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INTRODUCTION
The concept of body posture is broad. It involves the relationship between body parts and the position of the body in space1 and postural control, which is associated with the restoration of balance after the loss of stability2. Proper posture occurs with musculoskeletal balance, which prevents the occurrence of injuries1. However, inadequate posture causes impairment of the blood flow and, consequently, discomfort and pain3,4,5.
Pain is considered an uncomfortable sensation related to injury and can impair the ability to perform activities of daily living (ADLs)6,7,8,9. Furthermore, pain can result in a limited range of motion and difficulty performing joint movements10,11. One of the possible causes of pain, especially that in the spine, is posture while performing various ADLs11,12,13, such as watching television and using cell phones, notebooks, and tablets12,14,15. Additionally, adolescents carry backpacks and spend several hours sitting on non-ergonomic furniture16,17,18,19.
Knowledge about the health of the spine is essential to avoid inappropriate postures and, consequently, pain. In addition, obtaining information about the knowledge about spinal health on the part of adolescents can help in understanding the necessary attitudes in order to mitigate this scenario. In this context, the school has a primary role in teaching body awareness related to movement. These teachings provide a better quality of life, and may help to prevent back pain, in addition to observing the effectiveness of interventions in behavioral change20. In students, such body awareness teaching actions can contribute to the recovery process after episodes of acute pain. It is from the implementation of educational programs for knowledge about spine health and from their experiences that students learn how body movement works, creating more responsibilities with their own health21. Usually, instruments (mostly self-reported questionnaires) are used to measure pain, its causes, and knowledge of that pain22.
Measurement instruments are fundamental to studies involving health assessments23,24. The clarity of the measurement properties and the quality of the instruments help researchers choose which instrument is best for their research objectives25. Furthermore, it is pertinent for researchers to know the items, evaluation models, and domains that comprise the instrument23,25. When choosing an instrument, the first step is to determine its validity and reproducibility to ensure the scientific value of the obtained data and minimize the risk of bias24,25. Some of these instruments are the Back-Health Related Postural Habits in Daily Activities Questionnaire3, the Back Care Behavior Assessment Questionnaire for Schoolchildren: Development and Psychometric Evaluation13, and the Back Pain and Body Posture Evaluation Instrument for Children and Adolescents14. Despite the numerous instruments for assessing different factors, few meet the validation and reproducibility criteria25. Furthermore, the lack of a consensus regarding the use of assessment tools in the health field leads to low-quality research25,26,27.
The validity (or lack of validity) of an instrument can interfere with the results obtained and may even lead to errors28. Therefore, reliable instruments are necessary for the collection of good quality data28. The creation of new assessment instruments and the validation of these instruments result in the avoidance of redundancy during the assessment process, encourage the standardization of these instruments, and allow for consistent results29. To the best of the authors’ knowledge, this is one of the pioneering reviews to identify and assess the validity and reliability of instruments used to measure knowledge, attitudes, and postural habits related to spinal health among adolescents aged 14 to 17 years.
METHODS
Protocol and registration
This scoping review was prepared in accordance with the recommendations of PRISMA30. To increase transparency and reproducibility, this review was registered in PROSPERO (nº 42022347726)31, and the protocol has been published32.
Identification and selection of studies
Research of the PubMed, Embase, CINAHL, and Cochrane Library databases was performed on September 10, 2022. Four categories, “instrument,” “knowledge,” “back,” and “adolescents,” were created based on the key concept terms. Key concepts in the same category were related through the Boolean operator “OR”. To determine the relationship between categories, the Boolean operator “AND” was used. There were no restrictions regarding the year of publication or language. The search strategy is described in detail in table 1. Search strategies adapted for each of the databases are available in the supplementary material (Supplementary Material S1).
Table 1 Database search strategies
| 1 = “surveys and questionnaires” OR “health care surveys” OR “instrument” OR “form” OR “survey” OR “questionnaire” OR “measurement” OR “tool” OR “assessment” OR “score” OR “self report” |
| AND |
| 2 = “knowledge” OR “health knowledge” OR “attitude” OR “practice” OR “posture knowledge” OR “knowledgeability” OR “knowledgeably” |
| AND |
| 3 = “back” OR “back pain” OR “posture” OR “spine” OR “back posture” OR “back health” OR “posture habits” OR “spine health” OR “spine posture” OR “spine care” |
| AND |
| 4 = “adolescent” OR “students” OR “teen” OR “teenager” OR “youth” OR “juvenile” OR “school enrollment” OR “enrollment school” OR “young” OR “minor” |
| 5 = #1 AND #2 AND #3 AND #4 |
Articles that met the following inclusion criteria were considered eligible: detailed studies that included instruments used to assess knowledge about spinal health, postural habits, and body movement awareness; studies that used instruments that were (preferably) validated or at least tested to determine their reproducibility; and studies involving adolescent students 14 to 17 years of age. The exclusion criteria were as follows: previous scoping reviews, opinion articles, case studies, and case reports; articles describing other aspects of health knowledge (not referring to the spine); and articles including participants outside the target age range or those with physical and/or mental disabilities.
After identifying the articles in the databases, they were imported using Mendeley software. Next, the identification and exclusion of duplicate articles were performed. Then, after training was provided to teach the reviewers how to screen articles, two independent reviewers (A.C.F.R. and R.M.F.S.) read the titles and abstracts to check their eligibility using Rayyan software33. Disagreements between the two reviewers were resolved by a third senior reviewer (M.N.). Thereafter, the full selected articles were read to evaluate whether they should be included. Cohen’s kappa coefficient was used to analyze inter-rater agreement34. Cohen’s kappa coefficients for the titles and abstracts and for the entire articles were both 0.61, indicating moderate agreement35. The selection process is described in Figure 1.
Training of the reviewers
The reviewers were aware of the inclusion and exclusion criteria and underwent training to learn how to extract data; they read 50 titles and abstracts to verify the eligibility of the preselected articles36. They also received training to learn how to use Mendeley and Rayyan software33.
The methodological quality assessment as well as the risk of bias analysis were performed by the two aforementioned independent reviewers. Disagreements were resolved by the aforementioned third senior reviewer. The reviewers received training to learn how to use the checklists to assess the methodological quality and evaluate the risk of bias, before the start of the analysis37.
Data extraction
Data extracted from the included articles were as follows: article title; author; year of publication and country of origin; type of study; participants; age of participants; instrument evaluated; instrument validation; method; instrument reliability and reproducibility; conflict of interest; and ethical approval. Data were extracted by the two aforementioned independent reviewers. Disagreements were resolved by the aforementioned third senior reviewer.
Methodological quality
The evaluation of the methodological quality of the included articles was performed using the critical appraisal tool checklist, which was developed by Brink and Louw38. This checklist comprises 13 items (questions) separated into three domains. Four items (4, 5, 6, and 8) mention articles that assess reliability. Another four items (3, 7, 9, and 11) refer to the analysis of articles that assess validity. Five items (1, 2, 10, 12, and 13) that assess the reliability and validity of the articles were used for this review. The response for each item was “yes”, “no,” or “not applicable”. According to the Brink and Louw checklist, high methodological quality was verified if the article had a score ≥60%38.
Risk of bias
The Downs and Black checklist were used to analyze the risk of bias39. This instrument is a verification checklist comprising 27 items applied to quantitative studies. A short version of the checklist (adapted from previous research) was used. Therefore, for cross-sectional studies, 12 items (equivalent to 12 points) were used; for longitudinal studies, 16 items (16 points) were used. Items 1, 2, 3, 5, 6, 7, 9, 10, 11, 12, 17, 18, 20, 21, 25, and 26 were applied40.
The risk of bias was calculated for each article as a percentage of the total score. Studies with scores more than 70% were considered to have a low risk of bias39.
Evidence synthesis and statistical analysis
An overview of the questionnaires that assess spinal health knowledge and ADLs of adolescents 14 to 17 years of age was provided. The overview indicated which and how many articles met the inclusion criteria. The questionnaires as well as their methodological quality and risk of bias were explained. When selecting articles for inclusion in this scoping review, the kappa coefficient was used to analyze the agreement between the reviewers35. It was not possible to perform a meta-analysis because of the heterogeneity of the included studies.
RESULTS
Article selection
A search of the PubMed, Embase, CINAHL, and Cochrane Library databases yielded 6773 articles; however, 1220 duplicates were removed, resulting in a total of 5553 articles. After reading the titles and abstracts, 5506 articles were excluded, resulting in 47 full articles. After reading these full articles, seven were included in this review (figure 1). These seven studies were published between 2001 and 2019 and performed in the following countries: Norway (n=2)41,42; India (n=1)43; Spain (n=1)44; Brazil (n=1)45; Australia (n=1)46; and Nigeria (n=1)47 (figure 2).
Fonte: https://br.freepik.com/vetores-gratis/
Figure 2 Countries of origin of the questionnaires that assessed spinal health knowledge of adolescents 14 to 17 years of age
The samples described by the studies varied between 15541 and 1087 participants of both sexes; in two articles, most participants were male (56.8% and 57.5%)41,43. The target age group of the study was 14 to 17 years; however, three articles described participants 10 to 17 years of age45, 13 to 17 years of age47, and 14 to 19 years of age43. Such studies portrayed the age groups separately; therefore, they were allowed in this review. There were five cross-sectional studies (71.4%)41,42,43,45,47, one instrument validation study (14.3%)44, and one longitudinal study (14.3%)46.
The seven studies used questionnaires to collect data. Most studies (71.4%; n=5) used the Standardized Nordic Questionnaire41,42,45,46,47. One study used an adapted version of the Standardized Nordic Questionnaire41. The other studies (28.6%; n=2) developed their own questionnaires43,44 (table 2).
Table 2 Characteristics of the studies
| Title | Author, year, country | Instrument used | Instrument description | Instrument validated | Reliability and reproducibility |
|---|---|---|---|---|---|
| Significance of High Lumbar Mobility and Low Lumbar Strength for Current and Future Low Back Pain in Adolescents | Sjölie 2001 Norway | Standardized Nordic Questionnaire, adapted version | Norwegian origin; 17 items that assess musculoskeletal disorders related to ergonomic issues; adapted for analyzing the lower back | Yes | Yes |
| Psychosocial Correlates of Low-Back Pain in Adolescents | Sjölie 2002 Norway | Standardized Nordic Questionnaire | Norwegian origin; presents 17 items that assess musculoskeletal disorders related to ergonomic issues | Yes | Yes |
| An Insight into Adolescents’ Knowledge and Attitudes on Low Back Pain and Its Occurrence | Lobo 2013 India | Created its own instrument with 25 questions | Indian origin; assesses knowledge, attitudes, and the occurrence of low back pain of adolescents | Yes | Yes |
| Development and Psychometric Evaluation of a Health Questionnaire on Back Care Knowledge in Daily Life Physical Activities for Adolescent Students | Monfort-Panego 2016 Spain | Health Questionnaire on Back Care Knowledge Concerning Physical Activities in Daily Life Activities (HEBACAKNOW) | Spanish origin; 24 structured questions referring to the anatomical knowledge of the spine, postural habits, and methods of transporting objects | Yes | Yes |
| Factors Associated with Back Pain in Adolescents from Public Schools in One City from South Brazil | Soares 2017 Brazil | Standardized Nordic Questionnaire | Norwegian origin; presents 17 items that assess musculoskeletal disorders related to ergonomic issues | Yes | Yes |
| Low Back Pain with Impact at 17 Years of Age Is Predicted by Early Adolescent Risk Factors from Multiple Domains: Analysis of the Western Australian Pregnancy Cohort (Raine) Study | Smith 2017 Australia | Standardized Nordic Questionnaire | Norwegian origin; presents 17 items that assess musculoskeletal disorders related to ergonomic issues | Yes | Yes |
| Musculoskeletal Problems and Backpack Carriage Among Students in Nigeria | Abaraogu 2019 Nigeria | Standardized Nordic Questionnaire | Norwegian origin; presents 17 items that assess musculoskeletal disorders related to ergonomic issues | Yes | No |
Assessment of methodological quality and risk of bias
Of the seven studies analyzed, five (71.4%) had high methodological quality (score, ≥60%). Two studies had low methodological quality (score, 40%) (table 3). The conflict of interest declaration was not explicit in four articles, and three articles reported no conflict of interest. Six articles reported that ethical approval was obtained before the studies were performed, and one article did not report this information (table 4).
Table 3 Methodological quality of studies that used questionnaires to determine the spinal health knowledge of adolescents 14 to 17 years of age
| Studies | A | B | C | D | E | Total score (points) | Score (%) |
|---|---|---|---|---|---|---|---|
| Sjölie et al.41 | Yes | Yes | Yes | Yes | Yes | 5/5 | 100% |
| Sjölie et al.42 | Yes | No | No | No | Yes | 2/5 | 40% |
| Lobo et al.43 | No | Yes | Yes | Yes | Yes | 4/5 | 80% |
| Monfort-Panego et al.44 | Yes | Yes | Yes | No | Yes | 4/5 | 80% |
| Soares et al.45 | Yes | Yes | Yes | No | Yes | 4/5 | 80% |
| Smith et al.46 | Yes | No | Yes | No | Yes | 3/5 | 60% |
| Abaraogu et al.47 | Yes | No | No | No | Yes | 2/5 | 40% |
*High methodological quality (≥60%). A, sample description; B, characterization of the evaluators; C, description of the experimental test collection procedures; D, description of sample loss; E, adequacy of the statistical method.
Table 4 Conflict of interest, ethical approval, and risk of bias of studies that used questionnaires to determine the spinal health knowledge of adolescents 14 to 17 years of age
| Studies | Conflict of interest | Ethical approval | Downs and Black checklist | Total score (points) | Score (%) | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| A | B | C | D | E | F | G | H | I | J | L | M | N | O | P | Q | |||||
| Sjölie et al.41 | Not specified | Yes | 1 | 1 | 1 | 0 | 1 | - | 1 | 1 | 1 | 1 | - | 0 | 0 | 1 | - | - | 9/12 | 75% |
| Sjölie et al.42 | Not specified | Yes | 1 | 1 | 1 | 0 | 1 | - | 0 | 1 | 1 | 1 | - | 0 | 1 | 1 | - | - | 9/12 | 75% |
| Lobo et al.43 | No | Yes | 1 | 1 | 1 | 1 | 1 | - | 1 | 1 | 1 | 1 | - | 1 | 1 | 1 | - | - | 12/12 | 100% |
| Monfort-Panego et al.44 | No | Yes | 1 | 1 | 1 | 1 | 1 | - | 0 | 1 | 1 | 1 | - | 1 | 1 | 1 | - | - | 11/12 | 91.60% |
| Soares et al.45 | Not specified | Yes | 1 | 1 | 1 | 1 | 1 | - | 0 | 1 | 1 | 1 | - | 1 | 1 | 1 | - | - | 11/12 | 91.6% |
| Smith et al.46 | Not specified | Yes | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 14/16 | 87.5% |
| Abaraogu et al.47 | No | No | 1 | 1 | 1 | 0 | 1 | - | 0 | 1 | 1 | 1 | - | 0 | 1 | 1 | - | - | 9/12 | 75% |
A, clearly stated purpose; B, clearly described main outcomes; C, clearly defined sample characteristics; E, clearly defined main findings; F, random variability of the estimates was provided; G, loss to follow-up was described; H, probability values were reported; I, target sample was representative of the population; J, recruitment sample was representative of the population; L, study was based on data dredging (if applicable); N, statistical tests were properly performed; O, primary outcomes were valid/reliable. These factors correspond to items 1, 2, 3, 6, 7, 9, 10, 11, 12, 16, 18, and 20.
The risk of bias was analyzed using the Downs and Black checklist39. All articles had a score more than 70% .
DISCUSSION
This scoping review intended to identify the instruments used to measure the spinal health knowledge of adolescents and detect which studies evaluated the psychometric properties (reliability and reproducibility) of those instruments. The instruments evaluated during this review addressed factors related to the knowledge of postural habits, ergonomic issues, anatomical parts of the spine and pain. Seven articles that surveyed 3890 students from six countries on five continents were included.
Questionnaires for children include the Back Care Behavior Assessment Questionnaire for Schoolchildren: Development and Psychometric Evaluation3 and Assessing Behavior on Spinal Health, Postural Habits, Anatomical Issues in Addition to Ergonomics Questionnaire. The Back Pain and Body Posture Evaluation Instrument, which is designed for children and adolescents, includes questions about behavior associated with spinal health, including physical activity, postural habits, and ergonomic practices22.
Furthermore, the Computer Ergonomics in Schools Questionnaire analyzes the ergonomic characteristics of computers used by children in schools, such as the height of the computer screen and distance of the screen from the children48. The Knowledge and Practices of Back Care, Experience in Colombian Children Questionnaire revealed that back care begins during childhood, when adequate postural habits, the anatomy of the spine, as well as ergonomic situations at school are learned49. The study question, “Why do children think they feel discomfort related to daily activities,” analyzes subjects such as postural habits and ergonomics50.
The Back Care Behavior Assessment Questionnaire3 and Back Pain and Body Posture Evaluation Instrument22, which are both used to evaluate children, include questions related to behavioral aspects, whereas the Computer Ergonomics in Schools Questionnaire48 and Knowledge and Practices of Back Care, Experience in Colombian Children Questionnaire49 evaluate spinal health knowledge. However, all the aforementioned questionnaires analyze, in different ways (in terms of the number and specificity of questions), subjects such as postural habits, anatomy, and ergonomics.
Compared to the three questionnaires included in this scoping review43,44,51, the other aforementioned questionnaires are used for children or adolescents. The three questionnaires included in this study are used for adolescents 14 to 17 years of age and emphasize spinal health knowledge rather than spinal health behavior. These questionnaires include relevant items regarding postural habits (while sleeping, while sitting, while using electronic devices, while carrying and transporting loads) and ergonomics (height of the computer screen, height of the television, height of the desk, height of the chair, and others) and their associations with spinal health.
Distinct characteristics were observed among the three questionnaires. The questionnaire developed in India41, for example, also addresses issues such as physical activities and the role of health professionals in back care. The questionnaire developed in Spain (Development and Psychometric Evaluation of a Health Questionnaire on Back Care Knowledge in Daily Life Physical Activities for Adolescent Students)42 lists anatomical issues, postural habits, and ergonomics in broad and in-depth ways. The Standardized Nordic Questionnaire, which is used to analyze musculoskeletal symptoms49, is used most often, both in its original format and as adapted versions. It highlights items related to pain in the neck, shoulders, and back and investigates the symptoms of musculoskeletal disorders.
Two studies43,44 stand out for cumulatively presenting the following strengths: they are current studies, they have no conflicts of interest, they have ethical approval, they were validated, they presented a low risk of bias and high methodological quality. Among the studies included in this scoping review41,42,44,46, more than half were carried out in developed countries, proving the increased interest of developed countries in this topic and in the instruments developed for BP research52.
Some limitations were observed, the review only identified studies from six countries based on the specific keywords used in the search strategy. This may limit the generalizability of the findings to other regions or populations. The findings may also be limited by the search terms used; other relevant studies could exist with alternative keywords. The broad terminology used for the concept of postural habits. The lack of standardization of the instruments applied to assess spinal health knowledge was also a restrictive factor when searching for articles in the databases. Moreover, the lack of standardization makes it difficult to identify faults and problems, can lead to recurring errors, generates excessive work and rework, and can have low reliability52.
It is important to highlight several aspects of this study, The language and year of publication of the articles were not restricted. In addition, the review included an evaluation of the methodological quality of the studies and a verification of the risk of bias, although these are not typically required for scoping reviews. The use of a protocol, previously structured by the same group of researchers. The review also considered whether the articles reported ethical approval and conflicts of interest.
CONCLUSION
We examined three instruments created in Norway, Spain, and India that are used to assess the spinal health knowledge of adolescents 14 to 17 years of age. These instruments were validated, tested for reproducibility, and exhibited satisfactory psychometric properties (reliability and reproducibility). There are only a few available instruments for assessing the spinal health knowledge, postural habits, and ergonomic practices of adolescents 14 to 17 years of age. Further studies should be performed to expand these instruments through adaptations or create new instruments with satisfactory psychometric properties that can be standardized.
