Cross-Cultural Adaptation and Validation of the Persian Version of the Oral Health Values Scale

doi:10.21203/rs.3.rs-3870733/v1

Background

The decisions people make regarding oral health reflect their values. Prioritizing oral and dental health is crucial for public health. This study aimed to assess the validity and reliability of the Persian version of the Oral Health Values Questionnaire.

Methods

A cross-sectional study was conducted on 500 adults aged 18 years and older in the health centers of Shiraz in 2011. The OHVS questionnaire was translated into Persian and conceptually and operationally equated. Participants completed the Iranian version of the OHVS, which consists of a 12-item scale with a four-factor structure (professional dental care, appearance and health, flossing, and preservation of natural teeth). Test-retest and Cronbach's alpha were used to evaluate the internal consistency of the questionnaire. To determine the adequacy of the sample, the Kaiser-Meyer-Olkin (KMO) index with a minimum value of 0.7, Bartlett's test of sphericity, eigenvalues greater than 1, and the Varimax rotation model were used with SPSS Version 24 statistical software.

Results

The findings of the study indicated that all questions had satisfactory Content Validity Ratio (CVR) and Content Validity Index (CVI), scoring above the expected thresholds of 0.8 and 0.9, respectively. The test-retest correlation results confirmed the questionnaire's reliability, with a correlation coefficient of less than 0.7 for all questions and their sub-areas. Internal consistency was also observed, as Cronbach's alpha exceeded 0.7 in all areas, including the overall assessment. Factor analysis identified four main components with eigenvalues greater than 1, which together explained 58.963% of the total variance.

Conclusions

The Persian version of the OHVS questionnaire has demonstrated excellent levels of validity and reliability. Therefore, it can be considered a reliable and valuable instrument for epidemiological and behavioral dental studies.

health values

OHVS

validation

Persian

Oral health encompasses the condition of the mouth, teeth, and oral structures. It not only enables individuals to carry out essential functions such as eating, breathing, and speaking, but also has a significant impact on psycho-social aspects. These include increasing self-confidence, promoting well-being, and facilitating social interaction and engagement in activities without pain, discomfort, or embarrassment [1]. The influence of oral health on overall well-being varies across different stages of life and can empower individuals to participate in social activities and reach their maximum potential [2]. The contemporary understanding of oral health considers an individual's overall well-being, encompassing physical, mental, psychological, and social aspects. This updated definition emphasizes the holistic nature of health and moves away from solely relying on the patient's perspective when evaluating disease-related factors [3]. The World Health Organization (WHO) regards oral health as a crucial component of overall health and recognizes that poor oral and dental health can significantly impact quality of life and daily activities. According to the WHO, oral and dental health is defined as "a state of being free from oral and facial pain, oral and throat cancer, oral infections and ulcers, periodontal disease, tooth decay, tooth loss, and other diseases and disorders that restrict a person's ability to bite, chew, smile, speak, and maintain mental health" [4].Numerous factors, including psychological, social, and environmental aspects, influence behaviors related to oral health, making it an indispensable element of personal well-being [5]. The importance of oral health should not be underestimated, as it is influenced by various factors such as psychological, social, and environmental elements. These factors interact with an individual's socioeconomic status, patterns, beliefs, behaviors, personal and social values, and level of oral health literacy to determine their oral health outcomes [6]. Beliefs play a crucial role in empowering individuals to take charge of their oral health. These values also contribute significantly to prioritizing behaviors that promote good oral health [7]. Concept of oral health values is defined by the level of significance an individual places on their oral health and their commitment to preserving and enhancing the well-being of their mouth, jaw, and face. In 2021, Edwards et al. [8] introduced the Oral Health Value scale (OHVS). This comprehensive index evaluates individual values pertaining to oral health and behaviors associated with oral health [8]. Before the introduction of the OHVS, there was a lack of direct measurement and evaluation of Oral Health Values (OHV) in studies related to oral and dental health. Various questionnaires have been developed to assess different aspects of oral and dental health, such as the Oral Health Belief Questionnaire and a questionnaire specifically designed for teenagers to evaluate their beliefs regarding oral and dental hygiene behaviors. These tools have been used to assess knowledge, attitude, and behavior towards oral health. The OHVS is the closest measurement to the OHV, but it only evaluates how oral diseases impact overall health, emotional well-being, and abilities, without considering individual preferences and the importance placed on oral health. Research has shown a connection between education about oral care and a stronger belief in oral health. Beliefs are often instinctive and illogical, while values require contemplation and examination. Individuals' understanding and literacy about their own oral health play a role in their awareness of values. The OHVS is a comprehensive tool that assesses an individual's awareness of oral health and their commitment to supplementary oral care. It consists of twelve items with responses based on a 5-point Likert scale. The tool evaluates four subscales: professional dental care and related costs, appearance and health of teeth, flossing teeth as continuous self-care behaviors, and maintaining natural teeth as a value that affects a person's performance and personal health. Multiple studies have shown a connection between OHVS outcomes and other assessments of oral and dental health, including oral health literacy, oral self-care, quality of life related to oral health, fear of tooth loss, and mistrust of dentists. The questionnaire has been translated and analyzed in various countries. However, it is important to recognize that cultural norms, oral health literacy levels, investment in oral and dental health across different social classes, and societal perceptions may result in diverse attitudes towards this concept. The aim of this study is to validate the Persian version of the OHVS as a tool for assessing people's investment in oral health in Iranian societies.

Conceptual equivalence and equivalence for each item

In the initial phase, the original version of OHVS was developed. Subsequently, conceptual equivalence for Iranian culture was examined through a review of relevant literature to identify similarities and differences in the structure of the OHVS questionnaire, as well as the perception of oral health values in the target population. To enhance conceptual equivalence, the matter of OHVS was extensively deliberated by 2 dentists and 2 experienced oral health specialists in a focus group. Equivalence for each item was assessed individually within the same focused group (9 expert dentists). These individuals, who were invited to partake in the focus group, deliberated on the relevance and acceptability of each OHVS item. The members of this group were requested to provide feedback on each of the items utilized in Iran using the following responses:

1-Irrelevant 2- Less relevant 3- Relevant but needs minor change 4- Completely relevant

Two questions were added to ensure the relevance and acceptability of OHVS items for use in the Iranian population:

1. Does this questionnaire include the main behaviors related to OHV shown by Iranian society?
2. Are there any related behaviors about OHV that are not included in this questionnaire?

Semantic equivalence

Since the source questionnaire (in English) and the target questionnaire (in Persian) have different languages, it was necessary to translate and then reverse translate them. We evaluated semantic equivalence to assess the similarity in meanings and usage of terms, following the four steps suggested by Guillemin, Bombardier, and Beaton (1993) between the original translation and the version agreed upon after an expert panel [17].

- Reverse translation

- Back translation of the consensus version (Persian to English)

In this research, two independent Persian translators were involved in the translations: one was a dentist fully proficient in English, and the other was a professional English to Persian translator. Subsequently, the back translation was carried out by two native English-speaking translators with a good command of Persian expressions. It is important to note that both translators were unaware of the questionnaire's content. The back-translations of the OHVS were then compared with the original to address any discrepancies, identify the need to eliminate inadequate information for the target population, and ultimately, a preliminary agreed-upon version was presented.

Operational equivalence

The operational equivalence was established using the original Persian version of the OHVS, which was provided to 12 dentists from the dental school of Shiraz University of Medical Sciences for evaluation through cognitive interviews in terms of format, content, and comprehensibility. The principal investigator conducted the cognitive interviews to identify potential issues before the experiment. The interviewers explained the questionnaire's objectives and obtained consent from the dentists. The respondents completed the questionnaire individually under the interviewer's continuous supervision, who addressed their questions and resolved any misunderstandings using the cognitive interview method. All interviews were recorded for further analysis. After addressing the identified issues, the study moderators prepared the first version of the Persian OHVS in accordance with Iranian culture. Then, a preliminary test was carried out to assess the items and the format of the instrument translated into Farsi on a sample of 20 adults aged between 20 and 40. The participants were then requested to share their views on the clarity and level of understanding of the content. Following a discussion of the issues identified in the questionnaire and those reported in the initial study, the final version of the Persian OHVS was developed to align with Iranian culture.

Reliability test

To assess the reliability of the questionnaire, two methods were employed. Cronbach's alpha was used to measure internal consistency, while stability was evaluated using test-retest correlation methods with a two-week interval in a sample of 50 participants, and the Intraclass Correlation Coefficient test was also utilized.

Exploratory factor analysis and internal consistency

In order to assess the structure's validity, we utilized factor analysis to examine the internal similarity of the questionnaire statements and identify the variables with the strongest relationships. We conducted exploratory factor analysis (EFA) using the Keyser-Meyer-Elkin sampling index test (KMO) and Bartlett's test of sphericity (BT), principal component analysis, scree plot, and varimax rotation. A minimum factor loading of 0.40 was considered necessary to retain each term in the extracted factors from the factor analysis.

In a cross-sectional study conducted from August to December 2022, a total of 500 participants were included in the study using multi-stage sampling. The participants were chosen from all 30 health centers in Shiraz, the capital of Fars province in southern Iran. The mean age of the participants was 38.53 ± 10.92 years, ranging from 14 to 74 years. The majority of participants (65.7%) were male. In terms of education, the majority of participants were university graduates (69%), followed by those with secondary education (22%) and postgraduate studies (7%). The majority of participants (87%) came from urban areas. In relation to employment, 76.9% of individuals were employed, 7.9% were students, and the remaining were unemployed. The assessment of the content validity index (CVI) for the initial questions revealed that three questions (2, 4, and 7) had an index of 0.77. After revising and correcting the wording of the questions, and re-evaluating the CVI index, the content was found to be valid and in accordance with the conceptual framework (CVI range between 0.9 to 1.00). The average content validity index scale (S-CVI/Ave) of the questionnaire was 0.98. Additionally, the content validity of all questions in the questionnaire has been confirmed based on the minimum acceptable content validity ratio (CVR) index, as determined by a panel of experts. The CVR index ranges from 0.83 to 1. Once the content validity and face validity of the questionnaire were confirmed, the pilot questionnaire was administered to a group of 50 participants to assess its internal consistency. The Cronbach's alpha coefficient was computed for four factors: professional dental care, appearance and health, flossing, and the retention of natural teeth. The findings indicated that the subscales exhibited a coefficient above 0.70, while all 12 items demonstrated a coefficient of 0.82. The results of the intra-cluster correlation index (ICC) test indicated a significant agreement between the scores of the first and second tests (P < 0.001), confirming the repeatability of the subscales (ranging between 0.97 and 0.98) and the entire questionnaire (0.98), demonstrating high stability in the OHVS questionnaire. Factor analysis to assess the adequacy of the data and sample, Bartlett and KMO tests were utilized. After identifying the factors, the contribution of each factor to the total variance explanation was determined. The Varimax (orthogonal) method was employed for factor rotation, resulting in the formation of a matrix of rotated factors. Based on the correlation of each question with the factor (factor load) in this matrix, the questions were categorized into components. An exploratory factor analysis was performed on a set of 12 sentences using the principal components method. The KMO value obtained was 0.817, indicating that the data is suitable for factor analysis. Furthermore, Bartlett's sphericity test resulted in a significant outcome of 938.5884 at the 0.001 level, providing justification for using factor analysis based on the correlation matrix derived from the sample being studied.

The KMO index evaluation yielded a value of 0.75, demonstrating that the data is appropriate for factor analysis as it surpasses the recommended threshold of 0.7. Additionally, Bartlett's Test of Sphericity showed a non-significant result (Χ²(66) = 1121.276, p < 0.001), which indicates that there is an acceptable correlation between the variables, a prerequisite for conducting factor analysis. Table 1 presents the Communality results for each variable in regards to the main and extracted components.

Table 1

Communality sharing results related to main and extractive components
Communalities
items	Initial	Extraction
My smile is an important part of my appearance.	1.000	0.492
I think it is important that my teeth and gums are a source of pride.	1.000	0.540
The condition of my teeth and gums is an important part of my overall health.	1.000	0.603
Going to a dentist is not worth the cost to me	1.000	0.554
If I have a toothache, I prefer to wait and see if it will go away on its own before seeing a dentist	1.000	0.645
Going to the dentist is only important if my teeth or gums are bothering me.	1.000	0.697
Flossing my teeth every day is a high priority for me.	1.000	572/0
t is okay for me to miss a day or two of flossing when I am busy	1.000	0.433
I make sure I have dental floss available with me so I have it when I need it	1.000	0.597
It is important to me to keep my natural teeth	1.000	0.527
would rather get dentures than spend money to treat cavities or gum disease	1.000	0.796
I would not mind if I had to have a false tooth or dentures	1.000	0.620

The main components' solutions indicate that all variables have a communality value of 1, signifying that the variances associated with each variable have been adequately explained. Furthermore, the extracted components demonstrate that none of the variables have a low extracted share, ensuring that none of them were excluded from the analysis. Table 2 displays the amount of variance explained by each component.

Table 2

Amount of variances explained by each component
Total Variance Explained
Component	Initial Eigenvalues			Extraction Sums of Squared Loadings			Rotation Sums of Squared Loadings
Component	Total	% of Variance	Cumulative %	Total	% of Variance	Cumulative %	Total	% of Variance	Cumulative %
1	3.207	26.724	26.724	3.207	26.724	26.724	1.990	16.587	16.587
2	1.602	13.348	40.072	1.602	13.348	40.072	1.860	15.540	32.128
3	1.202	10.019	50.090	1.202	10.019	50.090	1.733	14.441	46.569
4	1.065	8.873	58.936	1.065	8.873	58.963	1.487	12.394	58.963
5	0.802	6.687	65.649
6	0.771	6.424	72.074
7	0.704	5.863	77.937
8	0.671	5.592	83.529
9	0.590	4.916	88.445
10	0.582	4.849	93.924
11	0.440	3.665	96.959
12	0.365	3.041	100.000

It reveals that only four components have eigenvalues greater than 1, collectively accounting for 58.963% of the total variance. Figure 1 portrays the scree plot of the eigenvalues from the principal components analysis.

The graph further validates that the solution's four components provide a better description of the main components. Combining the information from Table 2 and Fig. 1, it can be observed that four components with eigenvalues exceeding one were extracted. These components account for approximately 59% of the total variance related to oral health values. The first component explains around 16% of the variance, while the fourth component has the smallest contribution at about 12%. Table 3 exhibits the factor loadings for each item after Varimax rotation.

Table 3

Matrix of factors rotated by Varimax method (orthogonal)
Rotated Component Matrix^a
items	Component
items	1	2	3	4
q6	821/0	027/0-	067/0-	131/0-
q5	794/0	074/0-	039/0-	089/0-
q4	706/0	144/0	181/0-	048/0-
q11	147/0	880/0	011/0-	016/0-
q12	091/0	744/0	212/0-	116/0-
q10	033/0-	594/0-	408/0	078/0
q3	113/0-	025/0	762/0	093/0
q2	028/0-	244/0-	673/0	161/0
q1	118/0-	219/0-	652/0	070/0-
q9	109/0-	144/0-	048/0	750/0
q7	026/0-	074/0	139/0	739/0
q8	341/0	151/0	037/0	540/0-

The table illustrates those questions 4, 5, and 6 have the highest correlation with the first factor, while questions 10, 11, and 12 have the highest correlation with the second factor. Questions 1, 2, and 3 exhibit the highest correlation with the third factor, whereas questions 7, 8, and 9 have the highest correlation with the fourth factor. Question 10 displays a shared correlation between factors 2 and 3 and is categorized under the subgroup of factor 2 due to its stronger correlation with factor 2 compared to factor 3.

The OHVS questionnaire designers believed that the relevant values for oral health evaluate many areas related to oral health, but not all of them. The four areas of OHVS include professional care of teeth, appearance and health of gums and teeth, flossing, and preservation of natural teeth, which can affect oral health [8]. Professional care of teeth and related expenses, such as paid expenses, time, energy, and concentration, is an important and valuable field. Additionally, the appearance of teeth and gums and the overall health of a person clearly reflects an important aspect of oral health values. Flossing as a self-care behavior can represent personal investment and consistent behavioral output that reflects values. Finally, the preservation of natural teeth, with implications for the appearance and function of teeth, can sometimes visibly demonstrate oral health values [8]. In the process of localizing a tool, it is suggested that the first step in evaluating psychometric properties is to check the validity of its content. Omitting the review of content validity may lead to the need for the researcher to repeat the pilot study, as untested tools may require revision. Therefore, tools with measured content validity need to be revised and modified less during the evaluation phase [18]. Despite the small number of fields, the results of OHVS content validity in the current study showed that the questions have high representation/relationship and specificity/clarity. The value of CVR was acceptable and confirmed in all questions. The CVI for all questions except questions 2, 4, and 7 was estimated as 1. Considering the CVI value in the range of 0.7–0.79, the questions needed to be revised, and after two stages of composition correction, the CVI evaluation of these questions was also estimated above 0.79. This finding was consistent with the studies of Edwards et al. [8] in the American population, Balgiu et al. [15] on the Romanian population, and Machado et al. on the Portuguese population [16]. In the reliability testing phase, the Test-retest correlation test showed that all the fields were adapted to Iranian culture, and the entire questionnaire demonstrated high reliability. Also the analysis of the internal consistency of the questions revealed that Cronbach's alpha exceeded 0.7 in all areas, indicating the satisfactory internal consistency among the measures of these areas in the Persian version of the Oral Health Values Questionnaire. In a study conducted by Machado et al. [16] on the Portuguese population, it was discovered that the OHVS questionnaire and its four subscales exhibited a high and acceptable level of internal consistency (Cronbach's alpha = 0.97). The researchers attributed this to the valid symptoms of negligent oral health behaviors that previous studies have reported in the Portuguese scenario. Therefore, the OHVS questionnaire has the potential to enhance our understanding of psychological and social/environmental factors related to oral health beliefs. It could also facilitate the creation of intervention strategies for oral health behavior in the future. In a study of the Romanian population, Balgiu et al. [15] discovered that the overall scale and two subsets related to appearance and flossing demonstrated reliable internal consistency. However, the subsets concerning professional dental care and preserving natural teeth exhibited weaker internal consistency, which may be due to the limited number of items within these subsets. It is worth noting that the number of items in a scale can impact Cronbach's alpha internal consistency coefficients [19]. In the exploratory factor analysis of the Persian version of the OHVS Questionnaire, similar to the English [8] and Romanian [15] versions of the questionnaire, 4 main factors of professional care of teeth, appearance and health of gums and teeth, flossing, and preservation of natural teeth were identified. All 12 items exhibited appropriate factor loading, and none of the items had a low extracted share, so none of the items were excluded from the analysis. Despite utilizing a relatively large sample, the age range of participants in our study varied significantly. This provides an opportunity for future research to assess the scale's validity among specific age groups. Another limitation is the absence of data on dental visit frequency. Additionally, it is important to note that the majority of participants in our study had a university education, which does not accurately represent the general population in Iran. Despite these limitations, our study establishes the construct validity of the OHVS and serves as a starting point for further investigation. To gain a better understanding of the quality of items and information provided by the OHVS, future research should employ item response theory (IRT).

The validity and reliability indices of the Persian version of the OHVS questionnaire were all reported to be at the optimal level. Therefore, the Persian version of OHVS can be used as a reliable and useful tool in epidemiological research and dental behavioral evaluation.

This study has several limitations that are worth mentioning. In the process of collecting data, we made efforts to include individuals from diverse socio-economic backgrounds through a sizable and multi-stage sample. However, it is important to note that individuals with higher socio-economic status may be less likely to seek care at health centers. This could limit the generalizability of the results. In addition, most of the study participants were middle-aged and were university graduates, so the findings may not represent the perspectives of all members of society. Therefore, future research should focus on samples that are equally distributed in terms of age and education level to ensure a more accurate validation of the Persian version of the OHVS.

OHVS: Oral Health Values Scale questionnaire; WHO: World Health Organization; OHV: Oral Health Values; EFA: Exploratory Factor Analysis; KMO: Keyser-Meyer-Elkin sampling index test; BT: Bartlett's test of sphericity; CVI: Content Validity Index; CVR: Content Validity Ratio; S-CVI: Content Validity Index for Scale; ICC: Intra-cluster Correlation index; IRT: Item Response Theory

Acknowledgments

The authors greatly appreciate the cooperation offered by the Vice Chancellor for Research of the Shiraz University of Medical Science. The authors also wish to thank Dr. Arghavan Behbahani Rad ( Assistant Professor of Dental Public Health, School of Dentistry, Shiraz University of Medical Sciences) for her valuable comments on the study design.

Authors’ contributions

KM contributed to the study design, manuscript writing, and data analysis. MKH contributed to the data gathering. All the authors read and approved the final manuscript

Funding

This article is based on the thesis (Grant# 25692) prepared by Marjan Khalaji to fulfill the requirements for the dental doctor degree. The project was funded by the Vice Chancellor for Research of the Shiraz University of Medical Science.

Availability of data and materials

The datasets utilized and/or examined during the present study can be obtained from the corresponding author upon reasonable request.

Ethics approval and consent to participate

The protocol was approved by the Ethics Committee of Shiraz University of Medical Sciences (ethical code IR.SUMS.DENTAL.REC.1401.043). At the start of the study, the participants were given explanations about the objectives, and informed written consent was obtained from all of them. Complete anonymity and confidentiality of data was assured. The research conducted in this study is in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable.

Conflicts of Interest

The authors declare no conflict of interest.

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No competing interests reported.

Cross-Cultural Adaptation and Validation of the Persian Version of the Oral Health Values Scale

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Introduction

Material and methods

Conceptual equivalence and equivalence for each item

Semantic equivalence

Operational equivalence

Reliability test

Exploratory factor analysis and internal consistency

Result

Discussion

Conclusion

Limitations

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1