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 Table of Contents  
Year : 2017  |  Volume : 9  |  Issue : 5  |  Page : 236-241

Crosscultural translation and adaptation of the Moroccan version of the child-oral impacts on daily performance 11–14 oral health-related quality of life

1 Department of Orthodontics, Faculty of Dentistry, Hassan II University Casablanca-, Morocco
2 Department of Medical Informatics, Faculty of Medicine and Pharmacy, Hassan II University Casablanca-, Morocco
3 Department of English Studies, University of Chouaib Doukkali, El Jadida, Morocco

Date of Web Publication20-Oct-2017

Correspondence Address:
Farid Bourzgui
Department of Orthodontics, Faculty of Dentistry, University of Hassan 2, P. B: 9157, Casablanca
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jioh.jioh_84_17

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Aims: This study aimed to cross-culturally translate and adapt the Child-Oral Impacts on Daily Performance (OIDP) measure into Moroccan Arabic and assess its reliability and validity. Materials and Methods: The original Child-OIDP was translated from English into Moroccan Arabic and back again. The Moroccan version of the Child-OIDP instrument was, then, validated on 11–14-year-old school children in Casablanca, Morocco, who responded to questions assessing their perceived oral problems. Results: The study revealed that the average score of Child-OIDP was 8.3 (standard deviation 8.7). Internal consistency was confirmed with a Cronbach's alpha of 0.58; the testing-retesting procedures showed a satisfactory reproducibility (r = 0.93). The convergent validity was very satisfactory; the Child-OIDP score increased when the children had dental problems. The Child-OIDP score was able to discriminate the different sociodemographic groups. Conclusion: The study showed that the Moroccan version of the Child-OIDP had satisfactory psychometric properties, and is, therefore, a valid and reliable instrument.

Keywords: Children, Moroccan Arabic, morocco, oral health, psychometric properties, quality of life, validation

How to cite this article:
Lazrak L, Bourzgui F, Serhier Z, Diouny S, Othmani MB. Crosscultural translation and adaptation of the Moroccan version of the child-oral impacts on daily performance 11–14 oral health-related quality of life. J Int Oral Health 2017;9:236-41

How to cite this URL:
Lazrak L, Bourzgui F, Serhier Z, Diouny S, Othmani MB. Crosscultural translation and adaptation of the Moroccan version of the child-oral impacts on daily performance 11–14 oral health-related quality of life. J Int Oral Health [serial online] 2017 [cited 2022 Aug 10];9:236-41. Available from:

  Introduction Top

Oral health is defined in terms of complete physical, mental, and social-related dental status.[1] Several measures have been developed to assess oral well-being and describe oral impacts on people's quality of life.[2],[3] In general, these instruments assess the extent of the damage of the normal social functioning and leads to changes in the ability to work, attend school, or perform a family task.[4],[5]

Most oral health-related quality of life (OH-QOL) studies have been designed to assess adults; however, the impact of OH-QOL outcomes in children has been less researched. This is because there are numerous methodological and conceptual problems when developing OH-QOL measures in children.

Many OHRQOL measures have been developed in the last decade. Both the Child OHQoL [6] and the Child-Oral Impacts on Daily Performance (OIDP)[7] were based on a conceptual model of oral health-related quality of life, and only both were submitted to a psychometric evaluation.[8]

To validly use this measure among Moroccan children, it is important to examine its psychometric properties. The main objective of this study is to evaluate the validity of the Child-OIDP for use among children in Morocco. Specifically, the study aimed to cross-culturally translate and adapt the Child-OIDP measure into Moroccan Arabic and assess psychometric properties

  Material and Methods Top

For cross-cultural adaptation, a translation/back-translation method integrated with expert panel reviews was applied. A total of 1.064 children selected randomly from primary and junior state schools in Anfa Casablanca Prefecture took part in the study. To validate the English version in Moroccan Arabic. Two bilingual Moroccan Arabic-speaking professionals were asked to translate the Child-OIDP questionnaire from English into Moroccan Arabic. One of the translators (a dentist) was familiar with the concepts measured; the other translator, however, was an expert methodologist. Both translations of the Child-OIDP were compared; a few changes were made to preserve the meaning of the different items of the original version. Before the main study, a pilot study was carried out on focus group of children to assess children's understanding of the questionnaire. On the basis of the results of the questionnaire, two major changes were made. First, the children had difficulty filling out the second part of the questionnaire. To overcome this difficulty, the researchers decided to break the second part of the questionnaire into two tables; the first table included 8 activities with severity and its scale as well as the frequency and its scale. The child had just to tick his/her choice. The second table grouped all oral problems and the 8 daily activities; this allowed the child to tick the difficulty performing a given activity without going back to the first part of the questionnaire. This tab transformation facilitated the process of data collection [Appendix 1] [Additional file 1].

Second, other changes involved the inclusion of sociodemographic variables (age, sex, years of study, parents' occupation) and variables on oral habits (daily brushing frequency, sweet drinks per day, and the last visit to the dentist). The scheme of the severity scale was removed. Indeed, the children tended to choose the second scale in the middle of the arrow. In addition, terms causing misunderstanding were changed, for example, “permanent tooth” was always accompanied by “not milk tooth” and “mouth ulcers” by “burning mouth”).

This new version was retested in a second pilot study involving 30 school children. This confirmed the feasibility of the methodology and the usefulness of the corrections made; it also determined the time to fill out the questionnaire (15–20 min).

The researchers contacted the Department of Education to get permission to carry out the study and to obtain a list of various primary and junior state schools. Then, software to randomly select primary and junior schools by district was used. The list of selected schools was then communicated to the Department of Education, which had to inform the headmasters of the institutions concerned. In the schools, classes were stratified according to levels. All the children of the randomly chosen classes were invited to participate in the study. A written permission letter was obtained from the children's families. The research study was approved by the Ethics Committee of Casablanca Dental School (number 20/2013).

A self-administered questionnaire was administered by the researchers between January 2013 and March 2013. Only children with parental consent were allowed to take part in the study. Explanations about the purpose of the study were given to the children. Filling out the questionnaire was done in the classroom at the beginning of the session and in the absence of the teacher. The children were given 30 min to fill out the questionnaire.

For testing/retesting, 57 children from two different classes (6th and 9th grades) filled out the questionnaire a second time within a 2-week interval of the first administration.

Sociodemographic characteristics were assessed in terms of age, gender, parental education, and socioprofessional category, hygiene habits, and oral problems ( first part of the questionnaire); they were described by means of frequencies or means and standard type.

The properties studied were reliability (internal coherence, reproducibility) and validity (construct validity and validity); they were based on intercorrelations between 8 activities and the total score. Cronbach's alpha was measured for the 8 activities of the Child-OIDP. Reproducibility “test-retest” was estimated by two administrations of the questionnaire. Reproducibility is considered good when the intraclass correlation of coefficients is above 0.6.

Convergent validity was measured by studying the existing statistical link between the OIDP score and the number of problems reported by children. Construct validity explored the existing logical relationship between the OIDP score and oral problems. This leads to the claim that the quality of life is associated with the presence of oral problems. Put differently, the quality of life of individuals is more affected when the incidence of oral health problems is higher. The validity of divergence was evaluated in terms of children's sociodemographic characteristics, the father's occupation, the mother (active or not) and the number of children in the family (1, 2, 3, 4, and more).

Since the distribution of the score of Child-OIDP was not normal, nonparametric tests were used (Mann–Whitney or Kruskal–Wallis tests). The significance level was arbitrarily set at 0.05.

The statistical analysis was performed using SPSS software (Version 16.0, SPSS Inc., Chicago, IL, USA). For all the statistical tests, the significance level was set at P ≤ 0.05.

  Results Top

1100 questionnaires were filled out, 25 out of which were excluded because the students were more than 14 years old (repeaters) and 11 questionnaires had missing data. A total of 1.064 children participated in the validation study. The average age of the students was 13.06 (standard deviation [SD]: ±1.05). There were 517 girls (48.4%). 87.9% of our sample was brushing teeth, 97% were taking at least a sweet drink per day, and 26% had never consulted a dentist.

The sample reported high percentages of oral problems. The most frequently reported problem was sensitivity (50.5%), followed by tooth decay (42.3%). The most commonly affected daily activities were the ability to “eat” (48.4%), the ability to “brush teeth” (33.2%), and “smile” (26.5%). The children were rarely bothered by their ability to “study” (7.4%) [Table 1].
Table 1: Prevalence of oral impacts on daily activities (child-oral impacts on daily performance) in 11 to 14 Moroccan children

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For our study population, the average score OIDP was 8.32 (SD = ±8.70). When the OIDP score was analyzed in terms daily activities, the ability to “smile” scored highest, followed by the ability to “brush teeth.” The least affected activities were “studying” and “good relationships.”

The item-item correlation matrix and item-score are presented in [Table 2]. We did not get any correlation coefficient higher than item-item 0.8. Similarly, no negative correlation indicated negative coefficient.
Table 2: Pearson correlation coefficient index scores child-oral impacts on daily performance

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Correlations “smile” and “social relationships,” “rest” and “calm” were highly correlated with coefficients >0.30. All the other activities were moderately correlated.

All the items were well correlated with the total score with significant values ranging from 0.35–0.51 (P < 0.01). This corresponds to a fairly good internal coherence.

The intraclass correlation coefficient between the two score values measured during testing/retesting was 0.93 with intraclass correlation coefficients of eight activities ranging from 0.97 to 0.88 [Table 3]. The reproducibility is very satisfactory.
Table 3: Intraclass correlation coefficient between the scores of 8 items oral impacts on daily performance during the test/retest

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The Cronbach's alpha was 0.52. It is, therefore, well within the recommended range 0.5–0.7. The Cronbach's alpha decreased each time an item was deleted, which corroborates the coherence of the results. The correlation coefficients corrected item-score were all above 0.2 [Table 4].
Table 4: Cronbach's alpha standard, item-total correlation and alpha if item deleted

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The results show that the total OIDP score was significantly associated with all oral problems. Indeed, the OIDP score increased significantly between the absence (0) and the presence of oral problems. The children with oral problems had a higher total OIDP score (average 12.52 vs. 7.30 for those who had no problems, P < 0.001).

The OIDP score did not differ significantly according to the number of children in the family (P = 0.08) or the father's occupation (P = 0.12). In contrast, the occupation of the mother (active or inactive) was significantly associated with the OIDP score (P = 0.02). The Child-OIDP score was higher among children whose mothers had a professional activity (8.40 versus 7.96) [Table 5].
Table 5: Association between child-oral impacts on daily performance score and sociodemographic variables

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  Discussion Top

The aim of the study was to do a cross-cultural adaptation Child-OIDP index and assess its reliability and validity for application among Moroccan children aged 11–14. Simplifying the shape of the second part tabs allowed children to understand the questions. The study showed that the Moroccan version of the Child-OIDP had satisfactory psychometric properties. In terms of validity, the questionnaire presented a very good convergent validity. The relationship between the Child OIDP score and perception by the child of his mouth problems was very statistically significant.

The results also showed good divergent validity with a significant relationship between the OIDP score and the occupation of the mother. The reliability of the questionnaire was confirmed by the internal coherence of Cronbach α with a coefficient of 0.52 (in the recommended range of 0.5–0.7). Testing-retesting also showed excellent reproducibility (r = 0.93).

As a result, the Moroccan version of Child OIDP can be considered as a valid, reliable, and convenient instrument for use in the Moroccan population.

Up to now, the Child-OIDP questionnaire has been translated and adapted in a number of languages and different sociocultural contexts, demonstrating its applicability and satisfactory psychometric properties.

The psychometric properties of measures of quality of oral life depend largely on the linguistic and cultural attributes of the study population. The need for validation study of the measurement instrument when applied in a new sociocultural context was recognized.[9]

It is important to note that the Arabic version of the Child-OIDP was already validated in 11–14-year-old Saudi Arabian children Brown and Al-Khayal.[10] However, they outlined the limitations of this Arabic version. Specifically, it was too long and included questions that were culturally inappropriate. Another Arabic version of the Child-OIDP was, then, developed in Sudan,[11] but it could not be used either; the Sudanese version was in modern standard Arabic, a high variety compared to Colloquial Arabic, a low variety; both varieties differ in terms of use, attitudes, and grammar.

The existence of French, Spanish, Amazigh, and Arabic in Morocco has led to the incorporation of hundreds of loan words. Moreover, the Moroccan Arabic is quite complex because of the presence and interference of three variant forms of colloquial Arabic, three languages (French, English, and Spanish) and a national language, Modern Standard Arabic.[12]

In terms of test-retest reliability of the Child-OIDP, intraclass correlation coefficients were excellent with an average value of 0.93; this shows that the index Child-OIDP is a stable measure. This is in accord with other validation studies of the Child-OIDP.[13],[14],[15],[16],[17] This index can be used in public health programs as a sociodental indicator because it can be used by any person-be it a dentist or not. In terms of internal reliability, all the corrected-total correlations were 0.2.[18],[19] Furthermore, all inter-item correlations were positive and no correlation was high enough and thus does not make any element redundant.

The Cronbach's alpha was 0.52 and although not satisfactory against the criteria that define a threshold of 0.7 for proper coherence, it was found comparable to other validation studies of the Child-OIDP.[14],[15],[16] This low value of the Cronbach alpha is partly explained by the high number of children tested. Indeed, it seems that more satisfactory values of the Cronbach alpha coefficient (>0.87) were observed in young people using the short version of the OIDP (in consideration of the single frequency),[17],[18] but the sample size is unknown. Similarly, in 12–16-year-old Brazilian adolescents, Cronbach's alpha values were of 0.7 and 0.87 were observed for the OIDP score, but on small samples (<205).[20],[21] The value of the Cronbach alpha observed for the validation of the CPQ was 0.91. However, the study was conducted on only 123 children [22] compared to the present study that included 1064 children.

In addition, the quality of life is a multidimensional concept. Therefore, any assessment of the impact of oral health on daily life, including the Child-OIDP, must take into account various dimensions. This may explain why the Child-OIDP, given all its items, cannot have an alpha of more than 0.7; yet, it is considered satisfactory.

Moreover, when one of the items was removed, the value of alpha decreased, providing evidence that all items are important for establishing the Child-OIDP index. A full assessment of the validity of the Child-OIDP conducted in Peru concluded that the small number of items in the index resulted in low values of Cronbach's alpha.[16]

The value of alpha is based on the correlation between the items and the number of items in a scale, with a tendency toward a decreased Cronbach alpha when the number of items is low.[23],[24] There is no interest in increasing the number of items to achieve high alpha values, as this will have a negative effect on the applicability of the measure. A relatively low value of Cronbach's alpha can be, to some extent, an inherent attribute of a brief and practical measure of quality of life related to oral health, which can be used for the assessment of the needs of a population.

The validity of any discrepancy found with a significant relationship between the OIDP score and the occupation of the mother, as the OIDP score increased significantly when the mother of the child was not active. This highlights the role that the education and occupation of the mother plays in the children's quality of oral life. Indeed, the OIDP seems to discriminate children whose mothers are inactive.

The OIDP score did not differ significantly according to the father's occupation (P = 0.12) or the number of children in the family. These results are in agreement with the French study [14] that found that siblings had an impact on the quality of oral life of children.

This work validates an instrument specifically designed for children. Casas Anguita et al.[25] concluded that it was preferable to adapt an instrument rather than develop a new one. The development of a new instrument can be complex; the adapted version can be as reliable and valid as the original one, and the presence of a reference instrument allows for investigations in various countries, allowing replication of the study and direct comparison of results.

The prevalence of impacts observed in Morocco (77.1%) was comparable to that observed in other countries where the Child-OIDP was adapted and validated, i.e., Thailand (89.8%);[20] France (73.2%),[14] and Peru (82.0%).[15] However, it was higher than that found in England (40.4%)[20] and Tanzania (28.6%).[26] Regarding the most widespread impact, activities such as “eating,” “brushing one's teeth” and “smiling” were the most affected activities in Morocco; this was also true for France [14] and England,[21] where “tooth brushing” was the second most affected representation. So far, eating has been the most affected performance in all studies using the Child-OIDP as an index.

Regarding oral problems perceived by children, tooth sensitivity, and tooth decay were the most frequent problems reported by Moroccan children while in France the position of the teeth and mouth ulcers were the most frequent problems.[14]

The high levels of certain oral problems such as sensitivity, tooth decay, and pain reflect awareness of oral and functional problems of children and indirectly provide information on treatment needs.

The esthetic appearance of children becomes a significant concept when children reach adolescence.[27] In fact, our study found out that two main concerns for children were the position and coloring problems (33.3% and 23.7%, respectively) and when the OIDP score is analyzed in terms of daily activities, “smiling” had the highest average.

Nevertheless, the present study has some limitations. First, the selection of the sample was based on school units and not on individuals. It is known that the random selection of schools gives a somewhat biased sample and wider confidence intervals with respect to the true randomization of students. Therefore, even if participants are, to some extent, children living in the urban district of Casablanca with different socioeconomic contexts and that the gender balance was acceptable, they are not entirely representative of the general population of children of the same age group who attend different schools in school districts in Casablanca.

Further studies should be conducted to fully assess the Child-OIDP index psychometric properties epidemiologically. Its sensitivity to the change must also be implemented so that it can be considered for clinical indicators to evaluate the effect of treatment on the quality of life.[28]

  Conclusion Top

Despite these limitations, this cross-cultural adaptation study of the Moroccan Arabic self-administered Child-OIDP has successfully demonstrated its validity and reliability. Now, it is possible to use this instrument to measure the quality of oral life in children ages 11–14 Moroccan teenagers.


We would like to thank all the children and their parents who have kindly participated in this study as well as all the administrative and teaching staff who have facilitated the task.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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

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