116 J Contemp Med Sci | Vol. 2, No. 8, Autumn 2016: 116–118 Research aAssociate Professor of Dental Public Health; Chair, Community Oral health Department, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran. bPreventive Dentistry Research Center, Dental Research Institute, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran. cSchool of Medicine and Dentistry, Santiago de Compostela University, Santiago de Compostela, Spain. dSchool of Dentistry, Tehran University of Medical Sciences, Tehran, Iran. eSchool of Medicine, International Campus, Tehran University of Medical Sciences, Tehran, Iran. fDepartment of Oral and MaxilloFacial Surgery, University of Kufa, Kufa, An-Najaf, Iraq. Correspondence to Ammar N. H. Albujeer (email: ammar.dent@yahoo.com) (Submitted: 2 September 2016 – Revised version received: 25 September 2016 – Accepted: 3 October 2016 – Published online: 26 December 2016) Objective It has been well recognized that, oral health is more than beautiful teeth. Mouth has been considered to be the mirror of whole body, as much as a healthy mouth means healthy body. Given the epidemic status of oral diseases, monitoring the oral health status is essential for oral health promotion. The World Health Organization (WHO) have provided standard epidemiological survey methodology that requires systematic oral examination, data collection and recording system. Language barrier may be a reason to hinder extensive use of such important instruments in countries where English language is not predominantly used. Therefore, our aim was to standardize an Arabic translation of the WHO instrument for wide spreed use in many nations around the world. This would improve the standardization and quality of the oral health data in Arabic speaking countries. Methods Initially, the forward translation of WHO Oral Health Assessment questionnaire for adults was conducted from English to Arabic language. Backward translation of Arabic version to English language was done by professional English translator and the result was compared with original text to identify differences. A nominal group technique (NGT) was used in order to obtain expert’s opinion from a group of ten specialists who also helped to culturally adapt the questionnaire. Results The content validity index and ratio was calculated. After few recomended adjustments the final Arabic version was produced. After removing one question the overall impact score of the questionnaire improved considerably to acceptable level. When computing the internal consistency coefficient, it was found to be 0.88 for the subscales (which means good to excellent). Conclusion The results of this study prove that, the Arabic version of the WHO Oral Health Survey Questionnaire is reliable instrument to be used for oral health evaluation of adults among Arabic speaking populations. Keywords psychometric, oral health, survey, questionnaire, validity, adults Introduction It has been well recognized that oral health is more than beautiful teeth. Mouth has been considered to be the mirror of the whole body, as much as the healthy mouth means a healthy body. The oral-systemic disease relationship is well established in scientific literature.1 Therefore, it is very important to closely monitor the oral health status to continuously prevent the incidence of oral diseases and promote oral health and the quality for individuals and communities. As reported by most countries around the world, oral diseases are considered as the major public health issues globally.2 In order to better control this epidemic condition, the World Health Organization (WHO) has provided standard epidemiological survey meth- odology requirements for systematic oral examination, standard data collection, and recording system.3,4 On the other hand, the language barrier may be a reason to hinder the extensive use of such an important instrument in countries where English language is not predominantly used. Therefore, our aim was to make an Arabic translation of the instrument available for use in many nations around the world. This would improve the standardization and the quality of the research as well as making more comparable data available for better understanding of the oral health situation in Ara- bic-speaking countries. Likewise, it can help with the stand- ardized reporting of different interventions conducted in those countries. WHO Oral Health assessment questionnaire for adult This questionnaire is published as a part of the “Oral health surveys basic methods, 5th edition” by the World Health Organ- ization in 2013.5 This tool is particularly designed for self- reporting of individual’s oral health information. Aside from demographic information, the rest of the questions are per- taining to risk and protective factors for individual’s oral health outcomes as well as the frequency of personal oral hygiene and the utilization of oral health services. Other information such as socioeconomic status, place of residence, frequency of sugar intake and participation in any specific oral health program are inquired. The 16 primary items in this tool were assessed indi- vidually based on different responses. For more efficient use of this instrument, the WHO has encouraged countries to cultur- ally adapt with necessary adjustments if needed. Methods The forward translation of WHO Oral Health Assessment ques- tionnaire for adults was conducted into Arabic language. This step was followed by backward translation of this document into English language by professional English language translator. The English translation was compared with original text of the questionnaire to identify differences. Few items were slightly ISSN 2413-0516 WHO’s oral health assessment questionnaire for adult: psychometric properties of the Arabic version Mohammad Hossein Khoshnevisan,a,b Ammar N. H. Albujeer,c,d Nona Attaran,b Alya Almahafdha,e Abbas Taherf Mohammad Hossein Khoshnevisan et al. 117J Contemp Med Sci | Vol. 2, No. 8, Autumn 2016: 116–118 Research WHO’s oral health assessment questionnaire for adult Results After conducting NGT method, the culturally adapted final Arabic translation of questionnaire was available. Out of 16 original questions, only one question related to Alcohol use was excluded. The remaining questions were related to oral health self-assessment (7 questions), accessibility to dental treatment (2 questions), diet (1 question) and socio-economic status (3 questions). The rest of the findings are reported as follows: a) Content validity: When considering the total scale, the mean score for content validity index (CVI) was 0.9, demon- strating acceptable result. However, the content validity ratio (CVR) of the question number 15 was found to be lower than expected indicating that this question does not have the optimum level content validity. After exclusion of this question, the overall CVR was 0.81, which was at the satisfactory level based on Lawshe table. A few items were slightly adjusted or modified based on recommended professional reviews. When consensus was reached on semantic, idiomatic, and conceptual equivalence, the final Arabic version was produced. b) Face validity: The impact score was computed for face validity assessment. The index was found to be equal or greater than 1.6 (range: 1.7 – 4.8) except for question (15). After removing this question, the overall impact score of the questionnaire improved considerably (3.5) to a satisfactory level. At this stage, the qualitative face validity was recognized by all partic- ipants by declaring that they had no ambiguity in reading questions and comprehending them. c) Reliability: The Cronbach’s alpha coefficient was cal- culated in order to evaluate the internal consistency and relia- bility for this questionnaire. The calculated value was 0.85 with subscales ranged from 0.75 to 0.91 which were beyond the acceptable thresholds. After computing the internal consist- ency coefficient (ICC), it was found to be 0.88 and the values were 0.72–0.91 for the subscales (which means good to excel- lent). These findings confirm the steadiness of the Arabic ver- sion of WHO questionnaire. Confirmatory Factor Analysis (CFA): The principal com- ponent factor analysis was used to analyze questionnaire. The Comparative Fit Index (CFI) and Square Error of Approximation were computed. The CFI was 0.89 and RMSEA was 0.041. Also, the confidence interval was less than 0.01, which demonstrates the existence of correlation between variables. Therefore, these analyses confirmed the suitability of the data. The results of CFA for five-factor model for WHO Oral Health Survey questionnaire indicated satisfactory fit of the suggested model. The factors were as followed: i. Factor 1 (Oral health self-assessment) including 7 items (item 3, 4, 5, 6, 7, 8, 9). ii. Factor 2 (Accessibility to dental treatment) including 2 items (item 10, 11). iii. Factor 3 (Diet) including 1 item (item 13). iv. Factor 4 (Socio-Economic status) including 3 items (item 12, 14 and 16). Discussion When translating a questionnaire into another language, it must accurately reflect the content and the intent of the Original toll; so that the translated questions contain the same meaning as the Original version. It’s also important to ensure the quality and cultural appropriateness of the translated instrument into adjusted or modified based on professional recommendations. For using nominal group technique (NGT) a professional com- mittee of 11 specialists was formed. Meetings were held by two professional translators, two psychologist, five dental public health specialists and two epidemiologists in order to evaluate and culturally adapt the pre-final version of Arabic questionnaire. After linguistic and cultural adaptation, the final Arabic version of the WHO Oral Health Assessment questionnaire for adults was finalized with complete experts’ consensuce. Statistical analysis For the calculation of the content validity index (CVI) and content validity ratio (CVR) for the questionnaire, an expert panel composed of eight specialists in dental public health and pediatric dentistry were asked to provide comments independently on the necessity of each question was evaluated: (a) not necessary, (b) useful, (c) essential; as well as relevancy, clarity and simplicity of each question. Using a three-point rating scale, the CVR for the total scale was calculated following the expert’s final evaluation. According to Lawshe table, an accept- able CVR value for eight expert panels is 0.75.6 Based on the pro- portion of rating by experts for each item, the CVI was computed.7 Polit and Beck recommended 0.80 as the acceptable lower limit for the CVI value (e.g. 6 of 8 experts should rate 3 or 4).7 By using qualitative and quantitative methods, the face validity of the questionnaire was assessed. In the qualitative stage, 25 adults were asked to evaluate the questionnaire in terms of potential difficulties in responding to the Arabic ver- sion of the Oral Health Questionnaire. In the quantitative stage, the impact score (frequency × importance) was com- puted to determine the percentage of adults who identified the item was important or quite important. The items related with an impact score of equal or greater than 1.5 (corresponding to mean frequency of 50% and a mean importance of 3 on a 5-point Likert scale) were considered appropriate. An exploratory factor analysis was carried out to define the underlying constructs of the questionnaire, followed by principle components analysis with varimax rotation. The reliability of the questionnaire was measured by the dif- ference in a score that eventually shows the true score, rather than the random error to the extent that measures provide con- sistent results. There are two common forms of reliability methods. The internal consistency of a scale relates to its homo- geneity, where the higher the coefficient value, the higher the reliability and the lower the standard error of measurement. The internal consistency was assessed with a Cronbach’s alpha coefficient that ranges between 0 and 1. The values equal to or less than 0.7 indicate satisfactory internal consistency.8 The test– retest reliability measures stability over time, when applying the same test to the same subjects at different points of time. To per- form this test, a total of 25 adults were randomly selected from the Arabic-speaking population to complete the Arabic version of the oral health survey questionnaire. This process was repeated 2 weeks later, using exact same manner as the first round. The estimate of intra-class correlation coefficient was calculated to determine the reliability of the scale using test– retest method. In order to interpret the agreement levels, the following categories were selected: “0.0–0.2” for small level, “0.21–0.40” for fair level, “0.41–0.60” for moderate level, “0.61– 0.80” for substantial level and “0.81–1” for almost perfect level.9 118 J Contemp Med Sci | Vol. 2, No. 8, Autumn 2016: 116–118 WHO’s oral health assessment questionnaire for adult Research Mohammad Hossein Khoshnevisan et al. countries. In general, our results support the standardization (reliability and validity) of the Arabic version of the WHO Oral Health survey questionnaire. Conclusion The results of this study prove that, the Arabic version of the WHO Oral Health survey questionnaire is reliable tool to be used as a self-reported instrument for evaluating oral health among population in Iraqi and other Arabic speaking countries. This 15 digit Arabic version of the WHO Oral Health Survey Questionnaire will improve measuring the oral health status of the Iraqi people as well as other Ara- bic-speaking nations around the world. Conflicts of Interest There are no conflicts of interest. n new language. Similarly, it is important that the translated name of the instrument demonstrates adequate psychometric properties in terms of validity and reliability. Oral health disparities are mainly related to lifestyle and many other factors. This condition is considered as a major public health problem. Millions of children and adults are affected and based on available reports, the burden of oral dis- eases is very prominent globally.10 Using standard surveillance system for oral health status and programs is highly crucial for better oral health care, maintenance, as well as oral disease pre- vention, protection and promotion for individual and commu- nities over time.3,4 Other potential benefits of such system would be the availability of data for administrators and decision makers for using the most cost-effective plan and make the best use of resources towards oral health promotion.11 On the other hand, the availability of standard Arabic ver- sion of WHO recommended instrument may facilitate the generation of quality standard data in many Arabic-speaking References 1. Murray CJ, Lopez AD. On the comparable quantification of health risks: lessons from the Global Burden of Disease Study. Epidemiology-Baltimore, 1999;10:594–605. 2. Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st century–the approach of the WHO Global Oral Health Programme. Commun Dentist Oral Epidemiol. 2003;31(s1):3–24. 3. Yeung C. Book review: Oral health surveys: Basic methods. Br Dent J. 2014;217:333. 4. Organization WH. Oral health surveys: Basic Methods. 1987: World Health Organization. 5. Organization WH. Oral Health Surveys: Basic Methods. 2013: World Health Organization. 6. Lawshe CH. A quantitative approach to content validity. Pers Psychol. 1975;28:563–575. 7. Polit DF, Beck CT. Nursing Research: Principles and Methods. 2004: Lippincott Williams & Wilkins. 8. Cronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrika. 1951;16:297–334. 9. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977:33;159–174. 10. Mathers C, Fat DM, Boerma JT. The global burden of disease: 2004 update. 2008: World Health Organization. 11. Brownson RC, Fielding JE, Maylahn CM. Evidence-based public health: a fundamental concept for public health practice. Annu Rev Public Health. 2009;30:175–201.