Spanish Translation and Cross-Cultural Adaptation of the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (Spanish HSS Pedi-FABS)

Abstract

Background:

Language barriers during clinical care are a cause for particular concern for individuals from diverse linguistic backgrounds, especially the Hispanic and Latino US population, who comprise >19% of the American population and speak Spanish, the second most spoken language globally. Ensuring the inclusion of these patients in pediatric sports medicine and rehabilitation research is critical in minimizing bias and necessitates the development of patient-reported outcome measures available for use in Spanish. The Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) quantifies activity levels, developed for children and adolescents.

Purpose:

To validate a Spanish-translated and cross-culturally adapted version of the HSS Pedi-FABS questionnaire (Spanish HSS Pedi-FABS).

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

Phase I consisted of the development and pretesting of the Spanish HSS Pedi-FABS for content validity. Phase II consisted of administering the English and Spanish versions to bilingual children and adolescents aged 10 to 18 years for construct validity and reliability. Participant demographic data and questionnaire responses were recorded. Internal consistency reliability was tested using Cronbach α. Construct validity was assessed by calculating a 2-way random-effects model of intraclass correlation coefficient (ICC) between the total scores and each item of the English and Spanish questionnaires. Floor and ceiling effect testing was performed by calculating the proportion of minimum and maximum overall scores in the cohort, respectively, to ensure they did not exceed a 15% threshold.

Results:

The study included 50 patients with a mean age of 14.1 ± 2.0 years, of whom 52% were female. Internal consistency reliability of the Spanish HSS Pedi-FABS was excellent (Cronbach α = 0.92). Construct validity testing demonstrated excellent agreement between the English and Spanish questionnaires (ICC = 0.91). No floor or ceiling effects were demonstrated by either scale, as the minimum score was observed only twice (4%) in each scale and the maximum score was not observed.

Conclusion:

This study demonstrated that the Spanish HSS Pedi-FABS questionnaire is a valid and reliable tool that physicians can use to quantify physical activity levels in Spanish-speaking pediatric and adolescent populations. The validation of the Spanish HSS Pedi-FABS questionnaire is an important step in ensuring the inclusion of Spanish-speaking patients in pediatric sports medicine and rehabilitation research.

The increasing popularity of competitive youth sports participation and single-sport specialization among children and adolescents across the United States has produced an increasing incidence of sports-related injuries in this population.^{1,14,15,25,26} With this increasing burden comes the need to optimize both surgical and nonsurgical treatment strategies for these patients. Although several metrics are available by which treatment outcomes can be evaluated (eg, clinical outcomes, imaging results), patient-reported outcome measures (PROMs) are unique and critical in their ability to assess a patient's daily activity level, functional outcomes, and subjective quality of life, thus providing a more holistic assessment of disease burden, prognosis, and treatment efficacy.^{4,5,11,20,22,27} Historically, validated instruments reporting PROMs have been readily available throughout the adult literature, although questionnaires validated for use in pediatric and adolescent patients have been scarce.^{9,13,18,22,27}

In an effort to address this deficiency, the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) was developed and validated in 2013. ⁹ The HSS Pedi-FABS is a simple, valid, and reliable metric that assesses activity in children and adolescents 10 to 18 years old, consisting of 8 items (running, cutting, decelerating, pivoting, duration, endurance, competition, and supervision) and scored from 0 to 30 (0 being least active and 30 being most active). ⁹ The questionnaire has made a substantial effect on clinical practice and research in pediatric sports medicine and rehabilitation since its inception and has been translated and cross-culturally adapted from English to Japanese, Dutch, Italian, and French.^3,7,12,19 Development of translated and cross-culturally adapted questionnaires is extremely important for including non–English speaking patients in clinical research studies, especially in the United States, where many large academic research centers are located in urban areas with a significant Spanish-speaking population. Additionally, lack of Spanish-language PROM instruments may exclude Spanish-speaking countries and serve as a barrier to international collaboration in sports medicine research. Long-term, this trend risks the relative exclusion of certain ethnic groups from clinical research, leading to poor external validity and, in turn, the potential for bias and treatment disparities based on race or ethnicity.

The issue surrounding a lack of racial and ethnic inclusivity in biomedical research is not novel. In 1993, the National Institutes of Health Revitalization Act was signed into law, requiring that all federally funded clinical research projects prioritize the inclusion of minorities. ²¹ Nonetheless, <2% of over 10,000 cancer clinical trials funded by the National Cancer Institute since that time have included enough minority participants to meet the criteria laid out in the act. ⁶ Furthermore, although Black people, Indigenous people, and people of color comprise approximately 30% of the US population, they account for a mere 6% of all participants in federally funded trials. ²³ Although the reasons for these findings are multifactorial, language barriers have been identified as playing an important role.^8,10,17,23

In the United States, language barriers are a cause for particular concern for Hispanic and Latino individuals, who comprise >19% of the country's population. ³⁰ Furthermore, >40 million individuals older than 5 years in the United States are Spanish-speaking, making it by far the second most common language spoken in the country. ²⁹ Previous literature has demonstrated the association of limited English proficiency with adverse surgical outcomes, including patient evaluation and quality of care.^16,24 Therefore, ensuring the inclusion of these patients in pediatric sports medicine and rehabilitation research is of critical importance and necessitates the development of accurate and reliable PROM instruments available for use in Spanish. Thus, the purpose of the present study was to develop and validate a Spanish version of the HSS Pedi-FABS questionnaire (Spanish HSS Pedi-FABS) with the hope of improving the inclusion of Spanish-speaking pediatric and adolescent patients in sports medicine research. This advancement will facilitate shared decision making between physicians and Spanish-speaking patients, improve pediatric clinical care, and minimize bias in clinical research. This study tested the null hypothesis that no significant correlations, including the total scores and individual questionnaire items, would be found between the English and Spanish HSS Pedi-FABS questionnaires.

Methods

This was a multiphase, prospective, clinical outcome scale translation and cross-cultural adaptation study carried out according to the methods described in previous literature.^{2,3,7,12,19,28} Phase I consisted of development and pretesting of the Spanish HSS Pedi-FABS for content validity. The Spanish questionnaire was developed in a series of steps. First, forward translations were written by 2 independent native Spanish-speaking translators. Second, the 2 translators synthesized a consensus initial forward translation of the English questionnaire. Third, back translation was conducted by 2 native English speakers who were fluent in Spanish. Fourth, the Spanish questionnaire was consolidated into a “prefinal” questionnaire. The original English questionnaire and the prefinal Spanish questionnaire were administered to a pilot testing group of 11 English-Spanish bilingual children aged 10 to 18 years. The pilot testing group did not raise any concerns about format, wording, or comprehensibility. The Spanish HSS Pedi-FABS was then finalized (Figure 1).

Figure 1.

The Spanish Hospital for Special Surgery Pediatric Functional Activity Brief Scale (Spanish HSS Pedi-FABS). Scoring is performed by adding points from each question for total possible score range from 0 to 30 points. For questions regarding running, cutting, decelerating, pivoting, duration, and endurance, each question is worth 0, 1, 2, 3, or 4 points. For questions about competition and supervision, each question is worth 0, 1, 2, or 3 points. A scoring legend is shown in Appendix Figure A1, available online.

Phase II consisted of construct validity and reliability testing. After institutional review board approval was granted (IRB No. 2021-0246), the English and Spanish versions of the HSS Pedi-FABS questionnaire were administered to 50 bilingual children and adolescents aged 10 to 18 years between March 2022 and August 2024. Participants, including patients being seen in an outpatient pediatric orthopaedic clinic (n = 40) and a sample of healthy volunteers (n = 10), were enrolled after it was confirmed that they were fluent in both English and Spanish and that their activity level would not likely change due to treatment protocol (eg, patient undergoing surgery or other treatment between first and second questionnaires). Random assignment was performed to determine the order in which the two versions were completed, and a washout period of ≥5 days between questionnaires was allowed to limit recall.

Participant demographic data and questionnaire responses were recorded. Internal consistency reliability was tested using Cronbach α. Construct validity was assessed by calculating a 2-way random-effects model of intraclass correlation coefficient (ICC) between the total scores and each item of the English and Spanish questionnaires. Testing of floor and ceiling effects was performed by calculating the proportion of minimum and maximum overall scores in the cohort, respectively, to ensure they did not exceed an a priori 15% threshold.

Results

The study included 50 participants with a mean age of 14.1 ± 2.0 years, of whom 52% were female. Of these, 34 participants (68%) identified as non-White and 42 participants (84%) identified as Hispanic or Latino. A total of 25 participants (50%) completed the English questionnaire first. The mean English and Spanish HSS Pedi-FABS scores were 16.1 ± 8.6 and 15.9 ± 8.5, respectively (Table 1). Internal consistency reliability of the Spanish HSS Pedi-FABS was almost perfect (Cronbach α = 0.92). Construct validity testing demonstrated almost perfect agreement between the English and Spanish questionnaires (ICC = 0.91). Furthermore, all individual Spanish questionnaire items exceeded the threshold for acceptable agreement with their English item counterparts (Table 2). No floor or ceiling effects were demonstrated by either scale, as the minimum score was observed only twice (4%) in each scale and the maximum score was not observed.

Table 1

Patient Demographic Characteristics and HSS Pedi-FABS Questionnaire Results ^a

Characteristic
Age, y	14.1 ± 2.0
Female	52
Race
White	32
Other	42
Not reported/refused	26
Hispanic or Latino	84
Completed English questionnaire first	50
English HSS Pedi-FABS score	16.1 ± 8.6
Spanish HSS Pedi-FABS score	15.9 ± 8.5

a

Data are expressed as mean ± SD or percentage of sample. HSS Pedi-FABS, Hospital for Special Surgery Pediatric Functional Activity Brief Scale.

Table 2

Intraclass Correlation Coefficient Between English and Spanish Versions of the HSS Pedi-FABS ^a

HSS Pedi-FABS Questionnaire Item	ICC
Overall score	0.91
Running	0.91
Cutting	0.80
Deceleration	0.77
Pivoting	0.81
Duration	0.78
Endurance	0.80
Competition	0.89
Supervision	0.79

a

HSS Pedi-FABS, Hospital for Special Surgery Pediatric Functional Activity Brief Scale; ICC, intraclass correlation coefficient.

Discussion

The major findings of this study demonstrated almost perfect internal consistency reliability (Cronbach α = 0.92) and construct validity (ICC = 0.91) of the newly developed Spanish HSS Pedi-FABS. This scale is a valid and reliable tool that can be used in Spanish-speaking children and adolescents. As participation in youth sports and subsequent sports-related injuries continue to increase, development of simple, valid, and reliable PROMs will provide critical information regarding patients’ activity levels, functional outcomes, and quality of life. The development and validation of the Spanish HSS Pedi-FABS questionnaire are important steps in ensuring the inclusion of Spanish-speaking patients in pediatric sports medicine and rehabilitation research, thereby minimizing risk of bias due to exclusion of this population.

The HSS Pedi-FABS has previously been translated and cross-culturally adapted into several languages, including Japanese, ¹² Dutch, ⁷ Italian, ¹⁹ and French. ³ The English version ⁹ and these adaptations demonstrated acceptable internal consistency (English, α = 0.91; Japanese, α = 0.90; Dutch, α = 0.82; Italian, α = 0.92; French, α = 0.87) and reliability (Japanese, ICC = 0.90; Dutch, ICC = 0.76; Italian, ICC = 0.94; French, ICC not available), which were comparable to the Spanish questionnaire. Furthermore, no floor or ceiling effects were found in the current Spanish HSS Pedi-FABS questionnaire, similar to existing language versions of the HSS Pedi-FABS (floor/ceiling: English, 0%/4%; Japanese, 2%/1%; Dutch, 1%/0%; Italian, 19%/0%; French, 2%/7%).^3,7,9,12,19 The Spanish HSS Pedi-FABS developed in the current study yielded similar results to previous adaptations in various languages that are now widely used in pediatric orthopaedics and sports medicine. Although the development and validation of these previous adaptations are important additions to the active pediatric patient population in different parts of the world, the Spanish adaptation described in this study will be particularly impactful in the United States given its large and growing Spanish-speaking population. Use of the Spanish HSS Pedi-FABS in native Spanish-speaking patients will represent a substantial improvement toward providing more equitable care while building trust and comfort with clinicians throughout the treatment process.

Limitations

The study has some limitations that should be noted. First, the study was conducted in individuals who were assessed at enrollment to be unlikely to have any change in their activity level between completing the first and second questionnaires. Although study personnel made this assessment based on available clinical information, it was possible that activity level did change between the first and second administrations, which could bias the reliability results. However, if such bias had been introduced, this would have decreased the reliability of the score agreement between the English and Spanish administrations. Therefore, the reliability reported in the current study is, if anything, an underestimate of true reliability between the questionnaire versions. Second, the study population was predominantly drawn from a single urban tertiary care hospital, potentially limiting the scope of generalizability of results. However, the hospital's location in a highly racially, ethnically, and linguistically diverse urban city, and the study's inclusion of both privately and publicly insured patients as well as healthy volunteers, provided a widely diverse study population from which to sample.

In summary, the results of this study demonstrate that the Spanish HSS Pedi-FABS questionnaire is a valid and reliable tool to assess activity levels in Spanish-speaking children and adolescents aged 10 to 18 years. Development and validation of the Spanish version of the HSS Pedi-FABS questionnaire are crucial steps toward minimizing bias by ensuring inclusion of the large and growing US population of Spanish-speaking patients in pediatric orthopaedic sports medicine and rehabilitation research.

Conclusion

This study demonstrated that the Spanish HSS Pedi-FABS questionnaire is a valid and reliable tool that physicians can use to quantify physical activity levels in Spanish-speaking pediatric and adolescent populations. Validation of the Spanish HSS Pedi-FABS questionnaire is an important step in ensuring the inclusion of Spanish-speaking patients in pediatric sports medicine and rehabilitation research.

Supplemental Material

sj-pdf-1-ojs-10.1177_23259671251340987 – Supplemental material for Spanish Translation and Cross-Cultural Adaptation of the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (Spanish HSS Pedi-FABS)

Supplemental material, sj-pdf-1-ojs-10.1177_23259671251340987 for Spanish Translation and Cross-Cultural Adaptation of the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (Spanish HSS Pedi-FABS) by Ruth H. Jones, Akshitha Adhiyaman, Preston W. Gross, Sofia Hidalgo Perea, Daniel W. Green and Peter D. Fabricant in Orthopaedic Journal of Sports Medicine