Linguistic-cultural validation of the oral health assessment tool (OHAT) for the Italian context

The increase in the ageing population and the consequent establishment of a network of adequate structures to respond effectively to its healthcare have stimulated the discussion by healthcare professionals on the subject of oral hygiene since, as reported in the literature, there is evidence that oral healthcare is not delivered at the same level as other health needs [1]. Many studies have shown that oral health has a significant impact on the quality of life, especially for older adults [2‐4]. The results of several clinical and epidemiological studies have shown that there is a significant relationship between oral health and specific pathological conditions such as infections of the myocardium, meninges, mediastinum and joint prostheses [5]. Elderly adults who have physical and / or cognitive disorders and who have poor oral hygiene, frequently have a bacterial colonization in the dental plaque biofilm and are exposed to a high risk of aspiration pneumonia. Prevention is based on careful removal of the biofilm from daily dental plaque. However, this practice is often poor or non-existent although it is considered an essential nursing activity [6]. Poor oral health has a significant impact on the physical condition of elderly adults because it affects their ability to eat and feed themselves, obliges them to have unbalanced diets, facilitates weight loss, dehydration and malnutrition, affects communication skills as it impairs the articulation of sound, hinders social relationships as it facilitates the development of pathological behavioural attitudes [7‐10]. This is why nurses must not lose sight of the fundamental activities that guarantee an effective response to the needs of this population cohort. In a recent literature review, the concept of missed nursing care is presented [11], i.e., the tendency of nurses to prioritize complex activities, thus neglecting the basic care activities, such as assisted personal hygiene and, in particular, oral hygiene. A study by Wardh et al. [12] shows how oral care is considered the most unpleasant task for nurses, probably due to poor oral health training and the necessary support for the implementation of a comprehensive oral care strategy. Sumi et al. [13] also affirm that the topic of oral health is not sufficiently addressed in nursing educational curricula, a statement confirmed by several studies in which nurses have identified for this purpose the need for specific training on oral hygiene [14, 15]. Thorne et al. [16] argue that the effective development of a dental care and oral care service should be based on a regular assessment of all persons accepted in residential care facilities. Since the assessment of oral health is based on the personal ability to report symptoms related to dental suffering, many subjects may have lost this ability, especially if suffering from cognitive deficits, and consequently they are not able to self-report data. For these people assessment must be conducted by a qualified dental practitioner or an appropriately trained nurse [17]. In order to facilitate the assessment of oral health, many assessment tools have been developed and validated for non-dental or non-dental health professionals, but they have been designed for a population of patients admitted to intensive care units or in palliative care units, and are therefore unsuitable for use by elderly adults with cognitive impairments in residential care settings [17]. The validated tools for the assessment of oral hygiene in adults with cognitive deficits residing in social-healthcare facilities are: in the United States, the Brief Oral Health Status Examination (BOHSE) [18], in England, The Holistic and Reliable Oral Assessment Tool (THROAT) [19] and, in Australia, the Oral Health Assessment Tool (OHAT) [17].

The BOHSE scale was developed to detect the presence of oral cavity changes in elderly patients in nursing homes, with or without cognitive decline and neurological deficit [20]. This scale can be used by nurses who have undergone training conducted by oral health specialists; it consists of 12 categories that include palpation of the lymph nodes of the neck, observation of the lips, inspection of the oral cavity for assessment of the hard palate, the tongue and the gums, salivation, presence of natural teeth, presence of artificial teeth, chewing position and oral cleanliness. These methods require the use of an artificial light source, tongue depressors and gauze for tactile evaluation of any anomalies [18]. The BOHSE scale is a tool meant for screening activities and does not replace the need for a periodic examination performed by a professional dentist. Before using this tool, staff should receive field training from a dentist or dental hygienist.

The THROAT scale involves checking 9 dimensions which include assessment of the lips, presence of dental plaque, changes in the gingiva and oral mucosa, observation of the palate, tongue, sublingual mucosa, smell, consistency of the saliva. So far only a single study has been conducted on the implementation of the scale in a trial that involved a sample of 50 elderly patients; in this study there was no reference to any neurological or cognitive alterations of the elderly patients involved in the trial [19].

The OHAT scale is a re-adaptation of the BOHSE scale. The purpose of this change was to simplify the tool proposed by Kayser-Jones to allow a leaner assessment while maintaining the same criteria of effectiveness. The study of this validation path involved 455 subjects, the results obtained from the evaluation conducted by the nurses compared with those obtained from the evaluation of oral hygiene specialists showed no significant differences. A sufficiently intense artificial or natural light source and the use of disposable gloves were required to perform the assessments; it did not involve the introduction of instruments into the oral cavity or tactile inspection. Compared to BOHSE, assessment of the laterocervical lymph nodes was eliminated.

The OHAT implementation study involves its use on institutionalized elderly people suffering from cognitive and non-cognitive disorders, with varying degrees of dependence [17].

Oral care is particularly important for the elderly population, which, for the most part, has a great health fragility linked to comorbid conditions. The nurse is the reference professional figure taking care of users admitted to long-term care facilities or living in residential facilities for the elderly, and is the person mainly responsible for meeting the healthcare needs expressed by this population cohort. The nursing activity essential for care of the oral cavity is the assessment of the state of oral health. Considering that the literature reports the poor predisposition for the evaluation and care of oral hygiene by nurses, it is essential to plan strategies to implement and ensure this nursing activity.

Seeing that the assessment phase is central in the development of an effective oral care strategy, validated tools are available to the nurses to support them in this activity. It is therefore necessary to provide nurses with a scale for evaluation of oral hygiene also validated in Italian.

In order to find the face validity of the pre-final version of the OHAT, the tool was administered to the nurses and the experts panel the first time, asking them to judge whether the tool items were clear or not clear and to suggest any corrections. The items received a clarity score of 80% or more and, based on the methodological approach of Sousa & Rojjanasrirat [22], it was not necessary to re-evaluate and modify the items (Table 1).

The content validity was evaluated by the experts panel by inserting for each item of the scale a Likert scale that required estimation of the items as insignificant = 1, slightly significant = 2, quite significant = 3 and very significant = 4. Each item obtained an I-CVI equal to or greater than 0.8 (Table 2) and an S-CVI of 0.93 for the entire tool. For the reliability of the internal consistency, the Cronbach alpha was calculated which was found to be .816. For the test-retest, the tool was administered a second time after 15 days to the panel of experts. The correlation coefficient expressed through Pearson’s r was 0.5, showing a fair correlation.

Finally the construct validity was evaluated by factor analysis. The 8 items correlate at least 0.4 to each other, the measure of adequacy of the sample expressed with the Kaiser-Meyer-Olkin was found to be good with a value of 0.867 (p < 0.000). The Bartlett’s sphericity test (χ2 = 814.64, df = 36, p < 0.000) indicates that, for the available data, it is appropriate to perform the factorial analysis. Lastly, the communality values were all greater than 0.5, confirming that each item shares its variance with the other items (Table 3). The exploratory and confirmatory factor analysis with varimax rotation showed that the OHAT has two loading factors: internal inspection of the mouth and state of the teeth. At factor 1, internal inspection of the mouth saturates the items lips, tongue, gums and tissues, saliva and oral hygiene; at factor 2, state of teeth saturates the items natural teeth, artificial teeth and dental pain (Table 4).

The trans-cultural validation of the research tools is characterized by methodological criticalities, in particular, related to the quality of the translation and the comparability of the results among the different cultural and ethnic groups. This is why it is not enough to translate the questionnaire literally, but it needs to be adapted to make its culturally relevant content comprehensible.

The chosen cultural linguistic validation method is among the most complex if compared, for example, with that described by Sperber [24], in which the pre-final version of the questionnaire is not administered to a sample of subjects belonging to the target population, to find the face validity. The proposal by Sperber [24] does not appear as rigorous as the methodological approach chosen in this study in describing the modalities of translation and the characteristics of translators [25]. Different methods are hypothesized for validation of the translation: evaluation by a group of bilingual experts; focus groups with subjects representing the target population; evaluation by a group of experts that does not include translators who are independent of researchers.

The process of translation of the tool requires skills, knowledge and experience. The colloquial phrases and those characterized by emotional suggestions can be particularly difficult to handle. Moreover, the translation may be formally similar to the original language, but some items may be irrelevant for the target culture, and therefore need to be rephrased or deleted. The methodological approach used should avoid the problems described by Sperber [24] and Hilton [26]; in particular, we should avoid the criticality represented by the exclusive use of bilingual translators, who, as seen from the literature, may have adopted values ​​and attitudes of the culture to which the second language belongs, and may give interpretations different from those of a monolingual translator. On the contrary, it is also possible that the bilingual translator, who has to translate a tool in a language different from the original one, is stimulated by the task of acquiring awareness of the ethnic origin, and consequently to offer ethnocentric interpretations.

The validation process that was developed through the translation of the questionnaire from the source language to the target language produced the Italian version of the tool. The psychometric measures confirmed the validity and reliability of the Italian version of the OHAT. The lowest score, although sufficiently saturated with factor 2 in the factor analysis, concerns dental pain; this is the only item on the scale that concerns a symptom and that it must be reported by the subject that, if suffering from cognitive deficits, he is sometimes unable to express it.

The tool is currently ready to be administered to the target population, i.e. to elderly subjects also with cognitive deficits. As reported in the literature, there is evidence that oral health care is not delivered at the same level as other health needs [1], and that oral health has a significant impact on the quality of life especially for older adults [2‐4], constant assessment is essential in order to provide quality care.

The Italian version of the OHAT (Fig. 2) can help nurses get back some basic assistance activities and contribute to improving the quality of life of elderly subjects also with cognitive deficits by implementing a constant assessment of oral health. The OHAT, in its Italian version, is an easy-to-use tool that requires little time to be administered and that guarantees to identify oral complaints early. For these reasons the instrument assumes a great clinical relevance as it can contribute to decreasing the incidence of complications related to oral health.

This report describes the linguistic-cultural validation process of a tool for assessment of the state of health of the oral cavity in elderly subjects, also with cognitive disorders, to be used by nursing professionals. The Italian version of the OHAT, the validity and reliability of which has been demonstrated in this study, is a tool that can help to consider oral health as important as other health needs and to increase the quality of nursing care provided.