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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Submitted
January 12, 2025
Published
December 29, 2025
Keywords:
-
Nutritional risk screening, Children, Translation, Validation, STRONGkids Arabic version
Abstract
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.
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References
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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
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Authors
Barouaca, H. (2025). Translation, Cultural Adaptation, and Validation of the Arabic Version of the STRONGkids Nutrition Screening Tool in the Moroccan Pediatric Clinical Setting. 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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