Cross-cultural validation of the Child Adolescent Teasing Scale for Colombian students

ABSTRACT Objective: to carry out the cross-cultural validation of the instrument “Child Adolescent Teasing Scale” for the Colombian student population. Method: methodological study carried out with students aged 8 to 15, from public and private educational institutions in the municipality of Ibagué, Colombia. The form for the characterization of students and the Child Adolescent Teasing Scale were used. Results: the cross-cultural adaptation process was organized in seven steps: comparison of the Spanish version of the instrument with the original English version, back-translation, consensus version, face validity and terminology adjustment by students, face and content validity by experts, assessment committee for the final version, pilot test and reliability. Conclusion: the version adapted to the Spanish spoken in Colombia of the Child Adolescent Teasing Scale (Escala de burlas para niños y adolescentes), which assesses the frequency and distress caused by teasing, showed desirable results in terms of validity and reliability.


Introduction
Research in pediatric and adolescent nursing seeks to deepen the knowledge of phenomena related to health care by promoting studies that fill the gaps identified in the scientific literature and that aim to contribute to: new perspectives and alternatives for the resolution of problems affecting their health and welfare, as well as the welfare of their family.
One of the most prevalent phenomena in today's society, first described more than three decades ago, is the bullying among students. It is defined as the exposure of a student to the repetitive negative actions by another or more students, or difference in power, with the intent to cause damage or discomfort through words, physical contact or other forms, such as gestures, exclusion and defamation (1)(2) .
The American National Association of School Nurses defines bullying as persistent and repetitive dynamic patterns of verbal and/or nonverbal behaviors directed by one child or more children to another, who deliberately attempt to cause physical, verbal or emotional abuse in the presence of actual or perceived difference in power (3) .
It has been associated with a number of damages and consequences for the health of children and adolescents, and has become internationally recognized as a public health problem (4) .
Chromosomal changes in the telomeres (p=0.020), which are biomarkers of childhood stress and cell aging (11) .
According to this scenario, it is necessary to implement strategies through assessment methods for the early identification of students who experience teasing, because of their risk of becoming victims of bullying.
There are several instruments, such as the Questionnaire for the Ombudsman's report on school violence (12) and the "Bullying-Cali" (13) , used for older schoolchildren.
Many of the instruments originally available were published in languages other than Spanish, which requires for the study in the Colombian context that the instruments be submitted to the processes of cultural adaptation, through the development of the translation and validation stages (14) . Thus, the instrument can be used in a different culture from which it was developed.
In this way, an instrument that could be used for students from the age of eight and that assessed the causes of teasing in all risk categories was searched, and these criteria have been met by the Child Adolescent Teasing Scale (15) .   calculated. Values higher than 0.50 were considered as high (possible variation from 0 to 1) (18) .

Ethical considerations
According

Comparison of the Spanish version of CATS
The original English version was compared with the Spanish version, generating a version for students (CATS-VECO). The adjustments were made in the instructions and statements that contained the words "to bother" and "to annoy"; which were replaced by "to tease", the word most used in Colombia. The terminology was considered understandable, however, it was considered important that the instrument was submitted to face validity by Colombian students.

Face and content validity by students
The focal groups consisted of 42 students aged  Table 1).
The remaining 16 items required adjustment of the words in the statements, resulting in a different and more updated wording, or the addition of a word suggested as a synonym, or adjustments to indicate that it was related to something specific. The CATS-VEES version was proposed from this analysis ( Table 2).

Items changed by students (CATS-VEES ‡ )
3 "How intelligent and prepared I am" "How intelligent I am"; 20 "For being studious" "For being a nerd or studious" 9 "The brand of shoes that I use" "The brand of my shoes" 22 "For being a coward" "For being a coward or a chicken" 10 "With whom I live" "People that I live with"; 23 "How well I do at school" "How well I do in the studies" 12 "Behave myself strangely or differently" "Behave myself differently" 25 "My things" "My things or personal items" 14 "My way of speaking" "My way to speak" 25 "Be a fool" "They tell me that I am a fool or a loser"

15
"Get in trouble" "Get into a tight spot" 27 "Be shy or too quiet" "Be shy or quiet" 16 "Behave myself as gay" "They tell me that I am gay or lesbian" 30 "The music that I like to listen to" "The music that I like" 19 "How my family is "My family" 32 "Sports I participate in and do not participate in" "Sports that I practice or play and those that I do not practice or play" *CATS: Child Adolescent Teasing Scale. †CATS-VECI: Spanish version initial consensus. ‡CATS-VEES: Spanish version by students.

Validity by experts
The CATS-VECO and CATS-VEES versions were provided to the selected experts. Among the assessments, three items required clarity and wording adjustment: from "too much talking" to too much talk, "my jewels/chains" to my accessories and "get in trouble" to get into a tight spot. Three items were not clear to the experts, but to students, "Not being good at

Final consensus version
The necessary adjustments were made after identifying the items that were recognized by students as semantically different, but that did not alter their conceptual equivalence. In addition, the items were compared with the assessments made by experts in order to proceed the necessary adjustments of CATS, which would be used in the main study. No items were removed. The CATS-VECF version was proposed.

Pilot test
In this process, 19 students aged 11 to 13, from the sixth grade of elementary school of a private educational institution of Ibagué, with medium socioeconomic status, of which 6 were female and 13 Rev. Latino-Am. Enfermagem 2018;26e2968.
male, participated. The understandability of the items and the ease of completion by students was confirmed and the time spent for completing it ranged from 10 to 15 minutes. In this stage, the reliability of the scale was calculated using the Cronbach's alpha, with a result of 0.89 for the frequency subscale, 0.95 for the distress subscale, and 0.95 for the full scale. These values were considered as high (18) .

Discussion
Nursing is a discipline called to work on the phenomenon of teasing and bullying, as stated by the National Association of School Nurses of the United States (19) . It plays an important and decisive role in the early identification and implementation of bullying prevention strategies by screening the cases with this kind of problem and, therefore, helping to promote the health of students and their families.
Scientific literature describes several instruments used in research, but few with validity and reliability.
For this reason, the cross-cultural adaptation of a nursing measurement instrument was carried out, which measures the frequency of teasing and how much it bothers the student who receives it, and an appropriate methodological quality has been demonstrated (20)(21)(22) .
In the process of cross-cultural adaptation of CATS, a scientific and suggested methodology was used to ensure the comparability between the results of Colombian students and those of previous versions (14,22) .
The qualitative strategy with the focal groups was fundamental to achieve, among the Colombian students aged 8 to 10 years, with different socioeconomic status and type of educational institution, the understandability of CATS by older students. For this reason, the age interval for application of the instrument was enlarged, ranging from 8 to 15 years in the present study.
It is important to mention that the experts qualified three items of the face validity as unclear or with inappropriate wording; however, these items were clearly understood by students. The above refers to the value that the participation of a group of students similar to the group that will be investigated has, providing validity to the results and compliance with the requirements for an ethical research with children, avoiding biases due to the perspective of adults.
The validity by experts provided a perspective from the point of view of a researcher with scientific knowledge, and from a professional with practical care experience and ability with students, which has contributed significantly considering different points of view and lines of thought. This process has been shown to be important in achieving understandability and cultural coherence in the search for semantic and content equivalence (23)(24) .
The suggested adjustments were related to the wording of the items and to the observations that were analyzed from the students' point of view, as an interface between two visions. The importance of the participation of these groups for the validation of scales is confirmed by references in the literature (25) . which allowed to conclude that the proportion of times that the evaluators agreed was high (26)(27) .
As limitations, some authors mention the need to start from the official translation of the original version.
For this, the Spanish version of the instrument provided by the author was submitted to different validity and adaptation processes, such as back-translation, assessment by an expert nurse, validity by students and validity by experts. In addition, it was compared with the original English version.
Although the objective of this study was to carry out a qualitative assessment in terms of understandability of the items by representatives of the same population to which CATS would be applied, the Cronbach's alpha was calculated to achieve reliability, clarifying that due to the small sample size, additional studies could support the psychometric properties of CATS.
Regarding the number of subjects in the pilot sample, there are different opinions, some suggest 30 to 40 people (14) , or 5 to 10 people (22) , because the most important is to achieve understandability on: questions and answers, format of the applied instrument, or problems of the questionnaire (28) . This study was carried out with 19 students, a group that can be an important sample to check the clarity, feasibility and practicality of the instrument. However, further publications will present results on its application in a larger sample of students.
With regard to the phenomenon of school bullying, so widespread, health professionals are advised to perform an interdisciplinary work, since the ultimate goal is the health of students; and the implementation of actions to identify children at risk of bullying, who require care in relation to their health.

Conclusion
The cross-cultural adaptation of the Nursing Instrument Child Adolescent Teasing Scale (CATS) for its application in Colombian students aged 8 to 15 was carried out. This version was adapted to the Spanish spoken in Colombia, with the participation of students, by means of the focal group strategy, as well as a pilot test. The participants had high and low socioeconomic statuses, and experts in research on bullying also participated in this study.
The adapted version showed desirable results in terms of validity and reliability, which make it possible to point out CATS as a valid and reliable instrument to be applied among students with the aim of identifying the frequency and distress caused by bullying, and it is available for use in future investigations.