Home | About Us | Editorial Board | Current Issue | Archives | Search | Instructions | Subscription | Feedback | e-Alerts | Login 
Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
 Users Online: 574  
  Print this page Email this page   Small font sizeDefault font sizeIncrease font size

  Table of Contents    
Year : 2022  |  Volume : 40  |  Issue : 3  |  Page : 317-323

Malayalam language translation and validation of oral health-related early childhood quality of life tool (OH-ECQoL)

1 Department of Pediatric and Preventive Dentistry, Kannur Dental College, Kannur, Kerala, India
2 Department of Pediatric and Preventive Dentistry, Pushpagiri College of Dental Sciences, Thiruvalla, Kerala, India

Date of Submission12-Apr-2022
Date of Decision13-Sep-2022
Date of Acceptance13-Sep-2022
Date of Web Publication18-Oct-2022

Correspondence Address:
Faizal C Peedikayil
Department of Pediatric and Preventive Dentistry, Kannur Dental College, Kannur, Kerala
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisppd.jisppd_177_22

Rights and Permissions



Objective: The objective of this study was to adapt the Oral Health-related Early Childhood Quality of Life (OH-ECQoL) tool for the Malayalam-speaking community and investigate its validity and reliability. Methodology: Malayalam language version of OH-ECQoL was derived through a forward–backward translation and tested for content validity. A convenient sample (n = 300) was recruited by including children with and without early childhood caries (ECC). Parents of these children completed the derived Malayalam OH-ECQoL measure. The properties of translated OH-ECQoL were evaluated by determining its validity and reliability using concurrent validity, construct validity, discriminant validity, internal consistency, and test–retest reliability. Results: OH-ECQoL scores varied with ECC and caries-free groups (P < 0.001), supporting the ability to distinguish between patient groups. Discriminant validity tests show that children with ECC have greater median scores and interquartile range (21 ± 8) compared to children without ECC (14 ± 2). Concurrent validity was observed to be 0.72 and 0.71, respectively, for child section (P < 0.001). Convergent validity demonstrates a strong positive correlation between child impact and family impact with a Spearman's correlation coefficient significant of 0.73 (P ≤ 0.01). Cronbach's alpha for the child impact section and family impact section showed good internal consistency at 0.92 and 0.83, respectively. Test–retest reliability at 0.87 shows good reliability. Conclusions: The Malayalam version of the OH-ECQoL tool demonstrated acceptable validity and reliability. The study also shows that ECC presents a negative impact on the QoL of preschool children and their parents.

Keywords: Early childhood caries, oral health-related quality of life, preschool children

How to cite this article:
Peedikayil FC, Kottayi S, Subbalekshmi T. Malayalam language translation and validation of oral health-related early childhood quality of life tool (OH-ECQoL). J Indian Soc Pedod Prev Dent 2022;40:317-23

How to cite this URL:
Peedikayil FC, Kottayi S, Subbalekshmi T. Malayalam language translation and validation of oral health-related early childhood quality of life tool (OH-ECQoL). J Indian Soc Pedod Prev Dent [serial online] 2022 [cited 2022 Dec 3];40:317-23. Available from: http://www.jisppd.com/text.asp?2022/40/3/317/358827

   Introduction Top

Oral health-related quality of life (OHRQoL), is considered a multidimensional paradigm that reflects an individual's comfort, self-esteem, and fulfillment regarding their OH. The QoL scale measures functional characteristics such as eating and speech, psychological characteristics such as appearance and self-esteem, and social and pain impact of orofacial problems.[1],[2]

The concept of OHRQoL was first put forward by Giddon in 1978.[3] Literature points that QoL studies assesses variations in the OH status of the participants and have been based on the clinical indicators of the disease.[2] In the past two decades, numerous OHRQoL measures have been developed and are in use for evaluating the impact of oral well-being on their QoL, but most of them are not suitable for the preschool child population.[4] Early Childhood OH Impact Scale (ECOHIS), Michigan OHRQoL Scale, and Scale of Oral Health Outcomes for 5-year-old children (SOHO-5) are the current instruments which are available to assess the OHRQoL of preschool children.[5]

For a QoL tool to be effective, it should be in a language that is understandable and comfortable for the respondents. India has a distinct cultural, social, and ethnic diversity with more than 30 different vernacular languages in use. ECOHIS and Michigan OHRQoL have been translated into various languages.[5] ECOHIS had been earlier translated and validated in the Malayalam language by Bhat and Sivaram[6] and is the only tool available in Malayalam for preschool children in relation to OH.

In 2013, Mathur et al.[5] developed a tool for early childhood OHRQoL for the Indian population by the name OH-related Early Childhood QoL (OH-ECQoL). This scale has been translated and validated in a few Indian languages such as Manipuri,[3] Hindi,[5] Gujarati,[7] and also to the Nepali Language,[8] the vernacular language of Nepal, a country neighboring India which shares similar cultural and social ecosystem.

OH-ECQoL, if translated and validated, can be used for the Indian population who speak other languages.[5] In general, tools need to be adopted, modified, or translated to local dialect with minimal changes in content from the original tool. A tool thus developed in the local language is expected to help the individuals easily understand the questions related to the QoL.

The Malayalam language is a regional language spoken in Kerala, a south Indian state with a population of over 3 million. It is also spoken in a few territories in South India and the Lakshadweep Islands.[9] Existing literature shows that the prevalence of early childhood caries (ECC) in Keralite children ranges from 44% to 59.6%.[10] In a population with such high ECC prevalence, a tool adopted and translated to the spoken language will be accessible for epidemiological research including surveys and monitoring. The null hypothesis for this study is that there is a difference between the translated version and the original version of the OH-ECQoL among children with ECC and children without ECC. Therefore, the present study has been conducted to translate and validate OH-ECQoL to the Malayalam language and measure the OH ECQoL in preschool children with and without ECC.

   Methodology Top

Study setting and consent

A cross-sectional study was conducted at the Department of Pediatric Dentistry of a Dental College in Kerala State in India. Ethical approval for the research was obtained from the Institutional Review Committee of the same institution (KDC ETH/20/PED 024). The participant information sheet was given to the parents of preschool children and any queries about the study, after reading the information sheets, were answered and written consent was obtained for participation in the study.

There are no general criteria for calculation of the required sample size in a validation study.[11] Hence, the sample size from a similar study done by Dharmani et al.[3] was considered. A total of 300 participants within the age of 24–71 months reporting to the pediatric dentistry outpatient department (OPD) of dental college and pediatrics OPD of medical college were equally grouped based on the presence or absence of ECC (i.e., 150 participants with ECC and 150 participants who are caries free). Parents of the selected participants were also invited to participate in the study. Children who were extremely uncooperative and those with special health care needs were excluded from the study, also the parents who were not well-versed in reading Malayalam were excluded from the study.

Tool development

The tool for early childhood OHRQoL developed by Mathur et al.[5] by the name OH-ECQoL was translated into Malayalam language and was validated and shared with the parents of selected participants.

Translation into Malayalam

The translation of the English questionnaire to Malayalam was carried out by two certified bilingual legal translators. Both translations were matched for similarity. A group of seven (five dentists and two nondentists) checked the translation for the scientific terminologies, language logical flow, and understandability of each question. Special attention was given to the semantic sameness of the English version and to maintaining the colloquial expressions of the local culture.

Back translation

This was done by independent native professional translators who were fluent in Malayalam and English and who had no prior knowledge of the original version. It was compared with the original questionnaire. The differences were discussed by the research team and translators. Only some minor grammatical differences were noted without any change in question structure or its meaning.

Panel of experts

This version was sent to three independent advisors from the dental field who are fluent in Malayalam and English to check if the translation was appropriate and as per the local dialect.

Pilot testing

A pilot test was conducted to assess the understanding of the Malayalam questionnaire of 20 participant volunteers. The characteristics of the volunteers were similar to the proposed study population. A trained dentist noted down the questions in the tool which the participants reported to be confusing or unclear. After the administration of the tool, an informal talk was held with the volunteers regarding the understandability of the tool. The feedback received was discussed among the group of investigators and appropriate corrections were made and the version was finalized.

The final version of the tool had a total of 18 questions, of which 16 questions were on child's OH, for which responses were recorded on a three-point scale ([1] Never, [2] occasionally, [3] often) and two questions on perception of parents about their child's general and OH with a five-point response (1) Excellent (2) Very good (3) Good, (4) Fair, and (5) Poor.

This version was administered to the participants.

Validity testing

For the purpose of translation validation, the sample size was grouped based on the presence of ECC and caries-free participants. A total of 150 participants in each group were considered.

Clinical examination of child

The children were examined under standard aseptic conditions on the dental chair with mouth mirror and probe under dental unit light the dentition status was recorded as per the WHO OH assessment form (2013). The questionnaire was administered to the parents and the data was entered using Microsoft Excel and analyzed using Statistical Package for the Social Sciences (SPSS version 19, IBM Corporation, Chicago, IL, USA) software.

Validation exercise

To validate the translated questionnaire tool for the population, the following steps were done

Concurrent or criterion-related validity

This was tested by comparing Spearman's correlation coefficient between total OH-ECQOL scores and the perception of the parent.

Construct validity

This was done by relating the scores in the child impact section with that of the family impact section.

Discriminant validity

This was done by comparing the OH-ECQOL scores in participants with and without ECC.

Internal consistency reliability

It is tested by measuring the mean value correlation of items within OH-ECQOL using Cronbach's alpha coefficient.

Test–retest reliability

Among these 300 parents, a random sample of 30 (10%) parents was recalled after about 2 weeks and was readministered the questionnaire. It is determined by the level of agreement between initial assessments of OH-ECQOL and the scores obtained at the second assessment using intraclass coefficient (ICC)

   Results Top

A total of 300 questionnaires were distributed, and the response was taken from the parents. The demographic and gender distribution of participants are described in [Table 1]. Males constituted 49.3% and females constituted 50.7% of the total participants.
Table 1: Demographic characteristics of participants

Click here to view

Out of 18 questions in the questionnaire, 16 questions were about child impact items and family impact items. The distribution of responses given by parents for the child impact and the parent impact questions are given in percentage values in [Table 2]. Two questions were on parental perception of their child's general and OH to test the concurrent validity.
Table 2: Distribution of responses for the questions included in oral health-related Early childhood quality of life

Click here to view

The scores of different groups in relation to caries status are tabulated in [Table 3]. The average OH-ECQOL score of children without ECC was lesser (OH-ECQOL, median 14, 95% interquartile range [IQR] 13–15) compared to the OH-ECQOL score of the ECC category (OH-ECQOL, median 21, 95% IQR 18–26). The ShapiroWilk test was done to test for normality. Results show P ≤ 0.01 and values are not normally distributed.
Table 3: Average oral health-related early childhood quality of life score of children with early childhood caries and no early childhood caries

Click here to view

For determining the discriminant validity, the Mann–Whitney test is done as shown in [Table 4]. The average OH-ECQoL across the two groups of children, i.e., for children without ECC, the median ± IQR = 21 ± 8, and for children with ECC, the median ± IQR = 14 ± 2. Results show P ≤ 0.01 which is statistically significant.
Table 4: Discriminant validity of oral health-related early childhood quality of life

Click here to view

Concurrent validity was checked by comparing the results of child impact (OH-ECQoL) against the self-rating for oral and overall health scores. [Table 5] shows Spearman's correlation coefficient test statistics demonstrating a strong positive correlation between general health perception and child impact with a rho value of 0.72, which is highly significant at P < 0.01. OH perception and family impact has a rho value of 0.71, which also shows highly significant at P ≤ 0.01. A moderate positive rho correlation was identified between the OH perception and family impact with a rho value significant of 0.51 but highly significant at P ≤ 0.01. Moderate positive correlation was also identified between the variable general health perception and family impact with a rho value significant of 0.43 and highly significant at P ≤ 0.01.
Table 5: Concurrent validity of general health and oral health perception of parents

Click here to view

Convergent validity is investigated by correlating the family and child impact scores as shown in [Table 6]. Spearman's rank correlation coefficient test statistics demonstrate a strong positive correlation between child impact and family impact with a rho value significant of 0.73 and highly significant at P ≤ 0.01.
Table 6: Convergent validity of child impact section and family impact section

Click here to view

Cronbach's alpha score was 0.93 and 0.94 for the test of a total item and standardized item, respectively, indicating excellent internal consistency reliability. Further, the child impact section score was 0.93 indicating excellent internal consistency, and the family impact section showed 0.83 indicative of good internal consistency.

Test–retest reliability was assessed using ICC, the value of which was 0.876 which denotes good reliability

   Discussion Top

The QoL depends on a complete sociocultural milieu and the way people perceive health, interact with each other on health-related issues, and social norms and taboos along with their socioeconomic aspects.[12] ECC affects the QoL in children. ECC in children has an emotional, social, and financial impact on the family.[13] This study considers ECC as a parameter to check the QoL in children. Parental perception of their child's health is an important domain in assessing QoL of children and also the decisions about a child's health are dependent on their parents' perception of the situation.[14]

The results of this study show that OH-ECQoL score increased with the severity of ECC which demonstrated the poor OHRQoL among the participants with ECC. The results of the study are similar to the work done by Dharmani et al.,[3] Mathur et al.,[5] and Upadhyay et al.[8] using the same scale.

The present study evaluated the properties of translated OH-ECQoL by determining its validity and reliability using concurrent validity, construct validity, discriminant validity and internal consistency, test reliability, and test–retest reliability which is a standard procedure for any translation validation testing.[5]

Criterion validity is usually measured with a gold standard. As no such standard exists for ECC, in this study, concurrent/criterion validity was tested by correlating general and OH perception of parents with child impact scores and family impact scores.[15] The results suggest that the Malayalam version of OH-ECQoL shows good concurrent-related validity. The results of the study are in agreement with prior studies by Pahel et al.,[16] Mathur et al.,[5] Dhamini et al.,[3] and Upadhyay et al.[8] on concurrent validity testing.

Construct-related validity was tested by correlating child impact score with family impact score.[3],[17] The hypothesis related to this test is that the impact of child's OH status on his/her life is closely related to its influence on the family. In this study, the analysis of construct-related validity was found to be statistically significant. Therefore, it can be inferred that the impact on the family has a direct relationship with the impact on child's OH and OH-ECQoL in the Malayalam language was thus valid in terms of construct-related validity. The results of our studies are in concurrence with the findings by Dhamini et al.,[3] Mathur et al.,[5] and Upadhyay et al.[8]

Discriminant validity was tested by comparing OH-ECQoL between caries and noncaries groups. The Mann–Whitney U-test statistics give a significant P < 0.01 and thus reject the null hypothesis and accept the alternate hypothesis. The results demonstrate a significant difference in OH-ECQOL between the children who do not have ECC. It is assumed that poor OH condition in ECC leads to high score in OH-ECQoL than in children with no caries, suggesting that the tool being capable of discriminating impact on QoL which is in accordance with the studies by Jokovic et al.,[18] Lee et al.,[19] and Mathur et al.[5]

Consistency reliability or internal consistency expects the range to which items of a tool measure various aspects of the same characteristics.[20] The value of Cronbach's alpha for the child impact section and the overall scale shows good internal consistency. The results are consistent with other studies on OH QoL.[3],[5],[8]

Test–retest reliability reflects the variation in measurements taken by a questionnaire on the same participant under the same conditions.[3] The values obtained in this study show that the ICC was good reliability between the test and retest data which is in agreement with prior studies.[3],[5]

The importance of this study is that OH-ECQoL being designed mainly for the Indian population[5] and comprehensive countrywide disease features are included unlike the other scales. The existing scales assessing the OHRQoL were designed predominantly for the Western population, in which odontogenic infections in children seeking emergency dental care have not been given emphasis.[21]

The limitation of this study is that it has been conducted by convenient sampling, on patients reporting to a hospital and they may already be having a disease or condition requiring treatment, which could impact the QoL scores. The severity of ECC was not considered in this study, therefore, the nonclassification of the ECC group could affect the discriminant validity scores. This study has been done in the North Malabar region of Kerala state and should be tested for applicability in other Malayalam dialect-speaking areas also.

   Conclusions Top

This study shows that the Malayalam version of OH-ECQoL is a valid and reliable tool for assessing the QoL. The developed tool can assist in the planning and management of health programs in Kerala State and Malayalam-speaking territories in India. This study also shows that ECC presents a negative impact on the QoL of preschool children and their parents.


The authors would like to acknowledge Dr. Vijay Prakash Mathur, Professor and Head of the Division of Pediatric and Preventive Dentistry, CDER, AIIMS, New Delhi for his inputs and Dr Rahna Kizhessery, Dept of Public Health and Community Medicine, Central University of Kerala. Kasaragod, Kerala for the statistical analysis.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Sischo L, Broder HL. Oral health-related quality of life: What, why, how, and future implications. J Dent Res 2011;90:1264-70.  Back to cited text no. 1
Bennadi D, Reddy CV. Oral health related quality of life. J Int Soc Prev Community Dent 2013;3:1-6.  Back to cited text no. 2
Dharmani CK, Dhillon JK, Mathur VP. Validation of Manipuri version of oral health-related early childhood quality-of-life tool for preschool children. Indian J Dent Res 2019;30:742-6.  Back to cited text no. 3
  [Full text]  
Farsi NJ, Farsi DJ, Aldajani MB, Farsi NM, El-Housseiny AA. Sustainability of improvement in oral health-related quality of life in children after dental treatment. Patient Prefer Adherence 2021;15:271-81.  Back to cited text no. 4
Mathur VP, Dhillon JK, Logani A, Agarwal R. Development and validation of oral health-related early childhood quality of life tool for North Indian preschool children. Indian J Dent Res 2014;25:559-66.  Back to cited text no. 5
[PUBMED]  [Full text]  
Bhat SG, Sivaram R. Psychometric properties of the Malayalam version of ECOHIS. J Indian Soc Pedod Prev Dent 2015;33:234-8.  Back to cited text no. 6
[PUBMED]  [Full text]  
Fernandez S, Chaudary S, Bafna Y, Kalgudi J, Patel D , Habibullah MA . Impact of Secc on oral healthrelated quality of life of preschool children in Visnagar, North Gujarat. IJSR 2019;8:22-4.  Back to cited text no. 7
Upadhyay S, Mathur VP, Dhillon JK, Poudyal S. Translation and validation of oral health-related early childhood quality of life tool for Nepalese preschool children. Kathmandu Univ Med J (KUMJ) 2021;19:90-5.  Back to cited text no. 8
Chapter I – Language of the Union. Available from: https://rajbhasha.gov.in/en/constitutional-provisions. [Last accessed on 2022 Jan 01].  Back to cited text no. 9
Peedikayil FC, Ansari A. Dental caries prevalence of children in Kerala: A paradigm shift needed toward a Kerala model of health. Int J Community Dent 2019;7:29-33.  Back to cited text no. 10
  [Full text]  
Tsang S, Royse CF, Terkawi AS. Guidelines for developing, translating, and validating a questionnaire in perioperative and pain medicine. Saudi J Anaesth 2017;11:S80-9.  Back to cited text no. 11
Post MW. Definitions of quality of life: What has happened and how to move on. Top Spinal Cord Inj Rehabil 2014;20:167-80.  Back to cited text no. 12
Singh N, Dubey N, Rathore M, Pandey P. Impact of early childhood caries on quality of life: Child and parent perspectives. J Oral Biol Craniofac Res 2020;10:83-6.  Back to cited text no. 13
Ghanghas M, Manjunath BC, Kumar A, Shyam R, Phogat R, Panghal V. Validation of the Hindi version of the early childhood oral health impact scale among 3-5-year-old preschool children in Rohtak city, Haryana. J Indian Soc Pedod Prev Dent 2019;37:333-8.  Back to cited text no. 14
[PUBMED]  [Full text]  
Randrianarivony J, Ravelomanantsoa JJ, Razanamihaja N. Evaluation of the reliability and validity of the Early Childhood Oral Health Impact Scale (ECOHIS) questionnaire translated into Malagasy. Health Qual Life Outcomes 2020;18:39.  Back to cited text no. 15
Pahel BT, Rozier RG, Slade GD. Parental perceptions of children's oral health: The Early Childhood Oral Health Impact Scale (ECOHIS). Health Qual Life Outcomes 2007;5:6.  Back to cited text no. 16
Leelataweewud P, Jirarattanasopha V, Ungchusak C, Vejvithee W. Psychometric evaluation of the Thai version of the Early Childhood Oral Health Impact Scale (Th-ECOHIS): A cross sectional validation study. BMC Oral Health 2021;21:64.  Back to cited text no. 17
Jokovic A, Locker D, Stephens M, Kenny D, Tompson B, Guyatt G. Validity and reliability of a questionnaire for measuring child oral-health-related quality of life. J Dent Res 2002;81:459-63.  Back to cited text no. 18
Lee GH, McGrath C, Yiu CK, King NM. Translation and validation of a Chinese language version of the Early Childhood Oral Health Impact Scale (ECOHIS). Int J Paediatr Dent 2009;19:399-405.  Back to cited text no. 19
Richa R, Yashoda R, Puranik MP. Oral health status and parental perception of child oral health related quality-of-life of children with autism in Bangalore, India. J Indian Soc Pedod Prev Dent 2014;32:135-9.  Back to cited text no. 20
Asokan S, Geetha Priya PR, Viswanath S, Sivasamy S, Natchiyar SN. Development and validation of a novel Middle childhood oral health impact scale (MCOHIS). J Indian Soc Pedod Prev Dent 2022;40:55-61.  Back to cited text no. 21
  [Full text]  


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


Print this article  Email this article


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (485 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

    Article Tables

 Article Access Statistics
    PDF Downloaded49    
    Comments [Add]    

Recommend this journal

Contact us | Sitemap | Advertise | What's New | Copyright and Disclaimer | Privacy Notice
  2005 - Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer - Medknow 
Online since 1st May '05