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Table of Contents   
ORIGINAL RESEARCH  
Year : 2019  |  Volume : 30  |  Issue : 5  |  Page : 742-746
Validation of Manipuri version of oral health-related early childhood quality-of-life tool for preschool children


1 Department of Pedodontics and Preventive Dentistry, Regional Institute of Medical Sciences, Imphal, India
2 Department of Pedodontics and Preventive Dentistry, Maulana Azad Institute of Dental Sciences, New Delhi, India
3 Division of Pedodontics and Preventive Dentistry, CDER, AIIMS, New Delhi, India

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Date of Submission02-Jan-2018
Date of Decision13-May-2018
Date of Acceptance24-Sep-2018
Date of Web Publication18-Dec-2019
 

   Abstract 


Introduction: Early childhood caries can affect quality of life (QoL) in children and their parents. The Oral Health related Early Childhood Quality of Life scale (OH-ECQoL) is used for measuring oral health-related QoL in North Indian preschool children. Same tool cannot be utilized only by linguistic translation in culturally different Manipuri population. Aims and Objectives: The aim of this study is to translate OH-ECQoL tool into Manipuri language and to reestablish its psychometric properties. Methods: The OH-ECQoL tool was translated into Manipuri language by forward–backward translation. The questionnaire was tested on 300 parents/primary caretakers of healthy children with the age range of 24–71 months. It was also retested on 20 parents after a gap of two weeks. Demographic characteristics and socioeconomic status were recorded in a predesigned proforma. Oral health status of children was recorded as per WHO oral health assessment form (2004). Statistical Analysis: The data were tabulated using Microsoft Excel 2010 and analyzed using SPSS version 11 software. Results: The tool possessed good internal consistency (Cronbach's alpha = 0.836) and test–retest reliability (ICC = 0.94). Parents of children who scored higher on Manipuri-OH-ECQoL questionnaire perceived their children's general and oral health as poor when compared to children with lower scores, proving acceptable concurrent validity scores. Spearman's correlation coefficient between child and family impact scores of 0.668 is supporting convergent validity, which means that dental problems affect QoL of both children and their parents. Conclusion: The translated Manipuri-OH-ECQoL tool was found to be adequately valid, reliable, and repeatable without affecting the psychometric properties of the original tool. This suggests that it can be used in studies assessing the impact of oral diseases on QoL of preschool children and their families in Manipur.

Keywords: Dental caries, early childhood caries, quality of life, validation

How to cite this article:
Dharmani CK, Dhillon JK, Mathur VP. Validation of Manipuri version of oral health-related early childhood quality-of-life tool for preschool children. Indian J Dent Res 2019;30:742-6

How to cite this URL:
Dharmani CK, Dhillon JK, Mathur VP. Validation of Manipuri version of oral health-related early childhood quality-of-life tool for preschool children. Indian J Dent Res [serial online] 2019 [cited 2020 Aug 14];30:742-6. Available from: http://www.ijdr.in/text.asp?2019/30/5/742/273428



   Introduction Top


The effect of early childhood caries (ECC) in children is not only limited to pain and esthetics but also problems in speech and psychological problems.[1] It is assumed that they are unable to take adequate nutrition due to ECC and have difficulty in eating and sleeping due to ECC-related infection and pain.[2] Further, the life of parents of children with ECC is also affected in terms of emotional and financial distress. These problems altogether may affect the quality of life (QoL) in children and their parents.

Oral-health-related quality of life (OHRQoL) was first given by Giddon in 1978.[3] It is defined as an individual's assessment of how the following affect his/her well-being: functional factors, psychological factors, social factors, and experience of pain/discomfort in relation to orofacial concerns. The literature is scanty about the impact of oral diseases on the functional, psychological, and social well-being of children and their parents. This analysis has led to research in impact of dental problems on QoL. During the past 15 years, various OHRQoL instruments have been designed for assessing the impact of oral diseases on the child population. Some of them are Child-OIDP (Oral Impacts on Daily Performances),[4] the ECOHIS (Early Childhood Oral Health Impact Scale),[5] the CPQ (Child Perceptions Questionnaire),[6] the Michigan OHRQL Scale,[7] the Child Oral Health Impact Profile (COHIP),[8] Scale of Oral Health Outcomes for 5-year-old children (SOHO-5),[9] and Oral Health-Early Childhood related Quality of Life (OH-ECQoL).[10] Among these, the last four are the only tools for preschool children. However, these tools are not yet available in all the countries and languages.

A tool for early childhood oral health-related QoL for North Indian population was developed by the name Oral Health related Early Childhood Quality of Life (OH-ECQoL) in 2013.[10] This questionnaire-based tool was designed for recording replies from the parent (primary caretaker). It was composed of 16 items as child impact section (symptom, function, emotional, and social well-being) and family impact section (FIS). Additionally, it includes a fifth domain of systemic well-being with two items.

Till now, no such tool has been designed to assess the effect of dental problems on the QoL of children and their parents in Manipur state of India. A QoL tool developed for a population should not be used verbatim in another population without modification/validation due to cross-cultural variations. The tool developed elsewhere needs to be validated when used in a setting different from where it was developed and also when it is used after translation. It was assumed that OH-ECQoL tool can be adopted/modified for use in culturally different Manipuri population and then validation exercise can be undertaken so that this tool can be used for various surveys and monitoring, etc. in future. Thus, the aim of this study was to translate the OH-ECQoL tool into Manipuri language and to reestablish the psychometric properties (validity and reliability) of Manipuri-OH-ECQoL tool.


   Methods Top


The study consisted of hospital-based population of children. The questionnaire was tested on parents/primary caretakers of healthy children with the age range of 24–71 months attending the Out Patient Department (OPD) of the Department of Paediatric and Preventive Dentistry, Dental College, Regional Institute of Medical Sciences, Imphal, Manipur. Manipur is a state in northeastern India with the city of Imphal as its capital. Manipuri (also known as Meitei) is the official language of Manipur. As this study was done for the first time, it was proposed to take maximum sample size of 300 subjects for validation of Manipuri-OH-ECQoL tool. Parents who could read and understand Manipuri language were included, whereas parents who could not read or understand Manipuri language were excluded.

Ethical clearance for the study was obtained from the Institutional Ethics Committee of RIMS, Imphal. A brief description of the study was provided in the patient information sheet given to the parents of child patients. After answering all queries, written informed consent was obtained from the parent.

Tool modification/adoption/translation

The original 18-item English version of OH-ECQoL was translated into Manipuri language based on a linguistic translation exercise specifically standardized for translation of the health-related QoL questionnaires. The Manipuri-OH-ECQoL tool was derived by forward–backward translation. This process consisted of several stages.

1. Translation into Manipuri

Two accredited bilingual professional translators whose first language was Manipuri carried out the forward translation of the questionnaire from English to Manipuri language. Both versions were matched for similarity. A group of five bilingual investigators and other clinicians then looked at the translation for the scientific terms, flow, and understandability of each question. Special attention was paid to semantic equivalence of the English version and maintaining the colloquial expressions of the local culture.

2. Back translation

The Manipuri version of the tool was then back translated into English language by independent native English (professional) translators who were fluent in Manipuri and who had no prior knowledge of the original version. The translated English version was compared with the original questionnaire. The differences were discussed by the investigator and translators. Some minor grammatical differences were acceptable, but the question structure or its meaning did not change.

3. Panel of experts

This version was sent to three independent advisors, who were dental experts and were familiar with surveys to see if they find the translation to be appropriate. All the experts were satisfied with the semantic, idiomatic, experimental, and conceptual equivalencies of the Manipuri questionnaire.

4. Pilot testing

A small pilot test was then conducted in order to assess the level of understanding of the wording used and, where appropriate, to make any necessary changes. Manipuri questionnaire tool was administered to 20 participant volunteers. These volunteers were similar to the proposed population. At this time, a trained dentist was present to note down the questions in the tool where the participants seemed to be confused/stumble during answering. A small informal talk with these volunteers about understandability of the tool gave insight into the final usability of tool. Feedback was received from volunteers. No item was rated as difficult to understand by any of the parents. This finalized version was then administered to the sample of participants.

The demographic details and socioeconomic status (based on Kuppuswamy's Index)[11] were recorded and then the participants completed the Manipuri-OH-ECQoL questionnaire which consisted of 16 questions (12 questions in child impact section and 4 questions in FIS) on a 3-point Likert scale: (1) never, (2) occasionally, and (3) often. Two additional questions about the global rating of their child's (a) general and (b) oral health were included with 5-point scale, namely, (1) excellent, (2) very good, (3) good, (4) fair, and (5) poor.

Children were examined under standard aseptic conditions on dental chair in the operatory with mouth mirror and probe under dental unit light. The dentition status was recorded as per WHO oral health assessment form (2004) with PUFA. The children were divided into three groups based on classification of ECC given in AAPD (American Academy of Paediatric Dentistry) guidelines, that is, no caries, mild-to-moderate and severe ECC.[12] They were provided standard treatment as required.

Statistical analysis

The data were tabulated using Microsoft Excel 2010 and analyzed using SPSS version 11 software. Following statistical tests were performed of the data collected:

  1. Concurrent validity
  2. Convergent validity
  3. Discriminant validity: Both convergent validity and discriminant validity are the two subtypes that constitute construct validity
  4. Internal consistency reliability
  5. Test–retest reliability



   Results Top


The study included convenience hospital-based sample of 300 participants. The age of children ranged from 24 to 71 months and 53.3% of the children were boys and 46.6% were girls. Socioeconomic status of parents was scored based on Kuppuswamy Index for socioeconomic status [Table 1].[11]
Table 1: Demographic characteristics of parent and children included in the study

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[Table 2] represents the distribution of responses to the Manipuri-OH-ECQoL among the sample of parents. The items related to food caught between teeth, bad breath, pain, and mouth breathing were reported most frequently in child impact section. Items related to being worried and financial impact were reported most frequently in FIS. Parents reported more child impacts (97%) than family impacts (55.6%). Nine parents reported floor effect in CIS (score of 12), whereas 133 parents reported floor effect in FIS (score of 4). Ceiling effect was not observed for child and FISs, score of 36 and 12, respectively.
Table 2: Distribution of items included in Manipuri-Oral Health related Early Childhood Quality of Life

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Concurrent validity

The Spearman's correlation coefficient between the child impact section versus oral and general health was found to be 0.567 and 0.494, respectively. The Spearman's correlation coefficient between the FIS versus perception of oral and general health was found to be 0.389 and 0.309, respectively (P < 0.01) [Table 3].
Table 3: Concurrent validity

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The Spearman's correlation coefficient between total Manipuri-OH-ECQoL scores and the perception of parents regarding their child's oral and general health was found to be 0.479 and 0.468, respectively (P < 0.01) [Table 3].

Convergent validity

The scores in the child impact section were correlated with the FIS and this was calculated using Spearman's correlation coefficient and was found to be 0.668 signifying that various components of the tool are converging toward oral health and QoL indicators [Table 4].
Table 4: Convergent validity

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Discriminant validity

One-way ANOVA was used for comparison between the three groups and post hoc Bonferroni comparison was applied. The difference in the Manipuri-OH-ECQoL scores between the groups (no ECC, mild/moderate ECC, and severe ECC) was found to be statistically significant [Table 5] and [Table 6].
Table 5: Discriminant validity using one-way analysis of variance between early childhood caries subgroups

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Table 6: Intergroup comparison using post hoc Bonferroni comparisons indicating discriminant validity

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Internal consistency reliability

The internal consistency reliability of Manipuri-OH-ECQOL was evaluated by Cronbach's alpha test and item scale correlation. The Cronbach's alpha was calculated to be 0.836.

Test–retest reliability

Test–retest reliability of Manipuri-OH-ECQoL was evaluated with the help of intraclass correlation coefficient (ICC). Among 20 subjects on whom the questionnaire was administered for the second time after 2 weeks, the repeatability score was found to be 0.94.


   Discussion Top


The Manipuri-OH-ECQoL tool was developed to assess the impact of oral diseases on the QoL of children below 6 years of age. It is desirable to have a reliable tool for predicting OHRQoL of these children so as to educate their parents and general population regarding the effects of oral problems on the QoL of children. This will enable us to educate the parents and promote good oral health.

The Manipuri-OH-ECQoL tool was derived by forward–backward translation using standard method. The translated version was similar to the original version. It consisted of 16 items with 12 items in CIS and 4 items in FIS. These items composed of descriptive domains of symptom, function, emotional, and social well-being in the child impact section and family well-being as given by Jokovic et al.[6] The questionnaire also included a fifth domain of systemic well-being. A question on systemic health was that “whether the child had fever due to oral problems?” It is a common complaint reported by parents due to untreated dental caries and subsequent abscess, malaise, etc., in this part of the world. The simple 3-point Likert scale with three options allowed easy understanding and scoring. Two more global ratings of self-perception for general health and oral health of their children were based on 5-point scale to enable validity testing. The global ratings were correlated well with clinical indicators of oral health.

In order to discriminate scores of mild and severe ECC, the AAPD-defined grades of mild, moderate, and severe were used based on number of carious teeth.

Concurrent validity

The concurrent validity of Manipuri-OH-ECQoL was in line with Hindi-OH-ECQoL. It was seen that parents of those children who scored higher on Manipuri-OH-ECQoL questionnaire perceived their children's general and oral health as poor when compared to children with lower scores. This proved that Manipuri-OH-ECQoL was valid in terms of concurrent validity. This is also in agreement with study done by Pahel et al.,[5] Scarpelli et al.,[13] and Jabarifar et al.[14]

Convergent validity

The convergent validity as assessed by comparing the scores of CIS and FIS was found to be 0.668. This supported the convergent validity of Manipuri-OH-ECQoL, which means that dental problems in children not only affect QoL of children (in terms of pain, difficulty eating) but also affect QoL of parents (in terms of emotional and financial impact). The score was also similar to Hindi-OH-ECQoL by Mathur et al.[10]

Discriminant validity

The total mean score between children with severe ECC was significantly different from caries-free children. Thus, Manipuri-OH-ECQoL was able to differentiate well between children with ECC and children without ECC. The findings are similar to those found in studies done by Jokovic et al.,[6] Lee et al.,[15] Li et al.,[16] Pahel et al.,[5] and Filstrup et al.,[7] Mathur et al.[10] providing additional support for the relationship between dental status and HRQoL.

Internal consistency reliability

Cronbach's alpha of 0.836 in current study was in acceptable range signifying the extent of agreement between all possible subset of items.[13] The value of Cronbach's alpha found in this study is slightly lower than that reported by Jokovic et al.[6] and Pahel et al.[5] The reason for this is the lack of awareness among parents about the oral health of their children. Parents often attribute child's discomfort to other issues rather than oral health. Due to lack of knowledge, parents are not bothered to take the child for preventive or curative visits leading to lower impact on family in terms of emotional distress or financial impact.

Test–retest reliability

The ICC for test–retest reliability of Manipuri-OH-ECQoL was 0.94 signifying excellent repeatability. This score was better than Pahel et al.[5] and Mathur et al.[10]


   Conclusion Top


The translated Manipuri-OH-ECQoL tool was found to be adequately valid, reliable, and repeatable without losing its psychometric properties. This suggests that it can be used in studies assessing the impact of oral diseases on the QoL of preschool children and their families in Manipur. Based on the tool thus developed, systematic studies can be planned to study the impact of dental problems in children on their QoL in the region.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Giddon DB. The mouth and the quality of life. N Y J Dent 1978;48:3-10.  Back to cited text no. 3
    
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Broder HL, McGrath C, Cisneros GJ. Questionnaire development: Face validity and item impact testing of the child oral health impact profile. Community Dent Oral Epidemiol 2007;35 Suppl 1:8-19.  Back to cited text no. 8
    
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Tsakos G, Blair YI, Yusuf H, Wright W, Watt RG, Macpherson LM, et al. Developing a new self-reported scale of oral health outcomes for 5-year-old children (SOHO-5). Health Qual Life Outcomes 2012;10:62.  Back to cited text no. 9
    
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Mathur VP, Dhillon JK, Logani A, Agarwal R. Development and validation of oral health-related early childhood quality of life tool for North Indian preschool children. Indian J Dent Res 2014;25:559-66.  Back to cited text no. 10
[PUBMED]  [Full text]  
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Scarpelli AC, Oliveira BH, Tesch FC, Leão AT, Pordeus IA, Paiva SM, et al. Psychometric properties of the Brazilian version of the early childhood oral health impact scale (B-ECOHIS). BMC Oral Health 2011;11: 9.  Back to cited text no. 13
    
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Jabarifar SE, Golkari A, Ijadi MH, Jafarzadeh M, Khadem P. Validation of a Farsi version of the early childhood oral health impact scale (F-ECOHIS). BMC Oral Health 2010;10:4.  Back to cited text no. 14
    
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Lee GH, McGrath C, Yiu CK, King NM. Translation and validation of a Chinese language version of the early childhood oral health impact scale (ECOHIS). Int J Paediatr Dent 2009;19:399-405.  Back to cited text no. 15
    
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Li S, Veronneau J, Allison PJ. Validation of a French language version of the early childhood oral health impact scale (ECOHIS). Health Qual Life Outcomes 2008;6:9.  Back to cited text no. 16
    

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Correspondence Address:
Dr. Jatinder Kaur Dhillon
Associate Professor, Department of Pedodontics and Preventive Dentistry, Maulana Azad Institute of Dental Sciences, New Delhi - 110 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_5_18

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