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Validations of the Brazilian version of the Early Childhood Oral Health Impact Scale (ECOHIS)

Validations of the Brazilian version of the Early Childhood Oral Health Impact Scale (ECOHIS) ARTIGO ARTICLE 367 Validations of the Brazilian version of the Early Childhood Oral Health Impact Scale (ECOHIS) Validação da versão brasileira do Early Childhood Oral Health Impact Scale (ECOHIS) Paulo Antônio Martins-Júnior Joana Ramos-Jorge Saul Martins Paiva Leandro Silva Marques Maria Letícia Ramos-Jorge Abstract Introduction Universidade Federal dos This study aimed to evaluate the psychometric The assessment of quality of life has become an Vales do Jequitinhonha e properties of the Brazilian version of the Early integral part of evaluating health programs. In Mucuri, Diamantina, Brazil. Universidade Federal de Childhood Oral Health Impact Scale (ECOHIS). recent years, several instruments used to im- Minas Gerais, Belo Horizonte, A total of 247 children aged 2 to 5 years and their prove and validate oral health-related quality Brazil. parents/guardians participated in this study. A of life (OHRQoL) in children and adolescents Universidade Vale do Rio 1,2,3,4,5 Verde, Três Corações, Brazil. clinical oral examination was performed and the have emerged . The Early Childhood Oral parents/guardians completed the ECOHIS ques- Health Impact Scale (ECOHIS) was developed Correspondence tionnaire. Within a period of four-weeks, 20% of and validated in English in the United States to P. A. Martins-Júnior Universidade Federal dos the participants repeated the ECOHIS question- assess the impact of oral health problems and Vales do Jequitinhonha e naire. Construct validity was determined using related treatment on the quality of life of pre- Mucuri. Spearman’s rank correlation. Discriminant va- school children (aged three to five years) and Rua da Glória 187, sala 12, Diamantina, MG 6 lidity, internal consistency and test-retest reli- their families . Studies have determined that 39100-000, Brazil. ability were also evaluated. The children were the ECOHIS is valid for assessing the impact of paulo_martins86@hotmail. divided into 2 groups: group 1 (with dental car- OHRQoL in children between zero and five years com ies) and group 2 (caries-free). Children with car- of age and their families in Canada . ies showed higher mean ECOHIS scores than the Due to the target age group, the ECOHIS caries-free children. The child impact section (p < questionnaire is filled out by parental proxy. Up 0.01), family impact section (p < 0.01) and total to the age of five, children have difficulty in un- ECOHIS scores (p < 0.01) were significantly cor- derstanding basic health concepts, are incapable related with tooth decay. Cronbach’s alpha coef- of adequately expressing themselves and tend ficients demonstrated satisfactory internal con- to give exaggerated responses . Children’s self- sistency. The Brazilian version of the ECOHIS is a concept and health cognition is age dependent valid instrument for assessing oral health-relat- and results from continuous cognitive, emotion- ed quality of life in preschool children with Bra- al, social and language development . Accord- zilian Portuguese-speaking primary caregivers. ing to child developmental psychology, the age of six marks the beginning of abstract thinking Preschool Child; Questionnaires; Oral Health; and self-concept . Children begin to compare Quality of Life their physical features and personality traits to those of other children or to social norms. Their ability to make evaluative judgments regard- Cad. Saúde Pública, Rio de Janeiro, 28(2):367-374, fev, 2012 Martins-Júnior PA et al. ing their appearance, quality of friendships and impact section contains two subscales: parental other people’s thoughts, emotions and behavior distress and family function. The questionnaire is gradually develops throughout middle child- scored using a simple five-point Likert scale with hood (six to 10 years) . responses ranging from “never” to “very often” Preschool children may suffer from a number (equivalent to a score of 0 and 4, respectively). A of oral health problems such as teething pain , total score ranging from zero to 52 is calculated eruption disturbances , early childhood cari- as a simple sum of the responses with higher 13 14,15 es and dental trauma . A dental survey scores denoting a greater oral health impact among Brazilian preschool children found that and/or poorer OHRQoL. The different ranges of nearly 27% of children between 18 and 36 months the subscale scores are as follows: child impact of age have at least one primary tooth with caries section: child symptom – one item, range 0 to 4; and this proportion rises to nearly 60% among child function – four items, range 0 to 16; child five-year-olds . This data illustrates the dimen- psychology – two items, range 0 to 8; and child sion of caries as a public health problem in Brazil. self-image/social interaction – two items, range Measuring OHRQoL can make an important con- 0 to 8. Family impact section: parental distress tribution through providing further data on this – two items, range 0 to 8; family function – two issue to help guide oral health policies and there- items range 0 to 8. by contribute to the definition and prioritization of the socially appropriate use of resources. Translation into Brazilian Portuguese The cross-cultural adaptation of this instru- ment is necessary to enable the collection of To assess the use of the ECOHIS in Brazilian comparable information in different cultures. children, the questionnaires used in the present The ECOHIS has already been tested and validat- study were translated and adapted to Brazilian ed among children in the United States, Canada, culture . 6,7,17,18 China and Iran . It is imperative to evaluate the different language versions of this instrument to assure that each version exhibits psychomet- Main study ric properties similar to the original version and guarantee its effective utilization in cross-cultur- A total of 247 children (boys and girls) aged two to al comparisons . In Brazil, the ECOHIS has been five years were randomly selected from children translated, adapted and validated for use in chil- living in the town of Diamantina, in the State of 19,20 dren between two and five years of age . How- Minas Gerais, Brazil, participating in the Nation- ever, this instrument has yet to be evaluated with al Child Vaccination Day program in the town’s regard to certain psychometric properties, such ten health centers (n = 10) in August 2010. The as effect size measures which serve as a comple- children were selected according to order of ar- ment to the validation process. rival in the health centre. In 2010, 2,113 children The aim of the present study was therefore aged two to five years were living in the city of to evaluate the psychometric properties (valid- Diamantina and the vaccination program in Dia- ity and reliability) of the Brazilian version of the mantina had previously shown constant uptake ECOHIS. rates of over 90%. A total of 250 children were randomly se- lected as no specific recommendations are given Methods regarding the sample size required for discrimi- nant and construct validity testing. A sample size Measure of this magnitude is more than sufficient to de- tect correlation coefficients as low as 0.20 using The ECOHIS is an English language measure of a one-tailed test when the null hypothesis is r = 0, oral health-related quality of life developed and alpha = 0.05 and beta = 0.20. validated in the United States to assess the im- To participate in the study children had to ful- pact of oral health problems and related treat- fill the following inclusion criteria: must be aged ment on the quality of life of preschool children between two and five years; must not exhibit any (aged zero to five years) and their families . The serious underlying medical conditions, must not ECOHIS consists of 13 questions divided into two show the long-term use of medication, must not main parts: child impact section (part one) and have any physical or learning disabilities; must be family impact section (part two). The child im- accompanied by a Brazilian Portuguese-speak- pact section comprises of four subscales: child ing parent/guardian who lives with the child for symptom, child function, child psychology and at least 50% of the time. Parents of children who child self-image/social interaction. The family met these inclusion criteria were interviewed to Cad. Saúde Pública, Rio de Janeiro, 28(2):367-374, fev, 2012 VALIDATION OF THE BRAZILIAN VERSION OF THE ECOHIS complete the ECOHIS questionnaire and provide test-retest reliability. Internal consistency was additional social demographic information. All assessed by determining the mean item correla- parents agreed to participate in the study. The in- tion of the ECOHIS items using Cronbach’s alpha terviews were performed individually by trained statistic. Test-retest reliability was assessed by de- interviewers who were unaware of the results of termining the level of agreement between the re- the clinical examinations. Interviewees that did sults of the first and repeated ECOHIS question- not answer or responded “don’t know” to one or naire using the intraclass correlation coefficient more questions were excluded from the analysis. (ICC) in a one-way random effect parallel model. Based on recommended World Health Organiza- tion (WHO) criteria for the visual assessment of dental caries, children underwent a clinical oral Results examination carried out by 10 trained and cali- brated examiners . Caries experience was re- Of a total of 250 children initially selected, three corded using the d-DMFT index. Within a period were excluded from the sample because their of four-weeks after the first interview, 20% of the parents/guardians answered “don’t know” to one participants were randomly selected by lots and or more items (n = 3). The final sample size was agreed to repeat the ECOHIS questionnaire pro- therefore 247 individuals made up of 123 boys cess at the health care centre. The repeated inter- (49.8%) and 124 girls (50.2%), with mean age of view was performed individually with each par- 48.5 months (SD = 7.8), distributed in the follow- ent/guardian and the interviewer was unaware ing manner: 30 two-year-olds (12.1%), 104 three- of the results of the first interview. year-olds (42.1%), 96 four-year-olds (38.9%) and Prior to the study, a team made up of ten 17 five-year-olds (6.9%). The children were divid- examiners participated in a training program ed into two groups: group 1 – children with den- which included intra-examiner and inter-exam- tal caries (n = 125, 50.6%); and group 2 – children iner calibration exercises where minimum and without caries (n = 122, 49.4%). Table 1 displays maximum kappa values were agreed (0.81 and the characteristics of the sample. Caries status 0.86 respectively) between the examiners. A pilot was associated with parents’ schooling (p < 0.01), study with 30 children and their parents/guard- but not with child’s age or gender (p > 0.05). ians was also performed to determine the appli- Table 2 displays the responses to each item in cability of the measure. the ECOHIS questionnaire. In the child impact All parents that participated in this study section, “pain in the teeth, mouth or jaws” was signed an informed consent form. The study re- the most frequently reported item by the par- ceived approval from the ethics committee of the ents (21.5%). The items “irritation or frustration” Vales do Jequitinhonha e Mucuri Federal Univer- (12.6%), “difficulty drinking” (10.9%), “difficulty sity (Universidade Federal dos Vales de Jequiti- eating” (10.3%) and “trouble sleeping” (10.1%) nhonha e Mucuri; nº. 181/10). were also frequently reported in this section. In the family impact section, the most frequently re- Assessment of validity and reliability of ported items were “felt guilty” (14.2%) and “been the Brazilian version of the ECOHIS upset” (12.6%). Discriminant validity was determined by Data was inputted and organized using the soft- comparing scores between the clinical groups. ware SPSS version 17.0 (SPSS Inc., Chicago, United Variations in the mean ECOHIS and the two States). Construct validity of the Brazilian version subscale scores (child impact and family impact of the ECOHIS was determined by correlating the sections) (p < 0.001) were apparent between the ECOHIS scores with DMFT scores (Spearman’s caries and caries-free groups (Table 3). Median rank correlation). To evaluate discriminant valid- values for the two subscale scores and total score ity, differences in ECOHIS scores between chil- were 0.0. Effect sizes were considered moderate dren with caries and those without caries were for the total score and the two subscales. Chil- assessed using the Mann-Whitney U-test (non- dren with caries had higher mean ECOHIS scores parametric test equivalent to t-test). To estimate than the caries-free children, demonstrating that the effect size, statistics were calculated by di- the instrument was capable of discriminating be- viding the mean ECOHIS scores by the standard tween clinically different groups. deviation (SD). Effect size statistics of < 0.2 indi- The results of the correlations (Spearman’s cate a small, clinically meaningful magnitude of rank) between ECOHIS scores and caries experi- difference; effect size statistics of 0.2-0.7 indicate ence revealed that the child impact section (r = moderate difference; and effect size statistics of 0.36, p < 0.01), family impact section (r = 0.39, p < > 0.7 indicate a large difference . Reliability was 0.01) and total ECOHIS scores (r = 0.40, p < 0.01) assessed in two ways: internal consistency and were significantly correlated with tooth decay. Cad. Saúde Pública, Rio de Janeiro, 28(2):367-374, fev, 2012 Martins-Júnior PA et al. Table 1 Comparison of parent and child characteristics of caries and caries-free groups. Parent and child characteristics Patient group p-value * Entire sample Caries Caries-free (n = 247; 100.0%) (n = 125; 50.6%) (n = 122; 49.4%) n (%) n (%) n (%) Parent demographics Mother’s schooling (years) ≤ 8 97 (39.3) 61 (62.9) 36 (37.1) 0.003 > 8 142 (57.5) 62 (43.7) 80 (56.3) Father’s schooling (years) ≤ 8 106 (42.9) 63 (59.4) 43 (40.6) 0.008 > 8 107 (43.3) 44 (41.1) 63 (58.9) Child demographics Age 2 years-2 years 11 months 30 (12.1) 13 (43.3) 17 (56.7) 3 years-3 years 11 months 104 (42.1) 51 (49.0) 53 (51.0) 0.151 4 years-4 years 11 months 96 (38.9) 48 (50.0) 48 (50.0) 5 years-5 years 11 months 17 (6.9) 13 (76.5) 4 (23.5) Gender Male 123 (49.8) 61 (49.6) 62 (50.4) 0.751 Female 124 (50.2) 64 (51.6) 60 (48.4) * Chi-square test. Table 2 Distribution of Brazilian Early Childhood Oral Health Impact Scale (ECOHIS) responses in community-based sample (N = 247). Impacts Never Hardly ever Occasionally Often Very often n (%) n (%) n (%) n (%) n (%) Child impacts Oral/dental pain 194 (78.5) 13 (5.3) 29 (11.7) 9 (3.6) 2 (0.8) Difficulty drinking 220 (89.1) 1 (0.4) 20 (8.1) 6 (2.4) 0 (0.0) Difficulty eating 214 (89.7) 7 (2.8) 19 (7.7) 5 (2.0) 2 (0.8) Difficulty pronouncing words 230 (93.1) 6 (2.4) 5 (2.0) 5 (2.0) 1 (0.4) Missed preschool or school 235 (95.1) 4 (1.6) 6 (2.4) 2 (0.8) 0 (0.0) Trouble sleeping 222 (89.9) 4 (1.6) 14 (5.7) 6 (2.4) 1 (0.4) Irritable or frustrated 216 (87.4) 9 (3.6) 17 (6.9) 5 (2.0) 0 (0.0) Avoided smiling or laughing 235 (95.1) 1 (0.4) 8 (3.2) 2 (0.8) 1 (0.4) Avoided talking 240 (97.2) 1 (0.4) 4 (1.6) 0 (0.0) 2 (0.8) Family impacts Been upset 216 (87.4) 6 (2.4) 18 (7.3) 4 (1.6) 3 (1.2) Felt guilty 212 (85.8) 5 (2.0) 21 (8.5) 5 (2.0) 4 (1.6) Time off from work 230 (93.1) 3 (1.2) 13 (5.3) 1 (0.4) 0 (0.0) Financial impact 238 (96.4) 1 (0.4) 7 (2.8) 1 (0.4) 0 (0.0) Cad. Saúde Pública, Rio de Janeiro, 28(2):367-374, fev, 2012 VALIDATION OF THE BRAZILIAN VERSION OF THE ECOHIS Table 3 Discriminant validity: comparison of mean Early Childhood oral Health Impact Scale (ECOHIS) scores and sub-scales by caries status. ECOHIS Caries Caries-free p-value * Cohen’s d ** Mean (SD) Mean (SD) Child impact section 3.18 (5.42) 0.57 (1.48) < 0.001 0.66 Family impact section 1.30 (2.24) 0.26 (1.01) < 0.001 0.60 Total score 4.43 (6.88) 0.84 (2.18) < 0.001 0.70 SD: standard deviation. * Mann-Whitney test; ** 0.50 < d < 0.79 indicates medium effect size. The analysis of Cronbach’s alpha coefficients this group affirms that almost 1,070 preschool revealed satisfactory internal consistency, with children from the town have one or more carious coefficients of 0.85 in the child impact section, teeth. This represents a high prevalence of dental 0.65 in the family impact section and 0.86 for the caries when compared to the findings of a den- total ECOHIS score. A total of 50 parents/guard- tal survey carried out among Brazilian preschool ians repeated the Brazilian version of the ECOHIS children . The implementation of oral health questionnaire reporting no change in children’s policies and oral health promotion among this oral health status. The ICC values were 0.94 for age group is therefore essential to reduce the high the total score and child impact section and 0.88 prevalence of dental caries among this group. for the family impact section ( Table 4). The original version of the ECOHIS was de- veloped to be a self-completed questionnaire. However, considering the low educational level Discussion of most Brazilians, it was decided to assess the psychometric properties of the Brazilian version The present study evaluated the psychometric of the ECOHIS by interviewing participants . properties of the Brazilian Portuguese version of The effect of this method on completion rates the ECOHIS by determining its validity and reli- and the actual results is not clear. Further studies ability using discriminant validity, internal con- should be carried out to assess the psychometric sistency and test-retest reliability. This process properties using both methods for completing is imperative to assess the cross-cultural adapta- the ECOHIS questionnaire. Significant differ- 24,25,26 tion of this quality of life measure . ences in mean ECOHIS and subscale scores were Participants were selected from a commu- found between the caries and caries-free groups. 17,20 nity-based sample. In contrast with findings of As found in other ECOHIS validation studies 7,17 , 6 previous studies the majority of the parents/ and the original ECOHIS study , high scores were guardians reported no oral health impact on the obtained by children with dental caries. These quality of life of their children. This may be ex- findings demonstrate the ability of the Brazilian plained by the fact that the children which were version of the ECOHIS to discriminate between part of these other studies were from clinically these two groups of children. A number of studies based convenience samples and therefore al- also report that children with untreated dental ready exhibited some type of oral health problem, caries can have difficulty chewing, sleeping and whereas the children in the present study were socializing and that caries can affect self-esteem, 18,21,27,28,29 selected from the participants of a National Child growth and weight gain , so reducing Vaccination Day program and were not seeking quality of life. However, as public health pro- dental treatment. This approach was adopted to grams do not cover younger children, oral health achieve greater accuracy in the results . As is the in this group is often overlooked, leaving many 7,17,18 case in other ECOHIS validation studies , children with untreated dental caries and suffer- the present study assessed each age group cov- ing from chronic pain and discomfort . ered by this measure. It is interesting to note that the most common Considering that this study comprises a impacts reported by parents in the child impact representative sample of children living in Dia- section were practically the same as those found mantina, a 50.6% prevalence of dental caries in in studies of the original, French and Brazilian Cad. Saúde Pública, Rio de Janeiro, 28(2):367-374, fev, 2012 Martins-Júnior PA et al. Table 4 Reliability analysis – internal consistency (reliability) and test-retest reliability. ECOHIS (number of items) Internal consistency reliability Test-retest reliability (Cronbach’s alpha) ICC (95%CI) Child impact section (9) 0.85 0.94 (0.89, 0.97) Family impact section (4) 0.65 0.88 (0.79, 0.93) Total score (13) 0.86 0.94 (0.87, 0.96) ECOHIS: Early Childhood Oral Health Impact Scale; ICC: intraclass correlation coeffi cient; 95%CI: 95% confi dence interval. 6,7,20 20 versions of the ECOHIS . The most frequent items , while the child impact section contains responses in these three studies were “pain in nine. It has been demonstrated that the alpha val- the teeth, mouth or jaws”, “irritation or frustra- ue tends to be higher with measures that contain tion”, “difficulty eating” and “trouble sleeping”. more items . An important finding of the present study is the In the present study, the ECOHIS was sig- fact that the effect size analysis demonstrated a nificantly but not strongly correlated with caries moderate clinical significance in the difference experience. Most studies have used global mea- between the groups with and without caries . sures of oral health and actual disease status to Publications in the field of psychology have dem- examine the construct validity of the ECOHIS 6,7,18 onstrated an increasing trend in the use of effect . However, one study determined construct size measures and that such measures are con- validity by correlating the ECOHIS scores with sidered fundamental to investigations of excel- DMFT and DMFS scores . It was stated above 31,32 lence . However, the other validation of the B- that clinical measures may not be a very appro- ECOHIS did not evaluate the clinical significance priate means of assessment of construct validity of the study results . and subjective measures should be used for this The results of the present study showed Cron- purpose. Therefore, the fact that data on overall bach’s alpha coefficients of 0.85 for the child im- well-being and oral health status of children as pact section, 0.65 for the family impact section perceived by the parents was not collected is an- and 0.86 for the overall scale, demonstrating good other limitation of this study. Although evidence internal consistency for the Brazilian version of shows that parents can provide valid reports re- the ECOHIS, higher than the recommended value garding their preschool children’s OHRQoL when 33 27 of 0.70 . Other ECOHIS validation studies report dental conditions are observable , the validity of 7,17,18,20 similar Cronbach alpha values . The in- these reports may be conditioned to caries expe- tra-class correlation value for the total score was riences associated with pain symptoms. Clinical 0.94, indicating an excellent level of agreement measures may not be strongly correlated with the between the test-retest results . This coefficient d-DMFT, as untreated carious deciduous teeth is higher than that reported in the Farsi, Chinese can remain symptomless until shed . and original versions of the ECOHIS (0.82, 0.64 and 0.84, respectively) and similar to the ICC value of the French version (0.95). Another study of the Conclusion Brazilian version of the ECOHIS did not present an ICC value for the total score, but the values for The adaptation and psychometric evaluation of the child and family impact sections are similar the Brazilian Portuguese version of the ECOHIS to those revealed by the present study . It should suggested good construct validity, discriminant be noted that in the present study most of the re- validity and internal consistency as well as ac- sponses to the items in the ECOHIS questionnaire ceptable test-retest reliability. The Brazilian were “never”. This can be seen as a limitation of Portuguese version of the ECOHIS is therefore a this study and may explain the good level of test- valid instrument for assessing oral health-related retest agreement in comparison to other studies. quality of life in preschool children with Brazil- The result regarding the internal consistency reli- ian Portuguese-speaking primary caregivers. It ability of the family impact section is marginal, would be useful to evaluate the sensitivity and as found in the preliminary study of the Brazilian responsiveness of this measure using a longitu- version of the ECOHIS . This is due to the fact dinal study in order to assess the effectiveness of that the family impact section includes only four oral healthcare interventions. Cad. Saúde Pública, Rio de Janeiro, 28(2):367-374, fev, 2012 VALIDATION OF THE BRAZILIAN VERSION OF THE ECOHIS Resumo Contributors O objetivo deste estudo foi avaliar as propriedades All authors made an equal contribution to the produc- psicométricas da versão brasileira do Early Childhood tion of this paper. Oral Health Impact Scale (ECOHIS). Duzentas e qua- renta e sete crianças de 2 a 5 anos e seus pais/cuidado- res foram convidados a participar. Foi realizado exame Acknowledgments clínico bucal e os pais completaram o ECOHIS. Após quatro semanas, 20% dos participantes responderam The authors would like to thank the Brazilian resear- ao ECOHIS pela segunda vez. A validade de construto ch promotion agencies CNPq (Edital MCT/CNPq n . foi determinada através da correlação de Spearman. 14/2010 – Universal), FAPEMIG (APQ-02268-08; PPM- A validade discriminante, consistência interna e con- 00510-09) and CAPES (MEC/CAPES 29/2010) for their fiabilidade teste-reteste foram avaliadas. As crianças financial support for this study. foram divididas em dois grupos: grupo 1 (com cárie) e grupo 2 (sem cárie). As crianças com cárie tinham maiores escores médios do ECOHIS do que as crianças sem cárie. Os domínios impacto na criança (p < 0,01), impacto na família (p < 0,01) e escores totais ECOHIS (p < 0,01) foram significativamente correlacionados com dentes cariados. Coeficientes alfa de Cronbach demonstraram consistência interna satisfatória. 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Cad 32. Cohen J. A power primer. Psychol Bull 1992; 112: Saúde Pública 2008; 24:1897-909. 155-9. 20. Scarpelli AC, Oliveira BH, Tesch FC, Leão AT, Por- 33. Kline P. A hand book of psychological testing. Lon- deus IA, Paiva SM. Psychometric properties of don: Routledge; 1993. the Brazilian version of the Early Childhood Oral 34. Shrout PE, Fleiss JL. Intraclass correlations: uses Health Impact Scale (B-ECOHIS). BMC Oral Health in assessing rater reliability. Psychol Bull 1979; 2011; 11:19. 86:420-8 21. Abanto J, Carvalho TS, Mendes FM, Wanderley MT, 35. Levine RS, Pitts NB, Nugent ZJ. The fate of 1,587 Bönecker M, Raggio DP. Impact of oral diseases unrestored carious deciduous teeth: a retrospec- and disorders on oral health-related quality of life tive general dental practice based study from of preschool children. Community Dent Oral Epi- northern England. Br Dent J 2002; 193:99-103. demiol 2011; 39:105-14. 22. World Health Organization. Oral health surveys: Submitted on 18/Feb/2011 basic methods. Geneva: World Health Organiza- Final version resubmitted on 16/Jul/2011 tion; 1997. Approved on 03/Oct/2011 23. Cohen J. Statistical power analysis for the behav- nd ioural sciences. 2 Ed. Hillsdale: Lawrence Erl- baum and Associates; 1988. Cad. Saúde Pública, Rio de Janeiro, 28(2):367-374, fev, 2012 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Cadernos de Saúde Pública Unpaywall

Validations of the Brazilian version of the Early Childhood Oral Health Impact Scale (ECOHIS)

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ARTIGO ARTICLE 367 Validations of the Brazilian version of the Early Childhood Oral Health Impact Scale (ECOHIS) Validação da versão brasileira do Early Childhood Oral Health Impact Scale (ECOHIS) Paulo Antônio Martins-Júnior Joana Ramos-Jorge Saul Martins Paiva Leandro Silva Marques Maria Letícia Ramos-Jorge Abstract Introduction Universidade Federal dos This study aimed to evaluate the psychometric The assessment of quality of life has become an Vales do Jequitinhonha e properties of the Brazilian version of the Early integral part of evaluating health programs. In Mucuri, Diamantina, Brazil. Universidade Federal de Childhood Oral Health Impact Scale (ECOHIS). recent years, several instruments used to im- Minas Gerais, Belo Horizonte, A total of 247 children aged 2 to 5 years and their prove and validate oral health-related quality Brazil. parents/guardians participated in this study. A of life (OHRQoL) in children and adolescents Universidade Vale do Rio 1,2,3,4,5 Verde, Três Corações, Brazil. clinical oral examination was performed and the have emerged . The Early Childhood Oral parents/guardians completed the ECOHIS ques- Health Impact Scale (ECOHIS) was developed Correspondence tionnaire. Within a period of four-weeks, 20% of and validated in English in the United States to P. A. Martins-Júnior Universidade Federal dos the participants repeated the ECOHIS question- assess the impact of oral health problems and Vales do Jequitinhonha e naire. Construct validity was determined using related treatment on the quality of life of pre- Mucuri. Spearman’s rank correlation. Discriminant va- school children (aged three to five years) and Rua da Glória 187, sala 12, Diamantina, MG 6 lidity, internal consistency and test-retest reli- their families . Studies have determined that 39100-000, Brazil. ability were also evaluated. The children were the ECOHIS is valid for assessing the impact of paulo_martins86@hotmail. divided into 2 groups: group 1 (with dental car- OHRQoL in children between zero and five years com ies) and group 2 (caries-free). Children with car- of age and their families in Canada . ies showed higher mean ECOHIS scores than the Due to the target age group, the ECOHIS caries-free children. The child impact section (p < questionnaire is filled out by parental proxy. Up 0.01), family impact section (p < 0.01) and total to the age of five, children have difficulty in un- ECOHIS scores (p < 0.01) were significantly cor- derstanding basic health concepts, are incapable related with tooth decay. Cronbach’s alpha coef- of adequately expressing themselves and tend ficients demonstrated satisfactory internal con- to give exaggerated responses . Children’s self- sistency. The Brazilian version of the ECOHIS is a concept and health cognition is age dependent valid instrument for assessing oral health-relat- and results from continuous cognitive, emotion- ed quality of life in preschool children with Bra- al, social and language development . Accord- zilian Portuguese-speaking primary caregivers. ing to child developmental psychology, the age of six marks the beginning of abstract thinking Preschool Child; Questionnaires; Oral Health; and self-concept . Children begin to compare Quality of Life their physical features and personality traits to those of other children or to social norms. Their ability to make evaluative judgments regard- Cad. Saúde Pública, Rio de Janeiro, 28(2):367-374, fev, 2012 Martins-Júnior PA et al. ing their appearance, quality of friendships and impact section contains two subscales: parental other people’s thoughts, emotions and behavior distress and family function. The questionnaire is gradually develops throughout middle child- scored using a simple five-point Likert scale with hood (six to 10 years) . responses ranging from “never” to “very often” Preschool children may suffer from a number (equivalent to a score of 0 and 4, respectively). A of oral health problems such as teething pain , total score ranging from zero to 52 is calculated eruption disturbances , early childhood cari- as a simple sum of the responses with higher 13 14,15 es and dental trauma . A dental survey scores denoting a greater oral health impact among Brazilian preschool children found that and/or poorer OHRQoL. The different ranges of nearly 27% of children between 18 and 36 months the subscale scores are as follows: child impact of age have at least one primary tooth with caries section: child symptom – one item, range 0 to 4; and this proportion rises to nearly 60% among child function – four items, range 0 to 16; child five-year-olds . This data illustrates the dimen- psychology – two items, range 0 to 8; and child sion of caries as a public health problem in Brazil. self-image/social interaction – two items, range Measuring OHRQoL can make an important con- 0 to 8. Family impact section: parental distress tribution through providing further data on this – two items, range 0 to 8; family function – two issue to help guide oral health policies and there- items range 0 to 8. by contribute to the definition and prioritization of the socially appropriate use of resources. Translation into Brazilian Portuguese The cross-cultural adaptation of this instru- ment is necessary to enable the collection of To assess the use of the ECOHIS in Brazilian comparable information in different cultures. children, the questionnaires used in the present The ECOHIS has already been tested and validat- study were translated and adapted to Brazilian ed among children in the United States, Canada, culture . 6,7,17,18 China and Iran . It is imperative to evaluate the different language versions of this instrument to assure that each version exhibits psychomet- Main study ric properties similar to the original version and guarantee its effective utilization in cross-cultur- A total of 247 children (boys and girls) aged two to al comparisons . In Brazil, the ECOHIS has been five years were randomly selected from children translated, adapted and validated for use in chil- living in the town of Diamantina, in the State of 19,20 dren between two and five years of age . How- Minas Gerais, Brazil, participating in the Nation- ever, this instrument has yet to be evaluated with al Child Vaccination Day program in the town’s regard to certain psychometric properties, such ten health centers (n = 10) in August 2010. The as effect size measures which serve as a comple- children were selected according to order of ar- ment to the validation process. rival in the health centre. In 2010, 2,113 children The aim of the present study was therefore aged two to five years were living in the city of to evaluate the psychometric properties (valid- Diamantina and the vaccination program in Dia- ity and reliability) of the Brazilian version of the mantina had previously shown constant uptake ECOHIS. rates of over 90%. A total of 250 children were randomly se- lected as no specific recommendations are given Methods regarding the sample size required for discrimi- nant and construct validity testing. A sample size Measure of this magnitude is more than sufficient to de- tect correlation coefficients as low as 0.20 using The ECOHIS is an English language measure of a one-tailed test when the null hypothesis is r = 0, oral health-related quality of life developed and alpha = 0.05 and beta = 0.20. validated in the United States to assess the im- To participate in the study children had to ful- pact of oral health problems and related treat- fill the following inclusion criteria: must be aged ment on the quality of life of preschool children between two and five years; must not exhibit any (aged zero to five years) and their families . The serious underlying medical conditions, must not ECOHIS consists of 13 questions divided into two show the long-term use of medication, must not main parts: child impact section (part one) and have any physical or learning disabilities; must be family impact section (part two). The child im- accompanied by a Brazilian Portuguese-speak- pact section comprises of four subscales: child ing parent/guardian who lives with the child for symptom, child function, child psychology and at least 50% of the time. Parents of children who child self-image/social interaction. The family met these inclusion criteria were interviewed to Cad. Saúde Pública, Rio de Janeiro, 28(2):367-374, fev, 2012 VALIDATION OF THE BRAZILIAN VERSION OF THE ECOHIS complete the ECOHIS questionnaire and provide test-retest reliability. Internal consistency was additional social demographic information. All assessed by determining the mean item correla- parents agreed to participate in the study. The in- tion of the ECOHIS items using Cronbach’s alpha terviews were performed individually by trained statistic. Test-retest reliability was assessed by de- interviewers who were unaware of the results of termining the level of agreement between the re- the clinical examinations. Interviewees that did sults of the first and repeated ECOHIS question- not answer or responded “don’t know” to one or naire using the intraclass correlation coefficient more questions were excluded from the analysis. (ICC) in a one-way random effect parallel model. Based on recommended World Health Organiza- tion (WHO) criteria for the visual assessment of dental caries, children underwent a clinical oral Results examination carried out by 10 trained and cali- brated examiners . Caries experience was re- Of a total of 250 children initially selected, three corded using the d-DMFT index. Within a period were excluded from the sample because their of four-weeks after the first interview, 20% of the parents/guardians answered “don’t know” to one participants were randomly selected by lots and or more items (n = 3). The final sample size was agreed to repeat the ECOHIS questionnaire pro- therefore 247 individuals made up of 123 boys cess at the health care centre. The repeated inter- (49.8%) and 124 girls (50.2%), with mean age of view was performed individually with each par- 48.5 months (SD = 7.8), distributed in the follow- ent/guardian and the interviewer was unaware ing manner: 30 two-year-olds (12.1%), 104 three- of the results of the first interview. year-olds (42.1%), 96 four-year-olds (38.9%) and Prior to the study, a team made up of ten 17 five-year-olds (6.9%). The children were divid- examiners participated in a training program ed into two groups: group 1 – children with den- which included intra-examiner and inter-exam- tal caries (n = 125, 50.6%); and group 2 – children iner calibration exercises where minimum and without caries (n = 122, 49.4%). Table 1 displays maximum kappa values were agreed (0.81 and the characteristics of the sample. Caries status 0.86 respectively) between the examiners. A pilot was associated with parents’ schooling (p < 0.01), study with 30 children and their parents/guard- but not with child’s age or gender (p > 0.05). ians was also performed to determine the appli- Table 2 displays the responses to each item in cability of the measure. the ECOHIS questionnaire. In the child impact All parents that participated in this study section, “pain in the teeth, mouth or jaws” was signed an informed consent form. The study re- the most frequently reported item by the par- ceived approval from the ethics committee of the ents (21.5%). The items “irritation or frustration” Vales do Jequitinhonha e Mucuri Federal Univer- (12.6%), “difficulty drinking” (10.9%), “difficulty sity (Universidade Federal dos Vales de Jequiti- eating” (10.3%) and “trouble sleeping” (10.1%) nhonha e Mucuri; nº. 181/10). were also frequently reported in this section. In the family impact section, the most frequently re- Assessment of validity and reliability of ported items were “felt guilty” (14.2%) and “been the Brazilian version of the ECOHIS upset” (12.6%). Discriminant validity was determined by Data was inputted and organized using the soft- comparing scores between the clinical groups. ware SPSS version 17.0 (SPSS Inc., Chicago, United Variations in the mean ECOHIS and the two States). Construct validity of the Brazilian version subscale scores (child impact and family impact of the ECOHIS was determined by correlating the sections) (p < 0.001) were apparent between the ECOHIS scores with DMFT scores (Spearman’s caries and caries-free groups (Table 3). Median rank correlation). To evaluate discriminant valid- values for the two subscale scores and total score ity, differences in ECOHIS scores between chil- were 0.0. Effect sizes were considered moderate dren with caries and those without caries were for the total score and the two subscales. Chil- assessed using the Mann-Whitney U-test (non- dren with caries had higher mean ECOHIS scores parametric test equivalent to t-test). To estimate than the caries-free children, demonstrating that the effect size, statistics were calculated by di- the instrument was capable of discriminating be- viding the mean ECOHIS scores by the standard tween clinically different groups. deviation (SD). Effect size statistics of < 0.2 indi- The results of the correlations (Spearman’s cate a small, clinically meaningful magnitude of rank) between ECOHIS scores and caries experi- difference; effect size statistics of 0.2-0.7 indicate ence revealed that the child impact section (r = moderate difference; and effect size statistics of 0.36, p < 0.01), family impact section (r = 0.39, p < > 0.7 indicate a large difference . Reliability was 0.01) and total ECOHIS scores (r = 0.40, p < 0.01) assessed in two ways: internal consistency and were significantly correlated with tooth decay. Cad. Saúde Pública, Rio de Janeiro, 28(2):367-374, fev, 2012 Martins-Júnior PA et al. Table 1 Comparison of parent and child characteristics of caries and caries-free groups. Parent and child characteristics Patient group p-value * Entire sample Caries Caries-free (n = 247; 100.0%) (n = 125; 50.6%) (n = 122; 49.4%) n (%) n (%) n (%) Parent demographics Mother’s schooling (years) ≤ 8 97 (39.3) 61 (62.9) 36 (37.1) 0.003 > 8 142 (57.5) 62 (43.7) 80 (56.3) Father’s schooling (years) ≤ 8 106 (42.9) 63 (59.4) 43 (40.6) 0.008 > 8 107 (43.3) 44 (41.1) 63 (58.9) Child demographics Age 2 years-2 years 11 months 30 (12.1) 13 (43.3) 17 (56.7) 3 years-3 years 11 months 104 (42.1) 51 (49.0) 53 (51.0) 0.151 4 years-4 years 11 months 96 (38.9) 48 (50.0) 48 (50.0) 5 years-5 years 11 months 17 (6.9) 13 (76.5) 4 (23.5) Gender Male 123 (49.8) 61 (49.6) 62 (50.4) 0.751 Female 124 (50.2) 64 (51.6) 60 (48.4) * Chi-square test. Table 2 Distribution of Brazilian Early Childhood Oral Health Impact Scale (ECOHIS) responses in community-based sample (N = 247). Impacts Never Hardly ever Occasionally Often Very often n (%) n (%) n (%) n (%) n (%) Child impacts Oral/dental pain 194 (78.5) 13 (5.3) 29 (11.7) 9 (3.6) 2 (0.8) Difficulty drinking 220 (89.1) 1 (0.4) 20 (8.1) 6 (2.4) 0 (0.0) Difficulty eating 214 (89.7) 7 (2.8) 19 (7.7) 5 (2.0) 2 (0.8) Difficulty pronouncing words 230 (93.1) 6 (2.4) 5 (2.0) 5 (2.0) 1 (0.4) Missed preschool or school 235 (95.1) 4 (1.6) 6 (2.4) 2 (0.8) 0 (0.0) Trouble sleeping 222 (89.9) 4 (1.6) 14 (5.7) 6 (2.4) 1 (0.4) Irritable or frustrated 216 (87.4) 9 (3.6) 17 (6.9) 5 (2.0) 0 (0.0) Avoided smiling or laughing 235 (95.1) 1 (0.4) 8 (3.2) 2 (0.8) 1 (0.4) Avoided talking 240 (97.2) 1 (0.4) 4 (1.6) 0 (0.0) 2 (0.8) Family impacts Been upset 216 (87.4) 6 (2.4) 18 (7.3) 4 (1.6) 3 (1.2) Felt guilty 212 (85.8) 5 (2.0) 21 (8.5) 5 (2.0) 4 (1.6) Time off from work 230 (93.1) 3 (1.2) 13 (5.3) 1 (0.4) 0 (0.0) Financial impact 238 (96.4) 1 (0.4) 7 (2.8) 1 (0.4) 0 (0.0) Cad. Saúde Pública, Rio de Janeiro, 28(2):367-374, fev, 2012 VALIDATION OF THE BRAZILIAN VERSION OF THE ECOHIS Table 3 Discriminant validity: comparison of mean Early Childhood oral Health Impact Scale (ECOHIS) scores and sub-scales by caries status. ECOHIS Caries Caries-free p-value * Cohen’s d ** Mean (SD) Mean (SD) Child impact section 3.18 (5.42) 0.57 (1.48) < 0.001 0.66 Family impact section 1.30 (2.24) 0.26 (1.01) < 0.001 0.60 Total score 4.43 (6.88) 0.84 (2.18) < 0.001 0.70 SD: standard deviation. * Mann-Whitney test; ** 0.50 < d < 0.79 indicates medium effect size. The analysis of Cronbach’s alpha coefficients this group affirms that almost 1,070 preschool revealed satisfactory internal consistency, with children from the town have one or more carious coefficients of 0.85 in the child impact section, teeth. This represents a high prevalence of dental 0.65 in the family impact section and 0.86 for the caries when compared to the findings of a den- total ECOHIS score. A total of 50 parents/guard- tal survey carried out among Brazilian preschool ians repeated the Brazilian version of the ECOHIS children . The implementation of oral health questionnaire reporting no change in children’s policies and oral health promotion among this oral health status. The ICC values were 0.94 for age group is therefore essential to reduce the high the total score and child impact section and 0.88 prevalence of dental caries among this group. for the family impact section ( Table 4). The original version of the ECOHIS was de- veloped to be a self-completed questionnaire. However, considering the low educational level Discussion of most Brazilians, it was decided to assess the psychometric properties of the Brazilian version The present study evaluated the psychometric of the ECOHIS by interviewing participants . properties of the Brazilian Portuguese version of The effect of this method on completion rates the ECOHIS by determining its validity and reli- and the actual results is not clear. Further studies ability using discriminant validity, internal con- should be carried out to assess the psychometric sistency and test-retest reliability. This process properties using both methods for completing is imperative to assess the cross-cultural adapta- the ECOHIS questionnaire. Significant differ- 24,25,26 tion of this quality of life measure . ences in mean ECOHIS and subscale scores were Participants were selected from a commu- found between the caries and caries-free groups. 17,20 nity-based sample. In contrast with findings of As found in other ECOHIS validation studies 7,17 , 6 previous studies the majority of the parents/ and the original ECOHIS study , high scores were guardians reported no oral health impact on the obtained by children with dental caries. These quality of life of their children. This may be ex- findings demonstrate the ability of the Brazilian plained by the fact that the children which were version of the ECOHIS to discriminate between part of these other studies were from clinically these two groups of children. A number of studies based convenience samples and therefore al- also report that children with untreated dental ready exhibited some type of oral health problem, caries can have difficulty chewing, sleeping and whereas the children in the present study were socializing and that caries can affect self-esteem, 18,21,27,28,29 selected from the participants of a National Child growth and weight gain , so reducing Vaccination Day program and were not seeking quality of life. However, as public health pro- dental treatment. This approach was adopted to grams do not cover younger children, oral health achieve greater accuracy in the results . As is the in this group is often overlooked, leaving many 7,17,18 case in other ECOHIS validation studies , children with untreated dental caries and suffer- the present study assessed each age group cov- ing from chronic pain and discomfort . ered by this measure. It is interesting to note that the most common Considering that this study comprises a impacts reported by parents in the child impact representative sample of children living in Dia- section were practically the same as those found mantina, a 50.6% prevalence of dental caries in in studies of the original, French and Brazilian Cad. Saúde Pública, Rio de Janeiro, 28(2):367-374, fev, 2012 Martins-Júnior PA et al. Table 4 Reliability analysis – internal consistency (reliability) and test-retest reliability. ECOHIS (number of items) Internal consistency reliability Test-retest reliability (Cronbach’s alpha) ICC (95%CI) Child impact section (9) 0.85 0.94 (0.89, 0.97) Family impact section (4) 0.65 0.88 (0.79, 0.93) Total score (13) 0.86 0.94 (0.87, 0.96) ECOHIS: Early Childhood Oral Health Impact Scale; ICC: intraclass correlation coeffi cient; 95%CI: 95% confi dence interval. 6,7,20 20 versions of the ECOHIS . The most frequent items , while the child impact section contains responses in these three studies were “pain in nine. It has been demonstrated that the alpha val- the teeth, mouth or jaws”, “irritation or frustra- ue tends to be higher with measures that contain tion”, “difficulty eating” and “trouble sleeping”. more items . An important finding of the present study is the In the present study, the ECOHIS was sig- fact that the effect size analysis demonstrated a nificantly but not strongly correlated with caries moderate clinical significance in the difference experience. Most studies have used global mea- between the groups with and without caries . sures of oral health and actual disease status to Publications in the field of psychology have dem- examine the construct validity of the ECOHIS 6,7,18 onstrated an increasing trend in the use of effect . However, one study determined construct size measures and that such measures are con- validity by correlating the ECOHIS scores with sidered fundamental to investigations of excel- DMFT and DMFS scores . It was stated above 31,32 lence . However, the other validation of the B- that clinical measures may not be a very appro- ECOHIS did not evaluate the clinical significance priate means of assessment of construct validity of the study results . and subjective measures should be used for this The results of the present study showed Cron- purpose. Therefore, the fact that data on overall bach’s alpha coefficients of 0.85 for the child im- well-being and oral health status of children as pact section, 0.65 for the family impact section perceived by the parents was not collected is an- and 0.86 for the overall scale, demonstrating good other limitation of this study. Although evidence internal consistency for the Brazilian version of shows that parents can provide valid reports re- the ECOHIS, higher than the recommended value garding their preschool children’s OHRQoL when 33 27 of 0.70 . Other ECOHIS validation studies report dental conditions are observable , the validity of 7,17,18,20 similar Cronbach alpha values . The in- these reports may be conditioned to caries expe- tra-class correlation value for the total score was riences associated with pain symptoms. Clinical 0.94, indicating an excellent level of agreement measures may not be strongly correlated with the between the test-retest results . This coefficient d-DMFT, as untreated carious deciduous teeth is higher than that reported in the Farsi, Chinese can remain symptomless until shed . and original versions of the ECOHIS (0.82, 0.64 and 0.84, respectively) and similar to the ICC value of the French version (0.95). Another study of the Conclusion Brazilian version of the ECOHIS did not present an ICC value for the total score, but the values for The adaptation and psychometric evaluation of the child and family impact sections are similar the Brazilian Portuguese version of the ECOHIS to those revealed by the present study . It should suggested good construct validity, discriminant be noted that in the present study most of the re- validity and internal consistency as well as ac- sponses to the items in the ECOHIS questionnaire ceptable test-retest reliability. The Brazilian were “never”. This can be seen as a limitation of Portuguese version of the ECOHIS is therefore a this study and may explain the good level of test- valid instrument for assessing oral health-related retest agreement in comparison to other studies. quality of life in preschool children with Brazil- The result regarding the internal consistency reli- ian Portuguese-speaking primary caregivers. It ability of the family impact section is marginal, would be useful to evaluate the sensitivity and as found in the preliminary study of the Brazilian responsiveness of this measure using a longitu- version of the ECOHIS . This is due to the fact dinal study in order to assess the effectiveness of that the family impact section includes only four oral healthcare interventions. Cad. Saúde Pública, Rio de Janeiro, 28(2):367-374, fev, 2012 VALIDATION OF THE BRAZILIAN VERSION OF THE ECOHIS Resumo Contributors O objetivo deste estudo foi avaliar as propriedades All authors made an equal contribution to the produc- psicométricas da versão brasileira do Early Childhood tion of this paper. Oral Health Impact Scale (ECOHIS). Duzentas e qua- renta e sete crianças de 2 a 5 anos e seus pais/cuidado- res foram convidados a participar. Foi realizado exame Acknowledgments clínico bucal e os pais completaram o ECOHIS. Após quatro semanas, 20% dos participantes responderam The authors would like to thank the Brazilian resear- ao ECOHIS pela segunda vez. A validade de construto ch promotion agencies CNPq (Edital MCT/CNPq n . foi determinada através da correlação de Spearman. 14/2010 – Universal), FAPEMIG (APQ-02268-08; PPM- A validade discriminante, consistência interna e con- 00510-09) and CAPES (MEC/CAPES 29/2010) for their fiabilidade teste-reteste foram avaliadas. As crianças financial support for this study. foram divididas em dois grupos: grupo 1 (com cárie) e grupo 2 (sem cárie). As crianças com cárie tinham maiores escores médios do ECOHIS do que as crianças sem cárie. Os domínios impacto na criança (p < 0,01), impacto na família (p < 0,01) e escores totais ECOHIS (p < 0,01) foram significativamente correlacionados com dentes cariados. Coeficientes alfa de Cronbach demonstraram consistência interna satisfatória. 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