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Cross-cultural adaptation of the Dental Neglect Scale for five-year-old children in Brazil

Abstract

The aim of this study was to perform a cross-cultural adaptation of the Brazilian version of the Dental Neglect Scale (DNS). The process included (i) Translation; ii) Synthesis; iii) Back translation; (iv) Critical analysis by a committee of experts; (v) Pilot studies (n1=30 + n2=30); and (6) Evaluation and refinement of the instrument. The validated DNS presented a Content Validity Index (CVI) equal to 1.0 for the total score, as well as for each item. In the pilot studies, a minimum agreement level of 80% in understanding was achieved. DNS was properly adapted for Brazilian Portuguese, and it needs further study in a representative sample for reliability and construct validity assessment.

Oral Health; Child; Dental Caries; Child Abuse

Introduction

The Dental Neglect Scale (DNS) was created and tested in an Australian population to investigate the likelihood of occurrence of Child Dental Neglect (CDN), regarding dental issues.11. Thomson WM, Spencer AJ, Gaughwin A. Testing a child dental neglect scale in South Australia. Community Dent Oral Epidemiol. 1996 Oct;24(5):351-6. https://doi.org/10.1111/j.1600-0528.1996.tb00875.x
https://doi.org/10.1111/j.1600-0528.1996...
The DNS was applied in order to determine parental perception of their children’s oral health and evaluate the extent of individual care in relation to oral health, the professional care received, the belief in the importance of oral health, as well as to increase the understanding of lay people regarding the etiology of dental caries in children. This scale was first applied in two age groups (10–11 and 14–15),11. Thomson WM, Spencer AJ, Gaughwin A. Testing a child dental neglect scale in South Australia. Community Dent Oral Epidemiol. 1996 Oct;24(5):351-6. https://doi.org/10.1111/j.1600-0528.1996.tb00875.x
https://doi.org/10.1111/j.1600-0528.1996...
but it has been used with other ages since its original application.22. Ajagannanavar SL, Sequeira PS, Jain J, Battur H. Dental neglect among college going adolescents in Virajpet. J Indian Asso Public Health Dent. 2014 Oct;12(3):10-3. https://doi.org/10.4103/2319-5932.144803
https://doi.org/10.4103/2319-5932.144803...
,33. Skaret E, Astrøm AN, Haugejorden O, Klock KS, Trovik TA. Assessment of the reliability and validity of the Dental Neglect Scale in Norwegian adults. Community Dent Health. 2007 Dec;24(4):247-52.

The age of five years is standardly used in national and international epidemiological surveys on caries44. Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Secretaria de Vigilância em Saúde. Pesquisa Nacional de Saúde Bucal: resultados principais. Brasília, DF: Ministério da Saúde; 2012. (SP Brasil 2010).. In Brazil, according to the latest National Epidemiological Survey of Oral Health (2010), average caries experience was of 2.4 affected teeth. There was a reduction of only 13.9% in the seven years since the national survey of 2003.44. Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Secretaria de Vigilância em Saúde. Pesquisa Nacional de Saúde Bucal: resultados principais. Brasília, DF: Ministério da Saúde; 2012. (SP Brasil 2010). Therefore, based on the Brazilian epidemiological context, this age was selected for DNS validation. The aim of this study was to perform the cross-cultural adaptation of the Brazilian version of the DNS.

Methodology

The study was approved by the Research Ethics Committee of the Pontifícia Universidade Católica do Paraná (nº 2.361.906) and the Municipal Health Secretariat of Curitiba (nº 2.558.218). The consent of the research participants was obtained.

The protocol suggested by Beaton et al.55. Beaton D, Bombardier C, Guillemin F, Ferraz MB. Recommendations for the cross-cultural adaptation of the DASH & QuickDASH outcome measures. Toronto: Institute for Work & Health; 2007 [cited 2020 Apr 14]. Available from: http://www.dash.iwh.on.ca/sites/dash/files/downloads/cross_cultural_adaptation_2007.pdf
http://www.dash.iwh.on.ca/sites/dash/fil...
was used. Inclusion criteria of the study participants were: a) parents and/or caregivers of five-year-old children enrolled in municipal public schools in Curitiba, southern Brazil; and b) be literate and fluent in the Brazilian Portuguese language. Exclusion criteria were parents and/or caregivers who: a) were in mental health treatment; b) presented any limitation that could hinder communication with the researcher.

Methodological steps (Figure)

Translations

The original DNS was translated by two individuals fluent in English and native speakers of Brazilian Portuguese.

Figure
Flowchart of the adaptation process and validation of DNS to Brazilian Portuguese.

Synthesis

The researchers verified whether the two versions matched each other and reflected the content of the original scale, creating one synthesis version.

Back-translation

A native English speaker back-translated the synthesis version of the instrument from Brazilian Portuguese to English.

Face and content validity steered by a multidisciplinary and bilingual experts committee

Thirteen professionals participated in this stage. Two approaches were used to gain consensus among the experts. Firstly, the expert committee performed the face and content validation qualitatively, through the individual analysis of the items, respecting the idiomatic, semantic, experiential, and conceptual equivalences among the available (re)translations.

Subsequently, the experts were asked to assess the clarity of each item in the instrument and the quantitative process was carried out, which included the calculation of the percent agreement among the experts and Content Validity Index (CVI). This index measures the proportion or percentage of experts who agree on certain aspects of the instrument and its items.66. Alexandre NM, Coluci MZ. Validade de conteúdo nos processos de construção e adaptação de instrumentos de medidas. Cienc Saúde Coletiva. 2011 Jul;16(7):3061-8. https://doi.org/10.1590/S1413-81232011000800006
https://doi.org/10.1590/S1413-8123201100...
To calculate CVI, the relevance attributed to each item was considered; for this, each expert was asked to consider the degree of association between the scale item and the theoretical construct (established by the DNS development team). The items were considered adequate at an agreement of 80%.77. Wynd CA, Schmidt B, Schaefer MA. Two quantitative approaches for estimating content validity. West J Nurs Res. 2003 Aug;25(5):508-18. https://doi.org/10.1177/0193945903252998
https://doi.org/10.1177/0193945903252998...

Finally, to evaluate the overall agreement, the CVIs calculated for each item were added and divided by the number of items.66. Alexandre NM, Coluci MZ. Validade de conteúdo nos processos de construção e adaptação de instrumentos de medidas. Cienc Saúde Coletiva. 2011 Jul;16(7):3061-8. https://doi.org/10.1590/S1413-81232011000800006
https://doi.org/10.1590/S1413-8123201100...

Pilot studies

Two pilot studies were conducted, both with samples of 30 participants each. The samples were selected to resemble the profile of the target population. In the pilot study 1, the version of the DNS resulting from the multidisciplinary committee consensus was evaluated, while in the pilot study 2, a modified version was applied, according to the needed changes pointed out in the pilot 1. Again, items with less than 80% agreement in understanding were reassessed.88. DeVon HA, Block ME, Moyle-Wright P, Ernst DM, Hayden SJ, Lazzara DJ, et al. A psychometric toolbox for testing validity and reliability. J Nurs Scholarsh. 2007;39(2):155-64. https://doi.org/10.1111/j.1547-5069.2007.00161.x
https://doi.org/10.1111/j.1547-5069.2007...

Evaluation and refinement of the instrument

Fine adjustments were made according to the needs indicated by the pilot study 2, resulting in the final version of the instrument.

Results and Discussion

DNS was translated as the “Escala de Negligência Odontológica” (ENO). Table shows the final version of the ENO.

Table
Cross-cultural adaptation of the ENO for the Brazilian context.

The multidisciplinary committee consolidated the versions of the ENO in a single instrument for application to the target population. It was performed face validation regarding grammar, syntax, organization, adequacy, and logic;88. DeVon HA, Block ME, Moyle-Wright P, Ernst DM, Hayden SJ, Lazzara DJ, et al. A psychometric toolbox for testing validity and reliability. J Nurs Scholarsh. 2007;39(2):155-64. https://doi.org/10.1111/j.1547-5069.2007.00161.x
https://doi.org/10.1111/j.1547-5069.2007...
content validation was performed by appraising the degree to which each item represented the child dental neglect construct. Concerning relevance and clarity, all items presented an agreement higher than 80%. Regarding the evaluation of the CVI, all items were classified as requiring ‘little revision to be relevant’ or ‘relevant’.

Parents and/or caregivers of five-year-old children were chosen due to the importance they play in maintaining their children’s health. Approaches focused on the interaction between children and their parents and caregivers are fundamental for promoting health.99. World Health Organization. Global status report on preventing violence against children 2020. Geneva: World Health Organization; 2020 [cited 2021 May 17]. Available: https://www.who.int/teams/social-determinants-of-health/violence-prevention/global-status-report-on-violence-against-children-2020
https://www.who.int/teams/social-determi...
The subject covered by the ENO is complex and multifactorial; thereby, multiple aspects should be considered before the “accusatory” diagnosis of neglect – avoiding blaming the victims in some cases.1010. Bhatia SK, Maguire SA, Chadwick BL, Hunter ML, Harris JC, Tempest V, et al. Characteristics of child dental neglect: a systematic review. J Dent. 2014 Mar;42(3):229-39. https://doi.org/10.1016/j.jdent.2013.10.010
https://doi.org/10.1016/j.jdent.2013.10....
These characteristics make it difficult to define the ENO content, both because of the different explanatory models of neglect and because child neglect does not have a clear and unique definition of all the concepts involved in this construct.

Although the ENO has presented acceptable levels of validity and applicability, its final value must be tested.1111. Jamieson LM, Thomson WM. The Dental Neglect and Dental Indifference scales compared. Community Dent Oral Epidemiol. 2002 Jun;30(3):168-75. https://doi.org/10.1034/j.1600-0528.2002.300302.x
https://doi.org/10.1034/j.1600-0528.2002...
Therefore, further psychometric evaluations of this scale are required in the Brazilian context. The ENO is the only instrument that was developed in the area of child dental neglect, with higher scores of the scale indicating greater dental caries experiences.1212. McGrath C, Sham AS, Ho DK, Wong JH. The impact of dental neglect on oral health: a population based study in Hong Kong. Int Dent J. 2007 Feb;57(1):3-8. https://doi.org/10.1111/j.1875-595X.2007.tb00111.x
https://doi.org/10.1111/j.1875-595X.2007...

Conclusion

The results of this stage of the validation study contribute to the conceptual debate on cross-cultural adaptations. The application of the validated scale in a representative sample is required to obtain a complete assessment of the psychometric and statistical properties of the ENO.

Acknowledgments

This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.

References

  • 1
    Thomson WM, Spencer AJ, Gaughwin A. Testing a child dental neglect scale in South Australia. Community Dent Oral Epidemiol. 1996 Oct;24(5):351-6. https://doi.org/10.1111/j.1600-0528.1996.tb00875.x
    » https://doi.org/10.1111/j.1600-0528.1996.tb00875.x
  • 2
    Ajagannanavar SL, Sequeira PS, Jain J, Battur H. Dental neglect among college going adolescents in Virajpet. J Indian Asso Public Health Dent. 2014 Oct;12(3):10-3. https://doi.org/10.4103/2319-5932.144803
    » https://doi.org/10.4103/2319-5932.144803
  • 3
    Skaret E, Astrøm AN, Haugejorden O, Klock KS, Trovik TA. Assessment of the reliability and validity of the Dental Neglect Scale in Norwegian adults. Community Dent Health. 2007 Dec;24(4):247-52.
  • 4
    Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Secretaria de Vigilância em Saúde. Pesquisa Nacional de Saúde Bucal: resultados principais. Brasília, DF: Ministério da Saúde; 2012. (SP Brasil 2010).
  • 5
    Beaton D, Bombardier C, Guillemin F, Ferraz MB. Recommendations for the cross-cultural adaptation of the DASH & QuickDASH outcome measures. Toronto: Institute for Work & Health; 2007 [cited 2020 Apr 14]. Available from: http://www.dash.iwh.on.ca/sites/dash/files/downloads/cross_cultural_adaptation_2007.pdf
    » http://www.dash.iwh.on.ca/sites/dash/files/downloads/cross_cultural_adaptation_2007.pdf
  • 6
    Alexandre NM, Coluci MZ. Validade de conteúdo nos processos de construção e adaptação de instrumentos de medidas. Cienc Saúde Coletiva. 2011 Jul;16(7):3061-8. https://doi.org/10.1590/S1413-81232011000800006
    » https://doi.org/10.1590/S1413-81232011000800006
  • 7
    Wynd CA, Schmidt B, Schaefer MA. Two quantitative approaches for estimating content validity. West J Nurs Res. 2003 Aug;25(5):508-18. https://doi.org/10.1177/0193945903252998
    » https://doi.org/10.1177/0193945903252998
  • 8
    DeVon HA, Block ME, Moyle-Wright P, Ernst DM, Hayden SJ, Lazzara DJ, et al. A psychometric toolbox for testing validity and reliability. J Nurs Scholarsh. 2007;39(2):155-64. https://doi.org/10.1111/j.1547-5069.2007.00161.x
    » https://doi.org/10.1111/j.1547-5069.2007.00161.x
  • 9
    World Health Organization. Global status report on preventing violence against children 2020. Geneva: World Health Organization; 2020 [cited 2021 May 17]. Available: https://www.who.int/teams/social-determinants-of-health/violence-prevention/global-status-report-on-violence-against-children-2020
    » https://www.who.int/teams/social-determinants-of-health/violence-prevention/global-status-report-on-violence-against-children-2020
  • 10
    Bhatia SK, Maguire SA, Chadwick BL, Hunter ML, Harris JC, Tempest V, et al. Characteristics of child dental neglect: a systematic review. J Dent. 2014 Mar;42(3):229-39. https://doi.org/10.1016/j.jdent.2013.10.010
    » https://doi.org/10.1016/j.jdent.2013.10.010
  • 11
    Jamieson LM, Thomson WM. The Dental Neglect and Dental Indifference scales compared. Community Dent Oral Epidemiol. 2002 Jun;30(3):168-75. https://doi.org/10.1034/j.1600-0528.2002.300302.x
    » https://doi.org/10.1034/j.1600-0528.2002.300302.x
  • 12
    McGrath C, Sham AS, Ho DK, Wong JH. The impact of dental neglect on oral health: a population based study in Hong Kong. Int Dent J. 2007 Feb;57(1):3-8. https://doi.org/10.1111/j.1875-595X.2007.tb00111.x
    » https://doi.org/10.1111/j.1875-595X.2007.tb00111.x

Publication Dates

  • Publication in this collection
    19 Nov 2021
  • Date of issue
    2021

History

  • Received
    15 July 2020
  • Accepted
    28 Apr 2021
  • Reviewed
    17 May 2021
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