arabic version of the RoCKAS-ST was feasible, valid and reliable tool to be used for assessment of knowledge and attitude toward SRC in adolescent and young adults. Test-retest reliability for indices were good (CKI = 0.79 and CAI = 0.86), which indicated that the tool is consistent over time and can be used as an assessment for intervention programs. 12
In addition, the internal consistency for CAI was good (α = 0.69) in comparison to the fair internal consistency of the CKI (α = 0.31). This discrepancy can be explained by the wide range of responses in the CK index (range = 6–21) which exposes that there is a divergence in the level of knowledge about concussion among adolescents and young in Kuwait. Other translation attempt faced similar trends. Fairus et al. 10 reported an internal consistency of 0.44 for CKI and 0.66 for CAI for the Malaysian translation of the RoCKAS-ST. On the other hand, test-retest reliability of the Arabic version was consistent with the one presented by Fairus and colleagues. 10 In addition, Mahfooz and colleagues. 11 conducted a validation of an Urdu version of the RoCKAS-ST. They reported that due to 75% of participants answered the items incorrectly, that led to the use of a cluster analysis instead of Cronbach's alpha for testing the reliability of the items of this new version. 11 Due to the different statistics used in this study, we could not compare our results to their findings.
The mean score of CKI and CAI for participants in Kuwait demonstrated a lack of knowledge about and an unsafe attitude toward SRC. These scores were lower than other reports in the literature. Kraak and colleagues 19 showed that college athletes had CKI score and CAI raw scores of 18.8 ± 2.4 and 60.98 ± 6.32, respectively. This could be due to the age range included in our sample (i.e., 13–20 years) which included younger athletes that would not have the proper education about the condition. 19 Therefore, we suggest to introduce an educational programs that would raise the awareness about SRC about adolescents and young adults. As a result, more athletes would be able recognize and intern report their symptoms which would improve management and recovery for these athletes. This awareness would be spread to the couches and parents to help identify when the athletes is ready to go return-to-play and/or return-to-learn. 3
This version of the RoCKAS-ST is providing new venues to explore the knowledge about and attitude toward SRC in a new population- Arabic speaking populations. Concussion is still being considered underdiagnosed, especially in younger population. 8 In addition, the examination of the knowledge and attitude in case of SRC could be linked to intention to report symptoms of concussion. 20 For example, this link was explored in ice hockey players and Muay Thai kickboxing athlete.21,22 Cultural difference with the patterns of intentions of reporting symptoms could also be explored. This would lead better understanding of these patterns which would inform educational intervention to be better tailored for different populations.
This newly validated Arabic version of the RoCKAS-ST could also be used to examine educational interventions tailed to Arabic-speaking athletes to assess the effectiveness of these interventions. The exploration of the effect of the attitudes of coaches on the knowledge and attitudes of young athletes could be investigated. 7 Parents knowledge and attitude toward SRC should also be explored. Future studies should also focus on conducting larger validation studies for RoCKAS-ST-A, in which construct validity and responsiveness should be addressed. All of these studies should also inform guidelines that would help spread awareness about SRC and sequentially would help inform policies about athletes that would differ from SRC. RoCKAS-ST-A could also be used to examine the effectiveness of the reporting of SRC symptoms in the emergency departments, which would also help inform protocols to managing the acute cases of adolescent and young adults suffering from SRC. 23
Limitations
The current study has several limitations that warrant considerations. First, this study has a small sample size thus limit the generalizability of the study findings. Therefore, future studies should incorporate larger sample size that is randomly selected. Second, the lack of the diversity in the sex of the participants is another limitation of the study. Therefore, future studies should focus on implementing the tool with better representation of both sexes. Finally, the inconsistent knowledge among the participants was an additional limiting factor of the study. Therefore, to address this limitation, we propose that the RoCKAS-ST-A can be used to assess the effectiveness of educational programs about SRC.
Conclusion
The Arabic version of RoCKAS-ST-A is a reliable, valid and feasible tool to examine the knowledge about and attitudes toward SRC in adolescents and young adults with Arabic as their first language. In Kuwait, adolescents and young adults exhibited decreased knowledge about and unsafe attitudes toward SRC. This was evident by the low scores this population had on average on both the concussion knowledge index and concussion attitude index of RoCKAS-ST-A. Additional research is needed to further examine the knowledge about and attitude toward SRC in practicing athletes and other related population like coaches and parents to enhance the process in which this condition is managed. Moreover, further psychometric properties of this tool is suggested to ensure the robust of its use among adolescent and young adult athletes. Finally, the measurement of these variables among adolescents and young adults would provide a window into their ability to report symptoms of SRC, which should be further explored.
Footnotes
Acknowledgments
We would like to thank the participants and their families for agreeing to participate in our study.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
