Translation, Cultural Adaptation, and Validation of the Arabic Version of the STRONGkids Nutrition Screening Tool in the Moroccan Pediatric Clinical Setting

Hassan Barouaca

doi:10.51745/najfnr.9.20.339-351

Translation, Cultural Adaptation, and Validation of the Arabic Version of the STRONGkids Nutrition Screening Tool in the Moroccan Pediatric Clinical Setting

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Human and Clinical Nutrition Infant, Child, and Adolescent Nutrition

DOI https://doi.org/10.51745/najfnr.9.20.339-351

Issue Vol. 9 No. 20 (2025): July - December, 2025

Submitted 2025-01-12

Accepted 2025-11-30

Published 2025-12-29

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Background: Malnutrition among hospitalized children is associated with adverse clinical outcomes and prolonged length of stay. Systematic nutritional screening upon admission is a recognized standard of care.

Aims: This study aimed to validate the Arabic version of the STRONGkids nutritional risk assessment tool within a Moroccan pediatric population.

Methods: A single-center, observational longitudinal study was conducted at Moulay Ali Chrif Hospital, Errachidia City, Morocco between June 2019 and February 2020. The study enrolled 367 children under-five years of age (337 for the validity analysis and 30 for the reliability analysis). The STRONGkids tool was translated into Arabic and administered upon hospital admission. The weight-for-height index served as the gold standard for assessing acute malnutrition. Diagnostic accuracy was evaluated employing the area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, and predictive values. Agreement with the gold standard was assessed via Cohen’s Kappa coefficient.

Results: Interobserver reliability indicated substantial agreement (κ=0.67). The STRONGkids tool demonstrated substantial agreement with the weight-for-height z-score (κ=0.61) and body mass index z-score (κ=0.67). The tool exhibited high diagnostic accuracy for screening a weight-for-height z-score below -2 SD (AUROC=0.94), with a sensitivity of 92.68% and a specificity of 88.51%. For predicting a hospital stay of ≥ 7 days and weight loss > 2%, the accuracy measures were AUROC = 0.59 and AUROC = 0.87 respectively.

Conclusions: The Arabic adaptation of the STRONGkids instrument demonstrated robust concurrent validity and substantial interobserver reliability. While the tool exhibited limited predictive validity regarding the duration of hospitalization, it remains reliable metric for malnutrition risk screening among pediatric populations in Arabic-speaking countries.

Keywords

Nutritional risk screening Children Translation Validation STRONGkids Arabic version

Hassan Barouaca

Institut Supérieur des Professions Infirmières et Techniques de Santé, Fès. Morocco

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Translation, Cultural Adaptation, and Validation of the Arabic Version of the STRONGkids Nutrition Screening Tool in the Moroccan Pediatric Clinical Setting. (2025). The North African Journal of Food and Nutrition Research, 9(20), 339-351. https://doi.org/10.51745/najfnr.9.20.339-351

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Arifin, W. N. (2017). Sample size calculator (web). Available at http://wnarifin.github.io

Agostoni, C., Axelson, I., Colomb, V., Goulet, O., Koletzko, B., Michaelsen, K. F., Puntis, J. W., Rigo, J., Shamir, R., Szajewska, H., Turck, D., ESPGHAN Committee on Nutrition, & European Society for Paediatric Gastroenterology (2005). The need for nutrition support teams in pediatric units: a commentary by the ESPGHAN committee on nutrition. Journal of pediatric gastroenterology and nutrition, 41(1), 8–11. https://doi.org/10.1097/01.mpg.0000163735.92142.87

Barker, L. A., Gout, B. S., & Crowe, T. C. (2011). Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system. International journal of environmental research and public health, 8(2), 514–527. https://doi.org/10.3390/ijerph8020514

Barouaca., H., Rguibi, M. (2012). Nutritional paradox of the Moroccan population: coexistence of undernutrition and obesity. Nutrición Clínica y Dietética Hospitalaria, 32(Supl. 2): 70-75

Barouaca, H., Ben Loubir, D., El Bouhali, B., Tachfouti, N., & El Midaoui, A. (2021). The role of body mass index-for-age in the assessment of acute malnutrition and obesity in Moroccan hospitalized children. Journal of Applied Pharmaceutical Science, 11(07), 098-104. https://doi.org/10.7324/JAPS.2021.110710

Barouaca, H. (2023). Study pattern of nutritional recovery in edematous and non-edematous malnourished children after a short hospital stay of nutrition rehabilitation. North African Journal of Food and Nutrition Research, 7(15), 126-135. https://doi.org/10.51745/najfnr.7.15.126-135

Barouaca, H. (2024). Prognostic performance of serum proteins markers in assessing mortality risk for North-African pediatric population hospitalized with complicated severe acute malnutrition. North African Journal of Food and Nutrition Research, 8(17), 11-20. https://doi.org/10.51745/najfnr.8.17.11-20

Becker, P. J., Gunnell Bellini, S., Wong Vega, M., Corkins, M. R., Spear, B. A., Spoede, E., Hoy, M. K., Piemonte, T. A., & Rozga, M. (2020). Validity and Reliability of Pediatric Nutrition Screening Tools for Hospital, Outpatient, and Community Settings: A 2018 Evidence Analysis Center Systematic Review. Journal of the Academy of Nutrition and Dietetics, 120(2), 288–318.e2. https://doi.org/10.1016/j.jand.2019.06.257

Beser, O. F., Cokugras, F. C., Erkan, T., Kutlu, T., Yagci, R. V., & TUHAMAR Study Group (2018). Evaluation of malnutrition development risk in hospitalized children. Nutrition, 48, 40–47. https://doi.org/10.1016/j.nut.2017.10.020

Desai, Y., Marroquín, A., Hong-Zhu, P., Knebusch, N., Vazquez, S., Mansour, M., Fogarty, T. P., Tcharmtchi, M. H., Stein, F., & Coss-Bu, J. A. (2025). Nutritional Status, Social Determinants of Health and Clinical Outcomes in Critically Ill Children. Children, 12(3), 390. https://doi.org/10.3390/children12030390

Black, R. E., Victora, C. G., Walker, S. P., Bhutta, Z. A., Christian, P., de Onis, M., Ezzati, M., Grantham-McGregor, S., Katz, J., Martorell, R., Uauy, R., & Maternal and Child Nutrition Study Group. (2013). Maternal and child undernutrition and overweight in low-income and middle-income countries. The Lancet, 382(9890), 427-451. https://doi.org/10.1016/S0140-6736(13)60937-X

Blacker, D., & Endicott, J. (2000). Psychometric properties: Concepts of reliability and validity. In Handbook of psychiatric measures (pp. 7–14). American Psychiatric Association.

Cao, J., Peng, L., Li, R., Chen, Y., Li, X., Mo, B., & Li, X. (2014). Nutritional risk screening and its clinical significance in hospitalized children. Clinical nutrition, 33(3), 432–436. https://doi.org/10.1016/j.clnu.2013.06.009

Chourdakis, M., Hecht, C., Gerasimidis, K., Joosten, K. F., Karagiozoglou-Lampoudi, T., Koetse, H. A., Ksiazyk, J., Lazea, C., Shamir, R., Szajewska, H., Koletzko, B., & Hulst, J. M. (2016). Malnutrition risk in hospitalized children: Use of 3 screening tools in a large European population. American Journal of Clinical Nutrition, 103(5), 1301-1310. https://doi.org/10.3945/ajcn.115.110700

da Cruz Gouveia, M. A., Tassitano, R. M., & da Silva, G. A. P. (2018). STRONGkids: Predictive validation in Brazilian children. Journal of Pediatric Gastroenterology and Nutrition, 67(3), e51-e56. https://doi.org/10.1097/MPG.0000000000002029

De Onis M (2015). World Health Organization Reference Curves. In M.L. Frelut (Ed.), The ECOG’s eBook on Child and Adolescent Obesity. https://ebook.ecog-obesity.eu/wp-content/uploads/2015/02/ECOG-Obesity-eBook-World-Health-Organization-Reference-Curves.pdf

Fachal, C. V., Fernández-González, S. M., Moreno-Álvarez, A., & Solar-Boga, A. (2025). Nutritional Screening Tools in the Pediatric Population: A Systematic Review. Nutrients, 17(3), 433. https://doi.org/10.3390/nu17030433

Geisinger, K. F. (1994). Cross-cultural normative assessment: Translation and adaptation issues influencing the normative interpretation of assessment instruments. Psychological Assessment, 6(4), 304–312. https://doi.org/10.1037/1040-3590.6.4.304

Gerasimidis, K., Macleod, I., Maclean, A., Buchanan, E., McGrogan, P., Swinbank, I., McAuley, M., Wright, C. M., & Flynn, D. M. (2011). Performance of the novel Paediatric Yorkhill Malnutrition Score (PYMS) in hospital practice. Clinical nutrition, 30(4), 430–435. https://doi.org/10.1016/j.clnu.2011.01.015

Guillemin, F., Bombardier, C., & Beaton, D. (1993) Cross-cultural adaptation of health-related quality of life measures: literature review and proposed guidelines. Journal of Clinical Epidemiology, 46(12): 1417-32. https://doi.org/10.1016/0895-4356(93)90142-n

Hulst, J. M., Zwart, H., Hop, W. C., & Joosten, K. F. (2010). Dutch national survey to test the STRONGkids nutritional risk screening tool in hospitalized children. Clinical nutrition, 29(1), 106–111. https://doi.org/10.1016/j.clnu.2009.07.006

Huysentruyt, K., Alliet, P., Muyshont, L., Rossignol, R., Devreker, T., Bontems, P., Dejonckheere, J., Vandenplas, Y., & De Schepper, J. (2013). The STRONG(kids) nutritional screening tool in hospitalized children: a validation study. Nutrition, 29(11-12), 1356–1361. https://doi.org/10.1016/j.nut.2013.05.008

Johanson, G. A., & Brooks, G. P. (2010). Initial scale development: Sample size for pilot studies. Educational and Psychological Measurement, 70(3), 394-400. https://doi.org/10.1177/0013164409355692

Joosten, K. F., Hulst, J. M. (2011) Malnutrition in pediatric hospital patients: current issues. Nutrition, 27(2): 133-7. https://doi.org/10.1016/j.nut.2010.06.001

Kondrup, J., Allison, S. P., Elia, M., Vellas, B., Plauth, M., & Educational and Clinical Practice Committee, European Society of Parenteral and Enteral Nutrition (ESPEN) (2003). ESPEN guidelines for nutrition screening 2002. Clinical Nutrition, 22(4), 415–421. https://doi.org/10.1016/s0261-5614(03)00098-0

Landis, J. R., & Koch, G. G. (1977). The measurement of observer agreement for categorical data. Biometrics, 33(1), 159–174.

Maciel, J. R. V., Nakano, E. Y., Carvalho, K. M. B., & Dutra, E. S. (2020). STRONGkids validation: tool accuracy. Jornal de pediatria, 96(3), 371–378. https://doi.org/10.1016/j.jped.2018.12.012

Mărginean, O., Pitea, A. M., Voidăzan, S., & Mărginean, C. (2014). Prevalence and assessment of malnutrition risk among hospitalized children in Romania. Journal of Health, Population, and Nutrition, 32(1), 97-102.

McLaren, S., & Green, S. (1998). Nutritional screening and assessment. Professional nurse (London, England), 13(6 Suppl), S9–S15.

Mehta, N. M., Corkins, M. R., Lyman, B., Malone, A., Goday, P. S., Carney, L. N., Monczka, J. L., Plogsted, S. W., Schwenk, W. F., & American Society for Parenteral and Enteral Nutrition Board of Directors. (2013). Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions. JPEN. Journal of parenteral and enteral nutrition, 37(4), 460–481. https://doi.org/10.1177/0148607113479972

Ministère de la Santé et de la Protection Sociale du Maroc. (2019). Stratégie Nationale de Nutrition 2011-2020. https://www.sante.gov.ma/Publications/Guides-Manuels/Documents/Couv%20Strat%C3%A9die%20de%20Nutrition.pdf

Ministère de la Santé du Maroc & Ligue des États Arabes. (2018). Enquête Nationale sur la Population et la Santé Familiale (ENPSF-2018) (2eme éd.).

Moeeni, V., Walls, T., & Day, A. S. (2012). Assessment of nutritional status and nutritional risk in hospitalized Iranian children. Acta paediatrica, 101(10), e446–e451. https://doi.org/10.1111/j.1651-2227.2012.02789.x

Moeeni, V., Walls, T., & Day, A. S. (2014). The STRONGkids nutritional risk screening tool can be used by paediatric nurses to identify hospitalised children at risk. Acta paediatrica, 103(12), e528–e531. https://doi.org/10.1111/apa.12768

Neelemaat, F., Meijers, J., Kruizenga, H., van Ballegooijen, H., & van Bokhorst-de van der Schueren, M. (2011). Comparison of five malnutrition screening tools in one hospital inpatient sample. Journal of clinical nursing, 20(15-16), 2144–2152. https://doi.org/10.1111/j.1365-2702.2010.03667.x

Nunnally, J. C., & Bernstein, I. H. (1994). Psychometric theory (3rd ed.). New York: McGraw-Hill.

Ortíz-Gutiérrez, S., Pérez-Cruz, E., Lara-Pompa, N. E., Serralde-Zúñiga, A. E., Fewtrell, M., Peralta-Pedrero, M. L., Medina-Vera, I., Christlieb-Zaldívar, C. M., Damasco-Avila, E., & Guevara-Cruz, M. (2019). Validation and Adaptation of the Spanish Version of the STRONGkids Nutrition Screening Tool. Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition, 34(4), 589–596. https://doi.org/10.1002/ncp.10182

Qiao, J. Y., Guo, F. F., Li, F., Chen, L. X., & Luan, B. (2019). Nutritional assessment and clinical application of nutritional risk screening tools in critically ill children. Chinese journal of contemporary pediatrics, 21(6), 528–533. https://doi.org/10.7499/j.issn.1008-8830.2019.06.006

Teixeira, A. F., & Viana, K. D. (2016). Nutritional screening in hospitalized pediatric patients: a systematic review. Jornal de pediatria, 92(4), 343–352. https://doi.org/10.1016/j.jped.2015.08.011

Salerno, A., Gazineo, D., Lanari, M., Shehi, R., Ricco, M., La Malfa, E., De Rosa, M., Decaro, R., Mattioli, V., Lepore, V., Imeneo, R., Tomaso, T., Gennari, M., Dondi, A., Leardini, D., Santandrea, C., Ciotti, G., Bruno, E., Trani, M., & Godino, L. (2024). Italian cross-cultural validation of the STRONGkids tool for pediatric nutritional evaluation. European journal of pediatrics, 184(1), 55. https://doi.org/10.1007/s00431-024-05895-8

Santos, C. A. D., Rosa, C. O. B., Franceschini, S. D. C. C., Castro, J. D. S., Costa, I. B. M., Firmino, H. H., & Ribeiro, A. Q. (2020). StrongKids for pediatric nutritional risk screening in Brazil: a validation study. European journal of clinical nutrition, 74(9), 1299–1305. https://doi.org/10.1038/s41430-020-0644-1

Sermet-Gaudelus, I., Poisson-Salomon, A. S., Colomb, V., Brusset, M. C., Mosser, F., Berrier, F., & Ricour, C. (2000). Simple pediatric nutritional risk score to identify children at risk of malnutrition. The American journal of clinical nutrition, 72(1), 64–70. https://doi.org/10.1093/ajcn/72.1.64

Spagnuolo, M. I., Liguoro, I., Chiatto, F., Mambretti, D., & Guarino, A. (2013). Application of a score system to evaluate the risk of malnutrition in a multiple hospital setting. Italian journal of pediatrics, 39, 81. https://doi.org/10.1186/1824-7288-39-8

Swets J. A. (1988). Measuring the accuracy of diagnostic systems. Science (New York, N.Y.), 240(4857), 1285–1293. https://doi.org/10.1126/science.3287615

van Bokhorst-de van der Schueren, M. A., Guaitoli, P. R., Jansma, E. P., & de Vet, H. C. (2014). Nutrition screening tools: does one size fit all? A systematic review of screening tools for the hospital setting. Clinical nutrition, 33(1), 39–58. https://doi.org/10.1016/j.clnu.2013.04.008

Wild, D., Grove, A., Martin, M., Eremenco, S., McElroy, S., Verjee-Lorenz, A., and Erikson, P. (2005). Principles of Good Practice for the Translation and Cultural Adaptation Process for Patient-Reported Outcomes (PRO) Measures: Report of the ISPOR Task Force for Translation and Cultural Adaptation. Value in Health, 8(2): 94-04. https://doi.org/10.1111/j.1524-4733.2005.04054.x

World Medical Association. (1964). Declaration of Helsinki: Ethical principles for medical research involving human subjects. https://www.wma.net/what-we-do/medical-ethics/declaration-of-helsinki/

World Health Organization. (2008). Training Course on Child Growth Assessment. Geneva: World Health Organization. ISBN: 978-92-4-159507-0 .

Wonoputri, N., Djais, J. T., & Rosalina, I. (2014). Validity of nutritional screening tools for hospitalized children. Journal of nutrition and metabolism, 2014, 143649. https://doi.org/10.1155/2014/143649

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Translation, Cultural Adaptation, and Validation of the Arabic Version of the STRONGkids Nutrition Screening Tool in the Moroccan Pediatric Clinical Setting

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