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Year : 2019  |  Volume : 37  |  Issue : 4  |  Page : 333-338

Validation of the Hindi version of the early childhood oral health impact scale among 3–5-year-old preschool children in Rohtak city, Haryana

1 Department of Public Health Dentistry, Postgraduate Institute of Dental Sciences, Pt. B.D Sharma University of Health Sciences, Rohtak, Haryana, India
2 Department of Prosthodontics, SPPGIMS, Dr. RML Avadh University, Faizabad, Uttar Pradesh, India

Date of Web Publication7-Nov-2019

Correspondence Address:
Dr. Mamta Ghanghas
Department of Public Health Dentistry, Postgraduate Institute of Dental Sciences, Pt. B.D Sharma University of Health Sciences, Rohtak, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_128_18

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Background: The early childhood oral health impact scale (ECOHIS) has been developed for assessing oral health-related quality of life (OHRQoL) in the preschool children and translated and validated in different languages to conform to their cultures. This tool has not been validated in Hindi for use among Indian preschool children till now. Hence, the present study was undertaken to assess the validity of the Hindi version of the ECOHIS among 3–5-year-old preschool children in Rohtak city, Haryana. Materials and Methods: The Hindi version of the ECOHIS was developed through standardized forward–backward linguistic translation method. It was tested for validity and reliability among 469 parents and their children after obtaining informed consent. Construct validity of the measure was assessed by correlating ECOHIS score to dental caries experience (deft). For internal consistency, Cronbach's alpha was determined. A subsample of the parents repeated the ratings of the measure to enable test–retest reliability assessments. Results: Construct validity was r = 0.298. Reliability of the questionnaire was 0.873 (Cronbach's alpha), and test–retest reliability as assessed by intraclass correlation value was 0.91. Conclusions: The Hindi version of the ECOHIS is a valid instrument for assessing OHRQoL in preschool children.

Keywords: Early childhood oral health impact scale, oral health-related quality of life, preschool children

How to cite this article:
Ghanghas M, Manjunath B C, Kumar A, Shyam R, Phogat R, Panghal V. Validation of the Hindi version of the early childhood oral health impact scale among 3–5-year-old preschool children in Rohtak city, Haryana. J Indian Soc Pedod Prev Dent 2019;37:333-8

How to cite this URL:
Ghanghas M, Manjunath B C, Kumar A, Shyam R, Phogat R, Panghal V. Validation of the Hindi version of the early childhood oral health impact scale among 3–5-year-old preschool children in Rohtak city, Haryana. J Indian Soc Pedod Prev Dent [serial online] 2019 [cited 2022 Nov 29];37:333-8. Available from: http://www.jisppd.com/text.asp?2019/37/4/333/270473

   Introduction Top

Poor oral health may have a negative influence on the functional, social, and psychological well-being of young children, causing pain and discomfort which may influence quality of life (QoL).[1] QoL is an individual's perception of his/her position in life, in the context of the culture and value systems in which they live, and in relation to their goals, expectations, and concerns.[2] Assessment of the effect of oral health-related QoL (OHRQoL) is especially important in young children as it can affect their growth, socializing, self-esteem, and learning abilities.[3] Conventionally, oral health has been measured on the basis of clinical indicators which does not document the full impact of oral disorders on lives of affected individuals particularly QoL.[4] This led to origin of concept of OHRQoL which assess the functional and psychosocial outcomes of oral diseases and supplement clinical indicators to provide a comprehensive account of the health of individuals.[5] OHRQoL measures developed for adults have been deemed unsuitable for use among children as they have different health concerns, and further these measures are outside the realm of their linguistic and cognitive abilities.[6]

Early childhood oral health impact scale (ECOHIS) was developed by Pahel et al., to assess the impact of oral disorders on QoL among preschool children (0–5 years of age), comprising of thirteen items distributed among the child impact section (CIS) and family impact section (FIS).[7] The CIS has nine questions distributed among four domains: child symptom, child function, child psychology, and child self-image and social interaction while FIS has four questions distributed among two domains: parental distress and family function. It contemplate that parents/caregivers have a fundamental role in the treatment, decision-making process, and perceptions regarding their child's oral health. Each question asks about frequency of an oral health-related problem. The scale has five rating response options to record how often an event has occurred in the life of the child: 0 = never; 1 = hardly ever; 2 = occasionally; 3 = often; 4 = very often; and 5 = do not know. CIS and FIS ECOHIS scores range from 0 to 36 and 0 to 16, respectively, for which higher scores indicate a greater oral health impact and poorer OHRQoL.

It is imperative that the different language version of the same measure be evaluated to enable its use in those respective places so as to evaluate oral health status of children there and allowing its comparison with those elsewhere.[8] ECOHIS was developed in English and has been successfully translated and validated into various languages.[3] India is the second-most populous country in the world with a significant burden of oral diseases among children.[9] Hindi is national language of India and ECOHIS has not been validated in Hindi till now. Hence, the present study was undertaken with the aim to develop Hindi version of the ECOHIS and evaluate its validity and reliability among 3–5-year-old preschool children in Rohtak city, Haryana.

   Materials and Methods Top

A cross-sectional descriptive study was conducted among parents of 3–5 years' preschool children of Rohtak city, Haryana, between August 2015 and September 2015. The study protocol was reviewed by Institutional Ethical Committee and was granted ethical clearance (PGIDS/IEC/2015/54). Official permission was obtained from the District Education Officer and also from concerned school authorities. After explaining the purpose and details of the study, a written informed consent was obtained from the parents of all children aged 3–5 years.

Multistage cluster sampling technique was employed to ensure representativeness from all parts of city. In the first stage, Rohtak city was divided into nine clusters, and then one school was randomly selected from each cluster using lottery method. Finally, from each selected school, every odd roll number child of age group 3-5 years was enrolled to reach a sample of 469. Children present on the day of examination and those willing to participate in the survey were included whereas those uncooperative, with a history of systemic diseases and developmental anomalies and whose parents did not give consent were excluded. The sample size of 469 for the study was calculated based on number of items in questionnaire at 95% confidence interval and 5% margin of error and taking 90% response rate.

The ECOHIS was translated in Hindi language by an English–Hindi transcriptionist whose native language was Hindi. The Hindi version was then back-translated to English by another translator. The two translators worked independently, and the one responsible for the back-translation had no knowledge of the original English language version of the questionnaire. The back-translated English version was compared with original English version making adjustments in Hindi version through consultation with all translators and investigators. Prior to being finalized, the questionnaire was pilot-tested on a group of 25 parents of 3–5-year-old preschool children to ensure clarity, reliability, and validity. According to the results of this study, certain omissions/replacements were made, i.e. from item regarding “difficulty eating some food,” word “some” was omitted and expression “been irritable or frustrated” was replaced by “been irritable or disappointed,” and thus, the final Hindi version of ECOHIS was prepared.

Data collection included a combination of questionnaire administration and clinical examination for the assessment of oral health status. A structured questionnaire comprising of sociodemographic characteristics of participants and Hindi version of ECOHIS was sent to their homes to be filled by their parents. Dental caries experience was recorded using “deft” index.[10] Type III examination was done using mouth mirror and explorer using artificial light as a source of illumination in school rooms.

The data were entered into Microsoft Excel and analyzed using Statistical Package for Social Sciences version 20.0 (IBM Corporation in Armonk, New York, United States) package to assess psychometric properties of Hindi ECOHIS. Reliability was assessed in two ways: internal consistency reliability and test–retest reliability. Internal consistency reliability was tested by assessing the mean item correlation of items within ECOHIS using Cronbach's alpha coefficient. Test–retest reliability was assessed by determining the level of agreement between initial and repeat assessments of the ECOHIS after 1 month by calculating intraclass correlation coefficients (ICC) in a one-way random effect parallel model.

Convergent validity was assessed based on Spearman's rank-order correlations between ECOHIS scores and parental perspective of the presence of dental disease among their children and also ECOHIS scores in the CIS with that in FIS. The hypothesis related to this test is that parents' assessment of their child's oral health is likely to be closely related to parental perceptions of the effect of their child's oral health on the family. Interpretation of correlation coefficients was as follows: r ≤ 0.49, weak relationship; 0.50 ≤ r ≤0.74, moderate relationship; and r ≥ 0.75, strong relationship.[11]

Construct validity was examined by correlating ECOHIS scores with deft. The prior assumption was that deft scores have a moderate-to-high correlation with ECOHIS scores. Discriminant validity was evaluated by comparing the ECOHIS scores in children with and without dental caries using Mann–Whitney U-test. The hypothesis is that ECOHIS scores would be higher among children affected with caries as compared to caries-free children.

   Results Top

[Table 1] shows the results for demographic characteristics of the parents and children in the study sample (n = 469). Among the study participants, 57.8% (271) were male and 42.2% (198) were female population with mean age 4.05 ± 0.749 years old. The overall prevalence of dental caries was found to be 32% with mean deft 1.085 ± 2.27.
Table 1: Characteristics of child and parents from the study population (n=469)

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The parental responses to the Hindi version of ECOHIS are presented in [Table 2]. The distribution of responses to each question was skewed because majority of participants (82%–90%) reported “never.” In CIS items related to “pain” (9.4%), “eating” (4.5%), “drinking” (3.2%), and “difficulty in pronunciation” (3.1%) were more frequently reported while in FIS items related to “been upset” (1.3%), “felt guilty” (1.3%), and “financial impact on family” (1%) were reported more frequently.
Table 2: Distribution of early childhood oral health impact scale responses

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[Table 3] provides mean scores of ECOHIS domains mean ECOHIS score were 1.79 ± 4.018 with a range from 0 to 27. In CIS sore ranged from 0 to 21 with a higher mean score in child function domain 0.42 ± 1.254 and FIS score ranged from 0 to 11 with higher mean score on parental distress domain 0.46 ± 1.096.
Table 3: Score of each domain of early childhood oral health impact scale

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The Cronbach's alpha for ECOHIS as a whole was 0.873 and for child and FIS was 0.850 and 0.777, respectively. Intraclass correlation coefficient (ICC) was found to be 0.91 showing good agreement between test–retest results [Table 4].
Table 4: Reliability analysis

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Correlation between the parental perspective of the presence of dental disease in their child and ECOHIS score though weak but was found to be statistically significant (r = 0.387, P < 0.01) verifying convergent validity of Hindi version of ECOHIS. The correlation between ECOHIS score between child and FIS was found to be statistically significant (r = 0.0.451, P < 0.01), which further confirms its convergent validity.

Construct validity of Hindi ECOHIS is supported by the correlation between deft and ECOHIS score though weak but was found to be statistically significant (r = 0.298, P < 0.01). The mean ECOHIS scores for whole scale and of both child and FIS were higher among children with dental caries, and the difference was found to be statistically significant approving discriminant validity of ECOHIS (P < 0.01) [Table 5].
Table 5: Discriminant validity

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   Discussion Top

The present study evaluated the psychometric properties of the Hindi version of the ECOHIS by determining its validity and reliability using discriminant validity, internal consistency, and test–retest reliability which is essential for the cross-cultural adaptation of any QoL measure. Studies assessing validation of QoL scales enroll potential participants from hospital, schools or community. Regarding ECOHIS validation by Jabarifar et al.,[12] Li et al.,[8] and Lee et al.,[13] enrolled participants from clinics, a community-based sample which presents a real-life situation was used in the current study. Subjects from hospital-based settings present the picture from the tip of Iceberg, missing the underlying situation.

In the present study, the ECOHIS was translated into Hindi by forward–backward translation technique and although word modifications were made taking in account cultural differences, all of the 13 items of original ECOHIS were retained because of their universality and relevance in focus group discussion and hence the Hindi version of ECOHIS thus developed can be employed in cross-national comparisons because of its similarity to the original version.

The item regarding “difficulty eating some food” was slightly altered in Hindi ECOHIS by omitting the word “some” as parents enquired regarding specific foods, hence the term “some” was removed. Another modification introduced in Hindi ECOHIS was replacing expression “been irritable or frustrated” by “been irritable or disappointed” as word “frustrated” has multiple meanings – angry, aggravated, thwarted, disappointed and it was very difficult to specifically translate this word with a single meaning, hence to avoid confusion, it was replaced with word “disappointed” after the pilot phase. Such modifications have been done previously based on linguistic, ethnic, and regional considerations. Oliveira and Nadanovsky [14] replaced “pain in the mouth” by “toothache” while validating the Brazilian version of oral health impact profile-14 (OHIP-14) to improve content validity of the instrument as they found false-negative responses to this specific question in the interview. They further replaced the expression “been self-conscious” by “been worried” whereas Wong et al.,[15] while validating Chinese version of OHIP used the same phrases vice versa which made its use more appropriate in regards to the population and purpose of study.

Cronbach's alpha in the present study was 0.873, which was above the recommended value of 0.70 but lower than the original English version. Insignificant increase in Cronbach's alpha coefficient was seen if the item on “difficulty in pronounciation” was deleted. In addition, the value was lower than 0.95 indicating that no item was deemed redundant or overlapped with another in the construct. Cronbach's alpha coefficient describes the extent to which all the items in a test measure the same concept or construct and hence it is affected by inter-relatedness of the items. Moreover, the number of items and homogeneity of construct also influence Cronbach alpha and also it is intimately linked to the homogeneity of population. If a test has a strong internal consistency, it should show only moderate correlation among items (0.7–0.9).

It was found in the present study that Cronbach's alpha coefficient for family section though acceptable was lower that than of child domain. Martins-Júnior et al.,[16] also reported that result for reliability of internal consistency of family section was marginal similar to that observed by Scarpelli et al.,[17] and they attributed this to lesser number of items in family section.

In the present study, all inter-item correlations as well as corrected item-total correlations were positive and above the recommended level of 0.2. The rule of the thumb is that an item should correlate with the total score above 0.2 and items with scores below 0.2 must be discarded.[18] The corrected item-total correlations in the present study were all positive ranging from 0.314 to 0.702.

The ICC for test–retest reliability in the present study was 0.91, which is close to that of the French ECOHIS [8] and was higher than that of the original English version,[7] the Turkish version,[11] the Farsi ECOHIS,[12] the Chinese ECOHIS [13] and the Urdu version.[19] The Brazilian ECOHIS,[17] Malay version,[20] and Malyalam version [18] in comparison had a high test–retest reliability than found in the present study. In the present study, the gap between two administrations of the questionnaire was planned 2 weeks initially, but due to some administrative reasons, it was extended to 1 month which was sufficient to fade away memory effects. It is suggested that the interval between two administrations should be long enough to diminish the effects of memory and short enough to reduce the likelihood of systemic alterations. Although the definition of this interval is arbitrary, a period of 2–14 days is considered to be sufficient. The ICC in the present study supports evidence of satisfactory reproducibility of the Hindi version of ECOHIS.

It is important to note that Hindi version of ECOHIS showed high floor effect (i.e. lowest possible score of 0) inconsistent to various other versions of ECOHIS, i.e., original English, Chinese and Turkish versions. This could be due to lower caries prevalence in the present study as participants in the current study were selected from a community-based sample in contrast to previous studies which were hospital-based convenience samples. Poor perception of oral health problems and the fact that untreated carious deciduous teeth can remain symptomless until shed [16] could be reason for high floor effect. No ceiling effect was observed, i.e., scores of 36 and 16 in child and FIS in collaboration to other validation studies. While analyzing distribution of items in the present study, it was found that impacts reported more frequently by parents in child section were related to “pain,” “eating,” “drinking,” and “difficulty in pronunciation” and in family section were related to “been upset,” “felt guilty,” and “financial impact on family” similar to those reported in previous validation studies.

Correlation between ECOHIS scores in child and family section was used to assess convergent validity in the present study and was found to be significant similar to original English and Turkish versions of ECOHIS. Furthermore, the parental perspective of the presence of dental disease among their children was found to be significantly associated to ECOHIS thus further confirming convergent validity of Hindi version of ECOHIS. Most of the validation studies for ECOHIS had used global measure of oral health, i.e., “how do you rate your child's oral health?” and ECOHIS scores correlation to assess convergent validity with underlying hypothesis that parents who report high level of impacts would be more likely to rate oral health of their child “poor.”

Construct validity showed a significant but weak correlation between whole ECOHIS score and deft consistent to findings of Martins-Júnior et al.[16] These findings proved the construct validity of Hindi version of ECOHIS similar to findings for versions used in China and Turkey. It should be noted that researchers in other validation studies investigated the correlation among ECOHIS scores, deft, discolored upper anterior teeth, and gingival index to assess construct validity of ECOHIS.

Significant differences were observed between mean values for overall ECOHIS scores for children with and without caries. These findings are consistent to other ECOHIS validation studies which also reported higher ECOHIS scores in children with dental caries. This can be inferred from these findings that Hindi version of ECOHIS can discriminate between two groups of children with and without caries.

Pain is the most important reason for seeking treatment, with neglected oral health in Indian population the OHRQoL responses might be related to higher spectrum of disease missing carious lesion stages which are asymptomatic or do not have pain. Children under 3 years of age were not included in the study, but ECOHIS was developed and validated for use in 0–5-year-old children. No representation in sample subjects from rural area might have affected the generalizability of results of the present study. Limitations inherent to cross-sectional designed surveys were also associated with the present study.

   Conclusion Top

To conclude, the Hindi version of ECOHIS is a reliable and valid instrument for assessing the OHRQOL in 3–5-year-old preschool children. The use of this scale could help clinicians, researchers, and policymakers to interpret the effects of dental caries on young children and their families and to plan effective oral health promotion interventions and oral health care services. This scale provides an opportunity to compare similarities and differences in oral health impacts among young children in India with those in other countries.

Clinical indicators such as gingival index, trauma, and malocclusion along with dental caries could be used so as to provide a more comprehensive overview of oral health status of preschool children. Future studies should be conducted on the ECOHIS to evaluate its psychometric properties in both community- and clinic-based study settings with participants having representation of both urban and rural areas using interview-based approach.

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There are no conflicts of interest.

   References Top

Scarpelli AC, Paiva SM, Viegas CM, Carvalho AC, Ferreira FM, Pordeus IA. Oral health-related quality of life among Brazilian preschool children. Community Dent Oral Epidemiol 2013;41:336-44.  Back to cited text no. 1
Study protocol for the World Health Organization project to develop a quality of life assessment instrument (WHOQOL). Qual Life Res 1993;2:153-9.  Back to cited text no. 2
Jankauskienė B, Narbutaitė J, Kubilius R, Gleiznys A. Adaptation and validation of the early childhood oral health impact scale in Lithuania. Stomatologija 2012;14:108-13.  Back to cited text no. 3
Kramer PF, Feldens CA, Ferreira SH, Bervian J, Rodrigues PH, Peres MA. Exploring the impact of oral diseases and disorders on quality of life of preschool children. Community Dent Oral Epidemiol 2013;41:327-35.  Back to cited text no. 4
Jokovic A, Locker D, Stephens M, Kenny D, Tompson B, Guyatt G, et al. Validity and reliability of a questionnaire for measuring child oral-health-related quality of life. J Dent Res 2002;81:459-63.  Back to cited text no. 5
Barbosa TS, Gavião MB. Oral health-related quality of life in children: Part I. How well do children know themselves? A systematic review. Int J Dent Hyg 2008;6:93-9.  Back to cited text no. 6
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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. 8
Hiremath A, Murugaboopathy V, Ankola AV, Hebbal M, Mohandoss S, Pastay P. Prevalence of dental caries among primary school children of India – A cross-sectional study. J Clin Diagn Res 2016;10:ZC47-50.  Back to cited text no. 9
Gruebbel AO. A measurement of dental caries prevalence and treatment service for deciduous teeth. J Dent Res 1944;23:163-8.  Back to cited text no. 10
Peker K, Uysal Ö, Bermek G. Cross – Cultural adaptation and preliminary validation of the Turkish version of the early childhood oral health impact scale among 5-6-year-old children. Health Qual Life Outcomes 2011;9:118.  Back to cited text no. 11
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. 12
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. 13
Oliveira BH, Nadanovsky P. Psychometric properties of the Brazilian version of the Oral Health Impact Profile-short form. Community Dent Oral Epidemiol 2005;33:307-14.  Back to cited text no. 14
Wong MC, Lo EC, McMillan AS. Validation of a Chinese version of the Oral Health Impact Profile (OHIP). Community Dent Oral Epidemiol 2002;30:423-30.  Back to cited text no. 15
Martins-Júnior PA, Ramos-Jorge J, Paiva SM, Marques LS, Ramos-Jorge ML. Validations of the Brazilian version of the Early Childhood Oral Health Impact Scale (ECOHIS). Cad Saude Publica 2012;28:367-74.  Back to cited text no. 16
Scarpelli AC, Oliveira BH, Tesch FC, Leão AT, Pordeus IA, Paiva SM. Psychometric properties of the Brazilian version of the Early Childhood Oral Health Impact Scale (B-ECOHIS). BMC Oral Health 2011;11:19.  Back to cited text no. 17
Bhat SG, Sivaram R. Psychometric properties of the Malayalam version of ECOHIS. J Indian Soc Pedod Prev Dent 2015;33:234-8.  Back to cited text no. 18
[PUBMED]  [Full text]  
Riaz FM, Faisal J, Benish M. Translation, cross-cultural adaptation and validation of Early Childhood Oral Health Impact Scale (ECOHIS) in Urdu. Int J Dent Health Sci 2016;3:294-301.  Back to cited text no. 19
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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