| Abstract|| |
Context: Oral health is a fundamental aspect of general health which significantly affects quality of life (QoL) of an individual. Oral health-related QoL is a multidimensional concept determined by race, education, culture, and experiences related to oral diseases. Aim: This study aims to evaluate the Hindi (Indian) version of the child perceptions questionnaire (CPQ11-14) among 11–14-year-old school children in Rohtak City, Haryana, India. Materials and Methods: A cross-sectional study was carried out among 586 children in Rohtak city, Haryana, India, to find out the translation and cross-cultural adaptation of CPQ11-14. The original version of CPQ11-14was translated to Hindi language, and the dental caries experience was measured by caries assessment spectrum and treatment index. Statistical Analysis: The data were entered into Microsoft Excel and analyzed using SPSS 18. Reliability was assessed in 2 ways: internal consistency reliability and test-retest reliability. The level of significance was set at 0.05. Results: Construct validity was confirmed demonstrating statistically significant associations between total CPQ11-14 score and global ratings of oral health (P = 0.00) and overall well-being (P = 0.00). Mean CPQ11-14scores (20.30 ± 10.91) including all the domain scores were higher among children without dental caries when compared to children with dental caries (19.79 ± 9.88) and the instrument was not able to discriminate between two clinical groups significantly (P = 0.08). Conclusion: The Hindi version of the CPQ11-14 questionnaire is a reliable instrument having good reliability, good construct, and convergent validity but lacks discriminant validity. Shorter forms of CPQ11-14may be more useful when compared to original construct.
Keywords: Caries assessment spectrum and treatment index, child perceptions questionnaire 11–14, construct validity, dental caries, discriminant validity
|How to cite this article:|
Shyam R, Manjunath B C, Kumar A, Narang R, Goyal A, Ghanghas M. Validation of Hindi (Indian) version of the child perceptions questionnaire (CPQ11-14) among 11–14 year old School Children. Indian J Dent Res 2019;30:697-702
|How to cite this URL:|
Shyam R, Manjunath B C, Kumar A, Narang R, Goyal A, Ghanghas M. Validation of Hindi (Indian) version of the child perceptions questionnaire (CPQ11-14) among 11–14 year old School Children. Indian J Dent Res [serial online] 2019 [cited 2020 Aug 5];30:697-702. Available from: http://www.ijdr.in/text.asp?2019/30/5/697/273430
| Introduction|| |
Oral health is a fundamental aspect of general health which significantly affects quality of life (QoL) of an individual. Poor oral health is associated with pain, discomfort, embarrassment, and often leads to poor general health.
Oral health-related QoL (OHRQoL) is not a directly measurable condition, but represents the interplay of many factors such as health status, age, gender, and general standard of living and is dependent on general perceptions of an individual. Oral diseases such as dental caries and periodontal diseases are having high prevalence in population, and their effects are not only physical, but also include social, economical, and psychological factors.
Since oral diseases are common among children, they also suffer from the consequences which include poor OHRQoL. Until recently, children's OHRQoL was measured using questionnaires answered by parents and caretakers that had imminent bias as children were not the respondents. At present, many instruments have been developed, which have demonstrated adequate validity and reliability as the information is obtained from children.
OHRQoL is a multidimensional phenomenon of an individual's perception about the influence of oral health on the functional adequacy and emotional well-being. OHRQoL is determined by various interrelated factors such as gender, race, education, culture, and experiences related to oral diseases. Understanding of life-concept and health cognition is a complex phenomenon due to interplay of cognitive, emotional, and social development.
In recent times, many research studies have focused on developing indices (instrument/questionnaire) for assessing OHRQoL among children. These indices have been introduced based on age-specific and self-administered QoL which were found to be useful in many validation studies. Important among them include child perceptions questionnaire (CPQ8-10) and CPQ11-14 for children aged 8–10 and 11–14 years, respectively, child-OIDP and pediatric QoL inventory Oral Health Scale.,,,,
CPQ11-14 developed by Jokovic et al. is one of the instruments which has been validated in many languages in the world.,, India is the second populous country in the world with significant burden of oral diseases among children. Hindi is national language in India, and it is imperative to test the validity and reliability of CPQ11-14, and moreover, no such studies are available. Hence, the present study was undertaken to evaluate the Hindi (Indian) version of the CPQ11-14 among 11–14-year-old school children in Rohtak City, Haryana.
| Materials And Methods|| |
A cross-sectional study was carried out to evaluate Hindi (Indian) version of the CPQ11-14 among 11–14-year-old school children in Rohtak City, Haryana, India between June 2015 and August 2015. The study protocol was reviewed by Institutional Ethics Review Board and was granted ethical clearance (PGIDS/IEC/2015/53). An official permission was obtained from the District Education Officer and also from all the concerned school authorities. After explaining the purpose and details of the study, a written informed consent was obtained from the parents of all children aged 11–14 years. Children who were uncooperative, with systemic diseases and developmental anomalies and whose parents did not give consent were excluded from the study.
Depending on the prevalence obtained in a pilot study, the sample size was calculated using the standard formula z2 pq/l2 seeking results at 95% confidence interval for which the value of z = 1.96, the allowable error (e) taken as 0.05. As the sampling technique employed was cluster random sampling, thus a design effect of 1.8 was used to adjust sample size. The minimum sample size was determined to be 540.
A multistage cluster sampling technique was employed in which Rohtak city was divided into nine clusters. In the 2nd stage, five clusters were randomly selected, and two schools were included from randomly selected clusters through lottery method. Finally, from each selected school every odd roll numbered children of the age group of 11–14 years were enrolled to reach a sample of 586 through systematic random sampling technique.
A structured questionnaire CPQ11-14 was constructed in Hindi language before being administered to the participant by principal investigator. The response format ranged from 0 (best) to 4 (worst) conditions. The translation of the questionnaire was performed by two independent translators. A bilingual translator, whose native language was Hindi, translated the original questionnaire from English into Hindi. Another bilingual translator, who knew English, performed the back translation. The two translators worked independently, and the one responsible for the back translation had no knowledge of the original English language version of the questionnaire. Before being finalized, the questionnaire was pilot-tested on a group of (30) 11–14-year-old children to ensure clarity, reliability, and validity. The principles of cognitive debriefing were employed to ascertain cross-cultural adaptation of the construct. The additional information about sociodemographic particulars such as age, gender, and place of residence were also included in this study.
Interviews were carried out on the same day of dental screening before the clinical oral examinations by three-trained interviewers. The intraexaminer reliability was 85%. The interviewers were trained in the administration and intonation of each question of the Hindi version of CPQ11-14. A single examiner conducted the examination. The dental caries experience was measured by caries assessment spectrum and treatment index given by Frencken et al.
The data were entered into Microsoft Excel and analyzed using statistical package for social sciences version 18, IBM Corporation, (SPSS Inc., Chicago, IL, USA) for relevant statistical comparison. Descriptive statistics and inferential statistics were used. Reliability was assessed in two ways: internal consistency reliability and test-retest reliability. Convergent validity was assessed based on Spearman's rank order correlations between CPQ scores and CPQ domains scores. To test the construct validity, correlations between the scores of each domain, total score and global ratings were analyzed using Spearman's correlation coefficient. Discriminant validity was tested by comparing the mean CPQ11-14 scores between children with or without dental caries. As the scores CPQ11-14 scores were not normally distributed, the nonparametric Mann–Whitney test was used to evaluate the difference in mean scores between the two groups. The level of significance was set at 0.05.
| Results|| |
The present study was an observational, cross-sectional study assessing the Hindi (Indian) version of the CPQ11-14 among 11–14-year-old school children in Rohtak City, Haryana. A total of 586 participants of the age group of 11–14 years were recruited for the present study. There were 73% (428) males and 27% (158) females with the mean age of 11.92 ± 1.06 [Table 1].
The Cronbach's alpha for CPQ as a whole was 0.843 and for social well-being and emotional well-being, domain was 0.825 and 0.778, respectively. Intraclass coefficient was found to be 0.803 showing good agreement between test-retest results [Table 2].
|Table 2: Reliability analysis for child perceptions questionnaire domains and total scales|
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The correlation between global rating of oral health (r = 0.12, P = 0.00) and overall well-being (r = 0.14, P = 0.00) with CPQ score though weak but was found to be statistically significant. These findings support construct validity of Hindi version of CPQ11-14[Table 3].
|Table 3: Construct validity - rank correlations between total scale and subscale scores, and global rating of oral health and overall well-being|
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The mean CPQ scores for the whole scale and of all the domains were higher among children without dental caries and the difference found was not statistically significant disapproving discriminant validity of Hindi version of CPQ11-14[Table 4].
|Table 4: Discriminant validity - overall and subscale scores for children with caries and without caries|
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The correlation of oral symptom domain with functional domain (r = 0.427), emotional well-being domain (r = 0.421), and social well-being domain (r = 0.336) were found to be positively correlated. Similarly, correlation of functional limitation domain with emotional well-being (P = 0.427) and social well-being (r = 0.374) was found to be positively correlated. Correlation of emotional well-being with social well-being was also found to be positively correlated (r = 0.505) [Table 5]. Overall mean CPQ score was found to be 21.86 ± 9.60 among females and 21.50 ± 11.07 among males. Maximum score of CPQ was found to be of social domain (8.49 ± 3.97) whereas minimum score was found to be of oral symptoms (3.31 ± 2.68). Dental caries prevalence among study participants was 28.6% with mean DMFT of 0.60 ± 1.13.
|Table 5: Convergent validity - correlation of all child perceptions questionnaire domains scores|
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| Discussion|| |
Oral health is an essential component of general health and has negative impact on individual's QoL, affecting their speech, mastication, and socializing abilities. It often leads to pain, discomfort, and embarrassment. OHRQoL is an integral part of general health and well-being of an individual. OHRQoL is the result of the interplay of various symptoms and experiences, and it is the mirror image of person's subjective perspective. Although the evaluation of OHRQoL in children was made using questionnaires administered to parents, it has to be understood that the perceptions of children and adults on the impact of oral health on QoL is likely to be different.
By using appropriate constructs, it is possible to assess OHRQoL of children which is valid and reliable. Even though there are many validated instruments to measure OHRQoL among children, CPQ11-14 offers many advantages, and hence, it has been widely used. The development of CPQ11-14 was carried out in Canada and has been reported to have good validity in children suffering from various oral diseases such as dental caries, malocclusion, and craniofacial anomalies. Children's perceptions about the impact of their oral health and other affected conditions can be determined by CPQ. In the present study, CPQ11-14 questionnaire was used because of its previously tested validity and reliability in other languages such as Arabic, German, and Telugu a regional language in India.,, Since it was not validated in Hindi, the present study was carried out with an aim to evaluate the Hindi (Indian) version of the CPQ11-14 among 11–14-year-old school children in Rohtak City, Haryana.
Child perceptions questionnaire internal consistency and test-retest reliability
Assessing internal consistency of a questionnaire is an important step to find out whether all the items that make up the instrument are related to one another, and it is often assessed by Cronbach's alpha. Its values examine the extent to which a number of items measuring the same concept are actually doing so while assessing overall scale and subscale as well. A Cronbach's alpha value of 0.70 or greater can be interpreted as representing good internal consistency. Cronbach's alpha coefficient was 0.84 for the total scale, indicating adequate internal reliability., Test-retest reliability was confirmed by the intraclass correlation coefficient which was 0.80 of initial CPQ and repeat assessments also yielded good agreement among all subdomains.
For the domains, the coefficient ranged from 0.56 for “functional limitation” to 0.82 for “social well-being” [Table 2]. A similar result was observed among Canadian pedodontic patients where α = 0.64 was the lowest and α = 0.86 coefficients were the highest in the same subscales as our study. The questionnaire was administered in an interview to avoid the possibility of children taking help from their parents. Few of the items of the CPQ11-14 are “negatively worded.” Items such as “How often in the past 3 months have you been unhappy” were characterized as “negatively worded.” A recent study concluded that items presented in a negative form are better for assessing OHRQoL than items expressed in a positive form, either to reduced response rate or assesses positive oral health.
Construct validity is an important statistical procedure to find out whether the construct measures what is required to measure. It consists of various other forms of validity such as content validity, criterion validity, convergent validity, and divergent validity. The results of our study suggested that the instrument had good construct validity [Table 3]. Significant correlations were shown between the global rating of oral health and the overall CPQ scores, functional domain and emotional domain. When compared to the findings of our study, the validations studies carried out in various other languages such as Arabic, Spanish, Danish, Thai, and Chinese did not correlate with some domain scores with the global oral health rating.,,,,,
A possible explanation is that the 11–14 year olds consider their teeth to be healthy if caries-free or treated, while the global rating on overall well-being explores broader emotional and social aspects which may dominate in the minds of the 11–14 years old. Furthermore, the mean decayed, missing or filled teeth in our sample was 0.60 ± 1.13 which is considered as low caries prevalence according to the WHO, thus it was expected to have no correlation with the oral symptoms domain. Significant correlations were also shown between overall well-being and overall CPQ scores in all CPQ domains except social well-being. It indicates that children were able to give psychometrically acceptable accounts concerning their health status and its overall effects on their lives.
The property of a construct to distinguish the effect of a disease or impairment from apparently healthy conditions is called discriminant validity. In the present study, dental caries experience was not related to OHRQoL scores [Table 4]. There were no significant differences in CPQ11-14 scores in children groups with and without dental caries. Data regarding correlations between caries and OHRQoL in the literature vary widely and are the opposite in many cases. The findings of our study corroborates with the findings of few of the studies such as Bekes et al., Gururatana et al., Olivieri et al., and Marshman et al. who reported nonsignificant correlation with dental caries and in contrast with the study by Abanto et al., Goursand et al., Foster Page et al., and Brown and Al-Khayal who reported direct correlation.
This could be due to the fact that QoL is influenced by personality, culture, environmental surroundings, and socioeconomic factors as reported by O'Connor. This might be due to the fact that dental caries would not cause functional limitations and psychosocial dysfunction unless associated with pain. Another important finding of our study was that even though, many children had teeth with pulpal involvement; they were unaware about it denoting a deficient oral health-related knowledge.
Since there are 37 items in the CPQ11-14 questionnaire; children may lose interest as they answer the questionnaire and may not give prompt and correct answers. It is better to hold the attention of the children if the questionnaire is short and interesting. This may be one of the reasons for the failure of discriminant validity of CPQ11-14 questionnaire in the present study. Except this, all the other parameters of validity and reliability seem to be satisfactory. Shorter forms of CPQ11-14 consisting of 8 and 16 questions have been reported to provide satisfactory results similar to the original versions but requires further validation studies to provide more evidence.,,
The study utilized standard cognitive debriefing technique to translate English version of CPQ11-14 to Hindi and validated according to the accepted statistical procedures.
The sampling procedure was restricted to only one geographical area, and its results may not reflect the rest of the population. This study does not provide evidence regarding equality to the original. For that, a formal analysis of invariance with structural equation models or differential item functioning would need to be conducted.
| Conclusion|| |
The Hindi version of the CPQ11-14 questionnaire is a reliable instrument having good reliability, good construct and convergent validity but lacks discriminant validity. Even though CPQ11-14 has good reliability properties and appears to be a valid instrument, shorter forms of the questionnaire with graduated scale are recommended. Larger, population-based studies on representative groups of children are needed to establish normative data on oral health-related QoL and its determinants in Indian children.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Radhey Shyam
Department of Public Health Dentistry, Pt. B. D. Sharma University of Health Sciences, Rohtak, Haryana
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]