Developing the first draft of the scale
The Multidimensional Oral Health Scale (MOHS) proposed in this study contains 6 dimensions: (1) Oral Health Literacy (MOHS-L): This subscale uses the items on “disease prevention” and “health promotion” from the Chinese version of the HLS-EU-Q, adapting them to the oral domain. (2) Oral Health Self-evaluation and Status (MOHS-SS) and (3) Oral Health Misunderstandings (MOHS-M): After reading the literature, the members of our team designed each item by referring to the “Guide to Oral Health for Chinese Residents” and the “Guide to Oral Health Behavior for Chinese Residents”. Then, a team of dentists was asked to evaluate the items and determine which should be included in this dimension. Items were selected for inclusion based on a discussion with ten college students and the dentists’ evaluation. (4) Oral Health Care Behavior and Cognition (MOHS-BC) and (5) Oral Health Transmission Channels (MOHS-TC): First, the team interviewed 27 parents and 15 college students individually using a semi-structured outline and developed items based on the interview information. Then, three focus groups were invited to discuss the items, and some of the items were modified. The items selected for inclusion in this dimension were confirmed after the content of each item was reviewed by a dentist. (6) Policy Expectations (MOHS-PE): Based on the policies or public strategies related to dentistry that have been implemented in many other countries but not in China, this study designed each item to assess respondents' expectations regarding the implementation of these strategies and then determined which items to include after evaluation by the expert team.
The steps and process of modifying and finalizing the scale
To ensure the face validity of the multidimensional scale, after the first draft was developed, 18 undergraduate and graduate students were invited to discuss the content of each item and to read the questions to ensure that all the questions could be understood. Expert validity was assessed by the research team, which includes researchers (specialists in health promotion and health education, public health and preventive medicine, child and youth social work, pediatric behavioral psychology and nursing), a professional dentist (a certified dentist for the International Team For Implantology in Switzerland and Bicon in the USA with a master's degree from Loma Linda University in the USA and 15 years of dental working experience), and a management expert (with a master's degree in biomedical materials from South China University of Technology). The final version of this multidimensional scale was confirmed after repeated revision through centralized discussion by the research team.
Scale items and their measurement
MOHS-L
The MOHS-L contains two parts: 15 questions on oral disease prevention and 16 questions on oral health promotion, each including the four information processing steps of obtaining, understanding, evaluating and applying health information. A response scale of 0-3 (from “very difficult” to “very easy”) is used.
MOHS-SS
The MOHS-SS includes 8 items. The first question assesses respondents' self-rated oral health status. Questions 2 to 7 assess the frequency of toothbrush replacement, oral diseases, tooth decay, teeth cleaning, flossing, brushing time and posture.
MOHS-M
The MOHS-M assesses gum bleeding, tooth extraction, wisdom teeth and common oral health myths. An example item is “Suppose that your gums are bleeding. What's your reaction?”. There are a total of 13 questions. Six items cover gingival bleeding, and the item options range from 0 to 3 (“never think that way” to “always think that way”). Five items cover tooth extraction, with response options from 0 to 3 (“very incorrect” to “very correct”). Items related to wisdom teeth include “Do you know what wisdom teeth are?” and “Do you think wisdom teeth need to be removed?”
MOHS-BC
The MOHS-BC includes two parts. One assesses current brushing behavior, floss use and medical treatment behavior, such as “left and right lateral brushing” and “brushing the biting surface of the teeth”. There are 12 questions. The answers are given on a scale from 0 to 3 (“never do this” to “always do this”). The other part mainly assesses cognition on the need for medical treatment, cognition on the behavior of brushing, cognition on floss use and cognition on the behavior of dental cleaning. There are 22 questions in total, with response options from 0 to 3 (“very incorrect” to “very correct”).
MOHS-TC
This section contains six items that primarily assess respondents' oral health knowledge, including “Self-taught” or “Taught by parents or family members”. Responses are given on a scale from 0 to 3 (“never (0%)” to “almost always (71-100%)”.
MOHS-PE
In this section, there are six items evaluating respondents' expectations regarding policy, such as “How many times a year would you like to have free dental cleanings if health insurance were available?” and “Would you go to the dentist's office regularly if health insurance provided a “free” dental cleaning every year?”.
Formal pilot of the scales in a sample population
Research sample
Considering compliance as a factor, this study chose freshmen as the research sample. This population has just entered the college stage after finishing the stressful senior high school stage. They are more likely to ignore their own health care and represent future parents. If the oral health status of college students can be improved, it will have a positive spillover effect on the next generation. In summary, the team selected freshmen from the class of 2018 from two colleges on different campuses of a university in southern China as research objects.
The data collection process
The research process conformed to the Declaration of Helsinki. After students had had one month to adapt to university life, we contacted the counselors and monitors to invite the whole class selected for this study to participate in a presentation meeting, and the members of the research team explained the research plan and purpose. The questionnaire was distributed electronically. After reading the informed consent form and signing it electronically, the whole class completed the online self-report questionnaire at the same time. The entire process lasted 20-30 minutes.
As the subjects completed the scale, the investigator explained questions that could not be understood, which ensured that the data collection followed a unified procedure and that the data collected were of high quality. Ultimately, 179 people participated in the questionnaire survey.
Data analysis methods
After the data were exported to a cloud system, Excel 2016 was used to collate and check the data, SPSS 21.0 was used for reliability analysis and descriptive analysis (the quantitative data were expressed as the mean ± standard deviation, and the qualitative data were expressed as numbers and percentages), and LISREL 8.80 was used to analyze the validity of the scale.
Because the MOHS-L is a psychological scale for multitopic measurement of the same concept, it is necessary to test its reliability and validity to ensure its applicability. First, the construct validity was verified. For this purpose, confirmatory factor analysis was used, and the following four fitness indicators were used to judge the suitability of the model: (1) c2/df£5 indicates good fit; (2) GFI>0.90 indicates good fit; (3) AGFI>0.90 represents good fit; and (4) RMSEA£0.05 indicates good fit, a value between 0.05 and 0.08 is considered to indicate better fit, and a value between 0.08 and 0.1 indicates adequate fit. After the validity of the scale was confirmed, the internal consistency reliability was measured (Cronbach's α).
The validity results for “oral disease prevention” showed that the coefficient between each item and its scale exceeded 0.95, the t values were all greater than 1.96, and the values of GFI, AGFI, RMSEA and c2/df£5 were 1.00, 1.00, 0.01 and 1.03, respectively. Regarding reliability, the Cronbach's α value of the total scale was 0.96, and the Cronbach’s α values of the four subscales were between 0.85 and 0.93, which indicates that the reliability and validity of the scale are good (see Table 1). The validity results for “oral Health promotion “ showed that the coefficient between each item and its scale exceeded 0.96, the t values were all greater than 1.96, and the values of GFI, AGFI, RMSEA and c2/df£5 were 1.00, 1.00, 0.04 and 1.31, respectively. Regarding reliability, the Cronbach's α value of the total scale was 0.95, and the Cronbach’s α values of the four subscales were between 0.84 and 0.94, which indicates that the reliability and validity of the scale are good (see Table 2).
Table 1
The validity and reliability analysis results for oral disease prevention scale
Factors
|
Items
|
Validity analysis
|
Reliability analysis
|
Confirmatory factor analysis
|
Internal consistency reliability
|
λ values
|
t values
|
λ values with the total score of this factor
|
Standard Cronbach's α
|
On a scale from very easy to very difficult, how easy would you say it is to:
|
Obtaining health information
|
1. …find information on treatments of oral disease (such as dental caries, gingivitis, periodontal disease, etc.) that concern you?
|
0.96
|
62.16
|
0.72
|
0.93
|
2. …find information helpful to your oral health that concern you?
|
1.00
|
178.70
|
0.78
|
|
3. …find information on how to prevent oral disease that concern you?
|
1.00
|
--
|
0.79
|
|
4. …find information on how to prevent or manage oral health problems like certain pathogens or calculus that concern you?
|
0.98
|
123.56
|
0.78
|
|
Understanding health information
|
5. …understand health warnings about oral disease such as dental caries, gingivitis, periodontal disease?
|
0.98
|
94.80
|
0.75
|
0.88
|
6. …understand why you need teeth cleaning (such as dental stones unable to be cleaned up via brushing teeth)?
|
1.00
|
--
|
0.72
|
|
7. …understand why you need regular oral examination (such as dental caries, gingivitis)?
|
0.99
|
128.96
|
0.80
|
|
Evaluating health information
|
8. …judge how reliable health warnings are, such as dental caries, gingivitis, periodontal disease and other oral diseases?
|
0.96
|
60.22
|
0.75
|
0.92
|
9. …judge when you need to go to a doctor for a check-up?
|
0.97
|
990.44
|
0.75
|
|
10. …judge when you need teeth cleaning?
|
0.95
|
53.44
|
0.74
|
|
11. …judge which oral health screenings you should have?
|
1.00
|
--
|
0.77
|
|
12. …judge if the information on oral health risks in the media is reliable?
|
1.00
|
113.01
|
0.75
|
|
Applying health information
|
13. …decide if you should go to the clinic or hospital for oral health examination?
|
1.00
|
--
|
0.78
|
0.85
|
14. …decide how you can protect yourself from oral diseases based on advice from family and friends?
|
1.00
|
115.01
|
0.73
|
|
15. …decide how you can protect yourself from oral diseases based on information in the media?
|
1.00
|
85.58
|
0.67
|
|
Note: 1. Response categories range from 0 to 3 [0=Very difficult; 1=Fairly Difficult; 2=Fairly Easy; 3=Very Easy] 2. --: This item is the reference index of the relevant factor in the confirmatory factor analysis model. We preset the coefficient value of this item to 1.00, thereby the t value is not estimated.
|
Table 2
The validity and reliability analysis results for oral health promotion scale
Factors
|
Items
|
Validity analysis
|
Reliability analysis
|
Confirmatory factor analysis
|
Internal consistency reliability
|
λ values
|
t values
|
λ values
with the total score of this factor
|
Standard Cronbach's α
|
On a scale from very easy to very difficult, how easy would you say it is to:
|
Obtaining health information
|
1. …find information on oral health promotion activities such as correct tooth brushing behavior, teeth cleaning?
|
0.99
|
96.59
|
0.72
|
0.94
|
2. …find out about activities that are good for your oral health?
|
0.90
|
121.16
|
0.77
|
|
3. …find information on how your neighborhood and friends could be more oral health-friendly?
|
0.99
|
168.45
|
0.82
|
|
4. …find out about political changes that may affect oral health?
|
0.99
|
191.24
|
0.77
|
|
5. …find out about efforts to promote your oral health at work?
|
1.00
|
--
|
0.79
|
|
Understanding health information
|
6. …understand advice on oral health from family members or friends?
|
0.97
|
83.35
|
0.70
|
0.88
|
7. …understand information on how to choose toothbrush or toothpaste suitable for you?
|
0.96
|
120.12
|
0.76
|
|
8. …understand information in the media on how to make your oral healthier?
|
0.98
|
106.81
|
0.78
|
|
9. …understand information on how to keep your oral healthy like correct brushing and cleaning behavior?
|
1.00
|
--
|
0.79
|
|
Evaluating health information
|
10. …judge where your life affects your oral health and well-being?
(Instructions: Behavior, food)
|
0.96
|
162.99
|
0.77
|
0.93
|
11. …judge which habits and customs help you to stay oral healthy?
|
0.97
|
188.80
|
0.77
|
|
12. …judge which everyday behavior is related to your oral health?
|
1.00
|
--
|
0.75
|
|
Applying health information
|
13. …make decisions to improve your oral health?
|
0.95
|
68.22
|
0.65
|
0.84
|
14. …join a sports club or exercise class on oral health care if you want to?
|
0.96
|
62.06
|
0.49
|
|
15. …influence your living conditions that affect your oral health and wellbeing?
|
1.00
|
--
|
0.64
|
|
16. …take part in activities that improve oral health and well-being in your community or school?
|
0.96
|
66.46
|
0.49
|
|
Note: 1. The item options range from 0 to 3 [0=Very difficult; 1=Fairly Difficult; 2=Fairly Easy; 3=Very Easy] 2. --: This item is the reference index of the relevant factor in the confirmatory factor analysis model. We preset the coefficient value of this item to 1.00, thereby the t value is not estimated.
|