Epidemiological validation of a Malay version of the Child Perceptions Questionnaire (CPQ11-14) in Brunei

Background: Oral health-related quality of life (OHRQoL) instruments are being used with increasing frequency in oral health surveys. One such instrument is the Child Perceptions Questionnaire (CPQ11-14), developed in Toronto as a measure of OHRQoL specifically for 11-to-14-year-old children (Jokovic et al, 2002). It aims to improve the description of children's oral health, while taking into consideration the importance of psychological aspects in the concept of health. As the original version of this questionnaire was considered long (37 items), shorter forms were developed with 8 and 16 items to facilitate its use in the clinical settings and population-based oral health surveys (Jokovic et al, 2006). 
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\nThe developers of the CPQ¬11-14 have determined the psychometric properties of the long-form and the short-forms CPQ¬11-14 to be satisfactory, but state that these measures must be validated and employed in other cultures, involving clinical and population-based samples of children and adolescents in different countries. The short-form measure has been tested and validated in a representative population sample of schoolchildren in New Zealand (Foster Page et al, 2008). On the other hand, the long-form CPQ11-14 has been shown to be valid and reliable in a number of different countries including Canada, the United Kingdom, New Zealand, Uganda, Saudi Arabia, Australia, Brazil, Hong Kong and Denmark. However, neither the long-form nor the short-form CPQ11-14 has been translated into a Malay (Bahasa Melayu) version and tested in the South-East Asian region. 
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\nSchoolchildren are the main target group for public oral health services in Brunei. Until now, data on the Brunei population’s oral health included only the clinical status of oral diseases. Although the focus of the Brunei Ministry of Health has shifted from being disease-oriented to emphasising wellness and the maintenance of the quality of life of the population, a measure of OHRQoL appropriate for use in Brunei has not been available. 
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\nTherefore, the aims of the current study were: 
\n1. to produce a Malay version of the short-form CPQ11-14; 
\n2. to determine the construct validity of the CPQ11-14 in Brunei; and 
\n3. to determine the discriminative validity of the CPQ11-14 by assessing its ability to distinguish between schoolchildren with and without dental caries and malocclusion. 
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\nMethod: Ethical approval was granted by the Medical and Health Research and Ethics Committee, Brunei Ministry of Health. Five hundred and sixty-nine 11-14-year-old (Year 6) children in nine government primary schools were asked to participate. Parents and caregivers of the children in the study sample were then mailed (through their class teachers) an information sheet about the study, together with an enclosed consent form. A Malay version of the short-form CPQ11-14 was derived through a forward-backward translation process. The questionnaire was then piloted on 20 schoolchildren and refined for ease of use. Prior to clinical examination, all participants completed a copy of the Malay short-form CPQ11-14. The children were examined for dental caries experience (using the DMFS) and for malocclusion (using the Dental Aesthetic Index) by a single examiner (ARM). Both clinical data and data from CPQ11-14 were entered into a Microsoft Excel spreadsheet, and subsequently imported into SPSS. The psychometric properties of the Malay short-form CPQ11-14 were evaluated in terms of internal consistency, construct validity and discriminant validity. Test-retest reliability was assessed in a subgroup of these children (n = 48). 
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\nResults: A total of 457 children (mean age of 11.1 years, range = 10 to 14 years) were examined, giving an effective participation rate of 80.3%. The prevalence of dental caries in the permanent dentition was 44.4%. The mean dmfs and DMFS of deciduous and permanent dentitions were 1.51 (sd, 3.31) and 1.96 (sd, 3.74) respectively. About one-fifth had 4 decayed surfaces in either dentition. The DAI scores ranged from 17 to 91, with a mean of 31.4 (sd, 8.7). The distribution of participants across the four treatment need categories was: minor/none, 24.1%; definite, 37.0%; and severe/handicapping, 38.9%. 
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\nThe overall CPQ11-14-ISF16 score ranged from 0 to 43, with a mean of 16.8 (sd, 8.7). The number with the minimum score was minimal, with only 1.1% having a score of zero and there were no children with the maximum score. Construct validity was satisfactory, demonstrating significant associations between the mean CPQ11-14-ISF16 scores and the global ratings of oral health and overall well-being. The CPQ11-14-ISF16 was able to discriminate between different caries status, and there was a significant association between impact prevalence and the number of untreated decayed tooth surfaces in either dentition. Interestingly, the gradient of the scale scores across categories of orthodontic treatment need was in the opposite direction, whereby those in the ‘minor/none’ category had the highest and those in the ‘severe/handicapping’ category had the lowest mean CPQ11-14-ISF16 score and impact prevalence. The Malay short-form CPQ11-14-ISF16 had excellent internal consistency with a Cronbach’s alpha of 0.97 and test-retest reliability ICC of 0.94. 
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\nConclusion: The outcome of this study suggests that the Malay short-form CPQ11-14 is a valid, reliable and practical instrument for measuring OHRQoL in 11-14-year-old Bruneian children, although its ability to discriminate among children across the malocclusion treatment need categories seems to be limited. This provides further evidence of the instrument’s psychometric properties and its cross-cultural use. However, these are preliminary findings based on a convenience sample, and further testing in replicated studies involving clinical and population samples of children in various settings is necessary to establish the measurement sensitivity and discriminative properties of the Malay short-form CPQ11-14.

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