Development and preliminary psychometric evaluation of a brief oral health knowledge, attitudes, and practices questionnaire for parents of primary schoolchildren

Background: What parents know, believe, and do at home has a direct bearing on their children’s oral health. Yet, tools that enable clinicians to quickly assess parental knowledge, attitudes, and practices (KAP) during routine encounters remain scarce, particularly for parents of primary school-aged children. This study aimed to develop and conduct an initial psychometric validation of a brief parental oral health KAP questionnaire for potential use in pediatric dental practice in Malaysia. Methods: Questionnaire items were adapted from existing instruments and refined through content and face validation. The questionnaire was administered to 106 parents and guardians recruited from dental clinics, schools, and the general community across three regions in Malaysia, of whom 30 completed a two-week test–retest. Psychometric analyses included Item Response Theory for Knowledge, Exploratory Factor Analysis (EFA) for Attitudes and Practices, internal consistency (Cronbach’s α), and intraclass correlation coefficients (ICC). Results: The final 11-item Knowledge domain demonstrated modest internal consistency (α = 0.62) and moderate test–retest reliability (ICC = 0.650). EFA supported a unidimensional 9-item Attitude domain (49.1% variance explained) with α = 0.70 and ICC = 0.558. EFA on 6 practice items yielded a two-factor structure comprising family dietary practices and family oral hygiene practices, explaining 65.1%of total variance; two additional fluoride items were retained descriptively, giving a final 8-item Practice domain. Internal consistency was strong for both practice subscales (α = 0.86 and 0.82), with moderate-to-good test–retest reliability (ICC = 0.729 and 0.786). The combined practice scale also demonstrated good temporal stability (ICC = 0.754). Conclusions: The parental oral health KAP questionnaire demonstrated modest psychometric properties. It may help identify parental knowledge gaps, unfavorable attitudes, and household behavioral risks that may not be captured through clinical examination alone. Further validation in larger, more diverse samples is needed before broader application.

Children; Health knowledge; Attitudes; Practice; Parents; Surveys and questionnaires

[1] Berhan Nordin EA, Shoaib LA, Yusof ZYM, Manan NM, Othman SA. Oral health-related quality of life among 11–12-year-old indigenous children in Malaysia. BMC Oral Health. 2019; 19: 152.

[2] Gherunpong S, Sheiham A, Tsakos G. A sociodental approach to assessing children’s oral health needs: integrating an oral health-related quality of life measure into oral health service planning. Bulletin of the World Health Organization. 2006; 84: 36–42.

[3] Adair PM, Pine CM, Burnside G, Nicoll AD, Gillett A, Anwar S, et al. Familial and cultural perceptions and beliefs of oral hygiene and dietary practices among ethnically and socio-economically diverse groups. Community Dental Health. 2004; 21: 102–111.

[4] Cooper AM, O’Malley LA, Elison SN, Armstrong R, Burnside G, Adair P, et al. Primary school-based behavioural interventions for preventing caries. Cochrane Database of Systematic Reviews. 2013; 2013: CD009378.

[5] Almugairin S, Alwably A, Alayed N, Algazlan A, Alrowaily H, Eldwakhly E, et al. Parental knowledge, awareness, and attitudes towards children’s oral habits: a descriptive cross-sectional study. Acta Odontologica Scandinavica. 2025; 84: 65–75.

[6] Chen L, Hong J, Xiong D, Zhang L, Li Y, Huang S, et al. Are parents’ education levels associated with either their oral health knowledge or their children’s oral health behaviors? A survey of 8446 families in Wuhan. BMC Oral Health. 2020; 20: 203.

[7] Doğan GK, Polat Y, Özüdoğru S. Parental awareness and attitudes towards pediatric dentistry and children’s oral health. BMC Oral Health. 2025; 25: 672.

[8] National Health Service. Children’s teeth. 2025. Available at: https://www.nhs.uk/live-well/healthy-teeth-and-gums/taking-care-of-childrens-teeth/ (Accessed: 01 March 2026).

[9] Ruff RR. Transition probabilities for caries in children receiving silver diamine fluoride: a community-based randomized clinical trial. Scientific Reports. 2025; 15: 35982.

[10] Zarei F, Dehghani A, Ratansiri A, Ghaffari M, Raina SK, Halimi A, et al. ChecKAP: a checklist for reporting a knowledge, attitude, and practice (KAP) study. Asian Pacific Journal of Cancer Prevention. 2024; 25: 2573–2577.

[11] Liu D, Li H. Knowledge, attitude, and practice of adolescents and parents toward malocclusion and orthodontic treatment. Scientific Reports. 2024; 14: 26553.

[12] Oral Health Division. National health and morbidity survey 2017: national oral health survey of school children 2017. (NHMS 2017: NOHSS 2017). Ministry of Health: Putrajaya, Malaysia. 2017.

[13] Anuwar AHK, Ng CW, Safii SH, Saub R, Ab-Murat N. Modelling the national economic burden of non-surgical periodontal management in specialist clinics in Malaysia using a Markov model. BMC Oral Health. 2024; 24: 346.

[14] Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: A Cancer Journal for Clinicians. 2021; 71: 209–249.

[15] Oral Health Programme. Guidelines: primary prevention and early detection of oral potentially malignant disorders and oral cancers. 2018. Available at: https://hq.moh.gov.my/ohp/images/pdf/publication/4.12.2020_Oral%20Cancer%20Guidelines_edaran.pdf (Accessed: 01 March 2026).

[16] Ngah R, Hasan R, Abd Rahman N. Linguistic validity and reliability of cariogenic food frequency and oral health knowledge, attitude and practice questionnaires for parents of 6–11-year-old children in Kota Bharu, Kelantan. Malaysian Journal of Nutrition. 2019; 25: 79–97.

[17] Watt RG, Harnett RM, Daly B, Fuller SS, Kay E, Morgan A, et al. The oral health promotion evaluation toolkit. Stephen Hancocks Publishing: London, United Kingdom. 2004.

[18] Gallione C, Bassi E, Cattaneo A, Busca E, Basso I, Dal Molin A. Oral health care: a systematic review of clinical practice guidelines. Nursing and Health Sciences. 2025; 27: e70027.

[19] Selvaraj S, Naing NN, Wan-Arfah N, Karobari MI, Marya A, Prasadh S. Development and validation of oral health knowledge, attitude and behavior questionnaire among Indian adults. Medicina. 2022; 58: 68.

[20] Anwar N, Yusof ZYM, Mohd Nor NA. Effect of the SIMS program on oral hygiene levels of 5–6-year-old children in the Kampar district, Malaysia: a cluster-randomized controlled trial. Makara Journal of Health Research. 2020; 24: 128–139.

[21] Rajbhandari A, Aryal N. Assessment of knowledge, attitude and practice (KAP) on oral health among secondary-level students: a cross-sectional study in Kathmandu, Nepal. BMJ Public Health. 2024; 2: e000438.

[22] Nzabonimana E, Malele-Kolisa Y, Hlongwa P. Oral health knowledge, attitude and oral hygiene practices among adults in Rwanda. PAMJ Clinical Medicine. 2024; 14: 4.

[23] Kline RB. Principles and practice of structural equation modeling. 5th edn. Guilford Publications: New York, United States. 2023.

[24] Zahiruddin WM, Arifin WN, Mohd-Nazri S, Sukeri S, Zawaha I, Bakar RA, et al. Development and validation of a new knowledge, attitude, belief and practice questionnaire on leptospirosis in Malaysia. BMC Public Health. 2018; 18: 331.

[25] Goni MD, Naing NN, Hasan H, Wan-Arfah N, Deris ZZ, Arifin WN, et al. Development and validation of knowledge, attitude and practice questionnaire for prevention of respiratory tract infections among Malaysian Hajj pilgrims. BMC Public Health. 2020; 20: 189.

[26] Liu J, Wang YX, Li J, Wu D, Zeng GX, Cheng J, et al. Development and assessment of the health-related quality of life scale for children with hearing loss in China. BMC Public Health. 2025; 25: 39.

[27] Puzhankara L, Karuveettil V, Janakiram C, Vasthare R, Srinivasan S, Fenol A. Exploring medical and dental practitioner perspectives and developing a knowledge attitude and practice (KAP) evaluation tool for the common risk factor approach in managing non-communicable and periodontal diseases. BMC Oral Health. 2024; 24: 1017.

[28] Holgado-Tello FP, Chacón-Moscoso S, Barbero-García I, Vila-Abad E. Polychoric versus Pearson correlations in exploratory and confirmatory factor analysis of ordinal variables. Quality and Quantity. 2010; 44: 153–166.

[29] Namdar Areshtanab H, Vahidi M, Hosseinzadeh M, Khani Z. Developing the questionnaire of general population knowledge, attitudes and practices towards the COVID-19 outbreak. Nursing Open. 2024; 11: e2143.

[30] Taber KS. The use of Cronbach’s alpha when developing and reporting research instruments in science education. Research in Science Education. 2018; 48: 1273–1296.

[31] Streiner DL, Norman GR, Cairney J. Health measurement scales: a practical guide to their development and use. 5th edn. Oxford University Press: Oxford, United Kingdom. 2015.

[32] Yusuf H, Gherunpong S, Sheiham A, Tsakos G. Validation of an English version of the Child-OIDP index, an oral health-related quality of life measure for children. Health and Quality of Life Outcomes. 2006; 4: 38.

[33] McGraw K, Wong S. Forming inferences about some intraclass correlation coefficients. Psychological Methods. 1996; 1: 30–46.

[34] Sahab DA, Bamashmous MS, Ranauta A, Muirhead V. Socioeconomic inequalities in the utilization of dental services among adults in Saudi Arabia. BMC Oral Health. 2022; 22: 135.

[35] Tan YR, Jawahir S, Doss JG. Oral healthcare seeking behavior of Malaysian adults in urban and rural areas: findings from the National Health and Morbidity Survey 2019. BMC Oral Health. 2023; 23: 719.

[36] Simanainen M. How an increase in income affects the use of dental care services among a low-income population: evidence from the Finnish basic income experiment. BMC Health Services Research. 2024; 24: 499.

[37] Kamolchaiwanich K, Lee JY, Leelataweewud P. Exploring the link between maternal oral health literacy and child oral health behaviours. International Dental Journal. 2025; 75: 2042–2052.

[38] Pezeshki BS, Feizi A, Tahani B. Determinants of dental caries in deciduous teeth among Iranian school children: evidence from a developing country. PLOS ONE. 2025; 20: e0327141.

[39] Atanyan A, Muradyan D, Mkrtchyan M, Karbouian K, Yeretzian ST, Paranjkhoo P, et al. The relation between primary schoolchildren’s dental plaque index and their parents’ oral health knowledge in rural Armenia. Caries Research. 2025. PMID: 41166526.

[40] Gao J, Ruan J, Zhao L, Zhou H, Huang R, Tian J. Oral health status and oral health knowledge, attitudes and behavior among rural children in Shaanxi, western China: a cross-sectional survey. BMC Oral Health. 2014; 14: 144.

[41] Alhoot M, Alghadban A. Knowledge, perception, and attitude of parents toward dental treatment given to their primary school students in Tripoli, Libya. Malaysian Journal of Public Health Medicine. 2023; 23: 369–379.

[42] Buunk-Werkhoven YAB, Tamulienė R, Mačiulienė D. Exploring parental opinions on oral hygiene behavior and knowledge of their young children in Lithuania: a cross-sectional survey study. Frontiers in Oral Health. 2025; 6: 1530265.

[43] Patil AN, Karkare S, Jadhav HS, Damade Y, Punjari BK. Knowledge, attitude, and practice of parents toward their children’s oral health and its influence on the dental caries status of 5–10-year-old schoolchildren in Nashik, Maharashtra: a cross-sectional study. International Journal of Clinical Pediatric Dentistry. 2022; 15: S126–S130.

[44] Folayan MO, Kolawole KA, Oyedele T, Chukwumah NM, Onyejaka N, Agbaje H, et al. Association between knowledge of caries preventive practices, preventive oral health habits of parents and children and caries experience in children resident in sub-urban Nigeria. BMC Oral Health. 2014; 14: 156.

[45] Poutanen R, Lahti S, Tolvanen M, Hausen H. Parental influence on children’s oral health-related behavior. Acta Odontologica Scandinavica. 2006; 64: 286–292.

[46] Chin YJ, Mani SA, Doss JG, Musa S, Danaee M. Cross-cultural adaptation and psychometric properties of the Malay version of parenting and child tooth brushing assessment (M-PACTA). BMC Oral Health. 2024; 24: 949.

[47] Amarra MS, Khor GL, Chan P. Intake of added sugar in Malaysia: a review. Asia Pacific Journal of Clinical Nutrition. 2016; 25: 227–240.

[48] Institute for Public Health. National Health and Morbidity Survey (NHMS) 2024: Nutrition—key findings. 2025. Available at: https://iku.nih.gov.my/images/nhms2024/key_findings_nhms2024.pdf (Accessed: 01 March 2026).

[49] Sinharay S, Haberman SJ. How often is the misfit of item response theory models practically significant? Educational Measurement: Issues and Practice. 2014; 33: 23–35.

[50] Suárez-Fernández C, Barrientos C, García-Pola M. Public awareness on oral cancer: a population-based study in Asturias. Asian Pacific Journal of Cancer Prevention. 2023; 24: 4127–4131.

[51] Zhang X, Noor R, Savalei V. Examining the effect of reverse worded items on the factor structure of the need for cognition scale. PLOS ONE. 2016; 11: e0157795.

[52] Kam CCS. Why do regular and reversed items load on separate factors? Response difficulty vs. item extremity. Educational and Psychological Measurement. 2023; 83: 1085–1112.

[53] Onyejaka NK, Folayan MO, Folaranmi N. Barriers and facilitators of dental service utilization by children aged 8 to 11 years in Enugu State, Nigeria. BMC Health Services Research. 2016; 16: 93.

[54] Chan MK, Xiong Y, Lo ECM, Wong MCM. Facilitators and barriers that influence oral health behaviours among adolescents: a systematic review. International Dental Journal. 2026; 76: 109333.

[55] Tahani B, Asgari I, Golkar S, Ghorani A, Hasan Zadeh Tehrani N, Arezoo Moghadam F. Effectiveness of an integrated model of oral health-promoting schools in improving children’s knowledge and the KAP of their parents, Iran. BMC Oral Health. 2022; 22: 599.

[56] Xu X, Shi X, Xie X, Liu Y, Shi H, Wang Q, et al. Parental health belief and behavioral factors influencing oral health behaviors of preschoolers in Shanghai: a cross-sectional study. Scientific Reports. 2025; 15: 33644.

[57] Zarabadipour M, Mokhlesi A, Poorsoleiman T, Mirzadeh M. Parents’ attitudes toward their children’s oral health care during the COVID-19 pandemic: a cross-sectional study. International Journal of Dentistry. 2023; 2023: 7340105.

[58] Ab Mumin N, Yusof ZYM, Marhazlinda J, Obaidellah U. Exploring the opinions of secondary school students on the strengths and weaknesses of the school dental service in Selangor, Malaysia: a qualitative study. BMC Oral Health. 2021; 21: 394.

[59] Pignatiello GA, Tsivitse E, Hickman RL Jr. A preliminary psychometric evaluation of the eight-item cognitive load scale. Applied Nursing Research. 2018; 40: 99–105.