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Open Access Short report

Cross-cultural adaptation and psychometric properties of the Brazilian version of the scale of oral health outcomes for 5-year-old children (SOHO-5)

Jenny Abanto1*, Georgios Tsakos2, Saul Martins Paiva3, Daniela Goursand3, Daniela Prócida Raggio1 and Marcelo Bönecker1

Author Affiliations

1 Department of Pediatric Dentistry and Orthodontics, Faculty of Dentistry, University of São Paulo, Av. Lineu Prestes 2227, São Paulo, SP 05508-000, Brazil

2 Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 6BT, UK

3 Department of Pediatric Dentistry and Orthodontics, Faculty of Dentistry, Federal University of Minas Gerais, Av. Antônio Carlos 6627, Belo Horizonte, MG, 31270-901, Brazil

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Health and Quality of Life Outcomes 2013, 11:16  doi:10.1186/1477-7525-11-16

The electronic version of this article is the complete one and can be found online at: http://www.hqlo.com/content/11/1/16


Received:3 July 2012
Accepted:4 February 2013
Published:9 February 2013

© 2013 Abanto et al; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

Most of the instruments available to measure the oral health-related quality of life (OHRQoL) in paediatric populations focus on older children, whereas parental reports are used for very young children. The scale of oral health outcomes for 5-year-old children (SOHO-5) assesses the OHRQoL of very young children through self-reports and parental proxy reports. We aimed to cross-culturally adapt the SOHO-5 to the Brazilian Portuguese language and to assess its reliability and validity.

Findings

We tested the quality of the cross-cultural adaptation in 2 pilot studies with 40 children aged 5–6 years and their parents. The measurement was tested for reliability and validity on 193 children that attended the paediatric dental screening program at the University of São Paulo. The children were also clinically examined for dental caries. The internal consistency was demonstrated by a Cronbach's alpha coefficient of 0.90 for the children’s self-reports and 0.77 for the parental proxy reports. The test-retest reliability results, which were based on repeated administrations on 159 children, were excellent; the intraclass correlation coefficient was 0.98 for parental and 0.92 for child reports. In general, the construct validity was satisfactory and demonstrated consistent and strong associations between the SOHO-5 and different subjective global ratings of oral health, perceived dental treatment need and overall well-being in both the parental and children’s versions (p < 0.001). The SOHO-5 was also able to clearly discriminate between children with and without a history of dental caries (mean scores: 5.8 and 1.1, respectively; p < 0.001).

Conclusion

The present study demonstrated that the SOHO-5 exhibits satisfactory psychometric properties and is applicable to 5- to 6-year-old children in Brazil.

Keywords:
Oral health; Quality of life; Preschool children; Parents; Validation

Findings

Background

Different oral health-related quality of life (OHRQoL) measures have been developed for children older than 6 years [1-7]. For younger children, research related to OHRQoL measures is limited; however, there is some evidence that children aged 4–6 years can also reliably report their own HRQoL [8,9]. Four measures have been used for very young children [10-13]. Two of these measures [10,11] are based on parental proxy reports, although it is recognised that proxy and children’s self-reports measure different realities [14-17]. Another measure [12] uses only children’s self-reported parameters for children aged 8 years or older and parental proxy reports for younger children.

Recently, the scale of oral health outcomes for 5-year-old children (SOHO-5) [13] was developed to assess the OHRQoL in young children through both self- and parental reports. This measure has not yet been validated in any language except English. Therefore, we cross-culturally adapted the SOHO-5 to the Brazilian Portuguese language and tested its reliability and validity in 5- to 6-year-old children.

Methods

The SOHO-5 consists of a child self-report and a parental report of the child’s oral health history. Both versions contain 7 items. For the child version, the report refers to difficulties eating, drinking, speaking, playing, sleeping, smiling (due to pain) and smiling (due to appearance). The answers are reported using a 3-point scale (no = 0, a little = 1 and a lot = 2) aided by an explanation card with appropriate faces. The items in the parental version include difficulty eating, difficulty playing, difficulty speaking, difficulty sleeping, avoiding smiling due to pain, avoiding smiling due to appearance and affected self-confidence. The answering options follow a 5-point scale (no = 0, a little = 1, moderate = 2, a lot = 3 and a great deal = 4). A response of “Don’t know” was not used in the self-administered parental version, as we opted for an interview-administered questionnaire. The SOHO-5 scores are calculated as the sum of response codes. A higher score denotes a greater degree of oral impacts on the children’s quality of life.

Translation and cross-cultural adaptation

The SOHO-5 was translated and adapted according to published standard guidelines [18-21]. Two translations into Portuguese were made by two native Portuguese translators. A revision panel evaluated the translations and determined the conceptual and item equivalence. The consensus-translated version was pilot tested on twenty 5- to 6-year-old children and their parents. The panel developed a pilot version, which was translated back into English by two bilingual translators. The back-translated English consensus version was compared with the original English version to determine semantic equivalence.

Finally, the draft Brazilian version was pilot tested for a second time on a different convenience sample of twenty 5- to 6-year-old children and their parents. There were no changes regarding new suggestions or difficulties of comprehension, and the panel approved the final Brazilian Version of the SOHO-5.

Assessment of validity and reliability

Data were collected from interviews with 193 5- to 6-year-old children and their parents, who were recruited from a paediatric dental screening program at the Faculty of Dentistry, University of São Paulo (USP). Children aged 1–9 years living in São Paulo city were eligible to participate in the screening programme. Children that had not received dental treatment in the last three months, had no systemic diseases and lived with their parents were eligible for inclusion. The study was approved by the USP Ethics Committee in Research, and the parents signed informed consent forms.

The child and one of the parents completed the SOHO-5 in face-to-face independent interviews. The interviews were conducted on the same day prior to the clinical examinations by four trained interviewers who were blind to the clinical findings. The children’s oral examinations referred to dental caries according to standard widely applied clinical criteria [22] and were conducted by two paediatric dentistry specialists who were calibrated prior to data collection (Kappa: 0.92 for intra- and 0.87 for inter-examiner reliability).

The children’s and parental questionnaires both contained global rating questions. For the children’s questionnaires, the following ratings were included: satisfaction with oral health (‘How happy are you with your teeth?; not happy = 2, a little happy = 1 and very happy = 0’) and presence of dental cavities (‘Do you have any holes in your teeth?; No = 0, Yes = 1’). For the parental questionnaires, the following ratings were included: proxy-rated oral health (‘How would you rate your child’s dental health?; excellent = 0, very good = 1, good = 2, fair = 3, poor = 4’), satisfaction with child’s oral health (‘How happy are you with your child’s dental health?; very happy = 0 to very unhappy = 4’), the child’s overall well-being (‘Do you think the overall well-being of your child is affected by the conditions of their teeth?; not at all = 0 to a great deal = 4’), and the child’s perceived dental treatment needs (‘Do you think your child needs any dental treatment because of the state (holes in teeth or pain) of his/her teeth?; no = 0, Yes = 1’).

Data analysis

Internal consistency was assessed using Cronbach's alpha for the total score and the item-total score correlations. The test-retest reliability was assessed by calculating the intraclass correlation coefficient (ICC) for the SOHO-5 score using the data from 159 children and their parents who were interviewed for a second time 7–14 days after the first interview by the same interviewers. We tested construct validity through associations between the SOHO-5 scores and the global ratings using Spearman's correlation coefficients. Discriminant validity compared the SOHO-5 scores between the children with a history of caries and the children without a history of caries (dmft > 0 vs. dmft = 0) using Mann–Whitney tests.

Results

Overall, 219 children and their parents were invited to participate in the study. Sixteen were excluded because they did not conform to the study criteria. Of the 203 eligible participants, 193 provided signed parental informed consent (response rate: 95.1%).

The sample (n = 193) consisted primarily of boys (54.9%) and 5-year-old children (58.5%), and 44.6% of the sample population had a history of dental caries. Most of the parental questionnaires were answered by mothers (91.2%). The parental SOHO-5 score ranged from 0 to 24, with a mean of 3.67 (standard deviation: 5.54). The child SOHO-5 score ranged from 0 to 12, with a mean of 2.45 (sd: 2.92). More than 64% of the parents and 68% of the children reported oral impacts (SOHO-5 score > 0).

The Cronbach's alpha coefficients were 0.77 and 0.90 for the children’s and parental versions, respectively (Tables 1 and 2), which indicated good internal consistency. For test-retest reliability, the ICCs were 0.92 and 0.98 for the total scores of the children’s and parental versions, respectively, which indicated excellent reproducibility (Tables 1 and 2). The construct validity showed that the SOHO-5 total score was associated significantly and in the expected direction with two global rating questions for children and the four respective questions for parental proxy reports (Tables 3 and 4). For both versions, children with a history of dental caries exhibited significantly higher SOHO-5 total and item scores compared with children with no history of dental caries (Tables 5 and 6).

Table 1. Reliability statistics for total score and items in the children’s self-reported version (n = 159)

Table 2. Reliability statistics for the total score and items in the parental version (n = 159)

Table 3. Construct validity for the children’s version (n = 193)

Table 4. Construct validity for the parental version (n = 193)

Table 5. Discriminant validity for the child version

Table 6. Discriminant validity for the parental version

Discussion

This study cross-culturally adapted and successfully validated the SOHO-5 for use among Brazilian children and their parents. It also demonstrated that 5- to 6-year-old children in Brazil are capable of providing their own perceptions concerning their OHRQoL, and studies should no longer depend solely on parental proxy reports. Many subjects in the sample population (90.3%) were able to understand the SOHO-5 and respond appropriately to the questions, independently of the age or sex of the children.

In addition to a meticulous translation, we employed a pre-test phase, which is important for identifying potential problems with the questionnaire content, such as misunderstandings about the intended meaning of the items and their clarity. The results showed semantic equivalence between the English and Brazilian Portuguese language versions of the SOHO-5.

The psychometric properties of the SOHO-5 were satisfactory and provided strong support for its reliability and validity. The reliability of the SOHO-5 was established for both internal and test-retest consistency, and its validity was evident in the consistent and strong associations with different subjective global ratings of oral health, perceived dental treatment need and overall well-being in both the parental and children’s versions. The measure also demonstrated discriminant validity between clinical groups according to their caries history.

Despite the inclusive nature of the screening programme, the sample was not representative of the general population of 5- to 6-year-old children. Therefore, the prevalence of oral impacts in the general population may be different. Because our sample consisted of children that had already sought dental treatment in the screening program, the oral impacts among children with dental caries in the general population could be even higher because children may not seek or have access to dental care. However, the dental caries history in our sample (44.6%) was similar to that of the general population of 5-year-old children in Brazil (56.4%) [23].

We acknowledge that 5- and 6-year-old children are not developmentally identical. While the original SOHO-5 study referred to 5-year-old children, an older child may comprehend and answer the questions more easily due to more advanced cognitive development [24]. Our study, which included children primarily of middle and lower socioeconomic status with a low proportion of affluent children, would have benefited from a more balanced sample in relation to socioeconomic position. Finally, the paper focused on validating the SOHO-5 with clinical determinants accounting for the potential confounding effect of other factors, which would require a larger and more representative sample and is therefore a future priority.

Conclusion

This study provides strong evidence supporting the reliability and validity of the Brazilian SOHO-5 to be used as an OHRQoL measure for 5- to 6-year-old Brazilian children.

Competing interest

The authors declare that they have no competing interests.

Authors’ contributions

JA was responsible for the acquisition of data, assisted in the analysis and interpretation of data and drafted the manuscript; GT was responsible for the conception and design of the study and critical manuscript review; SMP performed the design of the study, acquisition of data (Revision Panel), and helped with the statistical analysis and critical manuscript review; DPR was responsible for the acquisition of data (Revision Panel) and critical manuscript review; PC performed the acquisition of data and critical manuscript review; DG helped with the statistical analysis, interpretation of data and critical review; MB was responsible for the conception and design of the study, acquisition of data (Revision Panel) and critical manuscript review. All the authors read and approved the final manuscript.

Acknowledgements

We thank Thiago Saads Carvalho and Christiana Murakami, who undertook the initial translations of the instrument. We also thank the participants of the post-graduation in paediatric dentistry seminar of FOUSP for their constructive comments. This study was financially supported by the FAPESP (Fundação de Amparo à Pesquisa do Estado de São Paulo) process n° 2009/17040-0.

References

  1. Jokovic A, Locker D, Stephens M, Kenny D, Tompson B, Guyatt G: Validity and reliability of a questionnaire for measuring child oral-health-related quality of life.

    J Dent Res 2002, 81:459-463. PubMed Abstract | Publisher Full Text OpenURL

  2. Jokovic A, Locker D, Tompson B, Guyatt G: Questionnaire for measuring oral health-related quality of life in eight- to ten-year-old children.

    Pediatr Dent 2004, 26:512-518. PubMed Abstract OpenURL

  3. Jokovic A, Locker D, Guyatt G: Short forms of the Child Perceptions Questionnaire for 11-14-year-old children (CPQ11-14): development and initial evaluation.

    Health Qual Life Outcomes 2006, 4:4. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  4. Jokovic A, Locker D, Stephens M, Kenny D, Tompson B, Guyatt G: Measuring parental perceptions of child oral health-related quality of life.

    J PublicHealth Dent 2003, 63:67-72. OpenURL

  5. Gherunpong S, Tsakos G, Sheiham A: Developing and evaluating an oral health-related quality of life index for children; the CHILD-OIDP.

    Community Dent Health 2004, 21:161-169. PubMed Abstract OpenURL

  6. Broder HL, Wilson-Genderson M: Reliability and convergent and discriminant validity of the Child Oral Health Impact Profile (COHIP Child's version).

    Community Dent Oral Epidemiol 2007, 35(Suppl 1):20-31. PubMed Abstract | Publisher Full Text OpenURL

  7. Yusuf H, Gherunpong S, Sheiham A, Tsakos G: Validation of an English version of the Child-OIDP index, an oral health-related quality of life measure for children.

    Health Qual Life Outcomes 2006, 4:38. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  8. Connolly MA, Johnson JA: Measuring quality of life in paediatric patients.

    Pharmacoeconomics 1999, 16:605-625. PubMed Abstract | Publisher Full Text OpenURL

  9. Varni JW, Seid M, Kurtin PS: PedsQL" 4.0: reliability and validity of the Pediatric Quality of Life Inventory version 4.0 generic core scales in healthy and patient populations.

    Med Care 2001, 39:800-812. PubMed Abstract | Publisher Full Text OpenURL

  10. Filstrup SL, Briskie D, da Fonseca M, Lawrence L, Wandera A, Inglehart MR: Early childhood caries and quality of life: child and parent perspectives.

    Pediatr Dent 2003, 25:431-440. PubMed Abstract OpenURL

  11. Pahel BT, Rozier RG, Slade GD: Parental perceptions of children's oral health: the Early Childhood Oral Health Impact Scale (ECOHIS).

    Health Qual Life Outcomes 2007, 5:6. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  12. Huntington NL, Spetter D, Jones JA, Rich SE, Garcia RI, Spiro A 3rd: Development and validation of a measure of pediatric oral health-related quality of life: the POQL.

    J Public Health Dent 2011, 71:185-193. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  13. Tsakos G, Blair YI, Yusuf H, Wright W, Watt RG, Macpherson LMD: Developing a new self-reported scale of oral health outcomes for 5-year-old children (SOHO-5).

    Health Qual Life Outcomes 2012, 10:62. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  14. Jokovic A, Locker D, Guyatt G: How well do parents know their children? Implications for proxy reporting of child health-related quality of life.

    Qual Life Res 2004, 13:1297-1307. PubMed Abstract OpenURL

  15. Barbosa TS, Gavião MB: Oral health-related quality of life in children: part III. Is there agreement between parents in rating their children's oral health-related quality of life? A systematic review.

    Int J Dent Hyg 2008, 6:108-113. PubMed Abstract | Publisher Full Text OpenURL

  16. Vetter TR, Bridgewater CL, McGwin G: An observational study of patient versus parental perception of health-related quality of life in children and adolescents with chronic pain condition: who should the clinical believe?

    Health Qual Life Outcomes 2012, 10:85. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  17. Ardon MS, Selles RW, Roebroeck ME, Hovius SE, Stam HJ, Janssen WG: Poor agreement on health-related quality of life between children with congenital hand differences and their parents.

    Arch Phys Med Rehabil 2012, 93:641-646. PubMed Abstract | Publisher Full Text OpenURL

  18. Guillemin F, Bombardier C, Beaton D: Cross-cultural adaptation of health-related quality of life measures: literature review and proposed guidelines.

    J Clin Epidemiol 1993, 46:1417-1432. PubMed Abstract | Publisher Full Text OpenURL

  19. Herdman M, Fox-Rushby J, Badia X: A model of equivalence in the cultural adaptation of HRQoL instruments: the universalist approach.

    Qual Life Res 1998, 7:323-335. PubMed Abstract | Publisher Full Text OpenURL

  20. Streiner DL, Norman GR: Health measurement scale: practical guide to their development and use. 3rd edition. New York: Oxford University Press; 2003. OpenURL

  21. Van Widenfelt BMV, Treffers PDA, Beurs E, Siebelink BM, Koudijs E: Translation and cross-cultural adaptation of assessment instruments used in psychological research with children and families.

    Clin Child Fam Psychol Rev 2005, 8:135-147. PubMed Abstract | Publisher Full Text OpenURL

  22. Knutson JW: An index of the prevalence of dental caries in school children.

    Public Health Rep 1944, 59:253-263. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  23. Ministério da Saúde:

    Departamento de Atenção Básica. Coordenação Nacional de Saúde Bucal. SBBrasil. 2010.

    In: http://189.28.128.100/dab/docs/geral/projeto_sb2010_relatorio_final.pdf webcite

    PubMed Abstract | Publisher Full Text OpenURL

  24. Hetherington EM, Parke RD, Locke VO: Child Psychology: A Contemporary Viewpoint. New York: NY, McGraw-Hill; 1996. OpenURL