The original ECOHIS aimed to assess the impact of both oral health problems and related treatment experiences on the quality of life of preschool children and their families [8]. This study is the first attempt to deploy a valid cross-cultural instrument used effectively in many countries worldwide to measure OHRQoL of preschool children in Thailand. ECOHIS focuses on the impact of ECC, which has been a major health problem in Thai preschoolers. The most recent NOHS in Thailand in 2017 revealed that the prevalence of ECC was 52.9% in 3-year-olds and 75.6% in 5-year-olds [32]. An assessment of the impact of these oral health problems on children’s quality of life has never been conducted. The ECOHIS has been adapted for use in some Asian populations with a similar ECC situation as in Thailand [22, 25]. The Thai version of ECOHIS was developed from the original version following the standard cross-cultural adaption process [36, 37]. All 13 items of the original ECOHIS were retained, and thus the Th-ECOHIS could be employed in cross-national comparisons. However, some minor revisions were made to be more applicable when used in Thai context.
The original version of the ECOHIS was developed as a self-completed questionnaire by proxy [8]. Although the Th-ECOHIS kept the original context, it was interviewer-administered. The interview approach was considered suitable for the studied population because it is a personal approach, ensures full return rates, lessens the possibility of missing data, and is non-literacy dependent. Although the literacy rate of working-age adults in Thailand is about 82%, the literacy rates of females and older persons are lower, at 78% and 52%, respectively [42]. One third of Thai adults aged 25 to 50 years are not fond of reading [42]. This was confirmed during the face validation process, when the mode of administration was discussed; the participants preferred the interviewing mode because they felt it would help them focus on the questions and process them better. The Brazilian version of ECOHIS had similar levels of reliability and validity and psychometric findings regarding self-administration and interviewer-administration [30]. Studies using other OHRQoL instruments demonstrated that the mode of administration does not affect the performance of the measure [43, 44]. However, self-administration has more advantages in terms of lower cost, the preservation of participants’ anonymity and autonomy, avoidance of interviewer bias, and availability for a large number of samples. The Th-ECOHIS questionnaire in self-completed mode should be tested in future studies.
Most of the caregivers who participated in this study were able to rate their children’s and family’s experience as asked in the Th- ECOHIS. The fact that there were only four responses of Don’t Know (1%) shows that few of the caregivers had underestimated the effects of ECC. There were no blank responses in our study because the interview-administration mode encouraged respondents to answer each question. Approximately one half of caregivers reported at least one impact on their children and families (Th-ECOHIS score > 0). The ceiling Th-ECOHIS score of each section was not detected, and this was consistent with other validation studies [8, 21, 22, 24, 29]. Regarding the floor effect, our study showed a higher rate in the child impact section than the original study [8] contributed by the lower percentage of affected children in this study. The participants recruited in this study were limited to 3-year-olds, whereas the original study included samples of 5-year-olds [8]. The younger age group could have been less affected by ECC, with a lower level of severity causing fewer symptoms and less impairment than the older age group. However, the three most common problems reported in the child impact section, pain, irritation and frustration, and eating difficulty, were similar to those reported in the original version [8] and other countries with different cultures [22, 26, 30]. Apparently, child’s physical complaints, psychological effects and limited routine function were more easily detected by parents than child’s social effects. In the family impact section, as in some other studies [8, 22, 26, 30], the most frequent feelings of caregivers were guilt and being upset. Although dental insurance is not available in Thailand, most simple dental services are provided free of charge for children younger than 12 years; only 10% of caregivers reported experiencing a financial impact on their family.
The reliability assessment of the Th-ECOHIS demonstrated an excellent result similar to the original version and previous studies. The test–retest analysis was conducted over a period of 2 weeks revealed good agreement (0.87), indicating that the Th-ECOHIS questionnaire was able to yield stability scores when administered at two different times. The ICC value was similar to that reported in the original English, German, and Farsi versions of the ECOHIS (0.84, 0.81, and 0.82, respectively) [8, 19, 21].
Regarding the consistency of results across items within questionnaire, the overall Cronbach's alpha value was 0.85, demonstrating good internal reliability of Th-ECOHIS. This value was slightly lower than that reported in the original English [8] and German versions [19] but was within the same range reported in the Arabic, Brazilian, Lithuanian, and Malay versions [21, 22, 24, 30]. Comparing the internal consistency of the child impact section and the family impact section, the Cronbach’s alpha coefficient in the family impact section (0.71) was lower than that in the child impact section (0.84). This was similar to previous studies in which the internal consistency in the child impact section and the family impact section ranged from 0.74 to 0.92 and 0.59 to 0.85, respectively [8, 19-31]. The smaller number of items in the family impact section in Th-ECOHIS might have been one of the factors influencing this lower consistency.
To assess the Th-ECOHIS validity, convergent and discriminant analyses were conducted. Both analyses showed that the Th-ECOHIS had good validity. Our study used the global measure of oral health to assess the convergent validity of the Th-ECOHIS. This measure is commonly used as a subjective indicator and has been demonstrated to be highly correlated with the clinical oral health status [45]. The Th-ECOHIS showed a moderate correlation with the global measure of oral health. The correlation of our finding was higher than in the original version [8] and was comparable with the Turkish and Brazilian versions [29, 30]. This finding showed that parents who perceived their children’s oral health as poor tended to have a higher ECOHIS score.
In the discriminant validity analysis, our study compared the Th-ECOHIS scores among children different caries status and treatment need. The results clearly suggested the Th-ECOHIS score could be a valid indicator for compromised quality of life of children by different severity of caries and treatment need. Children with more severe caries category and treatment need had higher both total and sub-section scores. Other studies found that the treatment need showing effect on children’s quality of life were those related to pulpal involvement and pain [31, 46], however, in our study even non-pulpal involved treatment need showed an effect on children OHRQoL. This also implied that parents are reliable for assessment of their child’s quality of life based on the child’s oral health. It was also noted that the ECOHIS scores were reported for the child and family impact sections even in caries-free children. ECOHIS might be able to detect other oral problems not limited to dental caries.
Most studies on translated versions of ECOHIS focused on a mixed-age group of preschoolers [19-31] while the original focused only on 5-year-olds [8]. Our study concentrated on 3-year-olds, the youngest group included in the NOHS and targeted for health policy in early intervention. Recent two consecutive Thai NOHSs have shown high ECC prevalence in this age group [25, 26], approximately 53% with mean dmft 2.8 in overall of the country and 49.5% with dmft 2.6 in Bangkok. Assessment of OHRQoL in this age group was scarce and deserves more attention. ECOHIS score could be a simple subjective indicator of their quality of life. However, validation in the younger age group with relatively lower oral problems might bring some concerns regarding possible less relevant question items or poor responded by the proxies. In our study, full response from caregivers was achieved with the design of the interview-administered questionnaire, thus, the age group of the children might not have affected the validity and reliability of the instrument. On the other hand, it might affect the magnitude of the impact of oral health problems. The ECOHIS was proved valid for this particular age group.
It should be noted that the study was carried out in specific group of children in the capital city from homogeneous socioeconomic status, middle-income families. In addition, we limited the socio-demographic characteristics of caregivers to relationship to the child and monthly income per household; age and level of education of caregivers were not collected. Further studies in different age groups and diversity of background would help strengthen our results. Future studies would also find it noteworthy to include more general health parameters such as perceived general health, general health behaviors, children’s weight, and height for convergent validity testing of this scale. However, those parameters at this young age with limited ECC severity might not show a correlation or an impact on OHRQoL as in this study, all child samples were healthy, and no any growth alteration was seen through their normal weight and height.
It could also add to the study limitation that classical test theory (CTT) was used for psychometric testing of the scale in this study, similar to many previous studies [19-31]. All versions have kept all items as the original. This would be useful in across countries comparison of children OHRQoL measured by different versions of ECOHIS. The CTT treats all questions equally, it contributes to simpleness in analysis and familiarity in dentistry. However, it would be useful to further analyze the translated version using item response theory (IRT) such as Rasch analysis [47, 48]. It would help detect any misfit item considered in modification or shortening the scale to customize specifically for Thai population.
This patient-based outcome measure will be a very useful parameter in demonstrating compromised quality of life in variety groups of preschool children. It could be incorporated in the national oral health survey. The illustration of deleterious effect of ECC would raise awareness of caries prevention in parents and families. It could help improve communication among dentists, patients and policy makers. Future study on responsiveness of Th-ECOHIS would be necessary prior to apply the tool as a metric parameter in evaluation of various intervention program in ECC affected children.