This was a screening utility study done between April 2020 to February 2021.
Translation Process
The following three screening questions of the pGALS tool were translated:
1) Question 1: Do you (or does your child) have any pain or stiffness in your (their) joints, muscles or back?
Je una uchungu au ugumu kwenye vifundo, misuli au mgongo?
Je mtoto wako ana uchungu au ugumu kwenye vifundo, misuli au mgongo?
2) Question 2: Do you (or does your child) have any difficulty getting yourself (him/herself) dressed without any help?
Je unapata ugumu unapovaa nguo bila usaidizi wowote?
Je mtoto wako ana ugumu wowote anapovaa nguo bila usaidizi wowote?
Question 3: Do you (or does your child) have any difficulty walking to school?
Je unapata ugumu wowote unapotembea kwenda shuleni?
Je mtoto wako anapata ugumu wowote anapotembea kwenda shuleni?
The translation was done according to the WHO standard for translation of a tool to achieve cross-cultural and conceptual equivalence. This was a six-step process (11). Step 1 was forward translation of the screening questions from English to Kiswahili was done by two independent translators from ‘Global Languages Masters’ translation agency in Nairobi Kenya. In step 2, an expert committee consisting of the translators, the principal investigator, and the supervisors then met and agreed on an equivalence between the two translations. For step 3, back translation of the agreed-upon Kiswahili translated tool was done from Kiswahili to English by an independent translator from Global Languages Masters translation agency. In step 4, pretesting of the selected Kiswahili tool was then done on 25 children who spoke Kiswahili to determine any flaws in translation before the main study (12). In step 5, modification of the Kiswahili tool was done by the expert team based on recommendations from the pre-test to produce the final version of the Kiswahili-pGALS screening tool. The Kiswahili- pGALS was then allowed to proceed for use in step 6 (Figure 1).
Design and study setting: This was a screening utility study conducted at AKUH in Nairobi, Kenya. AKUH is a 254-bed long term care facility offering general medical services, specialist clinics and diagnostic services. It is a premier, tertiary, teaching, and referral health care facility in sub-Saharan Africa.
Study population and inclusion criteria: Participants were recruited at the accident and emergency department at AKUH based on their ability to speak Kiswahili and the presence of MSK and systemic complaints suggestive of MSK disease as per a review of the pGALS “pGALS – a screening examination of the musculoskeletal system in school-aged children” by Helen foster and S Jandial (13). These complaints included fever, joint pain, joint stiffness, joint swelling, gait disturbance, delayed milestones, rash, weakness, chest pain, back pain, fatigue, reduced appetite, weight loss, and excessive sweating (13). The ages 5-16 years were selected as they reflect school-aged children, similar to participants enrolled in the original pGALS study. Upon recruitment, the participants were triaged by a nurse and those who met the level V Paediatric Canadian triage and acuity scale (classified as non-urgent, to be seen by the doctor within 2 hours) were selected by the research assistants as they were deemed medically stable.
The exclusion criterion was any patient already enrolled in the AKUH paediatric rheumatology clinic.
Data collection and measures
The participants were recruited using systematic random sampling where every second patient who met the inclusion criteria was assessed on specific days of the week in line with the paediatric rheumatologist’s availability so they can have the Kiswahili-pGALS administered and the gold standard review on the same day.
Recruitment and consent were done by two research assistants (resident doctors) already pre-trained on the pGALS by a paediatric rheumatologist. Research assistants were chosen based on their fluency in Kiswahili, successful completion of an online pGALS training module supervised by the paediatric rheumatologist. Training was done via video presentation available at the ‘Paediatric Musculoskeletal Matters’ official website issued by Newcastle University and a certificate was issued upon successful completion (14).
One research assistant posed the Kiswahili screening questions (to either the parent/guardian or the child) and supervised each child as he/she performed the manoeuvres as per the pGALS screening tool. The other research assistant observed the facial expressions of each child as the manoeuvres were being done, recorded these expressions (using a visual analogue scale), and administered questionnaires to the guardians or parents of the children. The questionnaires required demographic details of the guardians inclusive of level of education as well as Likert items about their opinion on level of discomfort their children experienced during the Kiswahili-pGALS and their opinion on the time it took. Guardians or parents were present during these procedures and acted as liaison when needed. The time taken to perform the Kiswahili-pGALS was recorded for each child. The outcome of the Kiswahili-pGALS was either a ‘positive’ or ‘negative’ result for MSK system abnormality. The Kiswahili-pGALS was considered positive if any of the screening questions or manoeuvres were positive for abnormal findings.
After being subjected to the Kiswahili-pGALS, each child was assessed on the same day by a paediatric rheumatologist. These children were classified as having normal or abnormal joints according to standard rheumatology practice (look, feel, move method of general MSK examination (15). Any child who met the standard criteria of having abnormal joints was offered to follow-up at the paediatric rheumatology clinic.
Study measures
Positive pGALS: The Kiswahili-pGALS was considered positive if any of the screening questions and manoeuvres were positive (or had ‘yes’ ticked).
Negative pGALS: The Kiswahili-pGALS was considered negative if all the questions and manoeuvres were negative (or had ‘No’ ticked).
Gold standard: This was the Paediatric Rheumatologist using standard rheumatology criteria for discerning abnormal joints (look, feel, move method).