The PedsQL™ Oral Health Scale in Iranian children: reliability and validity

Associations between fear of COVID-19, dental anxiety, and psychological distress among Iranian adolescents

Objectives

The present study evaluated the association of fear of COVID-19 with dental anxiety, oral health-related quality of life (OHRQoL), and psychological distress (depression, anxiety and stress), as well as exploring the mediating role of dental anxiety in the association of fear of COVID-19 with OHRQoL and psychological distress.

Methods

A cross-sectional study was conducted among adolescents in high schools of Qazvin city (Iran) from March-June 2021, recruited through a two-stage cluster sampling method. All the adolescents completed a self-administered survey assessing (i) fear of COVID-19, (ii) depression, anxiety and stress, (iii) OHRQoL, and (iv) dental anxiety. Structural equation modelling was used to evaluate all the hypothesised associations, and the model fit was estimated.

Results

A total of 2429 adolescents participated in the study. The conceptual model fitted the data well. Fear of COVID-19 had a direct effect on dental anxiety (B = 0.316; bias-corrected bootstrapping 95% CI = 0.282, 0.349), depression (B = 0.302; bias-corrected bootstrapping 95% CI = 0.259, 0.347), anxiety (B = 0.289; bias-corrected bootstrapping 95% CI = 0.246, 0.334), stress (B = 0.282; bias-corrected bootstrapping 95% CI = 0.237, 0.328), and OHRQoL (B = −0.354; bias-corrected bootstrapping 95% CI = −0.530, −0.183). Also, dental anxiety mediated the association of fear of COVID-19 with depression, anxiety stress, and OHRQoL.

Conclusions

High levels of fear of COVID-19 were associated with high levels of dental anxiety and poorer OHRQoL. Moreover, fear of COVID-19 was positively associated with anxiety, depression and stress. Increased levels of dental anxiety were also associated with increased anxiety, stress, depression, and poorer OHRQoL.

Turkish version of the faces version of the Modified Child Dental Anxiety Scale (MCDASf): translation, reliability, and validity

OBJECTIVES

To cross-culturally adapt of MCDAS_f into Turkish and to evaluate reliability and validity of the Turkish version of MCDAS_f using explorative factor analysis (EFA), confirmatory factor analysis (CFA), and receiver operating characteristic (ROC) analysis to form a less time consuming and easy to understand tool for measuring dental anxiety.

MATERIALS AND METHODS

A total of 300 children (174 females, 126 males) aged 6-12 years who were recruited at the Department of Paediatric Dentistry in RTEU at the first visit participated in the present study. For the internal consistency reliability, Cronbach's alpha was calculated. Intraclass correlation coefficients (ICCs) were calculated for test-retest reliability (n=67). Construct validity was determined by comparing with the Venham Picture Test (VPT). The factor structure was examined using EFA. CFA was used for dimensionality. The cut-off points of the Turkish version of MCDAS_f were plotted using a ROC curve.

RESULTS

The Turkish version of MCDAS_f showed high internal consistency (0.703) and an excellent ICC value (0.827). Good correlations were found between the global scores of MCDAS_f and VPT (r=0.632). Three factors were identified from EFA and verified with CFA. Discriminant validity was supported by high scores of females and younger children (p<0.05). The cut-off point was assigned as >24.50. The area under the ROC curve (AUC) was 0.921 (95% CI: 0.873-0.969).

CONCLUSIONS

The Turkish version of the MCDAS_f is a reliable and valid scale that satisfied psychometric properties.

CLINICAL RELEVANCE

The Turkish version of MCDAS_f is a usable tool for the measurement of dental anxiety among Turkish speaking children.

Validity and reliability of the Turkish version of the Child Perceptions Questionnaire 8-10

BACKGROUND

A reliable measurement tool is needed to gain more knowledge about Turkish children's oral health status that affects the quality of life.

AIM

To develop a translated version of CPQ_8-10 into Turkish language and evaluate its reliability, validity, and reproducibility.

DESIGN

The intra-class correlation coefficient (ICC) was used for the test-retest reliability in the 50 children. For the internal consistency, 418 children aged 8-10 years were evaluated using Cronbach's alpha Coefficient. Construct validity and discriminant validity were calculated using Spearman's correlation analysis, and exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) was also employed.

RESULTS

The mean CPQ_8-10 score was 13.3 ± 9.2. The translated Turkish version of CPQ_8-10 showed high test-retest reliability (ICC = 0.90) and internal consistency (Cronbach's alpha = 0.82). A statistically significant correlation was observed between the scores of the CPQ_8-10 and oral health and overall well-being, which revealed good construct validity (r = 0.50; P < .001 and r = 0.47; P < .001, respectively). Seven factors identified from EFA were statistically verified using CFA. Discriminant validity was supported by significant differences between CPQ and OHIS scores (P < .001).

CONCLUSIONS

The translated version of CPQ_8-10 to the Turkish language is reliable, valid, and reproducible for use in the Turkish culture in this age group.

Health-related quality of life in Iranian adolescents: a psychometric evaluation of the self-report form of the PedsQL 4.0 and an investigation of gender and age differences

Background

Research on the psychometric properties of the Persian self-report form of the Pediatric Quality of Life Inventory Version 4.0 (PedsQL 4.0) in adolescents has several gaps (e.g., convergent validity) that limit its clinical application and therefore the cross-cultural impact of this measure. This study aimed at investigating the psychometric properties of the PedsQL 4.0 and the effects of gender and age on quality of life in Iranian adolescents.

Method

The PedsQL 4.0 was administered to 326 adolescents (12–17 years). A subsample of 115 adolescents completed the scale two weeks after the first assessment. Confirmatory Factor Analysis (CFA), correlation of the PedsQL 4.0 with the Weiss Functional Impairment Rating Scale-Self-report (WFIRS-S), and Item Response Theory (IRT) analysis were conducted to examine validity. Cronbach’s alpha, McDonald’s Omega, and Intra class correlation (ICC) were calculated as well to examine reliability. Gender and age effects were also evaluated.

Results

Internal consistency and test–retest reliability of the total PedsQL 4.0 scale was .92 and .87, respectively. The PedsQL 4.0 scores showed negative moderate to strong correlations with the WFIRS-S total scale. The four-factor model of the PedsQL 4.0 was not fully supported by the CFA—the root mean square error of approximation and the comparative fit index showed a mediocre and poor fit, respectively. IRT analysis indicated that all items of the PedsQL 4.0 fit with the scale and most of them showed good discrimination. The items and total scale provided more information in the lower levels of the latent trait. Males showed significantly higher scores than females in physical and emotional functioning, psychosocial health, and total scale. Adolescents with lower ages showed better quality of life than those with higher ages in all scores of the PedsQL 4.0.

Conclusion

The PedsQL 4.0 showed good psychometric properties with regard to internal consistency, test–retest reliability, and convergent validity in Iranian adolescents, which supports its use in clinical settings among Persian-speaking adolescents. However, factor structure according to our CFA indicates that future work should address how to improve fit. In addition, studies that include PedsQL 4.0 should consider gender and age effects were reported.

Oral Health-Related Quality Of Life of Pre-School Children: Review and Perspectives for New Instruments

This study aimed to describe different approaches for the evaluation of the Oral health-related quality of life (OHRQoL) of preschool children and to discuss perspectives for future instruments. The OHRQoL is a concept that surpasses an exclusively clinical perception and includes functional, social, emotional, and environmental issues. The measure of OHRQoL represents a holistic approach for researchers and clinicians extending their visions beyond the mouth and understanding the entire context of the patient. Negative impacts of oral conditions on OHRQoL in childhood can reflect on health development, especially in a life stage marked by social and cognitive maturation. Instruments have been developed and cross-culturally adapted to evaluate the impact of oral conditions on the OHRQoL of preschool children and their families. Some features distinguish these instruments and influence their selection, such as: self- or proxy-report; generic- or specific-condition; long- or short-form, and less or more established used in literature. Moreover, theoretical framework, construct validation and availability should also be considered. Nine OHRQoL instruments for preschool children were included in the present literature review. They were created between 2003 and 2017 by developed countries in most cases. The shorter instrument has five items, and the larger has 31 items. Most of them are proxy-reported, generic-condition, and have been relatively well established in the literature. The diversity of instruments indicates the evolution of OHRQoL studies, but there are methodological issues still in need to be improved in future developments or cross-cultural adaptations, according to current psychometric evidence.

Validation for Brazilian Portuguese language of the Hong Kong Oral Health Literacy Assessment Task for Paediatric Dentistry (BOHLAT-P)

BACKGROUND

Oral health literacy (OHL) is associated with oral health outcomes.

AIM

To validate the Brazilian Portuguese version of the Hong Kong OHL Assessment Task for Paediatric Dentistry (HKOHLAT-P).

DESIGN

We performed cross-cultural adaptation of the HKOHLAT-P. A sample of 200 pre-schoolers and caregivers from Campina Grande, Brazil completed the Brazilian HKOHLAT-P (BOHLAT-P), sociodemographic questionnaire, the Brazilian Early Childhood Oral Health Impact Scale (B-ECOHIS), and the Brazilian Rapid Estimate of Adult Literacy in Dentistry (BREALD-30). Child dental caries was assessed. Instrument reliability was measured by internal consistency (Cronbach's alpha) and test-retest (ICC). Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) evaluated dimensionality. Regression models tested associations between BOHLAT-P and exploratory variables (P < .05).

RESULTS

BOHLAT-P demonstrated excellent reliability (Cronbach's alpha = 0.92; ICC = 0.95). BOHLAT-P and BREALD-30 scores (r = .71), number of schooling years (r = .60), and reading hours (r = .34) were positively correlated. BOHLAT-P and B-ECOHIS scores (r = -.22), and BOHLAT-P scores and number of cavitated teeth (r = -.15) were negatively correlated. After controlling for confounding variables, BOHLAT-P scores were not associated with caries or number of teeth with cavitated caries.

CONCLUSION

BOHLAT-P is a valid and reliable instrument to assess the OHL of Brazilian parents.

Adaptation and validation of the PEDSQL™ oral health scale for toddlers in Chilean population

BACKGROUND

The Pediatric Quality of Life Inventory™ (PedsQL™) Oral Health Scale was developed to measure oral health-related quality of life (OHRQoL). The aim of this study was to cross-culturally adapt the parent-reported version for toddlers of PedsQL™ Oral Health Scale into Spanish and to assess the acceptability, reliability and validity of this version in Chilean preschool population.

METHODS

The PedsQL™ Oral Health Scale for toddlers was cross-culturally adapted for the Spanish language using the recommended standards. To assess metric properties, a cross-sectional study was carried out with 301 children aged 2 to 5 years in Carahue, Chile. Chilean versions of the PedsQL™ Oral Health Scale, PedsQL™ 4.0 Generic Core Scales, and Early Childhood Oral Health Impact Scale (ECOHIS) were completed by the children's parents. Dental caries, malocclusion and dental trauma were examined by trained dentists. The PedsQL™ Oral Health Scale was administrated a second time 14-21 days after. The reliability of the scale was verified by analysis of internal consistency (Cronbach's alpha) and reproducibility (Intraclass correlation coefficient - ICC). The validity of the construct was assessed by confirmatory factor analysis and known groups method. The convergent validity was assessed by calculating the Spearman's correlation with the ECOHIS questionnaire.

RESULTS

The PedsQL™ Oral Health Scale demonstrated good reliability, with Cronbach's alpha coefficient of 0.79 and ICC of 0.85. A moderate-to-strong correlation was found between the PedsQL™ Oral Health Scale and the ECOHIS questionnaire (- 0.64); the PedsQL™ Oral Health Scale score was lower in children with poor than those with excellent/very good oral health (median 100 vs 85, p < 0.001); it also was lower in children with caries than in those caries-free (median 100 vs 90, p < 0.001). No statistically significant differences were found among groups according to malocclusion and traumatic dental injuries.

CONCLUSIONS

The PedsQL™ Oral Health Scale for toddlers in Spanish showed to be equivalent to the original version, and its psychometric properties were satisfactory for application in a Chilean pre-school population.

Short form development for oral health patient-reported outcome evaluation in children and adolescents

PURPOSE

Children and adolescents are vulnerable to dental problems and oral diseases. This paper presents the development of two multi-item self-report scales for use in assessing oral health status of children and adolescents.

METHODS

Following the Patient-Reported Outcome Measurement Information System framework, survey questions were designed using a newly developed conceptual model. These items were administered to 334 children and adolescents (8-17 years) along with concurrent dental exams. Exploratory and confirmatory factor analyses were conducted and the item response theory graded response model was used to estimate item parameters and oral health status scores and to identify short-form items. The items were selected by high level of information and wide coverage of different domains to assess Child Oral Health Status Index (COHSI) and treatment referral recommendations (RR).

RESULTS

The long form consists of 28 items. The short-form includes 12 items (8 for COHSI and 7 for RR with 3 common items).The intra-class correlations between long form and short-form were 0.90 for COHSI and 0.87 for RR.

CONCLUSION

The short-forms provide a possible solution for the longstanding challenge of oral health evaluation for large populations of children and adolescents. The calibrated long form provides the foundation for computer adaptive test administration. These oral health assessment toolkits can be used for oral health screening, surveillance program, policy planning, and research.

The relationship between body mass index (BMI) and quality of life in Iranian primary school students in Tehran, Iran

BACKGROUND

This study aimed to investigate the relationship between Body Mass Index (BMI) and quality of life in primary school students in Tehran.

METHOD

In this cross-sectional study 829 primary school children and their parents participated. Healthrelated quality of life (HROOL) was evaluated with the Persian version of Pediatric Quality of Life Inventory (PedsQL™4.0) questionnaire. According to objective measures of height and weight, children BMI computed, and adapted for age and gender. For data analysis we used Pearson correlation test, Independentsample t-test and ANOVA using SPSS version 18.

RESULTS

Mean of children self-reported HRQOL total score was 82.05 ± 12.04 and mean of parent proxyreported HRQOL total score was 81.66 ± 12.81. Based on HRQOL subscale scores, social functioning was the highest subscale score of HRQOL (84.67 ± 15.07) and the emotional subscale score was the lowest (77.79 ± 17.26). Lower HRQOL scores were significantly correlated with Higher BMI and normal weight children had significantly higher HRQOL total score than obese children (P < 0.05). The difference between normal weight and overweight children in HRQOL total scores were not significant. Same results were obtained from parent proxy-reports and a good harmony between children self-report and parent proxy-report of HRQOL was perceived.

CONCLUSION

This study showed that HRQOL of obese children were at the lower level in comparison to normal weight and overweight children. At further interventional studies these outcomes can be very important for improving quality of life in obese children.

The Effects of Two Planning Interventions on the Oral Health Behavior of Iranian Adolescents: A Cluster Randomized Controlled Trial

PURPOSE

The aim of this study was to investigate the effectiveness of a planning intervention (specifying when, where, and how to act) and an implementation intention intervention (specifying the same in the format of an if-then plan) in increasing self-reported brushing in adolescents.

METHODS

The study adopted a cluster randomized controlled trial design, and 1158 students in 48 schools were randomized to planning, implementation intention, or active control conditions. After baseline assessment, all participants received a leaflet containing information and recommendations on oral health and instructions on correct brushing behavior. After reading the leaflets, they were provided with a toothbrush and toothpaste plus a calendar in which to record their brushing. Participants in the planning condition and in the implementation intention condition also received instructions to form specific plans regarding brushing behavior. Self-reported brushing, perceived behavioral control, self-monitoring, intention, frequency of planning, oral health-related quality of life, and dental plaque and periodontal status were measured 1 and 6 months later.

RESULTS

Both intervention conditions showed a significant improvement in the frequency of self-reported brushing, self-monitoring, frequency of planning, intention, perceived behavioral control, plaque index, periodontal health, and oral health-related quality of life compared to the control condition at both follow-ups. Comparing the two intervention conditions revealed that adolescents who received the implementation intention intervention had significantly greater improvement in the frequency of self-reported brushing, intention, frequency of planning, and periodontal health than those in planning condition.

CONCLUSIONS

Taken together, the findings suggest that forming implementation intentions as well as planning has the potential to increase dental self-reported brushing rates in adolescents, but that forming implementation intentions has the strongest impact on dental hygiene behavior and is, therefore, recommended.

TRIAL REGISTRATION NUMBER

The trial was registered with the ClinicalTrials.gov database (NCT02066987) https://www.clinicaltrials.gov/ct2/show/NCT02066987 .

Rasch analysis of the Persian version of PedsQL(TM) Oral Health Scale: further psychometric evaluation on item validity including differential item functioning

Background: The study aimed to further evaluate the psychometric properties of one recently developed oral health related quality of life (OHRQoL) instrument (PedsQL Oral Health Scale), including student self-report and parent-proxy report. Specifically, we tested the item validity,threshold order, local dependency, and differential item functioning (DIF) across gender and rater.

Methods: This is a cross-sectional study, and study population was recruited in Qazvin, Iran using one-stage sampling with the unit of school. Students and their parents (1529 dyads) separately completed the Persian version of PedsQL Oral Health Scale. The psychometric properties were analyzed using Rasch rating scale model, including item validity, threshold order for response categories, and DIF across gender (boys vs. girls in student self-report) and rater (student self report vs. parent-proxy report).

Results: All items had satisfactory in fit and outfit mean square error. One disordering category (the response of often) was found in parent-proxy report, while all categories were ordered in student self-report. All items were DIF-trivial across gender and rater.

Conclusion: PedsQL Oral Health Scale is a valid instrument to measure OHRQoL. However, our results indicated that the parent-proxy report was inferior to the student self-report, and healthcare providers should primarily use the student self-report.

The effectiveness of gain-versus loss-framed health messages in improving oral health in Iranian secondary schools: a cluster-randomized controlled trial

BACKGROUND

Adherence to oral self-care behaviors is low among adolescents.

PURPOSE

This study aims to examine effects of two message framing interventions on oral self-care behaviors and health among Iranian adolescents.

METHODS

Cluster-randomized controlled trial, with four schools randomly assigned to receive gain-framed, loss-framed, or no messages. Brushing/flossing, attitudes, intentions, oral health related quality of life (OHRQOL), and clinical examinations were measured at baseline, two and twenty-four weeks. Data were analyzed using multilevel modeling.

RESULTS

At 2 weeks, loss-frame participants reported higher brushing and flossing rates, and more favorable attitudes and intentions to brush, compared to the other groups. At 24 weeks, loss-frame participants showed better OHRQOL, gingival health and less dental plaque compared to the other groups. Attitudes and intentions mediated intervention effects for the loss-framed group.

CONCLUSIONS

Loss-framed messages were more effective than gain-framed messages in encouraging oral self-care behaviors among Iranian adolescents. These effects were mediated through attitudes and intentions. (clinicaltrials.gov number NCT01421108.).

Validation of Persian rapid estimate of adult literacy in dentistry

AIM

The aim of the present study was to establish the psychometric properties of the Rapid Estimate of adult Literacy in Dentistry-99 (REALD-99) in the Persian language for use in an Iranian population (IREALD-99).

METHODS

A total of 421 participants with a mean age of 28 years (59% male) were included in the study. Participants included those who were 18 years or older and those residing in Quazvin (a city close to Tehran), Iran. A forward-backward translation process was used for the IREALD-99. The Test of Functional Health Literacy in Dentistry (TOFHLiD) was also administrated. The validity of the IREALD-99 was investigated by comparing the IREALD-99 across the categories of education and income levels. To further investigate, the correlation of IREALD-99 with TOFHLiD was computed. A principal component analysis (PCA) was performed on the data to assess unidimensionality and strong first factor. The Rasch mathematical model was used to evaluate the contribution of each item to the overall measure, and whether the data were invariant to differences in sex. Reliability was estimated with Cronbach's α and test-retest correlation.

RESULTS

Cronbach's alpha for the IREALD-99 was 0.98, indicating strong internal consistency. The test-retest correlation was 0.97. IREALD-99 scores differed by education levels. IREALD-99 scores were positively related to TOFHLiD scores (rh = 0.72, P < 0.01). In addition, IREALD-99 showed positive correlation with self-rated oral health status (rh = 0.31, P < 0.01) as evidence of convergent validity. The PCA indicated a strong first component, five times the strength of the second component and nine times the third. The empirical data were a close fit with the Rasch mathematical model. There was not a significant difference in scores with respect to income level (P = 0.09), and only the very lowest income level was significantly different (P < 0.01).

CONCLUSIONS

The IREALD-99 exhibited excellent reliability on repeated administrations, as well as internal consistency. The IREALD-99 can be used for the basic screening of oral health literacy among the Iranian population.

The PedsQL™ Oral Health Scale: feasibility, reliability and validity of the Brazilian Portuguese version

BACKGROUND

Oral and orofacial problems may cause a profound impact on children's oral health-related quality of life (OHRQoL) because of symptoms associated with these conditions that may influence the physical, psychological and social aspects of their daily life. The OHRQoL questionnaires found in the literature are very specific and are not able to measure the impact of oral health on general health domains. Consequently, the objective of this study was to evaluate the psychometric properties of the Portuguese version for Brazilian translation of the Pediatric Quality of Life Inventory™ (PedsQL™) Oral Health Scale in combination with the PedsQL™ 4.0 Generic Core Scales.

METHODS

The PedsQL™ Oral Health Scale was forward-backward translated and cross-culturally adapted for the Brazilian Portuguese language. In order to assess the feasibility, reliability and validity of the Brazilian version of the instrument, a study was carried out in Belo Horizonte with 208 children and adolescents between 2 and 18 years-of-age and their parents. Clinical evaluation of dental caries, socioeconomic information and the Brazilian versions of the PedsQL™ Oral Health Scale, PedsQL™ 4.0 Generic Core Scales, Child Perceptions Questionnaire (CPQ11-14 and CPQ8-10) and Parental-Caregiver Perception Questionnaire (P-CPQ) were administered. Statistical analysis included feasibility (missing values), confirmatory factor analysis (CFA), internal consistency reliability, and test-retest intraclass correlation coefficients (ICC) of the PedsQL™ Oral Health Scale.

RESULTS

There were no missing data for both child self-report and parent proxy-report on the Brazilian version of the PedsQL™ Oral Health Scale. The CFA showed that the five items of child self-report and parent proxy-report loaded on a single construct. The Cronbach's alpha coefficients for child/adolescent and parent oral health instruments were 0.65 and 0.59, respectively. The test-retest reliability (ICC) for child self-report and parent proxy-report were 0.90 [95% confidence interval (CI) = 0.86-0.93] and 0.86 (95%CI = 0.81-0.90), respectively. The PedsQL™ Oral Health Scale demonstrated acceptable construct validity, convergent validity and discriminant validity.

CONCLUSIONS

These results supported the feasibility, reliability and validity of the Brazilian version of the PedsQL™ Oral Health Scale for child self-report for ages 5-18 years-old and parent proxy-report for ages 2-18 years-old children.

Validity and reliability of the Iranian version of the Pediatric Quality of Life Inventory™ 4.0 (PedsQL™) Generic Core Scales in children

Background

This study aimed to investigate the reliability and validity of the Iranian version of the Pediatric Quality of Life Inventory™ 4.0 (PedsQL™ 4.0) Generic Core Scales in children.

Methods

A standard forward and backward translation procedure was used to translate the US English version of the PedsQL™ 4.0 Generic Core Scales for children into the Iranian language (Persian). The Iranian version of the PedsQL™ 4.0 Generic Core Scales was completed by 503 healthy and 22 chronically ill children aged 8-12 years and their parents. The reliability was evaluated using internal consistency. Known-groups discriminant comparisons were made, and exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted.

Results

The internal consistency, as measured by Cronbach's alpha coefficients, exceeded the minimum reliability standard of 0.70. All monotrait-multimethod correlations were higher than multitrait-multimethod correlations. The intraclass correlation coefficients (ICC) between the children self-report and parent proxy-reports showed moderate to high agreement. Exploratory factor analysis extracted six factors from the PedsQL™ 4.0 for both self and proxy reports, accounting for 47.9% and 54.8% of total variance, respectively. The results of the confirmatory factor analysis for 6-factor models for both self-report and proxy-report indicated acceptable fit for the proposed models. Regarding health status, as hypothesized from previous studies, healthy children reported significantly higher health-related quality of life than those with chronic illnesses.

Conclusions

The findings support the initial reliability and validity of the Iranian version of the PedsQL™ 4.0 as a generic instrument to measure health-related quality of life of children in Iran.