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Acta Odontológica Latinoamericana

versión On-line ISSN 1852-4834

Acta odontol. latinoam. vol.26 no.2 Buenos Aires oct. 2013



Cross cultural adaptation and validation of the early childhood health impact scale (ecohis) in peruvian preschoolers


Roxana P. López Ramos1, Carmen R. García Rupaya1, Rita Villena-Sarmiento2, Noemí E. Bordoni3

1 Dentistry School. Cayetano Heredia University, Lima, Perú.
2 Dentistry School. University San Martin de Porres, Lima, Peru.
3 Institute for Research in Public Health, University of Buenos Aires, Argentina

CORRESPONDENCE Mg. CD. Esp. Carmen Rosa Garcia Rupaya Maestria en Estomatologia Universidad Peruana Cayetano Heredia Lima, Peru e-mail:


The aim of the present work was to perform semantic adjustment and evaluation of the psychometric properties of the Early Childhood Health Impact Scale (ECOHIS) in Spanish on a sample of the Peruvian population. The study was conducted on a sample of 128 children aged 3-5 years, who attended a public school (Hualmay District, Huaura Province, Lima, Peru) in 2011. The ECOHIS questionnaire, developed to measure the impact of oral conditions and/or experiences of dental treatment on oral health-related quality of life in children under 5 years old and their parents or other family members was adapted cross-culturally and subjected to psychometric tests: validity (in terms of construct and discriminant) and reliability (in terms of internal consistency and stability). The cultural adaptation addressed ECOHIS semantic equivalence (Bordoni et al., 2012) and showed that 80-100% of respondents understood the questions. Construct validity was r = .557 (p <.05) between the scores of the Spanish version of ECOHIS and dental caries experience (dmft). Statistically significant differences (p <.001) were found for ECOHIS values between groups with and without tooth decay. Internal consistency was assessed by Cronbach's alpha (.948) and stability by intra-class correlation (.992). The Peruvian version of ECOHIS demonstrated acceptable validity and reliability, enabling assessment of the impact of oral health problems in children under 5 years old.

Key words: Quality of life; Dental care for children; Oral health.

Validación y adaptación cultural de la escala de impacto de la salud bucal en la niñez temprana


El objetivo de este trabajo fue realizar el ajuste semantico y la evaluacion de las propiedades psicometricas del Early Childhood Oral Health Impact Scale (ECOHIS), en la version en espanol, sobre una muestra de la poblacion peruana. El estudio se realizo en una muestra de 128 ninos de 3 a 5 anos de edad, asistentes a un centro educativo publico (Distrito Hualmay, Provincia de Huaura, Lima; Peru) durante el ano 2011. El cuestionario ECOHIS, desarrollado para medir el impacto de las condiciones bucales y/o experiencias de tratamientos odontologicos sobre la calidad de vida relacionada a la salud bucal de ninos menores de 5 anos y de sus padres u otros miembros de la familia fue adaptado transculturalmente y sometido a pruebas psicometricas: validez (en terminos de constructo y discriminante); y confiabilidad (en terminos de consistencia interna y estabilidad) La adaptacion transcultural abordo la equivalencia semantica del ECOHIS (Bordoni et al., 2012) y demostro que el 80-100% de los encuestados comprendian las preguntas. La validez de constructo alcanzo un valor de r=.557 (p<.05) entre las puntuaciones de la version en espanol del ECOHIS y la experiencia de caries dental (ceod). Los valores del ECOHIS entre los grupos con caries y sin caries se hallaron diferencias estadisticamente significativos (p<.001). La consistencia interna fue evaluada a traves del Alpha de Cronbach (.948) y la estabilidad a traves de la correlacion intraclase (.992). Puede concluirse que la version en espanol del ECOHIS demostro aceptables validez y confiabilidad permitiendo evaluar el impacto de los problemas bucales en ninos menores de 5 anos.

Palabras clave: Calidad de vida; Cuidados dentales en ninos; Salud bucal.



The World Health Organization (1997) defines health in terms of physical, psychological and social wellbeing. The concept of oral health calls for the inclusion of previously unconsidered factors such as oral symptoms, functional limitations, emotional and social wellbeing and reflection on its impact on quality of life.1 In general, individual and collective oral health status is still predominantly evaluated by means of clinical indicators which only determine presence or absence of disease and its severity. For dental caries, there are various indices including, among others, indices for the history of the disease (DMFT or its derivatives), development process (ICDAS, Nyval et al.), risk factors involved (Cariogram) and the need for treatment (N, and its consequences (PUFA). However, since the mid- 20th century, there has been concern to identify the impact of different diseases and/or treatments on the patient's quality of life. In this line, indicators have been developed to measure oral healthrelated quality of life (OHRQoL) applied to different age groups2. For children under 5 years of age, instruments such as the following have been developed: Michigan COHRQoL Scale3, Early Childhood Oral Health Impact Scale (ECOHIS) 4 and Scale of Oral Health Outcomes for 5- year-old children (SOHO-5)5, whose validity and reliability have been confirmed.
The ECOHIS measures the impact of oral problems and/or experience of dental treatment on the quality of life in children under 5 years old and their parents or other family members. It has 13 questions divided into two domains: one related to impact on the child (9 questions), and another to impact on the family (4 questions), measured using the Likert scale4,6-16. It was recently validated on a sample of Venezuelan and Argentine children from different socioeconomic groups11.
In Peru, caries prevalence in early childhood has been recorded as 11% to 96% in different populations17, but there is no study yet regarding its impact on quality of life. Recognizing its impact may contribute to prioritising the problem individually and collectively. The aim of this study was to perform semantic equivalence and validation of the ECOHIS in a sample of Peruvian families.


This study was conducted on a sample of 128 children aged 3 - 5 years at a preschool in Hualmay District (Huaura Province, Lima Department, Peru) in 2011. Hualmay District is located 150 Km. away from Lima at 32 meters above sea level. According to the 2007 11th National Population Census (conducted by the Peruvian National Institute of Statistics and Informatics, INEI) nominal population is 26,80818. Study design was approved by the Institutional Ethics Committee of Cayetano Heredia Peruvian University, Lima, Peru and authorized by the director of the preschool. Parents or guardians provided informed consent for the children to participate in the study. For the validation phase, inclusion criteria were children of both sexes with apparent good general health status and informed consent from parents or guardians.

Preliminary phase: semantic equivalence
The preliminary phase was a pilot test on a selected convenience sample of 25 caregivers of children who attended a preschool in Huaura Province. It was based on the ECOHIS translation and semantic and psychometric validation by Bordoni et al. (2012)11. Semantic equivalence was used to measure respondent understanding of the questions2.

Validation phase
The semantically adjusted questionnaire was administered to the 128 caregivers who did not participate in the preliminary phase. The clinical study included the participation of authorized children who showed an attitude of willingness to cooperate. Clinical diagnosis was done by applying the WHO25 criteria, by a researcher who was calibrated by a reference examiner.1 Kappa values were 0.97 between examiners and 0.969 within examiners. The same researcher applied the questionnaires according to the criteria recommended by Bordoni et al.11

Statistical processing: Validity and reliability of the ECOHIS instrument
Reliability was analyzed in terms of internal consistency and stability. Validity was analyzed in terms of construct and discriminant4,7-16.

Internal consistency
was measured by Cronbach's alpha coefficient4,7-16. Questionnaire stability was determined during the preliminary phase by having the same subjects answer ECOHIS a second time after a 1-week interval, in order to correlate their answers and determine whether there were any differences (test-retest). It was determined by Spearman's correlation 4,7-16.

Construct validity
was assessed by applying Spearman's correlation coefficient to determine how the overall score and the scores for each ECOHIS domain correlated to the dmft index and its components9,14-16. The correlation coefficients were interpreted as follows: r ≤ 0.49, weak correlation; 0.50 ≤ r ≤ 0.74, moderate correlation, and r ≥ 0.75, strong correlation26.

Discriminant value
was determined by comparing the overall score as well as the scores for each ECOHIS domain to absence and presence of caries in early childhood. Mann-Whitney's U test was applied using the following hypotheses:
• High ECOHIS scores correspond to children with caries in early childhood.
• Effect size (size of the difference between groups) should be statistically moderate or high8,15. The effect size (ES) was calculated using the formula ES = x1 - x2/ r , where x1 is the mean value for the group without caries, x2 is the mean value for the group with caries and r is the grouped standard deviation for the two groups8,27. For statistical analysis, data were stored in a database and processed using version 20.0 SPSS statistical software.


Demographics (Table 1):

Table 1: Demographics at a preschool in Hualmay District, Huaura Province, Lima Department, 2011 (n=128).

1. Children:
a. most frequent age was 5 years (42.2%) and
b. predominating sex was female (52.3%).

2. Caregivers:
a. most frequent sex was female (96.1%),
b. most frequent age group was 15 to 30 years (55.5%),
c. the majority had secondary school education (75.8%) and
d. the most frequent respondent relationship to the child was mother (89.1%).

The semantic equivalence of the Spanish version of the questionnaire applied to the sample of a Peruvian population showed the following results:

1. Caregiver understanding of the questions was 80% to 100% (Table 2)

Table 2: SEMANTIC EQUIVALENCE. Distribution of comprehension of questions in the ECOHIS questionnaire among 25 caretakers.

2. Some expressions were adapted by making changes such as:
has expressed irritation to has been irritated,
has avoided smiles to avoided smiling,
has been upset to has been upset or worried,
spend time to has spent time, and
have had an economic impact on your family to have affected the economy of your family or home

3. The questionnaire stability test showed that the intra-class correlation coefficient (ICC) was 0.992 for overall ECOHIS score, 0.993 for the domain Impact on Child and 0.961 for the domain Impact on Family. The Spanish version of the ECOHIS for the Peruvian population was validated on a total 153 preschoolers and their caregivers. Answers were grouped as: "never, hardly ever" and "occasionally, often, very often". It was found that:
a. The questions about pain (62.5%), difficulty eating (54.7%), irritation or frustration (55.5%) and difficulty drinking hot or cold beverages (47.6%) had the most answers in the domain Impact on Child (Table 3).

Table 3: Caretaker's perception of children's oral health-related quality of life at a preschool in Hualmay District, Huaura Province, Lima Department, 2011 (n=153).

b. The questions with greatest impact in the Family domain were about "have you or a family member been upset" (53.1%), "felt guilty" (42.9%) and "affected the economic situation of your home" (44.5%) (Table 3).
c. In the domain of Impact on Child, functional limitation had the highest average answers (5.22) (Table 4).

Table 4: Overall score and score for each domain in the ECOHIS.

d. The correlation between overall ECOHIS score and dmft was r= 0.557 (p<.001). For the domain Impact on Child, r= 0.540, (p<.001) and for Impact on family, r= 0.560 (p<.001). The correlation with the component "decayed" was r=0.559, (p<.001) (Table 5).

Table 5: CONSTRUCT VALIDITY: Correlation between the Early Childhood Oral Health Impact Scale (ECOHIS) and dmft.

e. Mean ECOHIS scores and scores in each domain differed significantly between children with and without caries in early childhood (p<.001). The Effect Size (ES) for overall ECOHIS score between groups with and without caries was 0.527; while for each section it was 0.460 and 0.531 respectively (Table 6).

Table 6: DISCRIMINANT VALIDITY: Mean overall ECOHIS scores and scores per section compared to early childhood caries status

f. For internal consistency, Cronbach's alpha test values were 0.925 for the domain Impact on Child, 0.882 for the domain Impact on Family, and 0.948 for overall ECOHIS score (Table 7).

Table 7: RELIABILITY ANALYSIS: Internal Consistency and Test-Retest.


This study validated the ECOHIS on a sample of 128 children and their caregivers.
Semantic equivalence was done with a convenience sample of participants (25 caregivers) and led to the modification of a few terms. Tesch et al. and other authors conducted a similar procedure6-9,11,14.
The ECOHIS questions most frequently answered by the caregivers for the section on Impact on Child were about pain, difficulties eating and drinking, and irritation or frustration, while for the section Impact on Family, they were about feeling guilty or worried. Similar results were found by other authors4,8,9,12-16. This might suggest that oral health often has a negative impact on quality of life. Other studies - on populations which either were a stratified sample according to living conditions, received care at a university hospital,9 were participants in oral health promotion programs15 or received care at different health institutions4,12,16 - found differences in the perception of impact.
Other studies report that children with untreated caries may have difficulty chewing, sleeping and socializing and that caries may affect self-confidence, growth and weight increase, thus producing a negative effect on quality of life.16 Lack of prevention policies and early care is a variable influencing these results.
The frequency of the answer "don't know" to the questions was low. Lee et al.8 report that parents rarely answered "don't know". This may suggest that these OHRQoL questionnaires could be used at clinics for to orient diagnoses for preschoolers. The answer "don't know" was treated as in previous studies,4,7-16 i.e. the number and distribution of "don't know" answers were taken into account in the statistical analysis, because they are important, particularly to the processes of instrument validation and use, providing insight into the relevance and understanding of the questions.14"Don't know" is an essential option in studies where participants report their perceptions of someone else's health or quality of life, because it reflects a particular characteristic of the phenomenon under evaluation. 15 Moreover, parents' awareness of oralhealth related quality of life could be explored by examining the frequency and distribution of "don't know" answers.28
Construct validity showed that there was moderate correlation between overall ECOHIS scores and caries experience (dmft). These results proved the validity of the measurement. There were similar findings for the versions used in China8, Turkey14 and Uganda16. However, Martins et al.15 report that ECOHIS was significantly but weakly correlated to caries experience. Levine et al. report that untreated decayed primary teeth may remain asymptomatic until exfoliation, which is why parents might not notice them.29
However, our study and studies by Pahel et al.4, Lee et al.8, Scarpelli et al.12 and Peker et al.14 determined construct validity by means of the correlation between ECOHIS scores and dmft and dmfs, finding moderate correlations. Similarly, Peker et al. report that ECOHIS construct validity could be proved by using other indicators such as gingival index, since according to McGrath et al.30 and Carvahlo et al.31, gingivitis is an inflammatory process which begins at about 5 years of age. It might be an oral condition that could compromise the child's oral health-related quality of life.
Discriminant validity was proved because significant differences were found between mean values for overall ECOHIS scores for groups of children with and without caries. These findings are similar to those of other ECOHIS validation studies4,9,14-16, where children with dental caries had the highest scores. These results prove that the Spanish version of the ECOHIS is able to discriminate between these two groups of children. One important finding is that the analysis of Effect Size showed moderate clinical significance of the difference between groups with and without caries. Martins et al. found similar results, and report that studies in the field of psychology increasingly measure Effect Size, which is essential to good research.15 Nevertheless, the socio-cultural homogeneity of the families in this study should be considered, as Bordoni et al. found differences in the ECOHIS score for answers from groups of parents from families with different socioeconomic levels.11
Our study found Cronbach's alpha coefficients of 0.935 for the domain Impact on Children, 0.882 for Impact on Family and 0.948 for the overall ECOHIS, which proves good internal consistency of the Spanish version of the ECOHIS. Cronbach's alpha values were close to the ones for ECOHIS versions for Latin America11, Iran9 and Turkey14 and higher than the ones for versions for France7, China8, Brazil15, Uganda and Tanzania16
The intra-class correlation for the overall score showed an excellent level of agreement between the test-retest results, similar to the value reported for Turkey14 (0.95) and higher than the values reported for the versions for North America4, China8, Persia9, Uganda16 (0.84, 0.64, 0.82 and 0.84 respectively). Other validation studies, such as the version in Portuguese,12 do not report an ICC value for overall score, but the values for the sections Impact on Child and Impact on Family are similar to ours. Martins et al. report that the result for reliability of internal consistency of the domain Impact on Family was marginal, as found in the preliminary study of the Portuguese version of the ECOHIS by Scarpelli et al.12 This may be due to the fact that this domain includes only four questions, whereas the section Impact on Child includes nine. It has been shown that the value of alpha tends to be higher for measurements that include a larger number of items.15
Psychometric tests of the scale showed optimum construct and discriminant validity, and reliability in terms of internal consistency and test-retest. Peker et al. suggest that ECOHIS sensitivity should also be determined because there are few studies in this regard (Li et al.)32. Sensitivity assesses the effect of dental diseases and their treatment on quality of life.33
Using the ECOHIS may help healthcare professionals, researchers and public and private agencies to describe the effects of dental diseases and experience of treatment on the quality of life of young children and their families, to plan oral interventions, to promote oral health and to improve and implement oral healthcare services for the Peruvian population, where children under 5 years of age represent one of the highest risk groups for oral health.


1. The Spanish version of the ECOHIS was crossculturally adapted to the Peruvian population by means of small changes to some of the questions.
2. Psychometric tests demonstrated construct validity, discriminant validity, internal consistency and reliability in the application of test-retest.
3. This study therefore provides initial evidence that the ECOHIS could be a useful tool for assessing oral health-related quality of life in preschoolers in the Peruvian population.


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