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RESEARCH REPORT |
1 Community Dental Health Services Research Unit, Faculty of Dentistry, University of Toronto, 124 Edward Street, Toronto, ON, Canada M5G 1G6;
2 Department of Dentistry, The Hospital for Sick Children, Toronto, ON, Canada;
3 Department of Orthodontics, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada; and
4 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada;
* corresponding author, aleksandra.jokovic{at}utoronto.ca
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS & METHODSRESULTSDISCUSSIONREFERENCES |
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KEY WORDS: child • oral health • quality of life • validity • reliability
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS & METHODSRESULTSDISCUSSIONREFERENCES |
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To date, several OHRQoL measures have been developed (Cushing et al., 1986; Atchison and Dolan, 1990; Locker and Miller, 1994; Slade and Spencer, 1994; Leao and Sheiham, 1996). However, they all are designed to assess OHRQoL in adult populations. No comprehensive measure has yet been developed for children. Since pediatric oral disorders are numerous (Surgeon General's Report, 2000) and are likely to have a negative effect on the quality of life, there is a need for a measure that documents oral health outcomes in child populations.
The absence of pediatric OHRQoL measures is due, in part, to the complex conceptual and methodological issues involved in the construction of self-report health status indicators for children (Pantell and Lewis, 1987; Pal, 1996). For example, the structure of children's self-concept and health cognitions is age-dependent as a result of their continuous cognitive, emotional, social, and language development. Similarly, the content of daily activities, understanding of feeling states, perceptions of relationships, and communication skills evolve with children's age (French and Christie, 1996; Theunissen et al., 1988). These age differences in the cognitive, emotional, functional, and behavioural characteristics must be accommodated within a child health status questionnaire (French and Christie, 1996; Pal, 1996).
According to child developmental psychology, the age of 6 marks the beginning of abstract thinking and self-concept (Hetherington et al., 1999). Children start to compare their physical features and personality traits with those of other children or against a norm. Their ability for evaluative judgments of their appearance, the quality of friendships, and other people's thoughts, emotions, and behaviors gradually develops through middle childhood (6-10 yrs) (Bee, 1998; Hetherington et al., 1999). By the age of 11 or 12, children have clear understanding of complex emotions such as worry, shame, and jealousy, and their self-concept acquires sophisticated dimensions such as romantic appeal and popularity with peers (Bee, 1998). These years also correspond to the onset of puberty. Children then enter a period of early adolescence (11-14 yrs) that is characterized by the increasing centrality of peer crowd and clique dynamics in children's lives and their pre-occupation with others' views of self (Bee, 1998; Hetherington et al., 1999). Children develop the concept of time about the age of 8, when their recall period starts to lengthen and their understanding of frequency of events begins to emerge (French and Christie, 1996; Rebok et al., 2001).
Given these developmental differences, a single standardized self-report health status measure for children of ages 6 to 14 cannot be developed. Instead, age-specific questionnaires for 6-7-, 8-10-, and 11-14-year-olds are required. These groups are homogeneous in terms of roles and cognitive abilities.
Questionnaire biases, such as position bias and acquiescence bias, are commonly encountered with child respondents (Pantell and Lewis, 1987). These problems have given rise to concerns that children's reports of their health may not meet the psychometric standards expected of health outcome measures. However, recently developed generic and disease-specific measures, such as the Child Health Questionnaire (Landgraf et al., 1996) and the Childhood Asthma Questionnaires (French and Christie, 1996), have demonstrated that, with appropriate techniques, it is possible to obtain valid and reliable reports of HRQoL from children.
This paper describes the development and validity and reliability testing of the Child Perceptions Questionnaire (CPQ11-14), a measure of the OHRQoL for children aged 11 to 14 yrs. The aim was to produce a measure which conformed to contemporary concepts of child health and had discriminative and evaluative properties, and which is applicable to children with various dental, oral, and oro-facial disorders. It forms one component of the Child Oral Health Quality of Life Questionnaire (COHQOL), which consists of a Parental-Caregiver Perceptions Questionnaire, a Family Impact Scale, and three age-specific questionnaires for children.
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MATERIALS & METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS & METHODSRESULTSDISCUSSIONREFERENCES |
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Development Process
The CPQ11-14 was constructed based on a process described by Guyatt et al. (1986) and Juniper et al. (1996). Items were generated in two stages. First, a preliminary pool of 46 items was developed by a review of existing oral health and child health status measures. These encompassed four domains: oral symptoms, functional limitations, emotional well-being, and social well-being (peer interaction, schooling, and leisure activities). Second, the comprehensiveness, relevance, and clarity of these items were assessed by an expert panel composed of 17 health professionals who treat children with oral and oro-facial disorders and 33 parents of child patients with these conditions. Based on their responses and comments, we developed a modified pool of 50 items by writing additional items, excluding irrelevant items, and combining items. These were revised further following in-depth interviews with 11 child patients.
Items for the final questionnaire were selected by means of an item impact study (Guyatt et al., 1986; Juniper et al., 1996). This identifies items on the basis of their frequency and importance to the target population. Participants were children from the three clinical groups defined above. Data were collected with the use of an item impact questionnaire administered in face-to-face interviews. The children were asked if in the past three months they had experienced the problem described by each item. Those responding positively then rated the importance of the problem on a 4-point Likert scale ranging from 0 ("Does not bother me at all") to 4 ("Bothers me very much").
For each item, we calculated an impact score by multiplying the percent of children with positive responses by the item's mean importance rating. Items were ranked within the four health domains (symptoms, functional limitations, emotional well-being, social well-being) according to their impact scores. Separate rankings were created for each clinical group. Items that were above the median in each ranking were selected for the final questionnaire: the CPQ11-14.
In the CPQ11-14, questions asked about the frequency of events in the previous three months. The response options were: "Never" = 0; "Once/twice" = 1; "Sometimes" = 2; "Often" = 3; and "Every day/almost every day" = 4. Global ratings of the child's oral health and the extent to which the condition affected his/her overall well-being were also obtained. The questions were worded as follows: "Would you say that the health of your teeth, lips, jaws and mouth is...?" and "How much does the condition of your teeth, lips, jaws or mouth affect your life overall?" These global ratings had a five-point response format ranging from "Excellent" = 0 to "Poor" = 5 for oral health, and from "Not at all" = 0 to "Very much" = 5 for well-being.
Evaluation of the CPQ11-14
The performance of the questionnaire was assessed in a validity and reliability study. For validity and internal consistency reliability testing, a new sample of children completed a copy of the questionnaire. After a period of 2 wks, a subgroup of these children completed a second copy of the questionnaire for assessment of test-retest reliability. This is defined as the proportion of the score variance attributable to true differences between patients whose health status is stable over time (Streiner and Norman, 1994). Consequently, the second questionnaire asked if the child's condition had changed since recruitment. Both baseline and follow-up questionnaires were self-administered. The clinical data pertaining to the oral and/or oro-facial conditions in question were abstracted from the dental charts at the site of recruitment.
We generated an overall CPQ11-14 score by summing the response codes for the questionnaire items. Scores for each health domain were also computed. We assessed discriminant validity by comparing scores overall and domain scores for the three clinical groups. Because of the small within-group sample size and asymmetrical score distributions, the Kruskal-Wallis one-way analysis of variance was used. The variation in scores according to the severity of the child's condition was also examined insofar as this was feasible, given the clinical data that were collected. In the pedodontic group, the correlation between the overall score and the number of decayed tooth surfaces (DS) at the time of recruitment was assessed. In the oro-facial group, differences in mean scores between the oral cleft diagnostic categories were tested. To examine construct validity, we determined the associations between questionnaire scores and the two global indicators. Internal consistency reliability was tested by means of Cronbach's alphas, and test-retest reliability by means of intraclass correlation coefficients calculated by the one-way analysis of variance random-effects parallel model (Bartko, 1966; Shrout and Fleiss, 1979).
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS & METHODSRESULTSDISCUSSIONREFERENCES |
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CPQ11-14 Descriptive Statistics
Although data were collected by self-completed questionnaire, the number of missing values was low. The CPQ11-14 scores ranged from 1 to 80, with a mean of 26.3 and a standard deviation of 16.7 (Appendix 2, www.dentalresearch.org). These results indicate that the measure detected substantial variability in the quality of life of the child participants. There were no participants with either floor effects (i.e., zero score) or ceiling effects (i.e., maximum score). The domain scores also showed substantial variability, with modest floor and no ceiling effects (Appendix 2, www.dentalresearch.org). According to the percent responding "often" or "every day" as an indicator, 34.1% of the children experienced one or more symptoms in the prior three months, 48.8% had functional limitations, 21.1% had impacts on their emotional well-being, and 30.1% had impacts on their social well-being.
CPQ11-14 Discriminant and Construct Validity
As predicted, there were significant differences among the three clinical groups in overall scale scores, with those of the oro-facial group being highest and those of the pedodontic group being the lowest. The oro-facial group also had significantly higher scores for two of the four subscales than did the other two groups (Table 2).
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Hypotheses concerning construct validity were confirmed—that is, there were significant positive correlations between CPQ11-14 scale scores and global ratings of oral health (p = 0.013) and overall well-being (p < 0.001). The rank correlation coefficient was higher for the rating of overall well-being (r = 0.40) than the rating of oral health (r = 0.23). Significant correlations were also observed between the scores for all health domains and the global ratings of oral health and overall well-being, except between the functional limitations score and the oral health rating (Table 3). Further, the mean score for children reporting that their well-being was "not at all" affected by their oral or oro-facial condition was 15.2, while the mean score for those reporting that it was affected "a lot or very much" was 36.6 (p < 0.001).
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). For the domains, the coefficient ranged from 0.64 for oral symptoms to 0.86 for emotional well-being, indicating acceptable to good internal consistency reliability (Streiner and Norman, 1994). Alphas for the CPQ11-14 were 0.93 for the pedodontic group, 0.89 for the orthodontic group, and 0.91 for the oro-facial group.
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). The ICCs for the pedodontic, orthodontic, and oro-facial groups were 0.89, 0.83, and 0.84, respectively. |
DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS & METHODSRESULTSDISCUSSIONREFERENCES |
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Accordingly, this paper describes the development and evaluation of a questionnaire to measure the OHRQoL of children aged 11 to 14 yrs who have a variety of dental, orthodontic, and oro-facial conditions. This questionnaire consists of 36 items organized into four health domains. The development process used ensured that these items concerned problems that were not only the most frequent but also created the most bother for the children concerned. This means that the questionnaire conforms to a central requirement of HRQoL instruments as defined by Guyatt et al. (1991) and Guyatt and Cook (1994)—that is, it addresses aspects of daily life that patients value.
Analysis of the data presented here shows that the questionnaire is valid and has excellent reliability. It also indicates that the impact of child oral and oro-facial conditions on functional and psychosocial well-being is substantial, and that children are able to give psychometrically acceptable accounts of that impact. In this regard, the questionnaire performs well as a discriminant measure. However, since we intended the questionnaire to be used as an outcome measure in clinical trials, its evaluative properties need to be assessed. Longitudinal studies are then necessary to determine its longitudinal construct validity, responsiveness, and minimal clinically important difference.
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ACKNOWLEDGMENTS |
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Received November 13, 2001; Last revision May 6, 2002; Accepted May 15, 2002
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REFERENCES |
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