The Reliability and Validity of Turkish Version of The School-Based Asthma and Allergy Screening Questionnaires

Background: Asthma is an important public health problem affecting children, causing school absenteeism and hospitalization. The aim of this study is to assess the validity and reliability for diagnostic accuracy of the Turkish version of the asthma and allergy screening questionnaire. Methods: This study included primary and secondary school students from grades 2 to 7, and their parents or caregivers. For validity, 40 children with asthma and 39 children with allergy diagnosed by the questionnaire were used to determine the sensitivity, and specicity was calculated by using the data of 100 children without asthma and allergies. For reliability, the Spearman correlation was used for dependent groups, for validity, the Receiver Operating Characteristic (ROC) analysis was used. Results: When the questionnaire cut-off point was 2/3 for asthma, according to the student and parent form, the sensitivity was 80.0% and 82.5%, and the specicity was 56.6% and 76.8%, respectively. When the questionnaire cut-off point was 0/1 for allergies, according to the student and parent questionnaire, the sensitivity was 74.4% and 84.6%, and the specicity was 66.3% and 54.2%, respectively. The reliability of the asthma and allergy questionnaires test-retest correlation values ( ≥ 0.68) of both questionnaires were found to be statistically signicant. Conclusion: According to the Turkish questionnaire of the students and their parents, questionnaire sensitivity for asthma and allergy was similar in proportion to the original questionnaire. The Turkish version of the questionnaire can be used for asthma and allergy screening in schools.

In the literature, it is seen that many studies conducted in Turkey for asthma screening scales are not national. The prevalence of asthma in children and adolescents in Brazil was determined to be 22% by an asthma screening scale which was found to be valid and reliable (8). In another similar study, it was emphasized that the prevalence of asthma in children aged 5-15 was 18.8%, and that the scale was a valid tool for the detection of asthmatic children (9). In the school-based asthma screening study, the use of the scale was reported to be a good method to identify students who were not diagnosed with asthma before. The severity of asthma can be better understood if further studies are conducted. In Turkey, there is not enough statistical data revealing the prevalence of asthma in children. Therefore, there is a need for studies in this eld.
A scale developed by the World Health Organization (WHO) and The International Study of Asthma and Allergies in Childhood (ISAAC) is used to detect asthmatic students (10). However, the application of the

Methods
This is a diagnostic accuracy study. Permission for this study was obtained from the Provincial Directorate of National Education, and ethics committee approval was obtained from Bozok University Faculty of Medicine Ethics Committee. Ethics committee decision date and number: 03 June 2014-12/9.
The students and their parents or caregivers were informed about the research and their written consents were obtained. Permission for use of the SBAASQ was obtained from the journal (11). The research was conducted in accordance with the rules and ethic codes mentioned in the Helsinki Declaration.

Participants
This study was carried out among students from grades 2 to 7 of Primary and Secondary Schools in Yozgat between July 2014 and December 2015. Primary and secondary schools in the city center were divided into 3 groups according to the socio-economic level of the region, and one primary and one secondary school were selected by lot from each group. The sample consisted of students from grades 2, 3 and 4 of three primary schools and grades 5, 6 and 7 from three middle schools (around 50 students and their parents from each grade). Two classes from each grade were selected randomly and included in the study. The sample size was calculated for Receiver Operating Characteristic (ROC) analysis used in the diagnostic test. When area under curve (AUC) = 0.8, 1-β = 0.9 for power analysis, sample size was calculated as n = 26 people (12).

Instruments
The SBAASQ consist of two forms: the student questionnaire form (SQ) which consisted of 13 questions, and the parent or caregiver questionnaire form (PQ) (14 questions). In the SQ, questions 1-7 were related to asthma, and questions 8-9 were related to allergy. In the PQ, questions 1-8 were related to asthma, and questions 9-10 were allergy related. The answers given to these questions were scored as '0' for never, and '1' for occasionally and often. The last 4 questions in both forms were about the diagnosis of asthma and allergies, and the use of drugs was not scored (11). In addition, 4 questions were added to the SQ, and 7 questions to the PQ, that included their socio-demographic characteristics.
In the original validity study of the SQ, for asthma the sensitivity was 80%, and speci city was 70% for those who answered at least 3 of the 7 asthma-related questions as occasionally or often (cut-off point 2/3). According to the PQ, for asthma the sensitivity was 58%, and speci city was 69% for those who answered at least 2 of the 8 asthma related questions as occasionally or often (cut-off point1/2). For allergy, the sensitivity of the SQ and PQ were 81% and 78%, and speci city were 42% and 53% respectively for those who answered one of two questions related to allergies as occasionally or often (cut-off point 0/1) (11).

Procedure
Turkish translation of the questionnaire First, the questionnaire was translated from English to Turkish by two English lecturers. The questionnaire was then assessed by two experts, one chest disease specialist and one pediatric specialist, who then developed a Turkish version of the questionnaire. Then, the Turkish version was translated back to English by a bilingual person. The original and the translated questionnaire were compared to see if the translated version conveyed the same meaning as the original. The translated questionnaire was determined to be su cient and 6 students and 6 parents (gender and age balanced) were interviewed separately for intelligibility of the Turkish version of the questionnaire. At last, the nal Turkish version of the questionnaire was formed.

Data collection
The researchers explained the study's purpose to the students. The students took the Informed Consent Form and PQ form, and their parents/caregivers lled it out at home. On the following day, the Informed Consent Form and PQ were collected from the students. The SQ form was given to the students after an explanation from the researchers. The students were instructed to mark the most suitable option. The study was completed with the participation of 704 students and parents.

Reliability of the questionnaire
For the test-retest reliability, one class was randomly selected from each grade, grades 2-7, participating in the research. These students and their parents/caregivers (200) were re-administered the same Page 5/13 questionnaires one week later. The questionnaire was repeated with 154 students and 111 parents.
Validity of the questionnaire The sensitivity and speci city of the questionnaire were examined to measure validity. To identify the sensitivity of the questionnaire, students who were previously diagnosed with asthma or allergy by a physician and according to the SBAASQ results, and students who have a risk for asthma or allergy were referred to the Child Health and Diseases policlinic of Bozok University Research and Application Hospital. Of the referred students, 40 were diagnosed with de nite asthma by the anamnesis, clinical examination and pulmonary function test (PFT) results. The anamnesis, clinical examination, and prick skin test con rmed the de nitive diagnosis of allergy in 39 students.
The Anamnesis, clinical examination and PFT results were reviewed by the pediatrician and asthma was ruled out in 99 students. The same physician con rmed that 83 students were free of allergy according to the anamnesis, clinical examination and prick skin test. The sensitivity of the questionnaire was determined according to the patients with a de nite asthma or allergy diagnosis, and the speci city of the questionnaire was compared to those without a de nite asthma or allergy diagnosis.

Data Analysis
The data was analyzed in IBM SPSS Statistics Standard Concurrent User V 25, Authorization Code: e31d836848b0a60e5756. The Cronbach's alpha coe cient for the internal consistency of the questionnaire and the test-retest results of the items for reliability were analyzed using the Spearman correlation test. Sensitivity and speci city cut-off scores of the questionnaire were analyzed by the ROC analysis. The size of the AUC is evaluating the accuracy of diagnostic tests.

Results
The validity of the asthma questionnaires was found to be 2/3 (≥ 3 points) in the SQ and PQ. The Sensitivity of the SQ was 80% (true positive (32) / diagnosed with asthma (40) x 100), and the speci city was 56.6% (true negative (56) / robust (99) x 100). the sensitivity of the PQ was 82.5% (true positive (33) / diagnosed with asthma (40) x 100), and the speci city was 76.8% (true negative (76) / robust (99) x 100) ( Table 1). The area under the ROC curve for asthma questionnaire was 0.793 in the SQ and 0.886 in the PQ (Fig. 1, Table 2). In the original questionnaire, the cut-off point for asthma was 1/2 (sensitivity 95%, speci city 53.5%) while in the PQ, taking 2/3 of the cut-off point in the ROC analysis was found to be more appropriate in increasing speci city (Table 3).    (Fig. 2, Table 2).
For the reliability of the asthma questionnaire, when the correlation between test-retest total scores was examined, it was found that r = 0.68 in the SQ and r = 0.75 in the PQ. The correlation of test-retest total scores of the allergy questionnaire was found to be r = 0.68 in both the SQ and PQ. Test-retest correlation values of both questionnaires were found to be statistically signi cant (Table 4). The internal consistency Cronbach α value of the asthma SQ and PQ were 0.72 and 0.80, respectively. Table 4 The test-retest reliability, computed as an intra-class correlation coe cient.

Discussion
In the study, the sensitivity of the Turkish version of the SQ for asthma (74.4%) was lower than the original questionnaire (81%), while the speci city (66.3%) was signi cantly higher than the original questionnaire (42%). The sensitivity of the Turkish version of the allergy parent/caregiver form (84.6%) was higher than the sensitivity of the original questionnaire (78%), and the speci city of the Turkish version (54.2%) and the speci city of the original questionnaire (53%) were similar (Table 1, 3) (11). For validity, in the Turkish version, the sensitivity of the allergy SQ was lower, and the speci city was higher than the original questionnaire. The sensitivity and speci city of the Turkish version of the allergy PQ were higher than the original questionnaire. In this study, using the International Childhood Asthma Allergy Questionnaire, the sensitivity was found to be 74% (13). In a study, where the questionnaire was translated into Turkish, the prevalence of asthma, wheezing and rhinitis was 14.1%, 22.4%, and 12.9%, respectively (14).
For asthma, the sensitivity of the Turkish version of the SQ (80%) and the sensitivity of the original SQ (80%) were the same, while the speci city was lower in the Turkish version (56.6%) compared to the original (70%). For asthma, the sensitivity of the Turkish version of the PQ (82.5%) and speci city (76.8%) were higher than the sensitivity (58%) and speci city (69%) of the original version of the PQ ( Table 1).
The cut-off point for asthma was taken as 1/2 (≥ 2) the same as the original PQ, the Turkish version of the PQ had very high sensitivity (95%) compared to the original (58%), and the speci city (53.5%) was lower than the original (69%). Therefore, taking 2/3 of the cut-off point in the asthma PQ provides a more appropriate level of sensitivity and speci city (Table 3) (11). In the Turkish validity study, the sensitivity of the asthma SQ was at the same level as the original, but its speci city was lower than the original. The sensitivity and speci city levels of the asthma PQ were higher than the original questionnaire.
The validity and reliability studies of the questionnaires used for asthma in children can be found in the literature. In Turkey, for children aged 4-11, childhood asthma control test sensitivity was 74.8%, and speci city was determined to be 88.7% (15). The sensitivity of a questionnaire used to identify children and adolescents with asthma in Brazil was found to be 74% (8). The sensitivity of the questionnaire used in asthma screening in children aged 5-15 was found to be 70% (9). The sensitivity and speci city of the asthma questionnaire administered to preschool children in Latin America were found to be 93.1% (16).
In the United States, the sensitivity and speci city of asthma questionnaires applied to children grades 3-5 of primary school were 90% and 49%, respectively (17). In a study in which primary school children were followed up with an asthma questionnaire for 2 years, the sensitivity and speci city of the questionnaire were 94% and 87% in the rst year, and 96% in the second year (18). In a study using the European Respiratory Health Questionnaire, the sensitivity and speci city of the questionnaire were found to be 75.1% and 80.1% (19). In another study, the sensitivity and speci city of the asthma control questionnaire applied to asthma patients were 78% and 77.5%, respectively (20). In the asthma screening survey applied to children (aged 9-12) and their families admitted to a hospital in Argentina, it was detected that the sensitivity of the student version (cut-off point 1/2) was 53.4% and the speci city was 84.3%, the sensitivity of the parent version (cut-off point 2/3) was 92.3% and the speci city was 86.4% (21).
In this study, the internal consistency (0.72, 0.80) of the asthma student and parent/caregiver form was adequate. Turkey's childhood asthma control test's reliability (test-retest) was 0.71. The internal consistency Cronbach α value was found to be 0.69 for children, for the parents, the value was determined to be 0.78 (15). In the language validity and reliability study of the Asthma Screening Scale in Argentina, the internal consistency Cronbach α value of the 9-12 year-old student questionnaire was found to be 0.69, and the parental questionnaire value was 0.88 (21). Since there were only two allergy questions, internal consistency was not considered. The reliability of the Turkish version of the SBAASQ is satisfactory according to the test-retest result (r = 0.68). Therefore, the questionnaire has a reliable characteristic (Table 4). In Turkey, children bene t from health services free of charge. Every family has a family doctor. The family physicians are obliged to follow up their registered persons once a year.
Therefore, examination of false positive cases by health institutions does not create a burden on the health system.

Conclusions
The Turkish version of the School-Based Asthma and Allergy Screening Questionnaire has a similar level of sensitivity and speci city with the original asthma and allergy screening questionnaires used in the literature. The reliability of the Turkish version of the questionnaire is acceptable. The Turkish version of questionnaire can be used for the screening of asthma and allergy in students grades 2-7 in Turkey.