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.

Keywords

Spanish HSS Pedi-FABS HSS Pedi-FABS translation validation cross-cultural adaptation pediatric sports medicine activity patient-reported outcome measures

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

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

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 version⁹ 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

Footnotes

Final revision submitted January 6, 2025; accepted February 12, 2025.

One or more of the authors has declared the following potential conflict of interest or source of funding: D.W.G. is a board or committee member of AAOS, New York County Medical Society, New York State Society of Orthopedic Surgeons, PatelloFemoral Foundation, Pediatric Orthopaedic Society of North America, and Pediatric Research in Sport Medicine; is a paid presenter or speaker for AO Trauma International and Arthrex Inc; has received IP royalites from Arthrex Inc and Pega Medical; is a paid consultant for Arthrex Inc; receives publishing royalties and financial or material support from Wolters Kluwer Health–Lippincott Williams & Wilkins and Current Opinion in Pediatrics; and is an editorial or governing board member of Current Opinion in Pediatrics. P.D.F. is a paid consultant for BICMD Inc; is an editorial or governing board member of Clinical Orthopaedics and Related Research; has stock or stock options in HS2 LLC, HSS ASC Development Network LLC, Joint Effort Administrative Services Organization LLC, and Osso VR; and receives publishing royalties and financial or material support from Springer. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Ethical approval for this study was obtained from Hospital for Special Surgery (IRB No. 2021-0246).

ORCID iDs

Ruth H. Jones

Daniel W. Green

Peter D. Fabricant

Supplemental Material for this article is available at .

References

Adirim

Cheng

TL.

Overview of injuries in the young athlete. Sports Med. 2003;33(1):75-81. doi:10.2165/00007256-200333010-00006

Beaton

Bombardier

Guillemin

Ferraz

MB.

Guidelines for the process of cross-cultural adaptation of self-report measures. Spine (Phila Pa 1976). 2000;25(24):3186-3191. doi:10.1097/00007632-200012150-00014

Bel

MJ Del

Kemp

Girard

, et al. Translation and validation of the Hospital for Special Surgery Pediatric Functional Activity Brief Scale for French paediatric populations. Physiother Can. 2020;72(4):348-354. doi:10.3138/ptc-2019-0033

Briggs

Lysholm

Tegner

Rodkey

Kocher

Steadman

JR.

The reliability, validity, and responsiveness of the Lysholm score and Tegner activity scale for anterior cruciate ligament injuries of the knee. Am J Sports Med. 2009;37(5):890-897. doi:10.1177/0363546508330143

Brophy

Lin

Smith

M V.

The role of activity level in orthopaedics. J Am Acad Orthop Surg. 2014;22(7):430-436. doi:10.5435/JAAOS-22-07-430

Chen

Lara

Dang

JHT

Paterniti

Kelly

Twenty years post-NIH Revitalization Act: enhancing minority participation in clinical trials (EMPaCT): laying the groundwork for improving minority clinical trial accrual. Cancer. 2014;120(S7):1091-1096. doi:10.1002/cncr.28575

Dietvorst

van de Kerkhof

Janssen

RPA

van den Berg

van der Steen

MC.

Translation and transcultural validation of the Dutch Hospital for Special Surgery Paediatric Functional Activity Brief Scale (HSS Pedi-FABS). BMC Musculoskelet Disord. 2021;22(1):853. doi:10.1186/s12891-021-04729-0

DuBard

Gizlice

Language spoken and differences in health status, access to care, and receipt of preventive services among US Hispanics. Am J Public Health. 2008;98(11):2021-2028. doi:10.2105/AJPH.2007.119008

Fabricant

Robles

Downey-Zayas

, et al. Development and validation of a pediatric sports activity rating scale. Am J Sports Med. 2013;41(10):2421-2429. doi:10.1177/0363546513496548

10.

George

Duran

Norris

A systematic review of barriers and facilitators to minority research participation among African Americans, Latinos, Asian Americans, and Pacific Islanders. Am J Public Health. 2014;104(2):e16-e31. doi:10.2105/AJPH.2013.301706

11.

Hidding

Chinapaw

MaiJM

van Poppel

MNM

Mokkink

Altenburg

TM.

An updated systematic review of childhood physical activity questionnaires. Sports Med. 2018;48(12):2797-2842. doi:10.1007/s40279-018-0987-0

12.

Hozumi

Akagi

Fabricant

, et al. Cross-cultural adaptation and validation of the Japanese version of the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS). Orthop J Sports Med. 2022;10(8):23259671221113284. doi:10.1177/23259671221113284

13.

Janz

Lutuchy

Wenthe

Levy

SM.

Measuring activity in children and adolescents using self-report. Med Sci Sports Exerc. 2008;40(4):767-772. doi:10.1249/MSS.0b013e3181620ed1

14.

Jayanthi

LaBella

Fischer

Pasulka

Dugas

LR.

Sports-specialized intensive training and the risk of injury in young athletes. Am J Sports Med. 2015;43(4):794-801. doi:10.1177/0363546514567298

15.

Jayanthi

Pinkham

Dugas

Patrick

LaBella

Sports specialization in young athletes. Sports Health. 2013;5(3):251-257. doi:10.1177/1941738112464626

16.

Joo

Fernández

Wick

Moreno Lepe

Manuel

SP.

Association of language barriers with perioperative and surgical outcomes. JAMA Netw Open. 2023;6(7):e2322743. doi:10.1001/jamanetworkopen.2023.22743

17.

Kim

Worley

Allen

, et al. Vulnerability of older Latino and Asian immigrants with limited English proficiency. J Am Geriatr Soc. 2011;59(7):1246-1252. doi:10.1111/j.1532-5415.2011.03483.x

18.

Kocher

Smith

Iversen

, et al. Reliability, validity, and responsiveness of a modified International Knee Documentation Committee Subjective Knee Form (Pedi-IKDC) in children with knee disorders. Am J Sports Med. 2011;39(5):933-939. doi:10.1177/0363546510383002

19.

Macchiarola

Grassi

Di Paolo

, et al. The Italian cross-cultural adaptations of the paediatric International Knee Documentation Committee Score and the Hospital for Special Surgery Paediatric Functional Activity Brief Scale are reliable instruments in paediatric population. Knee Surg Sports Traumatol Arthrosc. 2020;28(8):2657-2662. doi:10.1007/s00167-020-05903-y

20.

Marx

Stump

Jones

Wickiewicz

Warren

RF.

Development and evaluation of an activity rating scale for disorders of the knee. Am J Sports Med. 2001;29(2):213-218. doi:10.1177/03635465010290021601

21.

Mastroianni

Faden

Federman

, editors. Institute of Medicine (US) Committee on Ethical and Legal Issues Relating to the Inclusion of Women in Clinical Studies; Women and Health Research: Ethical and Legal Issues of Including Women in Clinical Studies: Volume I. B NIH Revitalization Act of 1993 Public Law 103-43. Washington, DC: National Academies Press; 1994. https://www.ncbi.nlm.nih.gov/books/NBK236531/.

22.

Noyes

Barber

Mooar

LA.

A rationale for assessing sports activity levels and limitations in knee disorders. Clin Orthop Relat Res. 1989;246:238-249.

23.

Galanter

Thakur

, et al. Diversity in clinical and biomedical research: a promise yet to be fulfilled. PLoS Med. 2015;12(12):e1001918. doi:10.1371/journal.pmed.1001918

24.

Pérez-Stable

El-Toukhy

Communicating with diverse patients: how patient and clinician factors affect disparities. Patient Educ Couns. 2018;101(12):2186-2194. doi:10.1016/j.pec.2018.08.021

25.

Stracciolini

Casciano

Levey Friedman

Meehan

Micheli

LJ.

Pediatric sports injuries. Am J Sports Med. 2013;41(8):1922-1929. doi:10.1177/0363546513490644

26.

Swenson

Collins

Best

Flanigan

Fields

Comstock

RD.

Epidemiology of knee injuries among U.S. high school athletes, 2005/2006–2010/2011. Med Sci Sports Exerc. 2013;45(3):462-469. doi:10.1249/MSS.0b013e318277acca

27.

Tegner

Lysholm

Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985;198:43-49.

28.

Terwee

Bot

SDM

de Boer

, et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol. 2007;60(1):34-42. doi:10.1016/j.jclinepi.2006.03.012

29.

US Census Bureau. Factfinder for the nation. Accessed September 1, 2024. https://www.census.gov/library/stories/2022/12/languages-we-speak-in-united-states.html.

30.

US Department of Health and Human Services Office of Minority Health. Hispanic/Latino health. Accessed September 1, 2024. https://minorityhealth.hhs.gov/hispaniclatino-health

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.07 MB