Philippine Journal of Allied Health Sciences Vol 3 Iss 1

Editorial The state of the journal (Ivan Neil Gomez, PJAHS Editor-in-Chief) Letters to the Editor Answering the health needs of the Filipino community (Consuelo Suarez) Challenges of research ethics committees (Anna Lea Enriquez) Original Articles Translation and validation of the Physical Activity Scale for the Elderly in Filipino community-dwelling older adult fallers and non-fallers (Donald Lipardo, Eudinel Joshua Lopez, Sharmaine Santiago, Mariel Tubig, Gerard Joseph Enriquez, Carmela Grace Canares, Marc Pagaduan, Kristina Devora) Translation and cross- cultural adaptation of the Friedrich Short Form of the Questionnaire on Resources and Stress (QRS-F) to measure the stress level of Filipino parents and other caregivers of children with disability (Paulin Grace Morato-Espino, Kim Gerald Medallon, Rigel Benzon, Mark Timothy Arroz, Carlo Angelino Buencamino, Cecilia Anne Ibay, Marie Selene Ko, Ivan Neil Gomez) The Filipino dietary habits and nutrition knowledge questionnaire (DHNKQ-FIL): a psychometric study (Karen Leslie Pineda, Alessandro Cardenas, Ronell Angelo Esteban, Stephanie Claire Pagarigan, Rayesha Azzedine Ma. Quilala, Johnmer Paul Se, Niccol Servañez) Association of lateral epicondylalgia and shoulder rotatory motion: a cross-sectional case control study (Lyle Patrick Tangcuangco, Valentin Dones III) Test-retest reliability, internal consistency, and discriminant validity of the Filipino version of Knee injury and Osteoarthritis Outcome Score among community-dwellers with knee osteoarthritis (Donald Manlapaz, Catherine Joy Escuadra, John Kenneth Ceazar Averia, Andrea Blancaflor, Rachel Ann Enriquez, Angela Mariz Ladeza, Angelica Marie Mandario, Jose Javier Mendoza, Thad Nuel Natividad) Short Report The birth of a national network for interprofessional education and collaboration: results from an inter-university partnership (Michael Sy, Catherine Joy Escuadra, Reeva Ann Sumulong) Special Research Article In gratitude for the PJAHS 2019 editorial board and reviewers (Ivan Neil Gomez, Anne Marie Aseron)



PJAHS • Volume 3 Issue 1 2019 Table of Contents Editorial Board Editorial Ivan Neil Gomez Editor-in-Chief 2 The state of the journal Catherine Escuadra Ivan Neil Gomez, PJAHS Editor-in-Chief Kim Gerald Medallion Letters to the Editor Managing Editors 4 Answering the health needs of the Filipino community Donald Lipardo Donald Manlapaz Consuelo Suarez Associate Editors 5 Challenges of research ethics committees Valentin Dones III, Reil Anna Lea Enriquez Vinard Espino, Paulin Grace Morato-Espino, Karen Leslie Original Articles Pineda 7 Translation and validation of the Physical Activity Scale for the Elderly PJAHS Review Board in Filipino community-dwelling older adult fallers and non-fallers Donald Lipardo, Eudinel Joshua Lopez, Sharmaine Santiago, Mariel Tubig, Gerard Consuelo Suarez Joseph Enriquez, Carmela Grace Canares, Marc Pagaduan, Kristina Devora Anne Marie Aseron Editorial Advisory Board Translation and cross- cultural adaptation of the Friedrich Short Form 15 of the Questionnaire on Resources and Stress (QRS-F) to measure the Anna Lea Enriquez Ethics Consultant stress level of Filipino parents and other caregivers of children with disability Joyce Anne Ponciano- Villafania, Archelle Callejo, Paulin Grace Morato-Espino, Kim Gerald Medallon, Rigel Benzon, Mark Timothy Zyra Villamor, Lyle Patrick Arroz, Carlo Angelino Buencamino, Cecilia Anne Ibay, Marie Selene Ko, Ivan Neil Gomez Tancuangco 28 Editorial Staff The Filipino dietary habits and nutrition knowledge questionnaire Genejane Adarlo, Stephanie (DHNKQ-FIL): a psychometric study Balid-Attwell, Rumpa Karen Leslie Pineda, Alessandro Cardenas, Ronell Angelo Esteban, Stephanie Boonsinsukh, Sjan-Mari 45 Claire Pagarigan, Rayesha Azzedine Ma. Quilala, Johnmer Paul Se, Niccol Servañez Brown, Ke-Vin Chang, Jesus Association of lateral epicondylalgia and shoulder rotatory motion: a Alfonso Datu, Janine cross-sectional case control study Margarita Dizon, Karen 53 Lyle Patrick Tangcuangco, Valentin Dones III Grimmer, Masayoshi Kubo, Test-retest reliability, internal consistency, and discriminant validity of the Filipino version of Knee injury and Osteoarthritis Outcome Cynthia YY Lai, Steve Score among community-dwellers with knee osteoarthritis Milanese, Ruth Segal, Sean Sullivan, Gian Carlo Torres, Donald Manlapaz, Catherine Joy Escuadra, John Kenneth Ceazar Averia, Andrea Jeric Uy, Les Paul Valdez, Blancaflor, Rachel Ann Enriquez, Angela Mariz Ladeza, Angelica Marie Mandario, Jose Javier Mendoza, Thad Nuel Natividad Candance Vickers International Academic Editors Short Report The Philippine Journal of Allied 62 The birth of a national network for interprofessional education and health Sciences [ISSN: 1908-5044] collaboration: results from an inter-university partnership is an Open Access, peer reviewed Michael Sy, Catherine Joy Escuadra, Reeva Ann Sumulong journal published by the University of Santo Tomas-College Special Research Article of Rehabilitation Sciences, Manila, Philippines. 67 In gratitude for the PJAHS 2019 editorial board and reviewers Ivan Neil Gomez, Anne Marie Aseron 68 PJAHS Submission Guidelines 1

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.002) Editorial The state of the journal Ivan Neil Gomez, Editor-in-Chief Article Received: 10 June 2019 Article Published: 22 July 2019 (Online) Copyright © 2019 Gomez. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. “The Philippine Journal of Allied Health Sciences stakeholder dissemination of quality scientific (PJAHS) is the Official Publication of the information2,3. Thus, despite the challenges University of Santo Tomas – College of previously, currently, and inadvertently, possibly Rehabilitation Sciences and is published semi- faced by PJAHS, the journal made a bold decision annually. Its mission is to produce quality allied to wake up from its slumber. health science clinical practice that will enhance performance, promote wellness in the Inasmuch as I would like to think that PJAHS’ prevention of diseases and improve function revival is spreading like a wildfire, publishing an among healthy and physically challenged international peer-reviewed journal is never individuals.” easy. Janairo1 cited several challenges involved in reviving a scientific journal in the Philippines. The year was 2006 when the first edition of the The current plight of PJAHS is not far from home, Philippine Journal of Allied Health Sciences came experiencing similar propositions. Of great out. The following couple of years saw three interest is confronting the competition for author more issues being published until 2008. The first submissions. The issue on appealing to two issues were print copies, while the latter researchers to submit in PJAHS as opposed to were online copies accessible via the now- other more established ones is palpable. defunct journal website. I am going out on a limb Sourcing manuscripts has involved grassroots to assert that at the time, PJAHS was one of the strategies involving personal and institutional first (if not the first) UST-based academic journal communications extending the call for paper to go online. However, after only four issues in submissions. Nevertheless, PJAHS is fortunate to the span of two years, as people in the research be supported by the University of Santo Tomas field like to put, was lost to follow-up. (UST) and the College of Rehabilitation Sciences (CRS), who have graciously funded the resources As experienced by PJAHS and other scientific needed for this revival to come in fruition. journals, one of the greatest challenges that publishers and the editorial board face is The democratization of science fuelled by the sustaining adequate quality articles submitted, technological innovations has pressured reviewed and published in the journal1,2. This, publishers of opening access to their among other possible academic, political and traditionally subscription-based article economic reasons remain to be adamant as repositories3. Humility aside, PJAHS was PJAHS embarks on a revival. With the advent of conceptualized and remained open access. technology, information has become ubiquitous. Sharing similar ideals, the University Journal The exactness of fidelity of such information, Affairs Committee of UST embarked on a however, is questionable. Thus, scientific herculean task of disseminating the research of journals remain to be a vital player in the university to the masses. In fact, this 2

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.002) initiative catalyzed the revival of PJAHS, as well as its online presence rebirth through our new website which you can access at https://pjahs.ust.edu.ph/. Quality allied health science information accessibility will always be a standard placed high within the journal across the coming years. With a renewed fervor in advocating for publishing scholarly articles in the field of allied health sciences, PJAHS re-opens its door, or should I say, inbox, to submission from authors in the fields of physical therapy, occupational therapy, sports science, speech-language pathology, nursing, psychology, biomedical engineering, pharmacy, nutrition, education and other allied health sciences. In this edition of PJAHS, we publish articles in research fields of geriatric and musculoskeletal physical therapy, nutrition, caregiving stress and occupational therapy, interprofessional education, health research ethics, and health innovations through collaborations. PJAHS envisions the future as hall-full, adopting an optimistic perspective of things to come. I invite our readers to continuously develop and make history with us. PJAHS is back, and we are here to stay. References: 1. Hausmann L, Murphy SP, Publication Committee of the International Society for Neurochemistry (ISN). The challenges for scientific publishing, 60 years on. Journal of neurochemistry. 2016 Oct;139:280-7. 2. Janairo JI. Reviving a scientific journal: challenges and strategies. Science Editing. 2018 Feb 19;5(1):59-61. 3. Zanchetti A. Editing a scientific journal: problems and challenges. Journal of hypertension. 2008 Jan 1;26(1):1-3. 3

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.008) Letter to the Editor Answering the health needs of the Filipino community Consuelo Suareza aResearch Center for Health Sciences, Faculty of Medicine and Surgery, University of Santo Tomas Article Received: 19 March 2019 Article Published: 18 July 2019 (Online) Copyright © 2019 Suarez. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Health research should answer the needs of the engineering researchers. On the other hand, Filipino community which range from engineering researchers are able to design communicable and non-communicable diseases, equipment, but they are not fully aware if their mental health, disaster risk reduction, maternal innovations are suitable for persons with and child health. The National Unified Health disabilities. Collaboration among scientists will Research Agenda 2017 -2022 (NUHRA) is a six- enable us to meet the needs of the disabled year plan developed by the Philippine National communities. Health Research System facilitated by the Philippine Council for Health Research and The other aspect that should also be considered Development so that health research will answer is the social dimension of disability. We have to the needs of the Filipinos. It is envisioned to be be attentive to the response of our patients to inclusive, realistic and collaborative. The the equipment that is being used in their collaboration will be among the academe, disability and not just look at it at the point of government agencies, the private sector, view of the developers. The end user of all these industry, and non-governmental organizations. innovations are our patients who are the most important stakeholders. And the social There are six themes of the NUHRA of which two researchers will be able to assist us in have an impact in rehabilitation. These are the determining the positive and negative effects of global competitiveness and innovation in health; the innovations. and research in equity in health. Most of the equipment used in rehabilitation are developed Barriers and borders among different disciplines in other countries. It is high time that we should should be minimized if not demolished to be able be able to develop this equipment. However, this to leap forward in finding solutions to the health will never happen if researches are only done needs of the Filipino community. within the discipline. Researches should be a collaboration of disciplines that are involved in health care. Medical and paramedical researchers in the field of Rehabilitation Medicine are cognizant of the needs of the persons with disabilities. The solutions to some of these problems could be answered by 4

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.004) Letter to the Editor Challenges of research ethics committees Anna Lea Enriqueza aEthics Research Committee, College of Rehabilitation Sciences, University of Santo Tomas Article Received: 10 July 2019 Article Published: 22 July 2019 (Online) Copyright © 2019 Enriquez. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The past two decades witnessed a colossal stride of research ethics committees as well as in scientific research in the academic community. monitoring and evaluating their performance As such, students and educators vibrantly carry through an accreditation process. In the out research activities either independently or academe, the Commission on Higher Education collectively. Aside from ensuring quality (CHED) issued a 2016 memorandum directing scientific technical soundness, it becomes the ethics committees in higher educational responsibility of investigators to ensure that institutions to undergo registration and participants’ rights are protected and that their accreditation.4 safety is secured at all times. Despite the extensive international and local Research ethics committees provide an frameworks, ethics committees face critical additional oversight for the protection of human challenges in their organization, membership, participants. Historically, the World Health and function. The establishment of the Organization (WHO) has prominently recognized committee is an institutional decision oftentimes this role and has issued a document entitled in compliance with existing regulatory Standards and Operational Guidelines for the requirements but less frequently as a genuine Ethics Review of Health-Related Research with concern for the ethical conduct for research. This Human Participants which clearly defines the likewise holds true in the case of researchers systems approach for the establishment of these who seek ethics approval primarily to comply committees.1 Additionally, the Council for with the requirements of funding institutions International Organizations of Medical Sciences and of scientific journals for potential (CIOMS) collaborated with the WHO and jointly publication. Are these behaviors reflective of the issued the International Ethical Guidelines for erroneous and disturbing notion that scientific Health-related Research Involving Humans.2 The interest takes precedence over the welfare of document provides ethical considerations for human participants? If so, there is a crucial need specific research scenarios, as well as a chapter to further transform an ethical research culture on the requirements for the establishment of with patience and understanding that can only ethics committees, and guidelines for the be processed over time. conduct of reviewing protocols. The existence of a research ethics committee in Locally, upon the enactment of the Philippine the academe is a unique setting. To demonstrate, National Health Research System (PNHRS) Act of the academic institution is depended upon for 2013, the Philippine Health Research Ethics providing the mandate and support for the Boards (PHREB) was appointed as the national committee. However, to prevent conflict of policy-making body for health research.3 Its legal interests, the same institution does not take part mandate includes promoting the establishment in the committee’s deliberations and decisions 5

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.004) and is expected to respect the latter’s professional fields. As such, there is difficulty in independence. It cannot, in any way, influence the recruitment of a unique breed of members the decision-making process. This may be a who will have the expertise and who can sustain potential conflict for both the institution and the the passion for the role. committee considering the perceived divergence in their primary mission. That is, to generate The challenges remain. Ethics committees will scientific evidence for the former and to protect continue to be confronted by issues as unique as research participants for the latter. Have the purpose that they serve. Hand in hand with researchers become too engrossed in the the scientific community, they move towards practice, turning a blind eye on the mandated parallel visions in improving the health of the process for the protection of their participants? society while remaining steadfast in their And for their part, have the ethics committees responsibility as guardians in ensuring safety become too stringent in their manner of review, among participants. In the end, both should restraining the chance of generating new aspire for the common good. knowledge? “Where people of goodwill get together and History has repeatedly taught us the painful transcend their differences for the common lessons on the unethical conduct of research; good, peaceful and just solutions can be found when good researchers, even doctors, forgot to even for those problems which seem most respect human dignity, to uphold autonomy, and intractable.” Nelson Mandela to guard against injustice.5 Let us not ignore the fact that ethical guidelines and research ethics References: committees came about as an aftermath of these unethical research behaviors.6,7 Some 1. Standards and Operational Guidelines for the Ethics researchers may perceive going through an Review of Health-Related Research with Human ethics review process as inconvenient but it Participants (WHO, 2011) (https://www.who.int/) becomes an obligatory inconvenience if we are to uphold the protection of research participants. 2. International Ethical Guidelines for Health-related Albeit certification courses for the ethical Research Involving Humans, Fourth Edition. Geneva. conduct of research are required among Council for International Organizations of Medical researchers, the ethics committee’s role is still Sciences (CIOMS, 2016) vital and mandated by law. (https://cioms.ch/shop/product/international-ethical- guidelines-for-health-related-research-involving- For its part, the committee is expected to have a humans/) high level of expertise and integrity. Members go through extensive training and re-certifications 3. Philippine National Health Research System’s Act in ethics education. Moreover, exhibiting high (Republic Act No.10532. May 7, moral values and upholding research integrity 2013)(https://www.officialgazette.gov.ph/2013/05/0 are crucial inherent traits. Additionally, with the 7/republic-act-no-10532/) growing complexities of research designs, methodologies, and expansive research areas, it 4. Registration and Accreditation of all Ethics Review becomes mandatory that members also become Committees in the Philippines. CHED Memorandum. updated on these technical areas. This is March 30,2015 (http://pchrd.dost.gov.ph/) necessary to ensure a pertinent, expert, and efficient review process. Hence, capacity- 5. Nuremberg Trials. Library of Congress, Nuremberg, building becomes obligatory. Lastly, members Germany are committed to spending time and effort in the (https://www.loc.gov/rr/frd/Military_Law/Nurember exercise of their role, often burdened with the g_trials.html) increasing number of protocols needing review. All of these are over and above their main role in 6. Declaration of Helsinki. World Medical Association the university, that is, to teach in their (https://www.wma.net/what-we-do/medical- ethics/declaration-of-helsinki/) 7. The Belmont Report. The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (https://videocast.nih.gov/pdf/ohrp_belmont_report.p df) 6

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.010) Original Article Translation and validation of the Physical Activity Scale for the Elderly in Filipino community-dwelling older adult fallers and non-fallers Donald Lipardoa,b, Eudinel Joshua Lopeza, Sharmaine Santiagoa, Mariel Tubiga, Gerard Joseph Enriqueza, Carmela Grace Canaresa, Marc Pagaduana, Kristina Devoraa aDepartment of Physical Therapy, College of Rehabilitation Sciences, University of Santo Tomas, Manila, Philippines; bCenter for Health Research and Movement Sciences, College of Rehabilitation Sciences, University of Santo Tomas, Manila, Philippines Correspondence should be addressed to: Donald Lipardoa,b; [email protected] Article Received: 15 February 2019 Article Accepted: 19 June 2019 Article Published: 18 July 2019 (Online) Copyright © 2019 Lipardo et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background: Increased falls rate in older adults may be due to a declining level of physical activity. However, there is currently no local assessment tool to assess the physical activity of older adults in the Philippines. Purpose: The objectives of the study were to: (1) translate the Physical Activity Scale for the Elderly (PASE) in Filipino (PASE-F); (2) establish the validity and equivalency of PASE-F version; and (3) determine the association between physical activity level and fall history in older adults living in the community. Methods: Standard translation procedure was followed. Qualitative analysis and appropriate revisions were done based on the comments of three health professionals in geriatric care. Equivalency was analyzed using two-sample t-test with equal variances, and Spearman Rho. The association of physical activity with fall history was established using simple logistic regression. Results: 310 (62.3% females) community-dwelling older adults, with mean age 68 ±6.5, from Manila, Philippines participated. The validated PASE-F and the original PASE were equivalent with a p-value of 0.84, and Spearman’s Rho of >0.05. No significant association was found between PASE-F scores and fall history, p-value = 0.16, 95% CI [1, 1.004]. Fallers show non-significantly higher PASE-F scores compared to non-fallers. Conclusion: PASE-F is a valid and equivalent translation of the original PASE. However, obtained PASE-F scores did not show association with a history of falls. Prospective studies may be done to determine the predictive value of PASE-F scores in the incidence of falls. Keywords: physical activity, older adults, fall history INTRODUCTION to reduced strength, flexibility, agility and endurance of older persons which could Occurrence of falls among older persons is a eventually result in a fall.4-6 common phenomenon with a global prevalence rate of 28-35% for those 65 years old or above.1 To assess PA in older adults, several direct and A fall could have fatal or non-fatal physical indirect measures have been developed.7 Direct consequences that could also result into measures objectively assess PA using psychosocial problems, and economic burden to accelerometers, pedometers, or doubly labeled the family and community.2,3 The increased water method. The indirect measures incidence of falls may be due to the associated subjectively assess PA using questionnaires such decrease in physical activity with advancing as the International Physical Activity age.4-6 Physical activity (PA) refers to any body Questionnaire (IPAQ), Community Healthy movement brought about by the action of Activities Model Program for Seniors (CHAMPS), skeletal muscles that result in increased expenditure of energy.6 Decreased PA may lead 7

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.010) Yale Physical Activity Scale (YPAS), and Physical Phase 1: Validation and Translation Activity Scale for the Elderly (PASE).8,9 The copy and the permission to translate the Direct PA measures are considered more original PASE questionnaire were first sought accurate by providing data on energy from the New England Research Institute. An expenditure and movement counts, compared to expert panel composed of three allied health indirect PA measures which are prone to recall professionals (medical doctor, physical therapist, bias.7 However, for community-based programs and occupational therapist) in geriatric care, who and large epidemiologic studies, indirect PA have at least 10 years of experience and were measures are more practical, cost-effective, and independent from the research being done, easier to administer.7 The subjective measures conducted the content and face validation, and can provide the specific types of activities the cultural adaptability to the Philippine setting of respondents are involved in, and not just PASE. numerical information. The experts conducted content validation by Among the commonly used questionnaires, PASE rating the degree of relevance of each item of the is the most concise tool composed of 10 tool, using a 4-point Likert scale which was questions on the frequency, duration, and adapted from previous studies.18,19 A score of 1 intensity of leisure, household, and work-related means not relevant and should not be included; 2 activities within the past seven days.10 It can be indicates marginal relevance and does not need completed in a relatively shorter period of time to be included; 3 is important and should be (5–15 minutes) and easily scored, which reduces included; and 4 is essential and must be the participant burden.11 The higher the total included. Remarks per item and for the entire score, which could range from 0-793, the greater questionnaire were also obtained. For face the level of physical activity.10-11 It can be self- validation, the experts were asked to use the administered, or directly administered in person Questionnaire Appraisal System (QAS) or via telephone.10 PASE has an established developed by the Research Triangle Institute.20 construct validity12-14 and good test-retest The QAS has eight general dimensions: reading, reliability.10,15 It has been translated also in instructions, clarity, assumptions, several languages such as Chinese, Japanese and knowledge/memory, sensitivity/bias, response Thai.11,16,17 categories, and other problems. Appropriate revisions to PASE were done by integrating the However, there is no local version of PASE in the recommendations and suggestions of the Philippines. Development of a valid Filipino experts. Some activities enumerated in the version of the tool is important for clinical and original PASE were replaced with metabolically research purposes and will be useful in making equivalent activities more commonly done by intercultural and international comparisons Filipino older adults.21 between the Philippines and other nations. Standard forward-backward translation This study aimed to: 1) translate the original procedure was followed. A language specialist, PASE in Filipino (PASE-F); 2) establish the who was a bilingual university Filipino validity and equivalency of PASE-F; and 3) professor, translated the modified PASE to establish the association between physical Filipino (PASE-F). Afterward, another language activity and fall history among older adults. specialist, who was a bilingual university English professor, translated PASE-F back to English. The METHODS original PASE and the back-translated English versions were then compared. A third language This study is a two-phase observational study. specialist mediated to resolve discrepancies and Ethical approval was secured from the Ethics concluded that the back-translated version is Review Committee of the University of Santo similar to the original PASE. Tomas– College of Rehabilitation Sciences. The participants signed a written consent form prior to participation. 8

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.010) The equivalency of PASE-F to the original PASE older persons hold their regular meetings. was then investigated in a pilot test. Fifteen (15) Trained researchers directly administered the older adults, who were literate in Filipino and PASE-F questionnaire in order to reduce the English, and who passed our eligibility criteria, chances of non-response. were recruited to answer the two versions of the questionnaire. To minimize sequence effect, Participants were also asked whether they had a there was no particular order on which version history of falls in the past 12 months. A fall is to conduct first or second. At least 30 minutes defined as the unintentional change in position separate the administration of the two or coming to rest on a lower level (on the questionnaires. ground, floor or chair).1 Phase 2: Association of PASE-F scores and History Data Analysis of Falls OpenStat (version 11.9.08) and Microsoft Excel Participants. Filipino older adults aged 60 years 2010 were used in data recording and analysis. or above, who may or may not have had any To determine the equivalency of PASE-F to the history of falls in the past 12 months, and who original, the scores of the 15 older adults during were living in Manila for at least 1 year were the pilot test were compared using two-sample t- recruited. Furthermore, they were included if test with equal variances. To establish the per they were ambulatory without an assistive item consistency of their responses, Spearman’s device, and have a functional range of motion of Rho was used. trunk, shoulder, hip and ankle that is adequate to perform balance tests. However, they were not Descriptive statistics, including mean, standard allowed to participate if they have unhealed deviation and percentage, were used to surgery or fractures in the past 12 months, joint summarize demographic information and PA of pains, amputation, leg length discrepancy, the participants during the second phase of the chronic neurologic condition, contracture, study. The association between the mean PASE-F cardiac conditions, and total blindness.11,14 scores and a history of falls among elderly patients was analyzed using the odds ratio. Sample size. The sample size was computed Association of the PASE-F items with history of using Open Epi. In the absence of published data falls was examined using simple logistic on fall prevalence in the Philippines, the lower regression. The threshold of significant margin of falls prevalence, which is 28%, difference was set at 0.05. according to WHO, was used.1 Assuming a margin of error of 5% and a 95% confidence RESULTS interval, a total of 310 participants are required for the study. Validity and Cultural Adaptation of PASE Participant Recruitment and Data Gathering. The consensus of the panel of expert on the This study initially intended to use stratified content of PASE was that all items in the proportionate random sampling, however, out of questionnaire were essential and must be six districts, approval from the Office of Senior included in the Filipino version. Several Citizens Affairs (OSCA) of Manila to conduct the suggestions were made to make the scale more study was obtained for Districts 1 and 2 only. culturally applicable in the Philippine setting. For The OSCA permitted the conduct of our study in the first question on activities in sitting, it was these districts because the association of senior suggested to qualify “reading” by changing it to citizens in these districts were well-organized. “reading a book or newspaper”. For the second And in the course of participant recruitment, question on walking outside the home or yard, only District 1 was able to provide assistance. additional examples were included such as Four barangays (small local units) of District 1 walking to church and walking inside the mall. consented to participate in the study. Data For light sport and recreational activities in the gathering was held in January 2014 at the third question, the given examples which were community centers of each barangay where the golf with a cart, shuffleboard, and fishing from a 9

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.010) boat or pier were replaced with billiards and Regarding the face validity of PASE, the expert folkdance. panel agreed that there was no difficulty in using the questionnaire for older adults in terms of For moderate sport and recreational activities in reading, instructions, clarity, assumptions, the fourth question, tennis doubles and ballroom knowledge/memory, sensitivity/bias, response dancing were retained as examples, while categories, and other problems. It was suggested hunting, ice skating, golf without cart, and that the font size used in the questionnaire softball were deleted because these were not should be big enough to be readable to older commonly done in the Philippines. For strenuous adults. Another modification was on the sports and recreational activities in the fifth alignment of the choices in the inner boxes such question, the term biking was used instead of that the choices were presented in one column cycling, and skiing was considered irrelevant in instead of two. the local setting and therefore, was not included in the list of examples. The sixth question on Based on a pilot test, the validated and culturally exercises to increase strength and endurance adapted Filipino version of PASE (PASE-F) was and the seventh question on light housework found to be statistically not different from the were unchanged. original PASE with a p-value of 0.84, and Spearman’s Rho of >0.05. This proves that the For question number eight on heavy housework, two versions are equivalent. washing cars was included in the example. For question number nine, the lawn work on snow PASE-F Scores and Falls History Association removal was deleted, while the lawn work on leaf removal was kept. The 10th and last question Demographic Characteristics. A total of 310 were retained with the insertion of other work (62.3% female) older adults with a mean age of examples like vendor or tending a mini-store in 68 ± 6.50 and age range of 60-91 were included the first category of work-related activities. in the study. Table 1 shows the demographic characteristics of the participants. The overall The modification and replacement of activities in falls prevalence was calculated at 15.16%. the questionnaire were based on the list of Fallers, who reported at least one occurrence of alternative activities provided in the PASE falls in the last 12 months, show a non- administration and scoring manual, and on the significantly higher PASE-F mean score of 135.42 expert opinion of the panel on activities with +99.92, compared to non-fallers, who had no common METS equivalence.21 history of falls in the last 12 months, with a mean score of 114.86 +90.21. Table 1. Participants’ Demographics Non-Fallers Fallers Total 263 (85.84%) 47 (15.16%) 310 No. of participants (%) 67.75 +6.41 68.89 +7.36 67.92 ±6.56 Mean Age (+SD) 159 (60.46%) 34 (72.34%) 193 (62.26%) Female n(%) Marital Status n(%) 28 (10.65%) 3 (6.38%) 31 (10.00%) 144 (54.75%) 20 (42.55%) 164 (52.90%) Married 91 (34.60%) 24 (51.06%) 115 (37.10%) Single Widowed Table 2 shows the mean PASE-F scores of the and stratified in three age groups: young-old (60- participants classified as fallers and non-fallers, 69), middle-old (70-79), and old-old (>79). 10

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.010) Physical activity level, as demonstrated in the counterparts, and this was reversed when they mean PASE-F scores, generally decreases with reach 80 years and above. For fallers, the middle increasing age for both male and female older age group showed higher mean PASE scores adults. Male older adults aged 60-79 are more compared to the young-old and old-old groups. Table 2. Mean PASE-F scores and standard deviations of fallers and non-fallers stratified in three age groups. Age groups Non-Fallers (n=263) Fallers (n=47) Total (n=310) 60-69 Male (n=104) Female (n=159) Male (n=13) Female (n=34) Male (n=117) Female (n-193) Total (n=310) (n=178) 125.91 122.06 +101.51 141.41 +81.18 140.75 127.07 +91.01 124.92 125.79 +100.21 70-79 +92.72 +132.02 +106.34 (n=69) 108.02 +69.49 97.06 +76.64 162.14 +68.88 148.62 +64.76 110.19 +68.88 107.18 +76.74 108.11 +73.99 >79 (n=16) 71 +37.06 90.59 +45.98 - 75.5 +57.48 71 +37.06 85.95 +47.83 80.72 +43.96 physically active compared to their female No significant association was found between regression revealed that participants who PASE-F scores and fall history (p= 0.16, 95% CI reported increased hours of volunteer work per [1, 1.004]. The per item analysis, however, of the week, and engagement to home repairs and questionnaire revealed that frequency of home outdoor activities are 1.035, 1.02 and 1.031 repairs (p= 0.05, 95% CI [1.001, 1.045], times, respectively, more at risk for falls, engagement to outdoor gardening (p= 0.05, 95% compared to those who did not engage in such CI [1.001, 1.054] and hours of volunteer work activities. Table 3 shows the association of the (p= 0.02, 95% CI [1.004, 1.068] are risk factors activities included in the PASE questionnaire to a for falls among the participants. Simple logistic history of falls. Table 3. Association of PASE scores and individual items with history of falls using simple logistic regression OR p value 95% Confidence interval Sitting activities 1.47 0.13 0.888, 2.443 Walking 1.15 0.58 0.699, 1.888 Sports or recreational activities 1.13 0.63 0.675, 1.902 Light 0.99 0.97 0.533, 1.838 Moderate 1.12 0.48 0.816, 1.538 Strenuous 0.86 0.88 0.349, 0.680 Strength and/or endurance exercise 0.98 0.98 0.423, 0.943 Housework 1.01 0.90 0.968, 1.038 Light 1.02 0.05* 1.001, 1.045 Heavy 1.01 0.35 0.90, 1.027 1.03 0.05* 1.001, 1.054 Other Household activities 1.01 0.63 0.992, 1.013 Home repairs 1.04 0.02* 1.004, 1.068 Lawn work or yard work Outdoor gardening Caring for other person Hours of volunteer/work Total PASE Score 1.002 0.16 1.000, 1.004 * statistically significant p<0.05 11

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.010) DISCUSSION work. Yokoya et al., however, found that The first two objectives of this study were on the community-dwelling older adults who leave process of cross-cultural adaptation of the PASE their houses more frequently have a lower risk questionnaire. This is an important procedure in for falls.25 ensuring that validity of the instrument is The prevalence of falls in our study was at maintained at a conceptual level across different 15.16%, which is lower compared to the global cultures and languages.22 We found that PASE-F prevalence of 28-35%.1 This may be a is equivalent to the original version of PASE. conservative rate of falls among our participants Using PASE-F may facilitate better who were relatively younger, starting from the comprehension among respondents when self- retirement age of 60, compared to the WHO administered, and ease in the measurement of report of older adults who were at least 65.1 This physical activity level of older Filipino adults as it may also be due to our eligibility criteria of is written in the vernacular language. including only those who were independent in ambulation, without use of assistive device, and Several translations and psychometric studies on who had no known medical conditions. PASE have been done in various countries.11,14,16 Modifications in the items and cited examples of The results of our study may be interpreted with the questionnaire were made to accommodate caution due to possible recall bias of the for the unique culture and activities of the older participants in reporting their fall history, and in Filipino adults. This was similarly done in the remembering their activities in the past week Japanese translation of PASE with some when answering the PASE questionnaire. This modifications in phrasing to avoid errors in the may lead to overestimation or underestimation classification of activities.16 of their actual PA level in the past seven days. The third objective of the study was to establish Although PASE is considered a valid tool to the association between physical activity and measure PA, objective and direct measurement history of falls among older adults. We found of PA using accelerometer, pedometer or doubly that PASE-F scores were not associated to fall labeled water method, may provide more history. In a cross-sectional study by Mazo et al., quantifiable and significant difference7 between it was concluded that more physical activity is fallers and non-fallers. associated with lower incidence of falls.5 In a longitudinal study by Peeters et al., on the other CONCLUSION hand, was not able to confirm that both low and PASE-F is a valid and equivalent translation of high levels of physical activity were associated with a higher risk of falling. They reported, the original PASE. However, PASE-F scores and history of falls are not associated. Fallers may however, that older persons with higher physical activity levels have reduced risk of recurrent not be those with low physical activity level but those with high level of physical activity. Among falling.23 the activities in the PASE questionnaires, In the current study, fallers show insignificantly frequency of home repair, doing outdoor higher PASE scores compared to non-fallers. The gardening, and rendering hours for voluntary preconceived notion that older persons with work are considered risk factors for falls. The limited physical activity are more vulnerable to conduct of prospective studies to establish if falling compared to those with higher physical PASE scores can predict falls incidence is activity level due to a possible decrease in recommended. muscle strength and proprioception associated with inactivity,6 may not be always true. The higher physical activity level would mean more Acknowledgments involvement in risky behaviors,24 and activities that lead to higher falls rate. In this study, these The authors are grateful to Prof. Cheryl Peralta, activities are doing home repair, engagement in Ms. Catherine Joy Escuadra, Mr. Lemuel Lim outdoor gardening, and more hours in volunteer (faculty members from the University of Santo Tomas-College of Rehabilitation Sciences- 12

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.010) Department of Physical Therapy), Internship References Groups 6 and 14 of the University of Santo Tomas-Bachelor of Science in Physical Therapy 1. World Health Organization. WHO Global Report on Batch 2014 for their contribution during data Falls Prevention in Older Age [Internet]. France:WHO gathering; to Ms. Sally Uy, Dr. Alvin Mojica, Dr. Press;2007 [updated 2007; cited 2013 Apr 16] Dorothy Dimaandal, the three allied health Available from: professionals who conducted face and content http://www.who.int/ageing/publications/Falls_preve validation of the tool; to the barangay officials of ntion7March.pdf?ua=1 Manila District 1 for the endorsement, coordination and promotion of our research; to 2. Stevens JA, Corso PS, Finkelstein EA, Miller TR. The Tanglaw Buhay Seniors who participated in our costs of fatal and non-fatal falls among older adults. Inj pilot test; and to all the participants who gave Prev. 2006;12(5):290–295. doi: their time to us. This study was carried out with 10.1136/ip.2005.011015. a partial grant from the UST Simbahayan Community Development Office. 3. Peel NM. Epidemiology of falls in older age. Can J Aging. 2011;30(1):7-19. doi: 10.1017/S071498081000070X. Individual author’s contributions Epub 2011 Mar 15. The specific areas of contribution of the authors 4. Milanovic Z, Oantelic S, Trajkovic N, Sporis G, Kostic R, are provided below: James N. Age-related decrease in physical activity and functional fitness among elderly men and women. Clin  Study concept and design: DL Interv Aging. 2013;8:549-556. doi: 10.2147/CIA.S44112. Epub 2013 May 21. 5. Mazo GZ, Liposcki DB, Ananda C, Preve D. Health conditions, incidence of falls, and physical activity level among the elderly. Rev Bras Fisioter [Internet]. 2007;11(6):437-442. doi.org/10.1590/S1413- 35552007000600004.  Acquisition of data: DL, EJL, SS, MT, GJE, 6. American College of Sports Medicine, Chodzko-Zajko CGC, MP. KD WJ, Proctor DN, Fiatarone Singh MA, et al. American College of Sports Medicine position stand: Exercise and  Analysis and interpretation of data: DL, physical activity for older adults. Med Sci Sports Exerc. EJL, SS, MT, GJE, CGC, MP 2009;5(7):1510-1530. doi: 10.1249/MSS.0b013e3181a0c95c.  Drafting of the manuscript: DL, EJL, SS, MT, GJE, CGC, MP, KD 7. Kowalski K, Rhodes R, Naylor P-J, Tuokko H, MacDonald S. Direct and indirect measurement of  Final revision and approval revision of physical activity in older adults: a systematic review of the manuscript: DL, EJL, SS, MT, GJE, CGC, the literature. Int J Behav Nutr Phys Act. 2012;9:148. MP, KD doi:10.1186/1479-5868-9-148. Disclosure statement 8. Forsé n L, Loland NW, Vuillemin A, Chinapaw MJM, van This study was carried out with partial grant Poppel MNM, Mokkink LB, et al. Self-administered from the University of Santo Tomas- Simbahayan physical activity questionnaires for the elderly: A Community Development Office. systematic review of measurement properties. Sports Med. 2010;40(7):601-623. doi: 10.2165/11531350- Conflicts of interest 000000000-00000. We declare no conflicting interests. 9. Moore DS, Ellis R, Allen PD, Cherry KE, Monroe PA, Supplementary file O’Neil CE, et al. Construct validation of physical activity S1_PASE-F. Copy of the Physical Activity Scale for surveys in culturally diverse older adults: A the Elderly in Filipino (PASE-F). comparison of four commonly used questionnaires. Res Q Exerc Sport. 2008;79(1):42-50. 10. Washburn RA, Smith KW, Jette AM, Janney CA. The Physical Activity Scale for the Elderly (PASE): Development and evaluation. J Clin Epidemiol. 1993;46(2):153-62. 11. Vaughn K, Miller WC. Validity and reliability of Chinese translation of the Physical Activity Scale for the Elderly (PASE). Disabil Rehabil. 2013;35(5):191–197. doi: 10.3109/09638288.2012.690498. Epub 2012 Jun 7. 12. Washburn RA, McAuley E, Katula J, Mihalko SL, Boileau RA. The physical activity scale for the elderly (PASE): 13

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.010) evidence for validity. J Clin Epidemiol. 1999;52(7):643- Pract. 2009;15(1):76-84. doi:10.1111/j.1365- 51. 2753.2008.00957.x 13. Schuit AJ, Schouten EG, Westerterp KR, Saris WH. 20. Willis GB, Lessler LT (Research Triangle Institute, Validity of the Physical Activity Scale for the Elderly Rockville, MD). Question Appraisal System QAS-99. (PASE): According to energy expenditure assessed by Behavioral Surveillance Branch of the Centers for the doubly labelled water method. J Clin Epidemiol. Disease Control and Prevention. 1999 Aug. Contract 1997;50(5):541-6. No.: 200-98-0103 TO#3. Sponsored by the National Center for Chronic Disease Prevention and Health 14. Ngai SP, Cheung RT, Lam PL, Chiu JK, Fung EY. Promotion. [cited 2013 Apr 16]. Available from: Validation and reliability of the Physical Activity Scale http://appliedresearch.cancer.gov/areas/cognitive/qa for the Elderly in Chinese population. J Rehabil Med. s99.pdf 2012;44(5):462-5. doi: 10.2340/16501977-0953. 21. Ainsworth BE, Haskel WL, Whitt MC, et al. 15. Svege I, Kolle E, Risberg MA. Reliability and validity of Compendium of physical activities: an update of the Physical Activity Scale for the Elderly (PASE) in activity codes and MET intensities. Med Sci Sports and patients with hip osteoarthritis. BMC Musculoskelet Exerc. 2000;32(9 Suppl):S498-504. Disord. 2012;13:26. doi: 10.1186/1471-2474-13-26. 22. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. 16. Hagiwara A, Ito N, Sawai K, Kazuma K. Validity and Guidelines for the process of cross-cultural adaptation reliability of the Physical Activity Scale for the Elderly of self-report measures. Spine. 2000;25(24):3186-91. (PASE) in Japanese elderly people. Geriatr Gerontol Int. 2008;8(3):143-51. doi: 10.1111/j.1447- 23. Peeters GM, van Schoor NM, Pluijm SM, Deeg DJ, Lips P. 0594.2008.00463.x. Is there a U-shaped association between physical activity and falling in older persons?. Osteoporos Int. 17. Binhosen V, Panuthai S, Srisuphun W, Chang E, 2010;21(7):1189-95. Sucamvang K, Cioffi J. Physical activity and health related quality of life among the urban Thai elderly. 24. Yuen HK, Carter RE. A measure of fall risk behaviors Thai J Nurs Res. 2003;7(4):231-243. [cited 2013 April and perceptions among community-dwelling older 20] Available from: adults. J Allied Health. 2006;35(4):e276-97. http://www.tnc.or.th/files/2011/05/tnc_journal- 612/thai_journal_of_nursing_research_vol_7_no_4_octo 25. Yokoya T, Demura S, Sato S. Relationships between b_17285.pdf physical activity, ADL capability and fall risk in community-dwelling Japanese elderly population. 18. Clemson L, Fitzgerald MH, Heard R. Content validity of Environ Health Prev Med. 2007;12:25-32. an assessment tool to identify home fall hazards: the Westmead Home Safety Assessment. Br J Occup Ther. 1999;62(4):171-9. 19. Bowman J, Lannin N, Cook, C, McCluskey A. Development and psychometric testing of the Clinician Readiness for Measuring Outcomes Scale. J Eval Clin 14

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.009) Original Article Translation and cross- cultural adaptation of the Friedrich Short Form of the Questionnaire on Resources and Stress (QRS-F) to measure the stress level of Filipino parents and other caregivers of children with disability Paulin Grace Morato-Espino,a Kim Gerald Medallon,b Rigel Benzon,b Mark Timothy Arroz,b Carlo Angelino Buencamino,b Cecilia Anne Ibay,b Marie Selene Ko,b Ivan Neil Gomeza aCenter for Health Research and Movement Science, University of Santo Tomas, Manila, Philippines; bDepartment of Occupational Therapy, College of Rehabilitation Sciences, University of Santo Tomas, Manila, Philippines Correspondence should be addressed to: Paulin Grace Morato-Espinoa; [email protected] Article Received: 15 February 2019 Article Accepted: 19 June 2019 Article Published: 18 July 2019 (Online) Copyright © 2019 Morato-Espino et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background: The Friedrich Short Form of the Questionnaire on Resources and Stress (QRS-F) is a tool that measures stress levels of parents of children with disabilities. Objectives: The objectives of this study are 1) To translate and culturally adapt the QRS-F for use by Filipino parents and other caregivers of children with disability in the Philippines, and 2) To establish its psychometric properties. Methods: The tool underwent the process of translation & cross-cultural adaptation with the following steps: 1) face & content validation, 2) translation and equivalence and 3) pilot study of the pre-final QRS-F. Convenience sampling was performed to select sixty Filipino parents and other caregivers of children with disability enrolled in special education schools and thirty Filipino parents and other caregivers of typically developing children enrolled in regular schools, all located in Metro Manila. Results: A translated, and culturally adapted QRS-F was developed and was found to have good reliability and construct (known group) validity. Conclusion: The QRS-F is a culturally valid tool that can be used to measure the stress levels of Filipino parents and other caregivers of children with disability. Key Words: questionnaire, stress, parents, children, disability Introduction resources and may be manifested in ways such as depression, anxiety, negative impact on Parenting or child rearing is the provision of care health, welfare, safety and psychosomatic and supervision to support the child’s symptoms.4 developmental needs. While it may pose several demands, for most, parenting is a positive Various factors contribute to the stress experience. However, parenting could also be experienced by parents of children with more difficult and stressful for some, such as in disability. The nature and severity of a child’s the case of parents of children with disability. disability and temperament, behavior problems, Literature supports that the stress levels and demands placed upon the parent are between parents and caregivers of children with significantly and directly related to each other.5 disability and parents and caregivers of typically Parents would rather consider the persistent developing children are different with the former needs and concerns of their children with showing higher levels.1,2,3 Stress is a negative disability than their own needs. The lack of rest psychological response to demands that are causes much strain on the parents. A study found usually greater than one’s currently available that there are Filipino parents who choose to 15

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.009) quit their jobs to devote their time fully in taking with chronic illness on the parent or care of their child with disability.6 This, caregiver.13,18 The short form was intended for unfortunately results to financial constraints use with parents of young children with Autism further causing stress to them.6 Spectrum Disorder. Psychometric properties showed good reliability, internal consistency, Elevated levels of stress may have negative and satisfactory convergent, divergent, and effects on the parent, child, and even the entire construct validity.1,12,13 family which may lead to substantial disturbance in relationships.4 Stress brought about by Most of the self-report measures available for nurturing a child with special needs may have use were developed in English-speaking adverse effects on the parent’s general well- countries. In countries with different language being which affects one’s overall functioning.7 and culture, such as in the Philippines wherein The presence of high levels of disturbed sleep, there is an absence of such a tool, there is a need emergence of mood problems, restricting for translation and cultural adaptation. The QRS- relationships between peers and other family F has been translated and cross-culturally members, limited participation in leisure validated for use in several countries, such as activities, and limited employment opportunities Spain, China, Turkey and Israel.15, 19, 20, 21 are common occurrences associated with caring for a child with disability.8,9 Stress can lead to The Philippines is said to be one of the countries unhealthy lifestyles, and restrict caregivers’ having the highest prevalence of disability who activities, which in turn, can result to various are classified to have low socioeconomic status.22 physical and psychosocial problems.5,7 Child With this, it is safe to conclude that there are a rearing, which includes the ability to good number of parents who already are in accommodate and respond to the child’s difficult predicament and have the additional behavior and unique contexts, can also be load of taking care of a child with disability. affected causing a negative, cyclic interaction.7,10 Parenting is an important occupation in the Elevated parent-related stress has been Philippines and is taken seriously and associated with poorer child outcomes in considered a priority by most. Stress levels of intervention programs. Overly stressed parents Filipino parents of children with disability may have been found to respond poorly to be highly similar to other cultures; however, the interventions made for families with a child with lack of research in the Philippines is glaring. ASD.6 To determine the stress level of Filipino- Due to the numerous detrimental effects of speaking parents and other caregivers of elevated stress, interventions and support for children with disability in the Philippines, there stressed parents of children with disability are is a need to create a culturally appropriate tool imperative. The role of occupational therapists to to cater to these parents. Thus, the aim of the advocate health and wellness and to help parents study is to establish a culturally adapted Filipino improve participation in child rearing are highly version of the QRS-F. The specific objectives of relevant.11 The first step to address the problem, this study are to 1) Translate and cultural adapt however, is to be able to identify these parents the QRS-F for use by Filipino-speaking parents who have elevated levels of stress and, therefore, and other caregivers of children with disability are in need of help. in the Philippines; and 2) Establish the psychometric properties of the cross-culturally There are various tools used to measure parental adapted QRS-F specifically face, content, stress level.12,13,14,15 The Friedrich Short-Form of construct validity specifically known groups the Questionnaire on Resources and Stress (QRS- validity, and internal consistency. F) is one of the widely used questionnaires used to measure parental stress.16,17 It was developed from Holroyd’s longer version of Questionnaire on Resources and Stress which was designed to measure the impact of a child with developmental disability or a family member 16

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.009) Methodology CVI was computed as the number of experts Participants giving a rating of 3 or 4 divided by the total number of experts. Item - Content Validity Index Purposive sampling was performed to select six (I-CVI) was derived by computing the mean CVI experts namely two occupational therapists per item. The Scale Content Validity Index (S- (OT), two guidance counselors and two parents CVI/Ave) is the mean I-CVI of all items. The of children with disability to validate the minimum acceptable CVI is 0.79. Items with CVI questionnaire on face and content level. Three below 0.79 has to be reviewed and revised or forward translators and two backward removed.23 translators were invited to translate the tool to Filipino and evaluate its equivalence. Modification of Tool. After validation of the QRS-F at face and content level, the comments of Convenience sampling was used to select two the experts were consolidated as a basis for the groups of parents and other caregivers of children changes done on the Short form of the aged 2 to 18 years old. Parents and other Questionnaire on Resources and Stress (QRS-F). caregivers of children with disability from one private and one public special education schools The revised QRS-F was sent back to the same were invited to participate in the pilot study. panel of experts for review. Each item on the Participants for the other group were invited QRS-F was re-assessed using the same questions. from private and public regular schools located All six experts were able to answer the second within Metro Manila. Other caregivers of children face validation questionnaire completely. A are those individuals whom the children spend written report regarding their comments on the most of their time with and provide the care and changes done to the QRS-F was generated. supervision they need in the absence of their Step 2: Translation and equivalence parents. The process of translation and cross-cultural Procedures adaptation of the questionnaire is based on the This study has been approved by the Ethics Guidelines for the process of Cross-Cultural Review Committee of the University of Santo Adaptation of Self Report Measures by Beaton, Tomas, College of Rehabilitation Sciences. The Bombardier, Guillemin, and Ferraz.24 Cross- cross-cultural adaptation process performed in cultural adaptation is different from merely this study consists of three steps: 1) Tool translating a questionnaire into the intended Validation (Face and Content), 2) Translation language of use. It is a process where the and Equivalence, and 3) Pilot Testing. Access to questionnaire is being prepared for use in the tool has been provided by one of the authors another setting and tries to produce equivalency of the short form which is readily available from between the source and target based on the the published article.17 content of the questionnaires. Different scenarios would dictate whether there is a need Step 1: Face and content validation to do both translation and cultural validation or cultural validation only. Since the QRS-F will be Face Validation. Each item of the Short form of used in another country and in another language, the Questionnaire on Resources and Stress and it was determined that both translation and the questionnaire as a whole were examined for cultural validation are required.24 face validity. All six-panel experts were able to answer the face validation questionnaire Forward Translation. Three independent completely. translators translated the questionnaire from Content Validation. The same panel of experts English to Filipino language. The first translator examined the QRS-F to validate its content. Each is an independent Filipino translator who does item on the questionnaire was assessed using the not have any background regarding the Content Validity Index (CVI) where four questionnaire. The translation made by the first parameters relevant to content validation were translator was labeled as FT1 (translator 1). The described: relevance, clarity, simplicity, second translator is a Filipino rehabilitation ambiguity and were rated using a 4-point scale. professional that has experienced administering 17

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.009) similar questionnaires and the translation made developing child. It was suggested to recruit was labeled as FT2 (translator 2). between thirty to forty persons according to the guidelines by Beaton.24 The researchers compared and consolidated the two translations to develop the Filipino version The participants who consented to participate in of the questionnaire. A third translator was hired the study were gathered in one room located in in order to translate item 28 from the the school and they were each provided a copy of questionnaire because of the difficulty to the questionnaire. Demographic data was consolidate the translations from translators 1 gathered from each of the participant before the and 2 for the said item only. The translation was instructions for the questionnaire was explained labeled as FT3 (translator 3). to the group. After each participant completed answering the questionnaire, the participants Backward Translation. Two independent were asked for 1) the meaning of each item in translators performed backward translation. The the questionnaire and their responses and 2) any two translators were independent translators parts or words in the questionnaire that are hard who do not have any background regarding the to understand, if any. Questions were asked questionnaire. The translation made by the first further regarding the item/s that are difficult to translator was labeled as BT1 and the translation understand. Parents of typically developing made by the second translator was labeled as children studying in regular schools were only BT2. asked to accomplish the questionnaire for the Equivalence. The researchers, experts and assessment of the tool’s known group validity. translators consolidated all of the translations to develop the pre-final Filipino Questionnaire on Data analysis Resources and Stress. One of the researchers All the written reports of the experts and who had previous training and experience in translators were consolidated and summarized. cross-cultural adaption and translation of Data analysis was performed using Microsoft questionnaires acted as the methodologist and Excel 2013 and SPSS 20.0 programs. Microsoft one of the forward translators who is part of a Excel was used to determine the face and content renowned national university Filipino language validity of the tool by computing the mean center acted as the language expert. A written scores. SPSS 20.0 was used for descriptive report was prepared based on the discussion of statistics to analyze the participant the translations. The researchers, translators and characteristics, internal consistency as measured experts determined equivalence between the by Cronbach’s Alpha and the differences among target version and the source in four areas by groups using the Mann Whitney U-test, the non- answering the following questions: 1) Semantic parametric equivalent of independent t-test, Equivalence: Do the words mean the same thing? following non-normal distribution of samples Are there multiple meanings to a given item? Are and non-homogeneity of variances. there grammatical difficulties in the translations?; 2) Idiomatic Equivalence: Were the idioms or Results colloquialisms properly and correctly translated?; 3) Experiential Equivalence: Are translated items in fact experienced in the target culture?; and 4) Phase I: Validation of Tool Conceptual Equivalence: Are the conceptual meaning of translated words same in both Face Validation. After face validation, results cultures?24 revealed that four items (1, 4, 10, 28) of the questionnaire was not able to meet the set Step 3: Pilot testing criteria (66%) and were found to be invalid at face level. All other items of the QRS-F were found to be valid at a face level. The pre-final Filipino version of the QRS-F was pilot tested and used to determine and compare the stress level of Filipino parents and other Content Validation. All items of the caregivers of a child with disability and Filipino questionnaire have met the set criteria (0.79) parents and other caregivers of a typically except for the relevance of item 2. The item was reviewed and after a discussion with the expert 18

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.009) panel, the item was retained in its current form. common and may even be unacceptable for most The scenario of putting children with special Filipinos; however, it was also discussed that it is needs in group homes or institutions is not a viable option for some families since there are Table 1. Content Validity Index Results of Filipino QRS-F Item CVI -Relevance CVI - Clarity CVI -Simplicity CVI -Ambiguity I-CVI number 1.00 1.00 1 1.00 1.00 1.00 1.00 .92 1.00 1.00 2* 0.67 1.00 1.00 1.00 1.00 1.00 1.00 3 1.00 1.00 1.00 1.00 1.00 1.00 1.00 4 1.00 1.00 1.00 1.00 1.00 1.00 1.00 5 1.00 1.00 1.00 1.00 1.00 1.00 1.00 6 1.00 1.00 1.00 1.00 1.00 1.00 1.00 7 1.00 1.00 1.00 1.00 0.96 1.00 1.00 8 1.00 1.00 1.00 1.00 1.00 1.00 0.96 9 1.00 1.00 1.00 1.00 1.00 1.00 0.96 10 1.00 1.00 1.00 1.00 1.00 1.00 0.96 11 1.00 1.00 1.00 1.00 1.00 1.00 1.00 12 1.00 1.00 1.00 1.00 1.00 1.00 1.00 13 1.00 1.00 1.00 1.00 1.00 1.00 1.00 14 1.00 1.00 0.83 0.83 0.96 1.00 1.00 15 1.00 1.00 1.00 1.00 1.00 1.00 1.00 16 1.00 1.00 1.00 0.99 0.99 17 1.00 0.83 1.00 18 1.00 1.00 1.00 19 1.00 1.00 0.83 20 1.00 1.00 1.00 21 1.00 1.00 0.83 22 1.00 1.00 1.00 23 1.00 1.00 1.00 24 1.00 1.00 1.00 25 1.00 1.00 1.00 26 1.00 1.00 1.00 27 1.00 1.00 1.00 28 1.00 1.00 1.00 29 1.00 1.00 1.00 30 1.00 1.00 1.00 31 1.00 1.00 1.00 Mean 0.99 0.99 0.98 * Item was reviewed in terms of relevance. groups and institutions currently providing this meet the set criteria (66%) and was revised service for a fee or as charitable work. according to the comments of the reviewers. All other items were retained, and no changes were Revised QRS-F. The tool was modified based on done. The revised QRS-F was sent back to the the comments of the experts after face validation. panel of experts for review. The format and all The four items (1, 4, 10, 28) were then revised. items of the questionnaire were then found to be The format of the questionnaire was not able to valid at face and content level. 19

PJAHS • Volume 3 Issue 1 2019 • Table 2. Forward and Backward Translations Item Original Forward Translation Bac number I worry about what will Nag-aalala ako kung ano ang I am w 1 happen to _____ when I maaaring mangyari kay happe can no longer take care __________ kung sakaling hindi am un 2 of him/her. ko na siya maalagaan. anym I have accepted the fact Tinanggap ko na ang I had 3 that _____ might have to katotohanang maaring that _ live out his/her life in mamuhay si _____ sa isang speci 4 some special setting espesyal na lugar (katulad ng home 5 (e.g., group home, group home o sa isang 6 institution) . institusyon) I had I have given up things I Tinalikuran ko na ang mga which have really wanted to bagay-bagay na talagang nais care o do in order to care for kong gawin para maalagaan si _____. ______. I am w It bothers me that _____ Nababahala ako na magiging alway will always be this ganito palagi si _________. way. I can I can visit my friends Maari kong bisitahin ang when whenever I want. aking mga kaibigan kailan ko man gustuhin. I am a I get upset with the Naiinis ako sa patutunguhan my lif way my life is going. ng buhay ko. 7 I am disappointed that Nadidismaya ako dahil hindi I am u _____ does not lead a makapamuhay nang normal si canno normal life. _____. 8 It is easy for me to Madali para sa akin ang It is v relax. makapagpahinga at rest a magrelaks. 9 I worry about what Nag-aalala ako kung ano ang I am w will be done with _____ gagawin kay _______ kapag care o when he/she gets matanda na siya. becom older. 10 I get almost too tired to Masyado na akong pagod para I am a enjoy myself. libangin pa ang sarili ko. recre 2

(doi:10.36413/pjahs.0301.009) ckward Translation 1 Backward Translation 2 Resolution of (BT1) (BT2) Expert Panel Accept the worried about what may I am worried with what might forward en to __________ in case I happen to __________ if I am no translation. nable to take care of him longer capable of taking care more. of him/her. Accept the already accepted the fact I have already accepted the forward __________ may stay in a fact that _____ may have to live translation. ial place (like a group in a special place (a group e or an institution). home or specialized institution) to forego some things I have already put aside on Accept the h I like to do just to take the things that I like to do to forward of __________. be able to care for ______. translation. worried that _________ will I am worried that _________ will Accept the ys stay this way. always be like this. forward translation. visit my friends I can visit my friends Accept the never I want to. whenever I wish to. forward annoyed with the way I am irritated with how my life translation. fe is leading to. might become. Accept the forward upset that _________ I am frustrated because _____ translation. ot live a normal life. cannot have a normal life. Accept the forward very easy for me to take a It is easy for me to be able to translation. and relax. rest and relax. Accept the forward worried about taking I am worried of what might translation. of __________ when he happen to _______ when he is Accept the mes old. old already. forward translation. already too tired to find I am already too tired already Accept the eation. to enjoy myself. forward translation. 20

PJAHS • Volume 3 Issue 1 2019 • 11 I feel sad when I think Nalulungkot ako sa tuwing I beco of _____. naiisip ko si __________. think 12 I often worry about Madalas akong nag-aalala I ofte what will happen to kung ano na ang mangyayari happe _____ when I can no kay _______ kapag hindi ko na can n longer take care of siya kayang alagaan. him/her. It is a 13 Caring for _____ puts a Nagpapahirap sa akin ang strain on me. pag-aalaga kay _________. care o 14 The constant demands Ang pagyabong at pag-unlad My se for care for _____ limit ng aking sarili ay fulfill my growth and nalilimitahan dahil sa patuloy the co development. na pangangailangan para of ____ alagaan si ________. 15 I rarely feel blue Bihira akong makadama ng I seld lungkot. 16 I am worried much of Madalas akong nag-aalala. I ofte the time 17 Other members of the Ang ibang miyembro ng The o family have to do pamilya ay ginagawa pa rin contin things despite limited ang kanilang normal na despi resources because of gawain sa kabila ng ______. kakulangan sa pangangailangan. 18 Our family agrees on Ang aming pamilya ay Our fa important matters. nagkakasundo sa impo mahahalagang bagay. 19 The constant demands Nalilimitahan ang pagyabong The g for care for _____ limit at pag-unlad (hb. Pisikal, physi growth and emosyonal, pakikitungo sa with o development (ex: ibang tao at espirituwal) ng spirit physically, emotionally, ibang miyembro sa aming memb socially and spiritually) pamilya dahil sa patuloy na of the of someone else in the pangangailangan para alagaan care o family. si ________. 20 _____ is able to fit into Si __________ ay may ______ the family social group. kakayahang makisalamuha sa mingl aming pamilya. 2

(doi:10.36413/pjahs.0301.009) ome sad whenever I I feel sad whenever I think of Accept the k of __________. __________. forward translation. en worry about what may I am often worried of what Accept the forward en to __________ when I might happen to _______ if I do translation. no longer take care of him. not take care of him/her. a burden for me to take Taking care of _________ has Accept the of __________. brought hardships to me. forward elf-growth and self- My personal development and translation. lment are diminished by growth is hindered because of Accept the onstant need to take care the need to continuously care forward _______. for ________. translation. dom become sad. I rarely feel any sadness. Accept the forward en worry. I am worried most of the time. translation. Accept the other family members The other members of the forward nue to live a normal life family can still do their work translation. ite the lack of resources. normally despite the lack of necessities. Remove “normal”; … kanilang mga gawain…” amily agrees with Our family agrees on Accept the ortant matters. important matters or forward decisions. translation. growth (whether The personal growth and Accept the ical, emotional, dealing development (eg. Physical, forward other people, and emotional, social, and translation. tual) of the other family bers is hindered because spiritual) of the other Accept the e constant need to take members of the family is forward of __________. hindered because of the need translation. to continuously care for _____ is capable of ________. ling with our family. __________ has the ability to communicate and socialize 21 with the family.

PJAHS • Volume 3 Issue 1 2019 • 21 In the future, our Sa hinaharap, magiging In the family’s social life will mahirap ang pakikisalamuha find it suffer because of ng aming pamilya sa ibang tao other increased dahil sa dumarami naming increa responsibilities and responsibilidad at and fi financial stress. problemang pinansyal. 22 Taking _____ on a Nasisira ang kasiyahang dulot We en holiday spoils the ng bakasyon ng pamilya kapag when pleasure for the whole isinasama si ________. along family. 23 The family does as Mas maraming ginagawang My fa many things together aktibidad ngayon ang aking now c now as we ever did. pamilya kumpara noong dati. 24 Members of our family Nagagawa rin ng mga Our fa get to do the same kind miyembro ng aming pamilya do wh of activities as other ang mga gawain na ginagawa doing families do. ng ibang pamilya. 25 _____ will always be a Palaging magiging problema si ______ problem to us. ___________ sa amin. probl 26 There is a lot of anger Maraming hinanakit at galit na Our h and resentment in our dinadala ang aming resen family. sambahayan. 27 _____ doesn’t do as Hindi nagagawa ni ____ ang ______ much as he/she should dapat na nagagawa niya. he is s be able to do. 28 There are many places Kapag nariyan si ______, We fe where we can enjoy maraming lugar upang when ourselves as a family maramdaman namin ang saya when _____ comes bilang isang pamilya. along. 29 __________ is over- Labis ang pagprotekta namin We ov protected. kay __________. 30 _____ has too much time Napakaraming oras ni _______. ______ on his/her hands. spend 31 Time drags for _____, Mabagal ang oras para kay Time especially free time. _____, lalo na ang libreng oras. espec 2

(doi:10.36413/pjahs.0301.009) e future, our family may In the future, it will be difficult Accept the t hard to mingle with for our family to interact with forward r people because of our other people because of the translation. asing responsibilities increasing number of inancial problems. responsibilities and financial Accept the problems. forward njoy less our vacations The enjoyment of having a translation. never we bring __________ vacation is ruined whenever g. the family decides to let Accept the ________ go with them. forward amily does a lot of things The family is busy with more translation. compared before. activities today than in the Accept the past. forward amily members can also The members of our family translation. hat other families are are still able to perform the g. activities that other families Accept the do. forward _____ will always be a ___________ will always be a translation. lem to us. problem to our family. Accept the forward household carries a lot of There are many ill feelings translation. ntment and anger. and grudges brought in our Accept the household. forward _____ is unable to do what ___________is not able to the translation. supposed to be doing. things he/she should be Revise to …”lugar doing. kung saan maari eel happy in many ways Whenever ______ is around, we kaming never __________ is around. can feel happy in different maglibang places as a family. bilang…” verprotect __________. Accept the We are very protective of forward ____ has a lot of time to __________. translation. d. Accept the ____________has so much time. forward seems slow for _________, translation. cially free time. Time is lengthy for __________, Accept the especially during periods with forward nothing to do. translation. 22

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.009) Phase II: Translation and Equivalence Known Groups Validity. The stress levels of Filipino parents and other caregivers with Forward and Backward Translation. The QRS- typically developing children and stress levels of F has been translated into Filipino language and Filipino parents and other caregivers with back to the English language. children with disability were compared. Literature supports that these two groups are Pre-final version of QRS-F. Unanimous different in terms of stress levels.26, 27, 28, 29 consensus was sought among the researchers, experts, and translators regarding the Analysis of the scores from the adapted QRS-F equivalence of the instructions and each item of revealed that there is a significant difference the Filipino QRS-F to the English version of the between the total scores of stress levels of QRS-F in four areas: semantic, idiomatic, Filipino parents and caregivers of typically experiential and conceptual equivalence in order developing children and Filipino parents and to develop the Pre-Final QRS-F. The instructions caregivers of children with disability (p<0.001). and all of the items of the Filipino QRS-F had met the equivalence in its English version in four General Comments on and Meaning of areas except for two items. The researchers Filipino QRS-F. The parents and other reached a consensus and made changes to one caregivers understood almost all of the questions item (item 26) based on a discussion with the of the translated and culturally adapted QRS-F expert panel. No changes were made to item 30 and had no difficulty comprehending the (Napakaraming oras ni _______.). Details regarding instructions during pilot testing except for item the forward and backward translations of the 30. The statement, “Napakaraming oras ni questionnaire can be seen in Table 2. _______” was not fully understood by a small number of parents (n= 4) due to its incomplete Phase III: Pilot Testing nature. The researchers met to consolidate comments during pilot testing and decided to Participant Characteristics. A total of 90 retain item 30 since the majority of parents participants participated in this study. Sixty understood this item. Difficulty to understand Filipino parents and other caregivers of children this particular item may be easily solved by with disability who are enrolled at special providing an example and filling in the blank. education schools and 30 Filipino parents and other caregivers of typically developing children The participants of the pilot study were able to were asked to accomplish the Pre-Final QRS-F. state the meaning of each item and their Most of the respondents of the questionnaire are responses according to how they understood mothers of the children and are high school them by rephrasing the items or explaining how graduates. Table 3 presents the participant the items relate to them personally. characteristics. No further modifications were made on the pre- Reliability of the 31-item Pre-Final QRS-F. The final QRS-F and the tool may now be used as a to 31-item culturally adapted QRS-F appears to measure the stress level of Filipino-speaking have good internal consistency, with a parents and other caregivers of children with Cronbach’s alpha of 0.82. The interpretation of disability. The final version, as well as all the values for internal consistency are as follows:> relevant files that documented the process, were 0.90 – Excellent, _ > 0.80 – Good, _ > 0.70 – sent to the author of the original tool. Acceptable, _> 0.60 – Questionable, _ > 0.50 – Poor, and _ < 0.50 – Unacceptable.25 23

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.009) Table 3. Participant Characteristics n=90 Total Respondents Age (median) 40.5 years old Relationship to the child 68 (75.6%) Parents 9 (10.0%) Grandparents Aunt/Uncle 10 (11.1%) Household Helper 3 (3.3%) Gender 24 (26.7%) Male 66 (73.3%) Female 5 (5.6%) Educational Attainment 47 (52.2%) Elementary Graduate 36 (40.0%) High school Graduate 1 (1.1%) College Graduate Vocational Course 8 years old Children 53 (58.9%) Age (median) (41.1%) Gender 37 (15.6%) Male Typically Developing n=30 (17.8%) Female With disability n=60 School School Public 30 (33.3%) Public 14 Private Diagnosis 30 (33.3%) Private 16 Autism Spectrum Disorder Global Developmental Delay 25 (27.8%) Cerebral Palsy 11 (12.2%) Attention Deficit Hyperactivity Disorder Down Syndrome 2 (2.2%) Intellectual Disability Angelman Syndrome 7 (7.8%) Hearing Impairment 8 (8.9%) Learning Disorder 3 (3.3%) Unknown 1 (1.1%) 1 (1.1%) 1 (1.1%) 1 (1.1%) Discussion Having an available tool in the Filipino language will also ensure that more parents of children A translated and culturally-adapted QRS-F for with disability could be reached and evaluated. use with Filipino speaking parents in the This may prompt greater participation and Philippines was developed by the researchers. A commitment on the part of the parents and the culturally valid tool is needed as it will be more caregivers in the occupational therapy process. applicable to the intended population and thus will be able to correctly capture what the tool is According to the 2010 Census of Persons with intended to measure. Using an assessment tool Disability (PWD) in the Philippines, Region IV-A developed in another country and of an had the highest number of PWD at 193,000, unfamiliar language will provide invalid and followed by the National Capital Region with inaccurate results due to language barrier and 167,000.32 Filipino, primarily derived from culturally irrelevant items. 31 This may Tagalog, is the main language used in these two consequently affect the provision of correct, regions. In addition, it is said that 1 of 3 persons client-centered, and context-specific intervention in the poorest wealth are disabled in the measures to attain the set outcomes in the Philippines.22 Low socioeconomic status and low occupational therapy service delivery. educational level usually go hand in hand and these parents, who may be experiencing the 24

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.009) highest level of stress, may have poor home. However, all of these may not essentially comprehension of the English language; thus, target the pressing concerns and limitations if an justifying the relevance and need for such authentic and comprehensive assessment cultural adaptation. process, through the use of appropriate tools, will not be advocated and performed. Stress poses heightened challenges in child rearing most especially since greater attention Conclusion and effort are needed in caring for children with disability. Thus, the role of occupational In conclusion, a cross-culturally valid QRS-F was therapists to advocate programs providing developed through translation and adaptation of support to these parents is emphasized.33 the tool into Filipino language and culture. The Occupational therapists work with the parents in said tool has a good internal consistency, is valid an attempt to help them manage and reduce the at face, content, and construct level (known stress they experience. Occupational therapists groups validity) and can now be used to measure may provide different interventions to the the stress levels of Filipino parents and other parents such as stress management and caregivers of children with disability. relaxation techniques to help them to cope with and manage their stress through various Knowing the stress level of parents and other means.34 Parents may also seek counseling caregivers who have children with disabilities groups, family training, support groups which can help occupational therapists provide provide safe venues for social networking, interventions to decrease their stress levels, ease sharing experiences, and generating common their concerns, improve their quality of life and solutions for resolving stress.21 prepare their child to be more independent which may help decrease the stress levels of In the Philippines, there are a number of Filipino parents and other caregivers of children organizations that provide different with disability. opportunities that cater to the needs of the parents and to the children with disability. One Limitation of which is Autism Society Philippines, a parent and child support group which aims to empower This research is without any limitations. It has to children with ASD to being dependent, be noted that the 31-item QRS-F was originally productive, and socially accepted in the intended for use with parents of children with community.35 Another organization, the autism spectrum disorder aged 2-5 years old. In Philippine Association for Citizens with this study, the questionnaire was tested on Developmental and Learning Disabilities Inc., parents of children with median age of 8 years organizes seminars, events and workshops to with various disabilities. Despite the difference, provide support and knowledge for parents and the results of this study show the items of the families of children with disability.36 questionnaire are relevant to parents of children with disability. Occupational therapists could also aid in decreasing parental stress, albeit indirectly, by Individual author’s contributions providing interventions to the child aimed at promoting independence and preparing the child All authors met all four criteria of authorship for future occupational participation. This will based on the recommendation of the help lessen parents’ worrying about their child’s International Committee of Medical Journal future. Provision of meaningful occupations, Editors (ICJME). P.E. conceptualized the restructuring the environment, and utilization of research, analyzed data and co-wrote the paper. an appropriate use the self are important I.G. analyzed and co-wrote the paper. KM co- considerations in planning and carrying out wrote the paper. R.G., M.A., C.B., C.I., and S.K. interventions for a child with disability. Home collected data and co-wrote the paper. instruction programs are also provided by occupational therapists to ensure that the interventions provided are followed through at 25

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.009) Disclosure Statement 8. Goldman SE, Bichell TJ, Surdyka K, Malow BA. Sleep in children and adolescents with Angelman syndrome: No funding was received for this work. association with parent sleep and stress. Journal of Intellectual Disability Research. 2012 Jun;56(6):600-8. Conflict of Interest 9. Yoong A, Koritsas S. The impact of caring for adults We wish to confirm that there are no known with intellectual disability on the quality of life of conflicts of interest associated with this parents. Journal of Intellectual Disability Research. publication and there has been no significant 2012 Jun;56(6):609-19. financial support for this work that could have influenced its outcome. Two of the authors of 10. Engström M, Skytt B, Nilsson A. Working life and stress this paper are part of the editorial board of symptoms among caregivers in elderly care with PJAHS. formal and no formal competence. Journal of nursing management. 2011 Sep;19(6):732-41. Supplementary File 11. American Occupational Therapy Association. S1_ QRS-F_FilVer. Copy of the Maikling Occupational therapy practice framework: Domain and Talatanungan sa Resources at Stress ni Friedrich process. Am J Occup Ther. 2002;56:609-39. (QRS-F Filipino Version). 12. Ender D, Kubra K, Asli A, Kezban O. The Examination of References the Needs and Stress Levels of the Parents of Handicapped Children in Terms of Some Variables. 1. Dunning MJ, Giallo R. Fatigue, parenting stress, self- Online Submission. 2011. efficacy and satisfaction in mothers of infants and young children. Journal of Reproductive and Infant 13. Antony PJ. How do social, cultural and educational Psychology. 2012 Apr 1;30(2):145-59. attitudes towards disability affect families of children with disabilities and there by affect the opportunities 2. Little L. Differences in stress and coping for mothers and daily experiences of people with disabilities in and fathers of children with Asperger's syndrome and Kerala-India?. Washington State University; 2009. nonverbal learning disorders.(Continuing Education Series). Pediatric nursing. 2002 Nov 1;28(6):565-71. 14. Baker BL, McIntyre LL, Blacher J, Crnic K, Edelbrock C, Low C. Pre‐school children with and without 3. McCarthy A, Cuskelly M, van Kraayenoord CE, Cohen J. developmental delay: behaviour problems and Predictors of stress in mothers and fathers of children parenting stress over time. Journal of Intellectual with fragile X syndrome. Research in developmental Disability Research. 2003 May;47(4‐5):217-30. disabilities. 2006 Nov 1;27(6):688-704. 15. Friedrich WN. A Validational Study of the 4. Hall HR, Neely-Barnes SL, Graff JC, Krcek TE, Roberts Questionnaire on Resources and Stress. Children's RJ, Hankins JS. Parental stress in families of children Health Care. 1983 Mar 1;11(4):166-8. with a genetic disorder/disability and the resiliency model of family stress, adjustment, and adaptation. 16. McKee MG, Gillinov AM, Duffy MB, Gevirtz RN, Issues in comprehensive pediatric nursing. 2012 Mar Russoniello CV. Stress in medicine: strategies for 1;35(1):24-44. caregivers, patients, clinicians. Cleve Clin J Med. 2011 Aug 1;78:S54-64. 5. Jones J, Passey J. Family adaptation, coping and resources: Parents of children with developmental 17. Honey E, Hastings RP, Mcconachie H. Use of the disabilities and behaviour problems. Journal on Questionnaire on Resources and Stress (QRS-F) with developmental disabilities. 2005;11(1):31-46. parents of young children with autism. Autism. 2005 Aug;9(3):246-55. 6. Gomez IN, Gomez MG. Quality of life of parents of filipino children with special needs. Education 18. Friedrich, Greenberg and Crnic. A Manual of Quarterly. 2013 Jul;71(2):42-58. Questionnaire on Resources and Stress. The Child Psychology Portfolio. 7. Baker-Ericzén MJ, Brookman-Frazee L, Stahmer A. Stress levels and adaptability in parents of toddlers 19. Antony PJ. How do social, cultural and educational with and without autism spectrum disorders. Research attitudes towards disability affect families of children and practice for persons with severe disabilities. 2005 with disabilities and there by affect the opportunities Dec;30(4):194-204. and daily experiences of people with disabilities in Kerala-India?. Washington State University; 2009. 20. Tehee E, Honan R, Hevey D. Factors contributing to stress in parents of individuals with autistic spectrum disorders. Journal of Applied Research in Intellectual Disabilities. 2009 Jan;22(1):34-42. 21. 21 Wang P, Michaels CA, Day MS. Stresses and coping strategies of Chinese families with children with autism and other developmental disabilities. Journal of autism 26

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.009) and developmental disorders. 2011 Jun 1;41(6):783- Pennsylvania: Wolters Kluwer Health/Lippincott 95. Williams & Wilkins; 2009: 546 – 560 22. Hosseinpoor AR, Stewart Williams JA, Gautam J, 35. Autism Society Philippines. About ASP 2014; [cited Posarac A, Officer A, Verdes E, Kostanjsek N, Chatterji S. 2015 Mar 23]. Available from: Socioeconomic inequality in disability among adults: a http://www.autismsocietyphilippines.org/p/about- multicountry study using the World Health Survey. asp.html. American journal of public health. 2013 Jul;103(7):1278-86. 36. Philippine Association for Citizens with Developmental & Learning Disabilities, 2011; [cited 2015 Mar 23]. 23. Polit DF, Beck CT, Owen SV. Is the CVI an acceptable Available from: http://www.pacdld.org/. indicator of content validity? Appraisal and recommendations. Research in nursing & health. 2007 Aug;30(4):459-67. 24. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine. 2000 Dec 15;25(24):3186-91. 25. George D, Mallery P. SPSS for Windows step by step: A simple guide and reference. 11.0 update. wps. ablongman. com/wps/media/objects/385. George 4answers pdf. 2003. 26. Zablotsky B, Bradshaw CP, Stuart EA. The association between mental health, stress, and coping supports in mothers of children with autism spectrum disorders. Journal of autism and developmental disorders. 2013 Jun 1;43(6):1380-93. 27. Lopez V, Clifford T, Minnes P, Ouellette-Kuntz H. Parental stress and coping in families of children with and without developmental delays. Journal on Developmental Disabilities. 2008 May 1;14(2):99. 28. Islam MZ, Farjana S, Shahnaz R. Stress among parents of children with mental retardation. Bangladesh Journal of Medical Science. 2013 Jan 17;12(1):74-80. 29. Montes G, Halterman JS. Psychological functioning and coping among mothers of children with autism: A population-based study. Pediatrics. 2007 May 1;119(5):e1040-6. 30. Vijesh PV, Sukumaran PS. Stress among mothers of children with cerebral palsy attending special schools. Asia Pacific Disability Rehabilitation Journal. 2007;18(1):76-92. 31. Mushquash CJ, Bova DL. Cross-cultural assessment and measurement issues. Journal on Developmental Disabilities. 2007;13(1):53-65. 32. Philippine Statistics Authority. Persons with disability in the Philippines (Results from 2010 Census); [cited 2019 Mar 06]. Available from: https://psa.gov.ph/content/persons-disability- philippines-results-2010-census 33. Cousino MK, Hazen RA. Parenting stress among caregivers of children with chronic illness: a systematic review. Journal of pediatric psychology. 2013 Sep 1;38(8):809-28. 34. Early Mary B. Stress Management and Relaxation Techniques. Mental Health Concepts and Techniques for the Occupational Therapy Assistant. 4th ed. 27

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.006) Original Article The Filipino dietary habits and nutrition knowledge questionnaire (DHNKQ-FIL): a psychometric study Karen Leslie Pinedaa, Alessandro Cardenasa, Ronell Angelo Estebana, Stephanie Claire Pagarigana, Rayesha Azzedine Ma. Quilalaa, Johnmer Paul Sea, Niccol Servañeza a Department of Sports Science, College of Rehabilitation Sciences, University of Santo Tomas, Manila, Philippines Correspondence should be addressed to: Karen Leslie Pineda; [email protected] Article Received: 18 February 2019 Article Accepted: 19 June 2019 Article Published: 18 July 2019 (Online) Copyright © 2019 Pineda et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background: The Dietary Habits and Nutrition Knowledge Questionnaire (DHNKQ) is a validated assessment tool that provides information about the nutritional practices of collegiate athletes as an integral support to sports performance. This psychometric study aims to translate and validate the DHNKQ for the Filipino collegiate population to come up with the DHNKQ-FIL using various psychometric protocols consolidated into two phases. Methods: The first phase involved the translation of the tool into Filipino and testing for face and content validity through a focus group discussion by an expert committee and was finalized with the administration of a pre-test to 30 collegiate athletes for final modification purposes. The second phase tested the validated DHNKQ-FIL on a new set of 30 collegiate athletes for internal consistency and reliability testing, statistically analyzed using Cronbach’s α and intraclass correlation coefficient, respectively. Results: The DHNKQ-FIL used modern Filipino terminologies, more appropriate for the modern Filipino collegiate athlete. Item Content Validity Index (I-CVI) had scores of 90% and above in semantic, idiomatic, experiential, and conceptual equivalence for both sections. Food guides and choices, along with the usage of medical jargon, were identified areas for modification in the validity testing. Pre-test subjects considered the questionnaire appropriate and applicable for Filipino athletes after cognitive interview. The pilot test showed scale reliability scores of 0.68 or “Questionable” for dietary habits section and 0.81 or “Good” for nutritional knowledge. Test-retest reliability had a score of 0.79 or “Acceptable” for dietary habits and 0.60 or “Questionable” for nutrition knowledge. Conclusion: The acceptable scores for the translation, validation, and reliability of the DHNKQ-FIL makes it a valid tool for assessing dietary habit and nutritional knowledge among Filipino collegiate athletes. Keywords: nutrition knowledge, dietary habits, translation, validation INTRODUCTION daily servings of food from USDA Food Guide Having adequate nutrition can improve athletic Pyramid3. Studies point out that good nutritional performance. It is known among athletes that knowledge was found to be significantly optimum nutrient and caloric intake with associated with good nutritional practice2,4,5. adequate nutrition knowledge is a crucial part of Knowledge should be well assessed in order to a training diet1. Still, many athletes continue relate the possible nutrition-related behavior of showing unhealthy nutrition practices and do athletes4. Questionnaires have been widely used not translate their nutrition knowledge to their to assess dietary habits and nutritional food choices2. Hornstrom et al.3 reported that knowledge. A validated sports nutrition the lower the nutrition knowledge of female knowledge questionnaire is needed to accurately softball players from different universities in the gather information about their knowledge and United States, the poorer their eating habits3,4. practices4. Zinn et al stated that the lack of College athletes with higher nutrition knowledge validity and reliability measures would result to were more likely to fulfill the recommended 28

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.006) inconsistencies in results4. Lack of validity and Therefore, this study aimed to translate, reliability measures may result to culturally adapt and investigate psychometric inconsistencies on the association between properties of the Dietary Habits and Nutrition dietary behavior and nutrition knowledge in Knowledge Questionnaire (DHNKQ) for Filipino athletes7. However, it is also important that a athletes. validated questionnaire is culturally adapted as examples, standards and situations in the METHODOLOGY original questionnaire may not be applicable to the local setting. Items related to food and Research Design dietary recommendations can be culturally adapted from the standard set by the Food and This two-phased psychometric study included a Nutrition Research Institute of the Philippines to systematic approach to the cultural adaptation of be acceptable in the present setting. the Filipino version of the DHNKQ by means of translation, validation, and reliability testing In the adaptation of a nutrition instrument from based on various translation guidelines (see one language and culture to another, it is Table 1)10,11,12,13,14. The DHNKQ, adapted from the essential to take into consideration the original study conducted by Paugh 201215, was applicability of the original instrument to the translated and back-translated by bilingual target population and their proficiency with the experts on the Tagalog and English languages to target language. While this may not be the case create the DHNKQ-FIL. for all adaptation of instruments, it is applicable to this study in particular, as the Philippines is Participants – Inclusion and Exclusion foremost considered a bilingual nation due to its history in using the US education system and The study obtained ethics approval from the UST English as its medium of instruction8. The College of Rehabilitation Sciences Ethical Review Bilingual Education Policy advocates the use of Committee. A total of 60 college student-athletes Filipino in the primary level and English during from the University of Santo Tomas and 11 the secondary and tertiary levels. This policy, experts which included a forward translator, two however, only benefits the regions such as the backward translators, three registered National Capital Region and major private and nutritionists, one sports scientist, one public schools but may be troublesome for those anthropologist, two sport coaches, and a whose primary language does not involve professional athlete participated in the study10. English8. Existence of the Bilingual Education The sample population was randomized through Policy happened in which Tagalog was mandated convenience sampling to maximize gathering to be the language of literacy and the language of various perspectives from different sports. A scholarly discourse. While for English, it was total sample size of 60 student-athletes was described as the international language and non- obtained, with 30 participants involved in the exclusive language for science and technology6. translation and validation phase and the To the authors’ awareness, no psychometrically remaining in the reliability phase16. Participants validated sports nutrition questionnaires have were randomly selected through convenience been investigated for the Filipino population. sampling, from UAAP Teams such as Athletics (n=11), Swimming (n=10), Martial Arts (n=9). 29

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.006) Table 1. Reference Guidelines Used for the Process of Translation Stages Beaton et WHO Sousa et Artino Wild Swaine- al X al et al et al Verdier et X X X X al X X Stage I – Forward Translation X X X X X Stage II – Synthesis of The Translation X X X X X Stage III – Back Translation X Stage IV – Expert Committee X Stage V – Pre-testing and Cognitive Interviewing Stage VI – Psychometric Testing of Prefinal Version Stage VII – Submission of Documentation to the Developers or Coordinating Committee of the Adaptation Process Instrument knowledge and poor dietary habits. Some items have answers that involved a reverse score of 1 The original DHNKQ is a validated tool used to as the highest. These include numbers 2-4, 8-9, assess and evaluate the different nutritional 14-15, and 17 for the Dietary Habits section and practices and information that may affect athletic numbers 2, 6, 8, 20, and 29 for Nutrition performance and health15 The DHNKQ Knowledge section. The total score per section is psychometric tests results showed acceptable equivalent to the number of items with the scores of moderate internal consistency with a highest point value. Possible points for Section 2 reliability of 0.66 and 0.65 for dietary habits and range from 18 to 72 points while Section 3 range nutrition knowledge respectively. It was then from 29 to 116 points. pilot tested to 117 American college student- athletes from various sports in the NCAA The total points per section are then compared to Division II15. the possible total number of points in that section. The computed percentage is then classified into DHNKQ Sections. The questionnaire was their respective interpretations. Sections would composed of three sections that identify the be remarked excellent should the actual score be athlete’s records, dietary habits, and nutritional 85-100% of the total score, good for 70-80%, fair knowledge. The personal information section for 55-69%, and poor for 54% or less of the total included demographics, sport played, chosen score. program, years of play and sources of nutritional information. The dietary habits section consisted Procedures of 18 items that identified nutritional practices of athletes such as how often a certain food item The procedures utilized in this study were was eaten, how often an athlete consumed food adapted from various translation guidelines and from each portion of the Food Guide Pyramid, were split into two phases. Phase 1 designated as and their consumption of beverages, vitamins, the ‘Translation and Validation’ section, includes and mineral supplements. The nutritional the main translation process of the questionnaire knowledge section composed of 29 questions into its Filipino version and its subsequent which distinguishes facts and information validation. On the other hand, phase 2, known, and skills acquired by the athlete either designated as ‘Reliability Testing’, includes the theoretically or experientially. administration of the questionnaire to a chosen set of participants and subjecting the results to Scoring Key. Items were evaluated using a chosen statistical analyses. scoring key developed by the original author in the form of a Likert scale ranging from 4 to 1, Phase 1: Translation and Validation. The each with a corresponding point value. A high initial phase of the study termed as Phase 1 – score of 4 indicates excellent habits and correct Translation and Validation, involved the nutritional knowledge while 1 indicates a lack of translation and subsequent validation of the questionnaire. Many translation guidelines were 30

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.006) utilized and consolidated to form the various registered sports nutritionists, a sports stages involved in the process of translation and scientist, 2 sport coaches, an anthropologist, validation. There are 5 stages in particular for and a Filipino professional athlete, along this phase: 1) Stage I – Forward Translation10,11, with the researchers who facilitated the 2) Stage II – Synthesis of the Translation10,11, 3) discussion. Content validity was assessed in Stage III – Back Translation10,11,17, 4) Stage IV – terms of semantic, idiomatic, experiential Expert Committee10,13, 5) Stage V – Pre-testing and conceptual equivalence to the Filipino and Cognitive Interviewing10,11,12,13,14. culture10,13. Item-Content Validity Index (I- CVI) was evaluated for individual content per Phase 1 Participants – Inclusion and question. Scale-Content Validity Index (S- Exclusion. The study obtained ethics approval CVI) was evaluated for comparison of from the UST College of Rehabilitation Sciences content in relation to other items within a Ethical Review Committee. For this phase, 30 given set of questions and Average college student-athletes from the University of Congruency Percentage (ACP) for the Santo Tomas and 11 experts which included a computed average of the relevance of forward translator, two backward translators, individual questions across all experts. three registered nutritionists, one sports Scores for I-CVI that ranged from 0.78 and scientist, one anthropologist, two sport coaches above, S-CVI with 0.90 and above, and ACP and a professional athlete participated in the for 90% and above were considered study10. The sample population was selected via acceptable, otherwise, questionable. convenience sampling through a selection of Feedback regarding the appropriateness and participants that were immediately available and applicability of the instrument from the were willing to participate in the randomly experts were compiled for face validity and selected different collegiate sports associated synthesized to produce the DHNKQ-FIL for with UST to maximize gathering various pre-test and cognitive interview. perspectives from different sports. A sample size of 30 was computed, for participants that were 4. Pre-testing and Cognitive Interview. Thirty involved in the translation and validation collegiate student-athletes aged 18 – 25 phase16. Selected participants were selected from years old were assigned to answer of the UAAP Teams, composed of Athletics (n=11), Tagalog version for the pre-test. A cognitive Swimming (n=10), Martial Arts (n=9). interview followed to check for the appropriateness and applicability of the 1. Forward Translation. Translation of the Tagalog version to Filipino athletes, as DHNKQ from English to Tagalog was done by feedback from the target population of the two bilingual forward translators of the questionnaire10,11,12,13,14. This was done by Tagalog-English language - one with a health asking the selected participants to review profession background and another without. every item on the questionnaire to record The two translated versions of the their responses and understanding of that questionnaire were synthesized to produce a specific item. This was mediated by the synthesized translated version10,11. researcher facilitators (see Table 2). 2. Backward Translation. The synthesized Phase 2: Reliability Testing. Reliability testing version of the questionnaire was translated of the DHNKQ-FIL was performed on another set back to English by two bilingual backward of Filipino college student-athletes aged 18-25 translators, both of English proficiency and years old (n=30)12, separated by a washout neither aware of the concept being explored. period of 1 week14. Statistical analysis was done This validated whether the Tagalog using the SPSS Software10,14. Internal consistency translation coincided with the original10,11,17. was used to assess reliability between items as reflected by Cronbach α scores while test-retest 3. Expert Committee Review. A focus group reliability was used to measure the consistency discussion was conducted by experts for of reliability as reflected in Intraclass Correlation content and face validity18. It comprised of a Coefficient (ICC) scores. forward translator, 2 backward translators, 3 31

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.006) Figure 1. Flow of Methodology RESULTS uminom ng “mineral supplements”. The S-CVI and ACP scores of both sections also demonstrated high ratings for all equivalence scores which Phase 1: Translation and Validation indicate the validation of the questionnaire (see Item-Content Validity Index (I-CVI) scores were Table 3). acceptable except for three items from the Face validity testing identified the need for dietary habits section; thus, modifications were instructions stated, wordings and grammar, made to simplify questions. These questions medical jargons, food choices, and use of the were “Batay sa tatlong beses na pagkain sa bawat local Food Guide Pyramid to be revised in the araw, gaano kadalas kang hindi kumain nang DHNKQ-Fil. Words such as “itala” were changed hindi bababa sa minsan kada araw?” changed to to “irekord”, and “mataas sa asukal” to “Gaano kadalas kang hindi kumakain?”, from “matatamis”. Medical jargons such as “vitamin “Gaano kadalas kang uminom ng supplement na supplements”, “mineral supplements, “iron”, and bitamina?” changed to “Gaano kadalas kang “fiber” were maintained as they had no accurate uminom ng “vitamin supplements”?”, and from translation of the term in Filipino. Adding “Gaano kadalas kang uminom ng supplement sa phrases like “sa isang araw” at the end of mineral?” changed to “Gaano kadalas kang 32

PJAHS • Volume 3 Issue 1 2019 • (doi:10.36413/pjahs.0301.006) Table 2. Demographic Profile of Participants Number of Participants (Total=60) Percentage Demographic 38 63% 22 37% Age Range 18-19 25 42% 20-25 35 58% 15 25% Sex Male 7 12% Female 21 35% 12 20% 1st 5 8% 42 70% 2nd 12 20% 6 10% Year Level 3rd 11 18% 10 17% 4th 8 13% 7 12% 5th 3 5% 3 5% 1-5 3 5% 3 5% Playing Years 1-10 3 5% 3 5% 11-15 2 3% 2 3% Athletics 1 2% 1 2% Swimming Judo Football Lawn Tennis Fencing Sports Baseball Badminton Cheerleading Volleyball Softball Basketball Chess Poomsae questions about food consumption based on the grammatical representation, would be Filipino Food Pyramid Guide were also synonymous to its original English concept. emphasized (see Table 4). Phase 2: Reliability Testing In the pre-testing and cognitive interview, For Dietary Habits Section, overall results comments and suggestions of the participants indicate a ‘Questionable’ rating, according to the focused on the format of the instrument, provided grading scale (see Table 6). Cronbach’s wordings or phrases, and scientific terms which α ranged from 0.63 to 0.70 across 18 items in affected the way questions were understood (see this section. A scale reliability α score of 0.68 Table 5). The choices of words and phrases were (95% lower confidence limit = 0.53) was made to be direct and simple so that the desired computed earning an overall ‘Questionable’ meaning of each sentence in Filipino would rating. Only two questions (Questions 4 and 7) convey the same meaning as originally stated in received an ‘Acceptable’ rating, with a English. Since a Filipino term may have more Cronbach’s α of 0.70. than one English translation, cognitive interviewing assured that the term’s meaning For Nutrition Knowledge Section, results being relayed in the question, as well as its indicated a rating of ‘Good’, through a range of 0.79 to 0.82 across 29 items. Section III resulted 33

PJAHS • Volume 3 Issue 1 2019 • Table 3. Content Validity Testing Results: Expert Committee Review Question Description Semantic I-CVI SECTION 2: DIETARY HABITS Question 1 Frequency of eating breakfast 0.91 Question 2 Skipping meals 0.27 Question 3 Taking of vitamin supplements 0.91 Question 4 Taking of mineral supplements 0.91 Question 5 Frequency of eating breakfast, lunch 0.73 and dinner Question 6 Recording of food intake 0.91 Question 7 Hydration 1.00 Question 8 Drinking carbonated drinks 1.00 Question 9 Frequency of dieting 1.00 Question 10 Frequency of eating carbohydrates 1.00 Question 11 Frequency of eating fruits 1.00 Question 12 Frequency of eating vegetables 1.00 Question 13 Frequency of eating dairy products 1.00 Question 14 Frequency of eating sweets 0.91 Question 15 Frequency of eating junk foods 1.00 Question 16 Frequency of eating snacks 0.82 Question 17 Frequency of eating fast foods 1.00 Question 18 Nutrition information 1.00 S-CVI Average 0.91 Average Congruency Percentage 0.91 SECTION 3: NUTRITIONAL KNOWLEDGE Question 1 Skipping breakfast 1.00 Question 2 Protein consumption 1.00 Question 3 Mental performance 0.82 Question 4 Pre-event meal 1.00 Question 5 Alcohol consumption 0.82 Question 6 0.91 Question 7 Food Guide Pyramid 1.00 Question 8 1.00 Question 9 1.00 Question 10 Concentration 1.00 Question 11 0.91 Carbohydrate consumption Question 12 1.00 Question 13 Excess vitamin consumption 1.00 Question 14 Iron deficiency 0.82 Question 15 Fat levels 1.00 Question 16 Carbohydrate food sources 0.82 Question 17 Protein food sources 0.91 Question 18 Protein consumption 1.00 Question 19 0.82 Question 20 0.82 34

(doi:10.36413/pjahs.0301.006) Idiomatic I-CVI Experiential I-CVI Conceptual I-CVI 1.00 0.91 0.91 0.45 0.82 0.73 0.91 0.91 0.91 0.91 0.91 0.73 0.82 0.91 0.73 1.00 0.91 0.82 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 0.82 1.00 1.00 1.00 1.00 1.00 1.00 0.91 0.91 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 0.64 0.82 0.91 1.00 0.91 1.00 1.00 0.91 0.94 0.94 0.90 0.94 0.94 0.91 0.91 1.00 1.00 1.00 1.00 1.00 0.82 0.91 0.91 0.91 0.91 0.91 0.82 0.91 0.91 1.00 1.00 0.91 1.00 1.00 0.91 1.00 1.00 0.91 1.00 1.00 0.82 1.00 1.00 1.00 0.91 1.00 1.00 1.00 0.91 0.82 1.00 1.00 1.00 0.91 0.91 0.91 1.00 0.91 1.00 0.91 0.82 0.82 1.00 1.00 1.00 1.00 1.00 1.00 0.82 0.91 0.91 1.00 1.00 1.00 4

PJAHS • Volume 3 Issue 1 2019 • Question 21 Iron food sources and absorption 0.91 Question 22 0.82 0.91 Question 23 1.00 0.82 Question 24 Protein and fat function 1.00 1.00 Question 25 1.00 1.00 Question 26 Fiber sources 0.93 Question 27 93.42 Question 28 Vitamin intake Question 29 Dehydration S-CVI Average Average Congruency Percentage Table 4. Face Validity Results: Expert’s Remarks Question Description Remarks/Comments fro SECTION 2: DIETARY HABITS The phrase “in the morni The question may be hard Question 1 Frequency of eating breakfast Vitamin supplements are Question 2 Skipping meals Question 3 Taking of vitamin supplements Question 4 Taking of mineral supplements Mineral supplements are Question 5 Frequency of eating breakfast, Three base meals may no Question 6 lunch and dinner Question 7 Recording of food intake Itala may be too deep for Question 8 Hydration None Question 9 Some athletes may associ Question 10 Drinking carbonated drinks water. None Frequency of dieting It is important to indicate Frequency of eating carbohydrates Question 11 Frequency of eating fruits There is no need for exam Question 12 Frequency of eating vegetables There is no need for exam Question 13 Frequency of eating dairy products Dairy products may not b food group. 35

(doi:10.36413/pjahs.0301.006) 1.00 1.00 1.00 0.91 0.82 0.82 1.00 1.00 1.00 1.00 1.00 1.00 0.91 0.91 0.91 1.00 1.00 1.00 1.00 0.91 0.91 1.00 1.00 1.00 1.00 1.00 1.00 0.96 0.96 0.94 95.92 95.61 94.36 om the Experts ing” should be included to set time frame. d to understand. It should be simplified. e well understood by collegiate-level athletes as compared to a literal translation. e well understood by collegiate-level athletes as compared to a literal translation. ot be fully understood by most people hence the need to specify. r the targeted population to comprehend iate carbonated drinks with solely soft drinks, and some may not think of carbonated e the designated food group for the question to lessen confusion. mples as most people would understand that the question pertains to fruits. mples as most people would understand that the question pertains to vegetables. be well understood by some athletes, so it is important to specify what falls under this 5

PJAHS • Volume 3 Issue 1 2019 • Question 14 Frequency of eating sweets Matatamis may not neces Question 15 Frequency of eating junk foods cannot be considered a sw The question pertains to Question 16 Frequency of eating snacks Question pertains to the h Question 17 Frequency of eating fast foods The concept of fast food d None Question 18 Nutrition information Not all athletes may be aw SECTION 3: NUTRITIONAL KNOWLEDGE inclusion of some exampl Pinakaepisyenteng may b Question 1 Skipping breakfast The concept of mental pe importance of adding exa Question 2 Protein consumption The phrase pre-event mea Question 3 Mental performance before competition. Inilalabas sa katawan ma Question 4 Pre-event meal word tumataas is closer t dumarami which may me Question 5 Alcohol consumption The original questionnair Question 6 Food Guide Pyramid information for appropria Question 7 Concentration Question 8 None Question 9 Pagkaing mataba may be Question 10 to the experts. Question 11 Not all athletes are famili knowing the inclusion of Question 12 Carbohydrate consumption Taba may be misinterpre Question 13 experts. (Same as #11) Question 14 Excess vitamin consumption Makalalason or toxic may Question 15 Iron deficiency and not merely some hea Question 16 Fat levels It is important to indicate Question 17 Carbohydrate food sources Katamtaman may mean d None 36

(doi:10.36413/pjahs.0301.006) ssarily mean sugary foods, as there are some foods that are naturally sweet-tasting but weet. snacks taken in-between meals, or meryenda hence local examples must be cited. habit of eating healthy snacks, hence examples should be replaced by local versions. differs in various cultures. ware of the benefits of breakfast and the complications of skipping such, hence the les of these negative effects. be too deep for the targeted population to comprehend erformance in the context of sports nutrition may not be apparent for athletes, thus the amples. al may not be widely used by athletes, hence it is better to indicate it simply as a meal ay mean too literally coming out of the body rather than the process of excretion. The to the word “increases” and equates to an appropriate single consumption rather than ean a longer period of time and collective effort of alcohol consumption re uses the standard US Food Guide Pyramid, so it is necessary to find a local source of ate cultural adaptation. e misinterpreted by some athletes as solely fat coming from animal products according iar with the concept of calories, as some may associate it with only carbohydrates, not protein and fat. eted by some athletes as solely fat coming from animal products according to the y impose a message that consumption of excess vitamin consumption may cause death, alth complications. e iron as a micronutrient. different to various types of athletes, it may help to have a specified type of example. 6

PJAHS • Volume 3 Issue 1 2019 • Question 18 Protein food sources Nuts and beans may pose Question 19 Protein consumption Question 20 Gaya may imply that twic Question 21 Iron food sources and absorption Usage of the word hayop Question 22 Protein fat function Sabayan is needed in this Question 23 Fat function enriched bread, to avoid m Protein function Question 24 Fiber sources Pagsipsip sa iron may not Question 25 Vitamin intake pagtanggap instead. Question 26 Dehydration Tisyu ng kalamnan may b Question 27 Question 28 Magka-hormones may im Question 29 Immune system may be s resistensya) None The word diet may imply Natutunaw na fiber is not version per recommenda None Retain vitamin C as a borr Maaaring should be adde Table 5. Face Validity: Pre-Testing and Cognitive Interviews – Athlete’s Remarks F5 version of Question DHNKQ SECTION 1: DEMOGRAPHICS Section I (Demographics) Section II 2. Gaano kadalas ang hindi mo pagkain? (Dietary Habits) 6. Gaano kadalas mong italâ (record) ang iyong kinakain? 37

(doi:10.36413/pjahs.0301.006) e to be too general for some athletes hence the need for more specific examples. ce the consumption is the recommended, instead of going over it. may seem misleading, thus it is better to indicated it as meat instead. s translation to imply that products with vitamin C must be taken together with iron- misleading messages such as the consumption of vitamin C-enriched bread. t properly convey the concept of nutrient absorption, hence it is better to use be misinterpreted by some athletes as some may understand muscle better. mply something else instead of the production of hormones. simply translated to sistemang panlaban sa sakit. (Some also suggest the use of y a strictly weight-loss diet, as compared to a person’s usual food routine. t a widely used translation for soluble fiber hence it is better to retain the original ation by experts. rowed term because it may be more used by the target population ed as the original mentions must not. Athlete Participant's Remarks No. (A#) A4 Outline “ saan makukuha ang nutrition pangnutrisyon” because of wide spacing A5 Indicate in the directions how many choices could be answered A22 “Hindi mo pagkain” is misleading & unclear A24 Suggested “Gaano kadalas kang hindi kumakain?” A5 Change “itala” to “irekord” A14 The word “itala” is too deep A22 7

PJAHS • Volume 3 Issue 1 2019 • Section III 9. Gaano kadalas kang “nagdidiyeta”? (Nutrition Knowledge) 14. Gaano kadalas kang kumain ng mga pagkaing matataas sa asukal? 17. Gaano kadalas kang kumain ng fast food tulad ng pizza, bur o fries? 18. Gaano kadalas kang maghanap ng impormasyong pangnutrisyon? 5. Tumataas ang inilalabas na calcium ng katawan kapag umii ng inuming alkohol. 6. Ayon sa Food Guide Pyramid, dapat kumonsumo ang isang ng 6-8 o 5-8 na serving mula sa pangkat ng pagkaing tinapay, cereal, kanin at pasta 7. Ayon sa Food Guide Pyramid, dapat kumonsumo ang isang ng 3 o 2-3 na serving mga pagkaing prutas 8. Ayon sa Food Guide Pyramid, dapat kumonsumo ng 1 na serving mula sa pangkat ng pagkaing o inuming gawa sa gat 9. Ayon sa Food Guide Pyramid, dapat kumonsumo ng 2½ o 3 na serving mula sa pangkat ng pagkaing karne. 14. Ang labis na pag-inom ng bitamina ay nakakasama sa kata 15. Ang anemia ay kakulangan ng mineral na iron sa dugo. 19. Ang mga atleta ay nakakaubos nang dobleng dami ng proti na higit sa inirerekomenda. 22. Ang pagkain ng cereal o tinapay na dinagdagan ng iron ay dapat sabayan nang iba pang pagkaing mayaman sa bitamina C para sa mas epektibong pagtanggap ng iron ng katawan. 26. Ang oatmeal, monggo, at prutas ang pinagkukunan ng solu fiber. 27. Ang inirerekomendang dami ng fiber ay 25 gramo kada ara 38

(doi:10.36413/pjahs.0301.006) rger, A24 Without the English version of the word “italâ”, the client will not understand the question A20 A22 Nagdiyediyeta connotates ‘nagpapapayat', strict in caloric intake, A23 practice of a healthy diet, respectively. A23 Change “matataas sa asukal” to “matatamis” A22 Add fried chicken to examples. inom A23 The term “impormasyong pangnutrisyon” is a tao A4 broad term & too literal in translation. A24 Replace “inuming alkohol” to alak. Replace “inilalabas na calcium ng katawan” to “inilalabas na calcium sa katawan.” tao Add “sa isang araw” at the end of the sentence A1 Fish or “isda” is part of the meat group or “karne”. tas. The word ‘bitamina” is not clear 3- 4 A20 Not familiar with the word “labis”. A21 Not familiar with the term “iron”. awan. A22 “What is the recommended amount of protein”? ina A23 “What is “bitamina”?” A8 Bold important keywords such as “bitamina C” & iron. Replace “soluble” to \"natutunaw\". A24 Add explanation on “soluble fiber” A8 “What is soluble fiber?” A1 “Ang oatmeal, monggo, at prutas “ay” A19 pinagkukunan ng soluble fiber.” C “What is fiber?” A5 A1 A3 A8 uble A18 A19 A26 A23 aw. A16 8

PJAHS • Volume 3 Issue 1 2019 • Table 6. Test-Retest Reliability Results Question Description P SECTION 2: DIETARY HABITS 0 0 Question 1 Frequency of eating breakfast 0 Question 2 Skipping meals 0 0 Question 3 Taking of vitamin supplements 0 0 Question 4 Taking of mineral supplements 0 0 Question 5 Frequency of eating breakfast, lunch and dinner 0 0 Question 6 Recording of food intake 0 0 Question 7 Hydration 0 0 Question 8 Drinking carbonated drinks 0 0 Question 9 Frequency of dieting 0 0 Question 10 Frequency of eating carbohydrates 0 Question 11 Frequency of eating fruits 0 0 Question 12 Frequency of eating vegetables 0 0 Question 13 Frequency of eating dairy products 0 0 Question 14 Frequency of eating sweets 0 0 Question 15 Frequency of eating junk foods 0 Question 16 Frequency of eating snacks 0 0 Question 17 Frequency of eating fast foods 0 0 Question 18 Nutrition information 0 0 Overall Score 39 SECTION 3: NUTRITIONAL KNOWLEDGE Question 1 Skipping breakfast Question 2 Protein consumption Question 3 Mental performance Question 4 Pre-event meal Question 5 Alcohol consumption Question 6 Question 7 Food Guide Pyramid Question 8 Question 9 Question 10 Concentration Question 11 Question 12 Carbohydrate consumption Question 13 Question 14 Excess vitamin consumption Question 15 Iron deficiency Question 16 Fat levels

(doi:10.36413/pjahs.0301.006) A17 A27 Pearson's r Interpretation Intraclass Interpretation (Pearson’s r) Correlation (ICC) 0.97 (< 0.00) 0.84 (< 0.00) Excellent 0.97 Excellent 0.80 (< 0.00) Excellent 0.84 Excellent 0.86 (< 0.00) Excellent 0.80 Excellent 0.82 (< 0.00) Excellent 0.86 Excellent 0.50 (0.0045) Excellent 0.78 Excellent 0.70 (< 0.00) Fair 0.48 Fair 0.83 (< 0.00) Good 0.54 Fair 0.83 (< 0.00) Excellent 0.83 Excellent 0.66 (< 0.00) Excellent 0.85 Excellent 0.77 (< 0.00) Good 0.66 Good 0.77 (< 0.00) Excellent 0.76 Excellent 0.72 (< 0.00) Excellent 0.75 Excellent 0.70 (< 0.00) Good 0.72 Good 0.47 (0.0081) Good 0.68 Good 0.66 (< 0.00) Fair 0.46 Fair 0.42 (0.02) Good 0.64 Good 0.79 (< 0.00) Fair 0.41 Fair 0.82 (< 0.00) Excellent 0.79 Excellent Excellent 0.79 Excellent 0.43 (0.02) 0.83 (< 0.00) Fair 0.39 Poor 0.45 (0.01) Excellent 0.83 Excellent 0.75 (< 0.00) Fair 0.45 Fair 0.71 (< 0.00) Excellent 0.75 Excellent 0.39 (0.03) Good 0.70 Good 0.48 (0.007) Poor 0.33 Poor 0.51 (0.0041) Fair 0.46 Fair 0.25 (0.19) Fair 0.50 Fair 0.10 (0.60) 0.45 (0.01) Poor 0.19 Poor 0.24 (0.20) 0.41 (0.02) Poor 0.10 Poor 0.62 (0.0003) Fair 0.44 Fair 0.18 (0.34) Poor 0.17 Poor 0.56 (0.0013) Fair 0.40 Fair Good 0.62 Good 9 Poor 0.15 Poor Fair 0.53 Fair