Cross-cultural adaptation and validation of a self-administered Urdu version of the child oral impacts on daily performances index among 11–12-year-old children in Lahore, Pakistan

1. Introduction

The Ottawa Charter declaration has transformed the concept of health [1]. Oral health is now recognized as comprising functional, social and psychological dimensions essential for overall well-being, with quality of life being profoundly influenced by individuals’ health perceptions, expectations, personal encounters, satisfaction with care and capacity to lead a pain-free, comfortable life [1].

Oral health-related quality of life (OHRQoL) represents a multidimensional framework that reflects an individual’s comfort during daily activities, thereby revealing the impacts of oral diseases and conditions on subjective perceptions, well-being and quality of life [2, 3]. This framework has significant implications for oral health research and clinical practice as it reshapes the understanding of the impact of oral health on individuals’ lives [3, 4]. Traditionally, clinical measures were used mainly to diagnose oral diseases and conditions. Although valid and reliable, such measures are considered inadequate for assessing the broader attributes of oral health [3]. For example, a person experiencing mild dental fluorosis may not require dental treatment based only on clinical indices. However, such a condition may affect the individual’s ability to smile and socialize without embarrassment, thereby impacting their emotional and psychological health and, ultimately, their quality of life. Thus, the recognition that clinical measures alone were insufficient for assessing people’s perceived needs and the impact of oral conditions on their quality of life has led to the development of OHRQoL measures to evaluate oral impacts that cannot be adequately captured using clinical measures alone [3, 4, 5].

In children, oral diseases can have significant impacts on their daily life. Poor oral health not only affects their ability to eat, speak and socialize without embarrassment but also diminishes their overall quality of life, disrupts school performance, and disrupts the lives of their families. Oral diseases affect more than half of the child population globally, making oral impacts on children a pressing global public health concern [6, 7, 8]. Previous studies have shown that the OHRQoL of children with dental caries is significantly lower than that of their healthy counterparts [9]. Furthermore, recent research has indicated that school-going children and adolescents experience considerable negative impacts on their OHRQoL due to conditions such as toothache, gingival diseases, dental trauma and malocclusion [10, 11, 12, 13].

According to the Federation Dentaire Internationale (FDI) report, oral health problems have affected approximately 90% of the global population at some point in their lives, with children being the most affected [14]. Therefore, numerous instruments have been developed to assess OHRQoL in children. For instance, the Child Oral Impacts on Daily Performances (Child-OIDP) index was designed specifically for evaluating OHRQoL in 11–12-year-old children [5]. Its theoretical framework was derived from the World Health Organization’s International Classification of Impairment, Disabilities and Handicap [15], as well as Locker’s conceptual model of oral health [16].

According to the World Health Organization’s (WHO) international classification, the consequences of diseases can be categorized into three levels: impairment, intermediate level (pain, discomfort, functional limitations), and ultimate impacts (disability and handicap). In 1988, Locker et al. [16] proposed a conceptual framework to explain the effects of oral diseases on OHRQoL and posited that untreated oral diseases can result in pain and discomfort, thereby impairing daily activities. Treatment of oral diseases at the intermediate level can alleviate symptoms. However, if left untreated, oral diseases can progress to disability and handicap, ultimately diminishing OHRQoL. For instance, a patient with a tooth cavity experiences difficulty in eating, indicating impairment. If the cavity is not treated, it may advance to irreversible pulpitis, causing severe pain. At this intermediate stage, a root canal treatment will save the tooth. Nevertheless, if left unaddressed, the tooth may require extraction, resulting in ultimate impacts such as social embarrassment and difficulty eating in public settings.

The Child-OIDP index targets the third level, assessing the repercussions of inadequate oral health on the capacity to perform daily activities, such as eating, speaking, teeth cleaning, sleeping, smiling, studying, maintaining emotional well-being and socializing. Essentially, the index encompasses functional, psychological and social dimensions of oral health that are not evaluated by clinical measures [5]. Since its inception, the index has been effectively translated and validated in numerous languages, establishing itself as a straightforward, succinct and pertinent tool for evaluating OHRQoL in children [17, 18, 19, 20, 21, 22, 23, 24, 25].

In Pakistan, among the total population of 220 million in 2020, 34% were children [26], with this proportion steadily rising over the years [27]. In regard to oral health, children in Pakistan experienced a moderate to high prevalence of various conditions, including dental caries [28, 29], severe toothache [30, 31], poor oral hygiene [28], gingivitis [32], fluorosis [33], malocclusion [34] and oral cancer [35], with a substantial portion requiring treatment [36]. These oral diseases and conditions significantly impact their daily activities [30, 33]. Despite considerable research conducted in Pakistan in recent years, there has been limited investigation into assessing the oral impact on children [37]. Thus, insufficient data are available in this regard, leaving children in Pakistan vulnerable to poor OHRQoL without effective interventions to address the issue. This underscores the necessity for a suitable instrument to evaluate oral impacts on children in Pakistan, which would facilitate the development of effective interventions to address these challenges at the population level.

A recent development in this field includes the creation of an interview-based Urdu Child-OIDP index, which was conducted among a limited sample of school children in Islamabad, Pakistan [37]. While this represents a positive step forward, this method may present challenges due to its time-consuming nature, higher administrative costs, and limited suitability for large-scale epidemiological surveys [38].

Therefore, the study aimed to cross-culturally adapt and validate an Urdu-translated version of the self-administered Child-OIDP index, evaluate its psychometric properties, and offer an initial assessment of oral impacts among 11–12-year-old children in Lahore, Pakistan. The Child-OIDP index was selected due to its user-friendly nature, cultural relevance, and inclusion of condition-specific (CS) items. It is considered suitable for application in population surveys and clinical settings alike, facilitating the prioritization of treatment allocation.

2. Materials and methods

The development of the Urdu Child-OIDP index adhered to established guidelines outlined by Herdman et al. [39] and Beaton et al. [40]. The adaptation and validation process comprised two phases: linguistic validation followed by the psychometric evaluation of the index.

2.1 Linguistic validation of the Urdu Child-OIDP

In Phase 1, the English Child-OIDP underwent forward translation into Urdu by three independent local translators: a pediatric dentist, an Urdu language school teacher, and a layman, all proficient in both languages. They were instructed to translate the questionnaire using simple, concise and clear language understandable to 11–12-year-old children, avoiding literal translations when possible to ensure meaningful and relevant sentences. Then, the forward translators (FTs) and researchers convened to review the translations, focusing on conceptual and item equivalence between the English and Urdu versions. After discussion, a consensus was reached on a single draft of the Urdu Child-OIDP. This draft was then back-translated into English by three independent bilingual translators: a community dentist, an English language school teacher, and a layman, proficient in both languages. A meeting between the back translators (BTs) and researchers was held to select a single back translation. Finally, an expert committee meeting involving the FTs, BTs and researchers compared the back translation with the original English Child-OIDP in terms of item and conceptual equivalence, content clarity, item arrangement and instructions. Minor modifications were made to the back translation based on the discussion, and relevant adjustments were applied to the draft Urdu Child-OIDP before finalization.

A pre-test of the draft Urdu Child-OIDP was performed using a convenient sample of 40 children aged 11–12 from two schools (one private and one public) in the Lahore district to evaluate its face validity. The children completed the questionnaire independently in a classroom setting, followed by a discussion with the researcher (KT) regarding their comprehension of the purpose, instructions, content, wording, response options, and general layout of the index. Additionally, the time taken to complete the questionnaire was recorded. After the discussion with the children, minor adjustments were made to the index. Then, a second pre-test was conducted with another group of 40 children, followed by a discussion. It was determined that no further modifications to the index were necessary, and the draft Urdu Child-OIDP was finalized. The flowchart depicting the process of linguistic validation is presented in Fig. 1.

Fig. 1.Flow chart of the linguistic validation in Phase 1. This step-by-step illustration outlines the translation process involving 11–12-year-old children and the expert committee to assess the content and face validity of the Urdu Child-OIDP index, adhering to guidelines by Beaton et al. [40] and Herdman et al. [39]. Child-OIDP: Child Oral Impacts on Daily Performances.

3. Results

Of the 300 eligible children, parental consent was obtained from 267, and 264 children agreed to participate in the study, resulting in a response rate of 98.9%. The gender distribution was nearly equal, with 51.1% female and 48.9% male participants. The children represented diverse socioeconomic backgrounds, with 29.5% from low-income, 42.4% from middle-income, and 24.2% from high-income groups. A larger proportion of children attended public schools (n = 139, 52.7%) compared to private schools (n = 125, 47.3%).

4. Discussion

This paper presents the cross-cultural adaptation and validation of the self-administered Urdu Child-OIDP index among 11–12-year-old children in Lahore, Pakistan. Taken together, the results suggest that the index is both valid and reliable for assessing OHRQoL in this demographic. A validated self-administered Urdu Child-OIDP index offers a practical and cost-effective means of data collection, applicable in both clinical and population-based epidemiological settings.

In this study, we followed established guidelines [39, 40] for the linguistic validation of the Urdu-Child OIDP. A pediatric dentist was included as one of the translators due to the attributed extensive experience with children, providing valuable insights into appropriate word choices and terminology. During the translation process, we found that the Urdu translation of the word “homework” had several meanings, each of which was conceptually different from the item concept in the English language. Therefore, to maintain the conceptual and item equivalence between the two versions, the experts decided to include the word “homework” in the Urdu version to refer to schoolwork given by teachers. This decision was well-received by the children involved in the study.

During the first pre-test, some children encountered difficulties understanding the Urdu translations of specific oral diseases/conditions. To address this issue, we decided to incorporate pictures depicting these conditions into the Urdu Child-OIDP index. Subsequently, during the second pre-test, the children unanimously expressed that the Urdu version was easy to comprehend, relevant, and practical. Following this feedback, the expert committee convened for a final meeting, affirming that the layout of the final Urdu Child-OIDP mirrored that of the original index and maintained contextual similarity.

In the analysis of internal consistency, all inter-item correlation coefficients were positive, suggesting a positive association among the eight items. However, a relatively weak correlation was noted between studying and smiling (0.11). This finding was consistent with studies conducted in Chile (0.15), Morocco (0.11), and India (0.10) [22, 23, 24] but higher than that reported in a Brazilian study (0.01) [19]. One possible explanation is that children in this age group may not perceive school-related activities as significantly impacted by oral health issues. Additionally, none of the inter-item coefficients suggested redundancy among the items [42]. Moreover, all corrected item-total correlation values exceeded 0.2, indicating their relevance to the overall index score. The standardized Cronbach’s alpha coefficient exceeded 0.70, signifying strong internal consistency in assessing oral impacts among Pakistani children within the local context [42]. This value is consistent with findings from studies conducted in Chile (0.71), Sudan (0.73) and Malaysia (0.80) [20, 21, 22]. Furthermore, the Cronbach’s alpha did not increase upon deletion of any items, highlighting the importance of retaining all items within the index [42]. Regarding test-retest reliability, both the overall weighted Kappa and the ICC surpassed 0.8, indicating excellent agreement and temporal stability of the index [42].

The criterion and construct validity assessments of the index revealed significant associations with all global oral health assessment items, history of mouth/teeth problems, and caries levels, aligning with the study’s hypotheses. Furthermore, the absence of floor or ceiling effects indicates the suitability and appropriateness of using the index within this population [42].

In this study, we observed that eating was the most commonly affected performance reported by the children, consistent with findings from studies conducted in Sudan, India and Egypt [20, 24, 25]. Toothache, sensitive teeth and bleeding gums were identified as the most common oral conditions contributing to this impact. This outcome is unsurprising given the significant importance children at this age typically place on eating and enjoying their meals. Experiencing toothache or tooth sensitivity can severely diminish their ability to savor their food, while bleeding gums may affect the taste of food and drinks, consequently impacting their overall enjoyment. As a result, these oral conditions can significantly impede their daily activities and overall well-being.

The second most prevalent impact was observed in cleaning teeth, a trend consistent with findings from studies conducted in Sudan, India and Egypt [20, 24, 25]. Toothache and bleeding gums emerged as the commonly reported causes. Children experiencing toothache and bleeding gums may be inclined to avoid brushing their teeth, consequently compromising their oral hygiene and diminishing their self-confidence in social interactions, both within their local communities and at school.

In this study, we observed that the ability to speak was the least affected performance due to oral diseases/conditions. This could suggest that children at this age may not prioritize verbal communication as adults do, or they may not fully grasp its importance. Interestingly, although studying ranked as the second least prevalent oral impact reported by the children, a higher proportion of children reported experiencing a “very severe” level of impact intensity on studying. Conversely, despite eating being the most prevalent oral impact, more children reported experiencing “very little” impact intensity in this regard. These findings suggest an inverse relationship between the prevalence of oral impact and its intensity, consistent with observations from related studies [21, 25]. It appears that while eating is considered a basic life necessity, children may prioritize certain performances over others. The severe impact intensity reported for studying could be attributed to fear of not being able to perform well at school, being criticized by teachers, and being mocked by friends for having low grades.

Moreover, it was found that 58.6% of children suffered from dental caries. As a result, it was not surprising that toothache, sensitive teeth and bleeding gums were the three oral conditions mostly reported to have caused oral impacts by the children. These findings are consistent with those of similar studies conducted elsewhere [24, 25].

Our study has several limitations. Firstly, our sample was not randomly selected, potentially limiting the representativeness of 11–12-year-old children in Lahore. However, for validation studies, the use of a non-random sample was justified as long as the index was relevant to the sample population [41]. Secondly, our study focused on children from urban and suburban areas of Lahore, excluding those from rural areas. Nonetheless, our sample encompassed children from various socioeconomic backgrounds, somewhat reflecting the demographics of rural areas. The assessment of dental caries using the DMFT/deft indices did not offer additional information on caries severities, possibly leading to an underestimation of caries progression and severity. Nevertheless, the use of this index is recommended by WHO for epidemiological surveys [44]. Future studies could incorporate samples of children from rural areas. Furthermore, assessing the sensitivity and responsiveness to change in the index is recommended to validate its utility in measuring changes in OHRQoL following dental treatment.

5. Conclusions

The study findings indicate that the self-administered Urdu Child-OIDP index is a valid and reliable tool for assessing oral impacts among 11–12-year-old children in Pakistan, as well as in other Urdu-speaking child populations. This index can effectively evaluate oral impacts in large-scale epidemiological surveys involving children of this age group in Pakistan.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.

Author contributions

KZ—contributed towards data collection, analysis, and writing the manuscript. ZYMY and JM—contributed towards data analysis, interpretation, critical analysis and appraisal of the manuscript. All authors read and approved the final manuscript. All authors conceived the idea and contributed to the concept, design and development of the study.

Ethics approval and consent to participate

Ethics approval for the study was granted by the Medical Ethics Committee, Faculty of Dentistry, Universiti Malaya (No: DFCO1806/0033(P)) and the Punjab Education Department, Pakistan (No: 7034). The research was conducted in accordance with the World Medical Association Declaration of Helsinki 1975 (with 2013 revision). Permissions to conduct the study were obtained from the schools. A signed consent form was obtained from parents/guardians of the children and verbal consent was obtained from the children before data collection.

Acknowledgment

The authors wish to thank the administrators, teachers, parents and children from the participating schools in Lahore, Pakistan for taking part in the study.

Funding

The authors received funding from the Research Maintenance Fee, Universiti Malaya (RMF0676-2021).

Conflict of interest

The authors declare no conflict of interest.