Psychometric evaluation of the Thai version of Early Childhood Oral Health Impact Scale (Th-ECOHIS): a cross sectional validation study

Methods

The study protocol was approved by the Ethical Review Committee for Research in Human Subjects, Ministry of Public Health. Written informed consent was obtained from primary caregivers for their participation in the study. The process of developing a Thai version of the ECOHIS consisted of two main phases; 1) translation, face and content validation, 2) psychometric testing (Figure 1).

Figure 1 Translation, face and content validation process and psychometric investigation

Translation, face and content validation

The translation and cross-cultural adaptation process of the original ECOHIS into the Thai version followed international standards for the development of new linguistic versions [36, 37]. The original English version of ECOHIS was translated into Thai by two dentists with high English proficiency. Content validation, then, was processed by a committee, a group of English-proficient Thai specialists in pediatric dentistry and public health who were familiar with a quality-of-life assessment, to ensure content equivalency to the original version. Each questionnaire item was reviewed and discussed over in terms of its concept being consistent with those in the original version until a first draft of the Thai version was reached.

Face validation of the first draft of Th-ECOHIS was conducted in convenience samples, a group of 20 Thai primary caregivers of kindergarten children in a Bangkok suburb. After a questionnaire interview, all participants were invited to discuss on the clarity and comprehensibility of each questionnaire item, the logic and relevance of the order of the items, and the understandability of the rating scale for answers. The committee did another review to improve each item using all comments from the face validation to produce the second draft of Th-ECOHIS.

The second draft was, then, blind-backward translated by a bilingual dentist who was a native speaker of Thai and English. The committee compared the back translated ECOHIS with the original version. The differences between the two versions were found minor; the translated version was consistent with the original version item by item. The working group reconsidered, reviewed all the details and finalized a Thai version of ECOHIS.

Psychometric testing phase

In order to evaluate reliability and validity of the Th-ECOHIS, psychometric testing phase was conducted.

Samples

The sample size for psychometric testing was calculated according to internal consistency for the Cronbach’s alpha using Bonnett’s formula [38] for 13 question items. The required level and a planning value for the Cronbach’s alpha was set at 0.70, and 0.80, respectively based on previous study [26] against a two-sided alternative at α = 0.05 with power of 90%. With 20% dropout rate, at least 176 subjects were required for the study. The sample size for test-retest reliability was set using estimated sample size table calculated from well-received formula proposed by Walter et al. [39]. The acceptable reliability and expected reliability were set at 0.7 and 0.9 respectively at α = 0.05 and β = 0.2. The minimum required sample size was 19. With 10% dropout rate, 21 subjects, approximately 10% of participants, were invited for test-retest reliability.

This phase was conducted in a subset of Bangkok samples of the 7th Thailand NOHS [33] where a systematic sampling design was deployed using districts according to urban and suburban zoning and subsequently, subdistricts as a sampling unit. Our study randomly selected one subdistrict from the designated subdistricts. The total samples of child-caregiver pairs in three randomly selected kindergartens in the specified subdistrict were simultaneously invited into this study along with the 7th Thailand NOHS recruitment. To be included, the child must be 36 to 48 months of age and could cooperate for dental caries examination. The proxy respondent must be parent or main caregiver who took primary responsibility for the child, and the Thai language literate. The only exclusion criterion was inability to complete the interview session. The schools were asked to arrange participant interview session around the designated time for student pick-up.

Questionnaire

The Th-ECOHIS questionnaire had two main parts containing a total of 13 items, as did the original. Nine items measured the impact of ECC on a child in four aspects: symptoms (1 item), function (4 items), emotional well-being (2 items), and self-image and social interaction (2 items). The other four items evaluated the impact on the family in two aspects: parental distress (2 items) and family function (2 items). Questions required parents/caregivers to recall how often they had observed their child and family encountering situations involving their child’s oral health since the child was born. Responses were formatted in a simple five-point Likert-type scale, with answers ranging from Never (0) to Very Often (4); a response of Don’t Know was an alternative response.

To evaluate the convergent validity of the Th-ECOHIS questionnaire, one global oral health rating question was added to the questionnaire: In general, how would you rate the dental health of your child? The response codes were 1 = excellent, 2 = very good, 3 = good, 4 = fair, and 5 = poor. Our study hypothesized that children whose general oral health was rated as poor would get high scores on both parts of the Th-ECOHIS.

Data collection

The main caregivers were interviewed with the structured Th-ECOHIS questionnaire by one interviewer and asked to provide demographic information. To avoid bias, the interviewer read the questions to the participants without explaining any of the questions or elaborating on any of the responses. For the rating scale, participants were shown a series of scale cards and asked to choose their response from the ones on the cards; their responses were then recorded by the interviewer. After 2 weeks, 10% of the caregivers were invited to a second interview at which they were asked the same questions.

The child’s weight and height were measured as general health indicators. The oral health status of each child was indicated by the dental caries experience index and dental treatment need adopted from the 7^th Thailand NOHS [33]. It was conducted by trained and calibrated examiners based on the World Health Organization basic criteria for the visual assessment of dental caries. The dental caries status of each child was classified into three groups by the number of decayed, missing, and filled teeth (dmft index): caries free; ECC (dmft 1 to 3); and severe ECC (dmft 4 or higher). The treatment needs were classified into three categories: no treatment need, one or more surface restoration, and pulp treatment and / or extraction.

Analyses

The Th-ECOHIS scores were calculated as a simple sum of the response codes for the child impact section, family impact section, and overall questionnaire. The Don’t Know response was recoded as a missing value. Our study managed the missing response by adapting the method proposed in the original version [8]. For subjects with up to two missing responses on the child impact section or one missing response on the family impact section, a score for the missing item was imputed as a median score of the remaining items for that section. Participants with more than two missing child items and one missing family item would be excluded from the analysis. The psychometric testing of the Th-ECOHIS was analyzed by assessing its internal consistency and test–retest reliability, as well as its convergent and discriminant validity.

The internal consistency reliability of the questionnaire was assessed for the child impact section, family impact section, and overall questionnaire using Cronbach’s alpha coefficient. The test–retest reliability was assessed using the intraclass correlation coefficient (ICC) calculated by a two-way analysis of variance. The convergent validity was determined by computing the Spearman’s rank-order correlations of the responses to the global question and each of the Th-ECOHIS sections and overall scores. The discriminant validity was tested by the Kruskal–Wallis test to compare the scores of the child impact section, family impact section, and overall questionnaire among children with different severities of caries experience and treatment need. The SPSS statistical package version 17 was used for data analysis. The level of statistical significance is set at a p-value < 0.05.

Results

Translation, face and content validation

All 13 items in the original ECOHIS were translated into Thai, incorporating cross-cultural concerns with an awareness of the lexical gaps between Thai and English. The translation was processed based on conceptual equivalence rather than linguistic/literal equivalence. Two translated copies from the blind parallel translation were compared and merged. The committee review for content equivalence adjusted the word difficulty which has many variations in Thai when used in different contexts, for instance, the English phrase “difficulty pronouncing” would be translated as “speech sound errors ” in Thai, and the English phrase “difficulty eating” would be translated as “hurt when chewing” in Thai.

Twenty participated primary caregivers in face validation process were 16 mothers, 2 fathers and 2 relatives of kindergarten children with mean age (SD) 42.7 (7.4) months. All questions appeared to be well understood and received no “Don’t know” response. Comments from the participants and interviewers during face validation suggested question sequence change to smooth the transition between questions for better flow and promote the recalls.

All 13 questions from the original ECOHIS were kept in the Thai version. The sequence of questions was adjusted. The psychological section, oral problem causing irritability or frustration and sleep problem, was moved to after the child symptom section because the section concerned child’s suffering which could be most noticeable. The functional section, the question involved “missing school” was moved to be the first in section because this occurrence was given priority in Thai culture and would be the most memorable and easiest to recall.

Psychometric testing

A total of 240 child-caregiver pairs were recruited, and 214 pairs completed the data for analysis. Sixteen pairs were excluded because their caregivers had limited time to complete the Th-ECOHIS questionnaire. Of the 214 caregivers, 65.4% (n = 140) were mothers, 75.2% (n = 161) were from families with an average income, and 97.6% were Buddhists. All children were healthy, most had weight (88.3%) and height (92%) appropriate to age (2SD) [40]. The mean (SD) age of the children was 42.93 (2.86) months, ranged from 36 to 48 months. Of the 214 children, 50% were boys, 60.7% were caries-free and 17.3% had severe ECC (dmft 4 or higher). The mean (SD) dmft score was 1.63 (2.92). The demographic information of the children and their proxy respondents is shown in Table 1.

Table 1 Demographic data of children and proxy respondents.

All of the proxy respondents completed the questionnaires with no blank items and no more than one Don’t Know response item for each child. The distribution of the proxy responses to the Th-ECOHIS items related to a child’s oral health problems is shown in Table 2, and the descriptive distribution by section is summarized in Table 3. The maximum scores of the Th-ECOHIS were 27 of 36 in the child impact section and 12 of 16 in the family impact section. The ceiling effect was negligible for each item and the total score. Two respondents answered Don’t Know to the item “child avoided talking,” and two respondents answered Don’t Know to the item “family member felt guilty.”

Table 2 Distribution of the proxy responses to the Th-ECOHIS items related to child’s oral health.

Table 3 Descriptive distribution of the Th-ECOHIS by sections.

Overall, 55.1% of caregivers reported at least one aspect related to child’s oral health had affected their children and family (Table 3). The percentage of proxy respondents reporting that oral health problems had affected their family (46.3%) was higher than those reporting that they had affected their children (36.9%). The three most prevalent response in the child impact section was “pain in the teeth, mouth, or jaws” (26.7%), followed by “became irritable or frustrated” (25.7%) and “difficulty in eating some foods” (16.8%) (Table 2). In the family impact section, the two most frequently reported impacts were “parents or family members feeling guilty” (39.7%) and “being upset” (39.3%) (Table 2).

Reliability

The overall reliability of the Th-ECOHIS showed good results (Table 4). The mean inter-item correlations (Cronbach’s alpha coefficient) of the total ECOHIS items, child impact section, and family impact section were 0.85, 0.84, and 0.71, respectively. The test–retest reliability scores (intraclass correlation coefficient, ICC) of the Th-ECOHIS were 0.87 for the total of the items, 0.78 for the child impact section, and 0.87 for the family impact section.

Table 4 Reliability analyses of the Th-ECOHIS: internal consistency and test-retest reliability

Validity

The convergent validity was analyzed using the Spearman correlation coefficient and showed a moderate correlation for the global oral health rating and total Th-ECOHIS score (r = 0.604; p < 0.01) (Table 5). The discriminant validity was assessed by comparing the Th-ECOHIS scores for the severity of caries experience and dental treatment need. Variations in the ECOHIS and the two subscale scores (child impact and family impact sections) (p < 0.001) were apparent among different caries status (Table 6). Children with caries had higher ECOHIS scores than caries-free children, Children with severe ECC had significantly higher Th-ECOHIS scores than children with ECC did. Differences of the Th-ECOHIS among treatment need categories were significant (p<0.001). Children who had dental treatment need had a higher Th-ECOHIS score than those who had not. (Table 6.)

Table 5 Convergent validity of the Th-ECOHIS.

Table 6 Discriminant validity of the Th-ECOHIS.

Discussion

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.

References

Chen KJ, Gao SS, Duangthip D, Lo ECM, Chu CH. Prevalence of early childhood caries among 5-year-old children: A systematic review. JICD. 2019;10:e12376.
Shen A, Bernabé E, Sabbah W. The bidirectional relationship between weight, height and dental caries among preschool children in China. PloS one. 2019;14:e0216227.
Ayhan H, Suskan E, Yildirim S. The effect of nursing or rampant caries on height, body weight and head circumference. J Clin Pediatr Dent. 1996;20:209-12.
Acs G, Lodolini G, Kaminsky S, Cisneros GJ. Effect of nursing caries on body weight in a pediatric population. Pediatr Dent. 1992;14:302-5.
Sheiham A. Dental caries affects body weight, growth and quality of life in pre-school children. BDJ. 2006;20:625-6.
Al-Shahrani N, Al-Amri A, Hegazi F, Al-Rowis K, Al-Madani A, Hassan KS. The prevalence of premature loss of primary teeth and its impact on malocclusion in the Eastern Province of Saudi Arabia. Acta odontol Scand. 2015;73:544-9.
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; 25:431-40.
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.
Muirhead VE, Quayyum Z, Markey D, et al Children’s toothache is becoming everybody’s business: where do parents go when their children have oral pain in London, England? A cross-sectional analysis. BMJ Open. 2018;8:e020771. doi: 10.1136/bmjopen-2017-020771.
Borges TS, Vargas-Ferreira F, Kramer PF, Feldens CA. Impact of traumatic dental injuries on oral health-related quality of life of preschool children: A systematic review and meta-analysis. PLoS One. 2017;12:e0172235. doi: 10.1371/journal.pone.0172235.
de Oliveira LJ, Torriani DD, Correa MB, Peres MA, Peres KG, Matijasevich A, Dos Santos Ida S, Barros AJ, Demarco FF, Tarquinio SB. Oral mucosal lesions' impact on oral health-related quality of life in preschool children. Community Dent Oral Epidemiol. 2015;43:578-85. doi: 10.1111/cdoe.12185.
Vieira-Andrade RG, Martins-Júnior PA, Corrêa-Faria P, Marques LS, Paiva SM, Ramos-Jorge ML. Impact of oral mucosal conditions on oral health-related quality of life in preschool children: a hierarchical approach. Int J Paediatr Dent. 2015;25:117-26. doi: 10.1111/ipd.12107.
Wong NH, Tran C, Pukallus M, Holcombe T, Seow WK. A three-year retrospective study of emergency visits at an oral health clinic in south-east Queensland. Aust Dent J. 2012;57:132-7. doi: 10.1111/j.1834-7819.2012.01688.x.
Aaronson NK. Quality of life: what is it? How should it be measured? Oncology (Williston Park). 1988;2:69-4.
Ruff RR, Sischo L, Chinn CH, Broder HL. Development and validation of the Child Oral Health Impact Profile - Preschool version. Community Dent Health. 2017;34:176-182. doi: 10.1922/CDH_4110Ruff07.
Tsakos G, Blair YI, Yusuf H, Wright W, Watt RG, Macpherson LM. Developing a new self-reported scale of oral health outcomes for 5-year-old children (SOHO-5). Health Qual Life Outcomes. 2012;10:62.
Rebok G, Riley A, Forrest C, Starfield B, Green B, Robertson J, et al. Elementary school-aged children's reports of their health: a cognitive interviewing study. Qual Life Res. 2001;10:59-70.
Hetherington EM, Parke RD, Locke VO. Child psychology: a contemporary viewpoint. New York: McGraw-Hill; 2003.
Bekes K, Omara M, Safar S, Stamm T. The German version of Early Childhood Oral Health Impact Scale (ECOHIS-G): translation, reliability, and validity. Clin Oral Investig. 2019;23:4449-54.
Bordoni N, Ciaravino O, Zambrano O, Villena R, Beltran-Aguilar E, Squassi A. Early Childhood Oral Health Impact Scale (ECOHIS). Translation and validation in Spanish language. Acta Odontol Latinoam. 2012;25:270-8.
Farsi NJ, El-Housseiny AA, Farsi DJ, Farsi NM. Validation of the Arabic Version of the Early Childhood Oral Health Impact Scale (ECOHIS). BMC Oral Health. 2017;17:60.
Hashim AN, Yusof ZY, Esa R. The Malay version of the Early Childhood Oral Health Impact Scale (Malay-ECOHIS-assessing validity and reliability. Health Quality Life Outcomes. 2015;13:190.
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.
Jankauskienė B, Narbutaitė J, Kubilius R, Gleiznys A. Adaptation and validation of the early childhood oral health impact scale in Lithuania. Stomatologija. 2012;14:108-113.
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.
Li S, Veronneau J, Allison PJ. Validation of a French language version of the Early Childhood Oral Health Impact Scale (ECOHIS). Health Quality Life Outcomes. 2008;6:9.
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.
Nzomiwu CL, Sote EO, Oredugba FA. Translation and Validation of the Nigerian Pidgin English Version of the Early Childhood Oral Health Impact Scale (NAIJA ECOHIS). West Afr J Med. 2018;35:102-8.
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 Quality Life Outcomes. 2011;9:118.
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.
Randrianarivony J, Ravelomanantsoa J, Razanamihaja N. Evaluation of the reliability and validity of the Early Childhood Oral Health Impact Scale (ECOHIS) questionnaire translated into Malagasy. Health Qual Life Outcomes. 2020;18:39.
Bureau of Dental Health. The 8^thThailand National Oral Health Survey Report 2017. Nonthaburi: Ministry of Public Health, Thailand, 2018.
Bureau of Dental Health. The 7^th Thailand National Oral Health Survey Report 2012. Nonthaburi: Ministry of Public Health, Thailand, 2013.
Nora ÂD, da Silva Rodrigues C, de Oliveira Rocha R, Soares FZM, Minatel Braga M, Lenzi TL. Is Caries Associated with Negative Impact on Oral Health-Related Quality of Life of Pre-school Children? A Systematic Review and Meta-Analysis. Pediatr Dent. 2018;40:403-11.
Zaror C, Pardo Y, Espinoza-Espinoza G, Pont À, Muñoz-Millán P, Martínez-Zapata MJ, et al. Assessing oral health-related quality of life in children and adolescents: a systematic review and standardized comparison of available instruments. Clin Oral Investig. 2019;23:65-79.
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; 46:1417-32.
Wild D, Grove A, Martin M, Eremenco S, McElroy S, Verjee-Lorenz A, et al. Principles of good practice for the translation and cultural adaptation process for patient-reported outcomes (PRO) measures: report of the ISPOR task force for translation and cultural adaptation. Value Health. 2005;8:94–104.
Bonett DG. Sample size requirement for testing and estimating coefficient alpha. J Educ Behav Stat. 2002; 27:335-40.
Walter SD, Eliasziw M, Donner A. Sample size and optimal designs for reliability studies. Stat Med. 1998; 17: 101-110.
Bureau of Health Promotion. Growth charts for Thai children 2005. Nonthaburi: Ministry of Public Health, Thailand, 2005.
Social Statistics Bureau. Household income and expenditure in Bangkok 2011. Bangkok: National Statistical Office, Thailand, 2011.
Social Statistics Bureau. The reading of population survey 2018. Bangkok: National Statistical Office, Thailand, 2019.
Tsakos G, Bernabé E, O'Brien K, Sheiham A, de Oliveira C. Comparison of the self-administered and interviewer-administered modes of the child-OIDP. Health Qual Life Outcomes. 2008;6:40.
Varni JW, Burwinkle TM, Lane MM. Health-related quality of life measurement in pediatric clinical practice: an appraisal and precept for future research and application. Health Qual Life Outcomes. 2005;3:34.
Gift HC, Atchison KA. Oral health, health, and health-related quality of life. Med Care. 1995;33(11 Suppl):Ns57-77.
Novaes TF, Pontes LRA, Freitas JG, Acosta CP, Andrade KCE, Guedes RS, et al. Responsiveness of the early childhood oral health impact scale (ECOHIS) is related to dental treatment complexity. Health Qual Life Outcomes. 2017;15:182.
Wong HM, McGrath CPJ, King NM. Rasch validation of the early childhood oral health impact scale. Community Dent Oral Epidemiol. 2011;39:449-57.
Prieto L, Alonso J, Lamarca R. Classical test theory versus Rasch analysis for quality of life questionnaire reduction. Health Qual Life Outcomes. 2003;1:27.

Tables

Table 1 Demographic data of children and proxy respondents.

	Total	Caries free	ECC (dmft 1-3)	Severe (dmft ≥4)	p-value*
	N (%)	n (%)	n (%)	n (%)
Number of child-caregiver pairs	214 (100%)	130 (60.7%)	47 (22.0%)	37 (17.3%)
Child demographic data
Gender					0.389
Male	107 (50.0)	64 (49.2)	21 (44.7)	22 (59.5)
Female	107 (50.0)	66 (50.8)	26 (55.3)	15 (40.5)
Mean age (month)(SD) Min - Max	42.93 (2.86) 36 - 48	42.98 (2.84) 38-48	42.94 (2.93) 38-48	42.70 (2.92) 37-48	0.870
Proxy demographic data
Relationship to the child
Mother	140 (65.4)	88 (67.0)	30 (63.8)	22 (59.5)	0.449
Father	47 (22.0)	24 (18.5)	11 (23.4)	12 (32.4)
Others	27 (12.6)	18 (13.8)	6 (12.8)	3 (8.1)
Monthly family income**					0.043
Low income (< 20,000 bath)	38 (17.7)	19 (14.6)	15 (31.9)	4 (10.8)
Average income (20,000 – 50,000 bath)	161 (75.2)	100 (76.9)	31 (66.0)	30 (81.1)
High income (> 50,000 bath)	15 (7.01)	11 (8.5)	1 (2.1)	3 (8.1)
Note * comparison among caries free, ECC and severe ECC group
** According to The National Statistics Office household income survey (by type of occupation) in Bangkok 2011 [41]

Table 2 Distribution of the proxy responses to the Th-ECOHIS items related to child’s oral health problems

	Never n(%)	Total (%) Affected				Don’t know n(%)
		Hardly ever n(%)	Occasionally n(%)	Often n(%)	Very often n(%)
Child impacts
How often has your child had pain in teeth, mouth or jaws?
	157 (73.3)	57(26.7)				0(0)
		25(11.7)	24(11.2)	7(3.3)	1(0.5)
How often has your child…………. because of dental problems or dental treatments?
had difficulty drinking hot or cold beverages	200(93.5)	14(6.5)				0(0)
		7(3.2)	3(1.4)	3(1.4)	1(0.5)
had difficulty eating some foods	178(83.2)	36(16.8)				0(0)
		14(6.5)	10(4.7)	8(3.7)	4(1.9)
had difficulty pronouncing any words	193(90.2)	21(9.8)				0(0)
		3(1.4)	7(3.3)	9(4.2)	2(0.9)
Missed preschool, daycare or school	204(95.3)	10(4.7)				0(0)
		4(1.9)	3(1.4)	3(1.4)	0(0)
had trouble sleeping	183(85.5)	31(14.5)				0(0)
		16(7.5)	11(5.1)	4(1.9)	0(0)
been irritable or frustrated	159(74.3)	55(25.7)				0(0)
		26(12.1)	22(10.3)	7(3.3)	0(0)
avoid smiling or laughing	204(95.3)	10(4.7)				0(0)
		7(3.3)	1(0.5)	2(0.9)	0(0)
avoid talking	206(96.3)	6(2.8)				2(0.9)
		2 (0.9)	1(0.5)	3(1.4)	0(0)
Family impacts
How often have you or another family member…..because of your child’s dental problems or treatment?
been upset	130(60.7)	84(39.3)				0(0)
		22(10.3)	28(13.1)	34(15.9)	0(0)
felt guilty	127(59.3)	85(39.7)				2(1.0)
		19(8.9)	26(12.1)	36(16.8)	4(1.9)
take time off from work	194(90.7)	10(9.3)				0(0)
		11(5.1)	4(1.9)	5(2.3)	0(0)
How often has your child had dental problems or dental treatment that had a financial impact on your family?
	193(90.2)	11(9.8)				0(0)
		7(3.3)	9(4.2)	4(1.9)	1(0.5)

Table 3 Descriptive distribution of the Th- ECOHIS by sections.

Impacts	Number of items	Possible range	Range	Floor effect (%score0)	Affected response (%)	Mean (SD)	Median IQR
Child impact section	9	0-36	0-27	63.1	36.9	2.05(3.94)	0(3)
Child symptoms	1	0-4	0-4	73.3	26.7	0.46(0.853)	0(1)
Child function	4	0-16	0-12	77.1	22.9	0.80(1.926)	0(0)
Child psychology	2	0-8	0-6	72.0	28.0	0.66(1.307)	0(1)
Self-image and social interaction	2	0-8	0-6	93.9	6.1	0.13(0.693)	0(0)
Family impact section	4	0-16	0-12	53.7	46.3	2.10(2.783)	0(4)
Parental distress	2	0-8	0-6	55.1	44.9	1.75(2.264)	0(4)
Family function	2	0-8	0-6	85.5	14.5	0.35(1.018)	0(0)
All sections	13	0-52	0-39	44.9	55.1	4.15(5.980)	2(6)

Table 4 Reliability analyses of the Th-ECOHIS: internal consistency and test-retest reliability

Impact	Internal consistency Cronbach’s alpha	Test- retest reliability [ICC] (95% CI)]
Child impact section	.842	0.78 (0.40, 0.92)
Family impact section	.706	0.87 (0.64, 0.95)
All sections	.854	0.87 (0.63, 0.95)

Intraclass correlation coefficient (two-way mixed effects model)

Table 5 Convergent validity of the Th-ECOHIS.

	Child impact	Family impact	Total score
Global oral health rating	0.423*	0.622*	0.604*
* p < 0.01

Table 6 Discriminant validity of the Th-ECOHIS.

Caries experience	Caries-free (n=130)	dmft 1-3 (n=47)	dmft ≥4 (n=37)	p-value
Child impact section
Mean(SD)	1.30(3.68)	2.47 (3.43)	3.97(4.69)
Median (IQR)	0(0)	1(4)	3(7)	< 0.001
Family impact section
Mean(SD)	1.52(2.59)	2.45(2.51)	3.68(3.16)
Median (IQR)	0(2)	2(4)	4(6)	< 0.001
All sections
Mean(SD)	2.51(4.13)	4.74(4.83)	7.65(7.05)
Median (IQR)	0(4)	4(8)	7(11)	< 0.001
Treatment need	No treatment (n=130)	Need filling (n=65)	Need pulp treatment / extraction (n=19)	p-value
Child impact section
Mean(SD)	1.18(3.47)	3.29(4.51)	3.68(3.38)
Median (IQR)	0(0)	1(6)	3(7)	< 0.001
Family impact section
Mean(SD)	1.45(2.60)	3.05(2.96)	3.32(2.11)
Median (IQR)	0(2)	3(6)	4(3)	< 0.001
All sections
Mean(SD)	2.64(5.25)	6.34(6.78)	7.00(4.49)
Median (IQR)	0 (4)	5(12)	8(7)	< 0.001

Psychometric evaluation of the Thai version of Early Childhood Oral Health Impact Scale (Th-ECOHIS): a cross sectional validation study

Abstract

Background

Methods

Results

Discussion

Conclusion

Abbreviations

Declarations

References

Tables