Development of a Health Programme Questionnaire Index 13

DEVELOPMENT OF A HEALTH PROMOTION QUESTIONNAIRE INDEX (HPQI)

TO MEASURE DOKTOR MUDA (JUNIOR DOCTOR) PROGRAMME IMPACT
ON SCHOOLCHILDREN’S ORAL HEALTH KNOWLEDGE, ATTITUDES AND
BEHAVIOUR

Z.Y.M. Yusof, N. Jaafar. Development of a Health Original Article

Promotion Questionnaire Index (HPQI) to Measure
Doktor Muda (Junior Doctor) Programme Impact on
Schoolchildren’s Oral Health Knowledge, Attitudes and
Behaviour. Annal Dent Univ Malaya 2013; 20(1): 13-19 Z.Y.M. Yusof1, N. Jaafar1

Department of Community Dentistry,

1

Faculty of Dentistry,
ABSTRACT
University of Malaya,
Kuala Lumpur,
Long term evaluations of impacts of community
Malaysia.
based health promotion programmes are not an easy or
straightforward task to do due to lack of validated and
Corresponding Author:
reliable indices. Objective: To develop and test an index
Dr Zamros Yuzadi Mohd Yusof
to measure schoolchildren’s oral health knowledge,
Email: [email protected]
attitudes, and behaviour as a result of a school-based health
promotion programme in Malaysia called the Doktor
Muda (Junior Doctor) Programme (DMP). Materials and
Methods: The index was developed in English based on
the DMP module and translated into Malay. The Malay (1). Generally, evaluation assesses how a programme
version was tested on 174, 11-12 year old schoolchildren. has been conducted, what has been achieved, and how it
Psychometric analysis of the index involved content and has been achieved (2). It is important to measure success
face validity tests as well as factor analysis, internal and levels, develop good practice, make best use of resources,
test-retest reliability. Results: Factor analysis yielded 3 provide feedback and inform policy development (3).
factors with groups of items viz. oral health knowledge In Malaysia, a school-based HP programme called
(OHK), oral health attitudes (OHA) and oral health the Doktor Muda (Junior Doctor) Programme (DMP) was
behaviour (OHB). The Cronbach’s alpha coefficients of the introduced in primary schools in the late 1980s (4). It is a
three factors were 0.61, 0.73, and 0.64, respectively. The smart partnership programme between the Ministries of
Kappa coefficients were 0.70, 0.77 and 0.73, respectively Health and Education. DMP is a child-to-child peer-led
(intraclass correlation coefficients = 0.72, 0.70 and 0.78). HP programme where a group of schoolchildren called
The final questionnaire comprised 33 items, namely; OHK Doktor Muda (DM) or ‘young doctors’ are empowered to
11 items, OHA 15 items, and OHB 7 items. Conclusion: give health education and conduct health related activities
The Health Promotion Questionnaire Index (HPQI) to at school all year long. They act as an agent of change
measure the DMP impact on schoolchildren’s oral health to promote healthy lifestyles to their peers, families, and
knowledge, attitudes, and behaviours was empirically the community (5). Following a successful introduction in
verified to be valid and reliable for use among 11-12 year Pahang and Kelantan states in 1989 and 1991, respectively,
old Malaysian schoolchildren. DMP was introduced in other states in Malaysia. By 2010,
there were 1255 DMP schools with 33,440 trained DM,
Keywords representing about 20% of primary schoolchildren in
Attitudes, behaviour, Doktor Muda Programme, Malaysia (6).
evaluation, Health Promotion Questionnaire Index Among DM tasks were heading DM Club activities,
(HPQI), knowledge, oral health. helping teachers and health personnel, giving health
talks during assembly and in ‘adopted classroom’,
distributing health leaflets, preparing scrap books, putting
INTRODUCTION up health posters, organising hand washing exercise, and
supervising toothbrushing with fluoride toothpaste. The
Increasing emphasis is now being placed upon the content of the health talks included topics on personal
evaluation of health promotion (HP) interventions to hygiene, environmental hygiene, oral health, mental
demonstrate their impact and long term effect on health health, prevention of disease, safety and injury prevention,
14 ADUM, University of Malaya, V0l. 20 (1), 2013

healthy nutrition and diet, healthy lifestyles, and healthy on the OHK outcomes, the evaluation outcome measures
teenagers (5). In 2009, a WHO representative visited one or items of the questionnaire were drafted. Likewise,
of the DMP schools in Negeri Sembilan which had won the items of the other 6 OHK domains were drafted in a
the national DMP School Excellence Award in 2008 (7). similar way.
The purpose of the visit was to witness the DMP activities For Oral Health Attitude (OHA) items, they were
at school and meet the teachers and the children. drafted based on the OHK items and their impact on oral
Despite the WHO informal recognition of DMP as health attitudes (11). Based on the drafted OHK items, 2
a health promoting school model in Malaysia during its OHA domains were identified to be highly relevant to most
representative visit to Malaysia in 2009, no evaluation of the OHK items; ‘attitude towards toothbrushing’ and
on DMP has been conducted. As far as oral health was ‘attitude towards consumption of sugary food and drinks’.
concerned, it was argued whether the DMP had any For example, a student with good knowledge on dental
additional effect on schoolchildren’s oral health over and caries would tend to have good attitude towards sugary
above caused by water fluoridation and school oral health food and drinks intake. For each of the OHA domains, a
service, especially when caries level among 12-year-olds set of attitude items were drafted.
is declining (8-10). It was also argued whether the cost and For Oral Health Behaviour (OHB) items, they
time invested by Ministries of Health and Education on were drafted based on the dental literature, and the draft
DMP for the past two decades has been worthwhile. Thus, OHK and OHA items. Consequently, the draft OHB
it was argued that the DMP effect on health and oral health items consisted of questions to measure schoolchildren’s
should be evaluated. toothbrushing, fluoride use, mouth rinsing after meal,
This present study focused on the DMP impact on flossing, soft drinks intake, sweets intake, and smoking
oral health. It was part of a larger study to evaluate the frequencies.
DMP impact on schoolchildren’s oral health knowledge, Next, the items were arranged into a questionnaire
attitudes, behaviour, oral health status and oral health related and organised into 3 parts; OHK, OHA, and OHB which
quality of life. The study was based on the PRECEDE- consisted of 12, 15, and 7 items, respectively. OHK items
PROCEDE health promotion model as the evaluation used a 5-point rating scale; strongly agree (scale 1) to
framework (11). According to the model, the immediate strongly disagree (scale 5). OHA items used a 4-point
DMP outcomes are changes in health knowledge and rating scale; strongly agree (scale 1) to strongly disagree
attitudes, followed by health behaviour. However, suitable
(scale 4). OHB items used a 7-point rating scale; more
validated indices to measure these changes have never
than twice daily (scale 1) to never (scale 7). Information
been developed. Given the above, the present study aimed
on the purpose of the research, answering techniques, and
to develop an index, the Health Promotion Questionnaire
questions on demographic profile were added.
Index (or HPQI) to measure changes in schoolchildren’s
oral health knowledge, attitudes, and behaviour as a result
Content Validation of Draft Questionnaire
of DMP.
The draft questionnaire was checked for content validity
by 3 dental public health specialists. Content validity refers
MATERIALS AND METHODS to the adequacy of the measure to assess the domain of
interest, i.e. whether the items were relevant to the topics,
the concepts were culturally relevant and acceptable to
The HPQI was developed based on a standard protocol
society, and the items conformed to current scientific
developed by Acquadro et al in 2004 (12). It consisted of 3
knowledge (15). The applicability, efficiency, clarity, and
phases; development of the draft questionnaire, followed
sensitivity of the measure were also assessed (15).
by linguistic and psychometric validation.
Following content validity assessment, a separate
discussion with each of the 3 reviewers was held. The
Development of Draft Questionnaire
aim was to discuss issues related to content validation
The questionnaire was drafted in English for use by 11- including choosing the most appropriate items for each of
12 year old schoolchildren. Its content was based on the the domains. Unsuitable, confusing, or redundant items
DMP module (5), Oral Health Promotion Evaluation Tool were rephrased or removed. Following the discussions,
Kit (13) and the dental literature (14). First, a total of 7 changes to the draft questionnaire were made. The final
oral health knowledge (OHK) domains were identified questionnaire consisted of 33 items; 11 items, 15 items and
from the DMP module. These were dental caries and 7 items for OHK, OHA and OHB domains, respectively.
prevention, gum disease, fluoride, oral hygiene methods,
dental visit, benefits of good oral health, and oral health Translation of Draft Questionnaire from English into
effect of smoking. Next, for each OHK domain, at least Malay
one OHK outcome was identified from the DMP module.
This process is called linguistic validation and involved
For example, in dental caries and prevention domain, one
2 stages; a forward translation of the draft English
of the OHK outcomes was ‘sugar causes caries’. Based
 Development of a Health Programme Questionnaire Index 15

questionnaire into Malay and a back translation of the Data Analysis

draft Malay version into English (12). Initially, the 33 items of the drafted Malay questionnaire
The draft questionnaire was translated into Malay by were reverse scored where indicated. This enabled a
3 independent translators who were experts in dental public student with good oral health knowledge, attitudes, and
health and proficient in English and Malay language. behaviour to score highly on the scale. Next, the 33 items
Then, a meeting with the translators was held to analyse were factor analysed using principal component analysis
the translated documents paying attention to conceptual (PCA) to extract potential factors (17). The number of
and item equivalence between the drafted questionnaire factors was limited to 3 factors as there were 3 intended
and its Malay version. Conceptual equivalence refers to factors or dimensions in the questionnaire. Varimax
whether answers to the same questions reflect the same rotation method with Kaiser Normalization was used
concept. Item equivalence refers to whether equivalence for factor loading. The Kaiser-Meyer-Olkin (KMO) test
of meaning of the items is maintained throughout the was used to measure the sampling adequacy and Barlett’s
translation (16). Consequently, the group agreed on a test of Sphericity to test for sample adequacy and items
single consensus translation. correlation (18).
The draft Malay questionnaire was tested for Following factor analysis, each factor was analysed
face validation on a non-random sample of 40, 11–12 for internal and test-retest reliability. Internal reliability
year old schoolchildren from a school not involved in was assessed using Cronbach’s alpha coefficient (19) and
the final study. Data collection was conducted by the corrected item-total correlation. Test-retest reliability was
researcher (ZY) and assisted by the classroom teacher. assessed using intraclass correlation coefficient (ICC)
The time taken to answer the questionnaire was noted. using two-way random effects model and Kappa statistics
Following the test, a discussion with the schoolchildren (17).
was held to discuss their understanding on the purpose, Ethical approval was granted by Medical Ethics
content, wording, instruction, and general structure of the Committee, Faculty of Dentistry, University of Malaya.
questionnaire. Following the discussion, minor changes to Permission to conduct the study was granted by the
the questionnaire were made. Planning and Research Division, Ministry of Education,
The next step involved a back translation of the Malaysia, the respective schools, and parents of
draft Malay questionnaire into English. It was done by an schoolchildren.
expert translator from Department of Asian and European
Languages, University of Malaya who is proficient in
English and Malay language. Then, a thorough discussion
RESULTS
on the output of the back translation by experts in dental
public health and English and Malay language was held,
comparing the back translation with the original English The face and content validity of the questionnaire was
version. After minor modifications, the back translation verified by experts in dental public health. Its Malay
of the draft questionnaire was verified and agreed upon version was also verified to have attained the conceptual
by all parties involved. Small changes to the draft Malay and item equivalence with the English version. The face
questionnaire were made before it was finalised. validity of the Malay version was further verified by a
Psychometric Validation of Malay Questionnaire Draft
The Malay questionnaire draft was tested on a non-random
sample of 174, 11–12 year old (Year 6) schoolchildren Table 1. Factor analysis of the draft questionnaire showing
from 2 urban schools in Kuala Lumpur. The 2 schools item loadings into 3 factors (N=174)
represented a middle class and lower socioeconomic class
neighbourhoods. All Year 6 students were included. Dimension Factor 1 Factor 2 Factor 3
The questionnaire was administered in a classroom Oral health K1 – K7 K8 – K9
setting. The feasibility of administrating the instrument knowledge (0.414 – (0.315 –
under field conditions was also assessed. The same 0.579) 0.642)
K10 – K11
questionnaire was re-administered 1 week later on 35 of
(0.147 –
the 174 schoolchildren, representing 20.1% of the sample.
0.486)
Apart from content and face validity, psychometric
Oral health A1 – A5 A6 – A15
properties of the draft Malay questionnaire were tested by
attitudes (0.385 – (0.109 –
means of factor analysis, internal and test-retest reliability
0.588) 0.661)
analysis.
Oral health P1 – P7
behaviour (0.116 –
0.669)
16 ADUM, University of Malaya, V0l. 20 (1), 2013

Table 3. The Cronbach’s alpha, Intraclass Correlation coefficient and Kappa coefficient of the 15 items of OHA dimension

Cronbach’s
Corrected Item-
No. Item / Question Alpha if item
Total Correlation
deleted
Brushing teeth is important to me because...
A1 it prevents my teeth from decay 0.38 0.71
A2 it freshens my breath 0.34 0.72
A3 it prevents my teeth from becoming yellow 0.24 0.72
A4 it is part of the whole body cleanliness 0.37 0.71
A5 it makes my gums healthy 0.44 0.71
A6 it makes my parents happy 0.39 0.71
A7 it helps improve my appearance 0.41 0.70
A8 it makes my friends to like me 0.46 0.70
A9 it makes my dentist to like me 0.37 0.71
Sweet food and drinks...
A10 if taken too often can damage my teeth 0.45 0.70
A11 should not be sold at the school canteen 0.21 0.73
A12 should be avoided if possible 0.42 0.70
A13 is my choice almost all the time 0.23 0.73
A14 will not harm my teeth 0.31 0.72
A15 are common during growing up 0.29 0.73
Cronbach’s alpha = 0.73
Intraclass Correlation coefficient = 0.70
Kappa coefficient = 0.77

Table 2. The Cronbach’s alpha coefficient, Intraclass Correlation coefficient and Kappa coefficient of the 11 items of OHK
dimension

Corrected Cronbach’s
No. Item / Question Item-Total Alpha if item
Correlation deleted
K1 Eating too much sugary food can cause tooth decay 0.34 0.57
K2 A person can reduce the risk of tooth decay by reducing sugary food 0.32 0.58
every day
K3 Brushing my teeth with a fluoride toothpaste prevents tooth decay 0.24 0.59
K4 For adequate fluoride supply, I must brush my teeth at least twice a day 0.31 0.58
K5 Dental plaque can cause gum disease 0.40 0.56
K6 Gum disease can cause teeth to become loose 0.27 0.58
K7 Brushing my teeth properly improves the health of my gums 0.35 0.57
K8 Using dental floss to clean the areas between my teeth improves the 0.20 0.60
health of my gums
K9 Healthy teeth enhance my appearance 0.27 0.59
K10 A person should see a dentist for a dental check-up at least once a year 0.17 0.61
K11 Smoking is bad for oral health. 0.22 0.60
Cronbach’s alpha = 0.61
Intraclass Correlation coefficient = 0.72
Kappa coefficient = 0.70
 Development of a Health Programme Questionnaire Index 17

Table 4. The Cronbach’s alpha coefficient, Intraclass Correlation coefficient and Kappa coefficient of the seven items of OHB
dimension

Cronbach’s
Corrected Item-
No. Item / Question Alpha if item
Total Correlation
deleted
P1 How often do you brush your teeth? 0.45 0.58
P2 How often do you use toothpaste when brushing your teeth? 0.42 0.58
P3 How often do you rinse your mouth after meal? 0.22 0.64
P4 How often do you use dental floss to clean the areas between your 0.42 0.56
teeth?
P5 How often do you drink coca-cola or carbonated drinks with sugars? 0.53 0.52
P6 How often do you eat sweets/chocolates/ice cream? 0.36 0.59
P7 Do you smoke? 0.07 0.64
Cronbach’s alpha = 0.64
Intraclass Correlation coefficient = 0.78
Kappa coefficient = 0.73

group of schoolchildren. The questionnaire took 7-10 Table 3 shows the Cronbach’s alpha, ICC and
minutes to answer. The feasibility of the questionnaire Kappa coefficient of the 15 items of the OHA dimension.
administration under field condition was also verified. The corrected item-total correlation for all 15 items was
Factor analysis of the 33 items revealed 3 factors; positive with values ranging from 0.21 to 0.46. Eleven
Factor 1 = Oral health knowledge, Factor 2 = Oral health items had values above 0.3 and the rest between 0.2-0.3.
attitudes, and Factor 3 = Oral health behaviour (Table 1). The Cronbach’s alpha coefficient was 0.73 and the value
Most items which were originally developed for Factor did not increase if any of the items was deleted. The ICC
1 and 2 had loaded into both factors, respectively. Two was 0.70 and the Kappa coefficient was 0.77.
items which were developed for Factor 1 (K8 and K9) had Table 4 shows the Cronbach’s alpha, ICC and Kappa
loaded into Factor 2 while 5 items which were developed coefficient of the 7 items of OHB dimension. The corrected
for Factor 2 (A1-A5) had loaded into Factor 1. For Factor item-total correlation for the 7 items was positive with
3, all the 7 items had loaded into that factor. The 3 factors values ranging from 0.07 to 0.53. Five items had values
explained 28.3% of the total variance in the data. Item above 0.3, 1 item between 0.2 – 0.3, and 1 item below 0.1.
loading values ranged from 0.147-0.588 for Factor 1, The Cronbach’s alpha coefficient was 0.64 and the value
0.109-0.661 for Factor 2, and 0.116-0.669 for Factor 3. did not increase if any of the items was deleted. The ICC
The KMO value was 0.66. The Barlett’s test of Sphericity was 0.78 and the Kappa coefficient was 0.73.
was significant (p<0.001).
For internal and test-retest reliability analyses,
attempts were made to analyse each factor with its original DISCUSSION
items, i.e. Factor 1 with 11 items, Factor 2 with 15 items,
and Factor 3 with 7 items. This was despite 7 out of the 33 This study aimed to develop an index called the HPQI to
items had loaded unexpectedly into different factors. Table measure the DMP effect on schoolchildren’s oral health
2 shows the Cronbach’s alpha, ICC and Kappa coefficient knowledge, attitudes, and behaviour. It would be used
alongside a validated sociodental measure in a larger study
of the 11 items of the OHK dimension. The corrected
on DMP schools (20). The HPQI was developed based on
item-total correlation for all items was positive with
a standard protocol (12) with psychometric analysis (21).
values ranging from 0.17 to 0.40. Five items had values Overall, this study has shown that the HPQI was valid and
above 0.3 and 4 items between 0.2-0.3. The Cronbach’s reliable for use among 11-12 year old schoolchildren in
alpha coefficient was 0.61 and the value did not increase Malaysia. Its psychometric properties in terms of face and
if any of the items was deleted. The ICC was 0.72 and the content validity, and internal and test-retest reliability had
Kappa coefficient was 0.70. been successfully tested and empirically verified.
18 ADUM, University of Malaya, V0l. 20 (1), 2013

Overall, the HPQI contains 33 items. They were 0.2 or above, except for item K10 and P7 where the values
developed based on the DMP module and included a were 0.17 and 0.07, respectively. This indicates all items
spectrum of important oral health topics on dental caries, in OHA and most items in OHK and OHB dimensions
gum disease, fluoride, oral hygiene, self-esteem, dental correlated well with the total score in each dimension,
visit, and smoking habit. These topics are highly relevant respectively (17). Although items K10 (dental visit) and
to schoolchildren and are included in health talks by DM P7 (frequency of smoking) had values below 0.2, both
to their peers at school. items were deemed essential items to measure frequencies
The content and face validity of the English version of dental visits and smoking habit among the children.
and the linguistic validation to produce its Malay version Dental visit and smoking habit are part of the messages
were carried out in a systematic way by experts in English in the DMP oral health module and it was decided both
and Malay languages and dental public health. Any minor items should be included in the questionnaire. In terms of
disagreements were resolved through discussions. It was test-retest reliability, the questionnaire had been proven
confirmed that the Malay version attained equivalent to be reliable in yielding consistent scores at different
subject content and meaning to its English version and times. The ICC for OHK, OHA and OHB dimensions
upon back translation had closely similar wordings to the were excellent with values between 0.70-0.78. Likewise,
English version taking into account feedbacks received the Kappa coefficients were substantial to excellent with
during the pre-test (16). values between 0.70-0.77 (23).
In the factor analysis, 2 OHK items (K8-K9) and Apart from evaluating the impacts of DMP on
5 OHA items (A1-A5) were loaded into Factor 2 and schoolchildren’s levels of OHK, OHA, and OHB, the
1, respectively. It was noted that if items A1-A5 were index or its separate subscales may also be used as an
transferred into OHK dimension, this would result in too evaluation tool for any oral health intervention as the
many toothbrushing-related items. Likewise, inclusion of items are highly relevant to assess oral health education
items K8-K9 into OHA dimension would not fit well with and promotion outcome.
the toothbrushing and sweet food and drinks domains. This study had several limitations. Only literate
Furthermore, the subsequent internal reliability analyses students may answer the questionnaire satisfactorily.
were moderate. A detailed discussion with dental public Children with learning difficulties may need help in
health experts led to the suggestion that items K8-K9 understanding the questionnaire. Future studies should
and A1-A5 could remain in OHK and OHA subscales, address this limitation. Also, a few students needed help
respectively, if the items were reliable as a group to in the answering technique despite the written instruction.
measure the construct they were supposed to measure. It is recommended that a verbal instruction be given to
Thus, it was decided that the reliability analyses of OHK, students with the researcher present when administering
the questionnaire.
OHA and OHB dimensions were carried out with their
items remained in the respective dimensions. In the factor
analysis, the KMO value was 0.66 indicating the sample
CONCLUSION
size was adequate for factor analysis (18). The Barlett’s
test of Sphericity was significant indicating factor analysis The Health Promotion Questionnaire Index (HPQI) to
was appropriate for all items (17). measure the DMP impact on schoolchildren’s oral health
The internal and test-retest reliability analyses of the knowledge, attitudes, and behaviours has been successfully
3 factors showed satisfactory outcomes. The Cronbach’s developed and empirically verified to be valid and reliable
alpha coefficients for OHK, OHA, and OHB dimensions for use among 11-12 year old Malay schoolchildren in
were 0.61, 0.73 and 0.64, respectively, indicating the 3 Malaysia.
dimensions are reliable to constitute an index to measure
schoolchildren’s oral health knowledge, attitudes, and
behaviour in the Malaysian setting (22). The Cronbach’s ACKNOWLEDGEMENT
alpha coefficients did not increase if any of the items was
deleted indicating no item should be removed as the items The author would like to thank Dr Marhazlinda Jamaludin
were highly correlated and relevant in each dimension. for her technical advice on the statistics. The study was
The corrected item-total correlation values for all items in funded by the University Malaya Research Grant (No:
UMRG 319/11 HTM).
OHA and most items in OHK and OHB dimensions were
 Development of a Health Programme Questionnaire Index 19

REFERENCES 13. Watt R, Harnett R, Daly B, Fuller S, Kay E, Morgan

A, et al. Oral health promotion evaluation toolkit.
1. Evidence-based Medicine. Evidence based medicine. London, Stephen Hancocks Limited 2004.
JAMA 1992; 268: 2420-5.
14. Poutanen R, Lahti S, Hausen H. Oral health-related
2. Ewles L, Simnett I. Promoting health. A practical knowledge, attitudes, and beliefs among 11 to
guide, 1st ed. London, Bailliere Tindall 1999. 12-year-old Finnish schoolchildren with different
oral health behaviors. Acta Odontol Scand 2005;
63(1): 10-6.
3. Blinkhorn A. Evaluation and planning of oral health
promotion programmes. In: Schou L, Blinkhorn
A, eds. Oral health promotion. Oxford, Oxford 15. Watt RG, Harnett R, Daly B, Fuller SS, Kay E,
University Press 1993: pp 249-70. Morgan A, et al. Evaluating oral health promotion:
need for quality outcome measures. Community
Dent Oral Epidemiol 2006; 34(1): 11-7.
4. Ministry of Health. Kertas kerja program Doktor
Muda (The Junior Doctor Program - Working
Paper). Kuala Lumpur, Ministry of Health, Malaysia 16. Herdman M, Fox-Rushby J, Badia X. ‘Equivalence’
2004. and the translation and adaptation of health-related
quality of life questionnaires. Qual Life Res 1997;
6(3): 237-47.
5. Ministry of Health. Modul Latihan Kelab Doktor
Muda Sekolah Rendah, 3rd ed. Kuala Lumpur,
Ministry of Health Malaysia 2008. 17. Field A. Discovering statistics using SPSS, 3rd ed.
Dubai, Oriental Press 2009.

6. Ministry of Health. Annual report 2010. Putrajaya,

Ministry of Health Malaysia 2010. 18. Kaiser HF. An index of factorial simplicity.
Psychometrika 1974; 39: 31-6.

7. Health Promotion Unit. Doktor Muda programme

achievement in 2009. Negeri Sembilan, State Health 19. Cronbach LJ. Coefficient alpha and the internal
Department 2009. structure of tests. Psychometrika 1951; 16: 297-334.

8. Oral Health Division. National oral health plan 20. Yusof ZYM, Jaafar N. A Malay version of the Child
for Malaysia 2011-2020. Putrajaya, Ministry of Oral Impacts on Daily Performances (Child-OIDP)
Health Malaysia 2011. Contract No.: MOH/K. index: assessing validity and reliability. Health Qual
GIG/7.2011(BK). Life Outcomes 2012; 10(1): 63.

9. Oral Health Division Ministry of Health. National 21. DeVon HA, Block ME, Moyle-Wright P, Ernst
oral health survey of schoolchildren 2007: 12-year- DM, Hayden SJ, Lazzara DJ, et al. A Psychometric
olds. Putrajaya, Ministry of Health Malaysia 2010. Toolbox for Testing Validity and Reliability. J Nurs
Scholarsh 2007; 39(2): 155-64.

10. Oral Health Division. Annual report 2010. Putrajaya,

Ministry of Health 2010. 22. George D, Mallery P. SPSS for Windows step by
step: A simple guide and reference. 17.0 Update,
10th ed. Boston, Allyn & Bacon 2010.
11. Green LW, Kreuter MW. Health Programme
Planning: An Educational and Environmental
Approach, 4th ed. New York, McGraw-Hill 2005. 23. Fleiss JL, Levin B, Paik MC. The Measurement of
Interrater Agreement. Statistical Methods for Rates
and Proportions, John Wiley & Sons, Inc. 2004: pp
12. Acquadro C, Conway K, Giroudet C, Mear I. 598-626.
Linguistic validation manual for patient-reported
outcomes (PRO) instruments. Lyon, Mapi Research
Institute 2004.