|Year : 2010 | Volume
| Issue : 3 | Page : 151-155
Reliability and factor analysis of children's fear survey schedule-dental subscale in Indian subjects
P Singh1, RK Pandey1, A Nagar2, K Dutt3
1 Department of Pedodontics with Preventive Dentistry, Faculty of Dental Sciences, Chhatrapati Shahuji Maharaj Medical University (Erstwhile King George Medical College), Lucknow, Uttar Pradesh, India
2 Department of Orthodontics and Dentofacial Orthopaedics, Chhatrapati Shahuji Maharaj Medical University, Lucknow, Uttar Pradesh, India
3 Department of Psychiatry, Chhatrapati Shahuji Maharaj Medical University, Lucknow, Uttar Pradesh, India
|Date of Web Publication||11-Dec-2010|
K-97, Sarita Vihar, New Delhi - 76
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: Fear to visit a dentist is a common observation even in adults; however, among children it becomes one of the most important issues for a dentist. Psychographic analysis of the factors that add to fear level of the children can be accessed through Children fear survey schedule-dental subscale (CFSS-DS); however, its varied applicability in different environmental situations has been tested through this paper. Aims: The aim of present study is to evaluate the reliability and factor structure of the Indian version of the CFSS-DS. Materials and Methods: The routine patients attending Outpatient Department of Pedodontics with Preventive Dentistry, Faculty of Dental Sciences, Lucknow, India (n=197, aged 7-12 years old) were evaluated for children's fear survey schedule-dental subscale which was filled by parents on behalf of the child. Statistical Analysis: Reliability analysis (alpha) was performed to assess the internal consistency of the Indian translation of the scale. Factor analysis (principle components, varimax rotation) was employed to assess the factor structure. Results: Children fear survey scale-dental subscale was found to be equally reliable (Cronbach alpha = 0.92) and applicable among Indian subjects. However, factorization revealed emergence of 1) hospital, injections and hospital personnel, 2) drilling and interaction with unknown, 3) dental care personnel and practices. Conclusion: The present study extended the universal applicability of children fear survey schedule -dental subscale, while at the same time it was able to highlight different facets of problem in different environments.
Keywords: Children fear survey schedule-dental subscale, factor analysis, reliability
|How to cite this article:|
Singh P, Pandey R K, Nagar A, Dutt K. Reliability and factor analysis of children's fear survey schedule-dental subscale in Indian subjects. J Indian Soc Pedod Prev Dent 2010;28:151-5
|How to cite this URL:|
Singh P, Pandey R K, Nagar A, Dutt K. Reliability and factor analysis of children's fear survey schedule-dental subscale in Indian subjects. J Indian Soc Pedod Prev Dent [serial online] 2010 [cited 2020 Jul 10];28:151-5. Available from: http://www.jisppd.com/text.asp?2010/28/3/151/73788
| Introduction|| |
Anxiety and fear of dental treatment in child patients have been recognized as potentially problematic entities in patient management. A variety of behavioral techniques have been exercised to counteract such negativity in behavior pattern. Early recognition and management of this dental fear is the key to an effective treatment delivery to the child patient. Subsequently, four types of measurements have been used for assessing dental fear in children: Behavior rating scales during dental visits (e.g. Frankel's Scale),  physiological measures (e.g. pulse rate, blood pressure, muscle tension etc.),  projective techniques (e.g. children's dental fear picture test) , and various other psychometric scales. Among these psychometric methods, children's fear survey schedule (CFSS), a fear scale for young children, designed by Scherer and Nakamura has been shown to be most reliable and valid. Children's fear survey schedule along with its dental subscale has been shown to be better than other scales, such as VPT (Venham's picture test)  and DAS (dental anxiety scale). 
Children's fear survey schedule was originally described in a version where young children answered the test using a fear thermometer. The test comprised two versions: a self report by the child him/herself and a parental version. Cultural differences play an important role in building the psychology of a child. A survey tool having a great reliability in some part of the world may not have universal validity unless its constituents are unaffected by cultural changes and address the core issue.
The reported internal consistency in terms of Cronbach's alpha has been reported to be ranging from 0.85  to 0.90.  As regards the factorization of the subscale in a Dutch study, three factors were identified. These were as follows: 1) fear of highly invasive dental procedures, 2) fear of less invasive aspects of treatment, and 3) fear of medical aspects.  It was highlighted in the present study that if cultural differences and demographic variability play a role in determining the fear levels of the individuals, especially those who are less exposed to varying cultural situations and environments such as children, then there are bound to be differences in pattern of constituents of fear among children visiting dental clinics in India. The present study is an attempt to check the reliability as well as factor structure of children's fear survey schedule - dental subscale among Indian population.
| Materials and Methods|| |
Collection of sample
The present study was carried out in the Department of Pedodontics and Preventive Dentistry, Faculty of Dental Sciences, Chhatrapati Shahuji Maharaj Medical University, Lucknow, India in collaboration with Department of Orthodontics and Department of Psychiatry, Chhatrapati Shahuji Maharaj Medical University, Lucknow, India. The trial was conducted to evaluate the reliability of children's fear survey schedule-dental subscale and recognition of principal components in Indian subjects after gaining clearance from the institutional ethical board.
A total of one hundred and ninety seven subjects of Indian origin in the age group of 7-12 years were examined with an intelligence quotient of more than 70, irrespective of sex, race and socioeconomic status. The subjects having severe physical illness, psychiatric illness and mental subnormality were excluded from the study.
The test taken into account in the present study was children's fear survey schedule -dental subscale (CFSS-DS),  a fear scale for young children designed by Scherer and Nakamura and later revised to include specific dental fear items as one of its subscales by Cuthbert and Melamed. 
Children with accompanying parents were included in the study because a brief history about the child was required during the first visit. Details of the procedures, purpose of study were explained to the parents and informed consent was obtained. The study spanned over a period of one year.
Children's dental fear was assessed by the parents using a Hindi version of the fifteen item dental subscale of the children's fear survey schedule (CFSS-DS). ,, In an attempt to achieve a valid instrument for use, the children's fear survey schedule-dental subscale was translated into Hindi (a local language) by a native speaker and then translated back to English to incorporate in the present study.
The response format ranges from one (not afraid at all) to five (very afraid), giving a score range from 15 to 75. The scores of 38 and above indicated of high dental fear. Their parents were asked to complete the scale once.
For the purpose of analysis of data, Statistical Package for Social Sciences Version 15.0 was used. Principal component analysis was used to factorize the scale. Reliability analysis (alpha) was performed to assess the internal consistency of the Indian translation of the scale. Factor analysis (principle components, varimax rotation) was employed to assess the factor structure. Factor analysis uses the correlations between items on a scale to determine whether subsets of items exist that might relate to each other strongly, even though all scale items are related to the general concept of interest. Factor scores above 0.5 indicate a strong loading on a particular subset of items. The strength of these subsets is usually represented in Eigen values indicating which factors, or subsets of items, account for the strongest part of the total scale variance. Eigen values above 1.0 are considered strong enough to be taken into account.
| Results|| |
The mean total CFSS-DS score was 33.25 (SD 10.03, range 16-53). No significant differences in total fear scores between boys (32.92±10.45) and girls (33.61±9.58) were found. Age-wise scores ranged from 29.86±10.06 (7 years) to 36.89±6.82 (12 years) showing a significant difference (P=0.039), though showing a poor correlation (r=0.052).
Reliability of the CFSS-DS
The internal consistency of the CFSS-DS among Indian children proved to be good; Cronbach's alpha was 0.92. For females, the Cronbach's alpha value was 0.91 whereas for males it was 0.92.
The factor analysis after varimax rotation revealed three major factors with Eigenvalues above 1.0: 3.755, 3.661 and 2.290. On the first factor, explaining 25.03% of the variance, eight items had loadings less than 0.5. Item Nos. 2, 3, 11-15, all had strong factor loadings ranging from 0.577 to 0.763. The second factor explained 24.41% of the variance had five items with loadings above 0.5; these items were item No. 6-10. The third item explained a variance of 15.26% with three items - item 1, 4 and 5 showing loadings ranging between 0.555 and 0.886. Most of the items in first factor were related to hospital, injections and hospital personnel. The items in second factor were related to drilling and interaction with unknown followed by the items in third factor that were specifically related to dental care personnel and practices. Reliability for each of these three factors was once again checked and Cronbach's alpha values for the factors 1, 2 and 3 were found to be 0.86, 0.86 and 0.74 respectively, thus showing them to be reliable.
Factor analysis using the scores of boys and girls separately resulted in similar factor patterns. In context with girls, four factors were found explaining total % variance of 26.80%, 22.31%, 14.23% and 11.92%, thus making a total cumulative % variance to be 75.25%. In case of boys, the analysis resulted in only three factors explaining total % variance of 26.28%, 21.80% and 19.80% respectively, thus making a total cumulative % variance of 67.88% [Table 1].
|Table 1 :Rotated Children fear survey schedule-dental subscale factor matrix for Indian, Dutch and Finnish Children |
Click here to view
| Discussion|| |
Reliability of CFSS-DS in Indian subjects was found to be 0.92 which is very much in accordance with the findings reported by Cuthbert et al and Arapostathis et al  (0.85 to 0.90). Thus the scale was found to be reliable for overall, as well as for respondents of different genders. The Cronbach alpha value was above 0.6 which is coincided with the well accepted reliability limits as supported by Moss et al.  The Cronbach's alpha values obtained in the present study even meet the more stringent and widely recognized 0.7 threshold.  The high reliability of the scale can be attributed to its focal characteristics and highly specific yet easily understandable questions. Following the general acceptability of the scale, the scores obtained for different items were further analyzed through factorization.
The numbers of factors emerging in the present study were in concurrence with ten Berge et al,  who reported the emergence of three factors in Dutch and Finnish children although the components of the factors were different. The three factors that emerged were the following: 1) fear of highly invasive dental procedures, 2) fear of less invasive aspects of treatment, and 3) fear of medical aspects. However, in the present study, the three factors that emerged were the following: 1) hospital, injections and hospital personnel, 2) drilling and interaction with unknown, 3) dental care personnel and practices. Thus, although the scale has a good reliability as reported in other studies, , the mechanism of affecting the psychology of the children was different. This may be attributed to the cultural/environmental differences in the two studies. In developing countries like India, children are less exposed to health awareness campaigns. This in turn may be as a result of lack of awareness on part of local authorities. Since the driving force in building a child's psychology largely depends upon the personal experience of an individual, a comprehensive strategy is needed for building the psychology of a child in a structured manner. This could further be implemented by recognition of valid fears of children and then managing them effectively through the help of strategic planning.
In the present study, maximum % total variance was seen for factor 1) hospital, injections and hospital personnel - indicating that addressing these problems effectively may affect the fear level among the children to a great extent. In fact, this aspect includes both physical and behavioral management of the problem. Fear of seeing people wearing white uniform, nurses, hospital itself etc. can be managed efficiently by changing the color and style of uniform, making physical amenities such as toys and swings available in the clinic so as to give it a different look from a hospital, etc. The second major component i.e., drilling and interaction with unknown, is totally dependent on the behavioral management aspect of the problem. A dentist, particularly those dealing with pediatric patients, must first try to build a rapport with the patient before starting the treatment. Before the actual treatment starts, the noise of drilling must be equated with some objects that a child can relate with positively. Grrhhh…. the sound of screeching wheels, Ghoooo…….. the sound of a freewheel set in motion in air, the sound of hair drier, juicer, and all that can be equated before the start of actual treatment. If feasible, a toy drill must be there in the clinic itself which the child can handle and relate to. In the third factor i.e. dental care personnel and practices can also be managed by behavioral management for which the management strategy as required for the first factor can play an important role. The crux of the whole problem calls for establishing a rapport with the patient. This is also evident from the factor loadings that indicate that almost all items load on more than one factor (≥0.20). This indicates a somewhat weak factor structure which shows that the problem can be managed by a single strategy rather than seeking multiple strategies to resolve the problem.
In general, the objective of the study to check the reliability of the CFSS-DS in Indian subjects was successfully fulfilled. The emergence of factors with different components reinforced the view that if cultural differences and demographic variability play a role in determining the fear levels of children, those who are less exposed to varying cultural situations and environments, then there are bound to be differences in pattern of constituents of fear among children visiting dental clinics in India.
| Acknowledgment|| |
The authors would like to thank Mr. Varun Arora, Research Consultant, Active Research Group, Arun Professional Services, Lucknow for providing statistical and analytical inputs.
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