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Original Article
Assessment of Validity and Reliability of Hindi Version of Geriatric
Oral Health Assessment Index (GOHAI) in Indian Population
Romi Jain1, Roshni Dupare1, Rajeev Chitguppi2, Puttaswamy Basavaraj3
1
Lecturer, 2Professor, Department of Public Health Dentistry, Terna Dental College, Navi Mumbai, Maharashtra, 3Lecturer, Department of
Public Health Dentistry, Government Dental College, Goa, India
Abstract
Objective: The objective of this study was to translate the Geriatric Oral Health Assessment Index (GOHAI) into the
Hindi language and assess its validity and reliability for use among people in India. Materials and Methods: GOHAI
was translated into the Hindi language and self-administered to 420 subjects aged 55 years or above. The measures for
reliability, and concurrent, convergent, and discriminant validity were assessed. The questionnaire sought information
about sociodemographic details, habits related to tobacco, dental visits, tooth brushing, and self-reported perceptions of
general and oral health. Results: Cronbach’s alpha (0.774) showed high internal consistency and homogeneity between
items. Low GOHAI scores were associated with the perceptions of poor oral and general health, low satisfaction with
oral health, and a perceived need for dental care. Respondents with high socioeconomic status were likely to have
high GOHAI scores. Conclusion: The Hindi version of the GOHAI demonstrated acceptable validity and reliability,
and will be an important instrument to measure oral health-related quality of life (OHRQoL) for people in this region.
Keywords: Geriatric oral health assessment index (GOHAI), oral health-related quality of life (OHRQoL), reliability, validity
Introduction
Oral health has traditionally been defined in term of
disease and illness. The contemporary definition of oral
health rejects the notion that health is equivalent to the
absence of physical disease.1 The use of only clinical
indicators for oral health status and treatment-needs
evaluation is recognized to have serious limitations.2
Currently, conceptual models of oral health are focused
on a psychosocial perspective, qualitative measurements,
and the incorporation of the patient’s point of view.
Perception of oral health depends upon the subject’s
understanding of what normal oral health is and of the
Corresponding Author: Dr. Romi Jain, C-503, Intop Heights,
Sector 22, Airoli - 400 708, Navi Mumbai, Maharashtra, India.
E-mail: jain.romi215@yahoo.com
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specific symptoms he/she may have experienced, the
cultural values, past experiences with the health care
system, general health, and psychosocial well-being.3
Self-reported measures of the impacts of oral conditions
(generic health status and disease-specific) on quality
of life have increased in number rapidly in the medical
literature. Specific measures of oral health-related quality
of life (OHRQoL) are likely to be more sensitive than
generic health status measures because oral health is
perceived as a distinct dimension of overall quality of
life.4
A variety of OHRQoL instruments have been developed
during the past 20 years. Frequently used questionnaires
This is an open access article distributed under the terms of the
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DOI: 10.4103/0019-557X.169654
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Cite this article as: Jain R, Dupare R, Chitguppi R, Basavaraj P. Assessment
of validity and reliability of Hindi version of geriatric oral health assessment
index (GOHAI) in Indian population. Indian J Public Health 2015;59:272-8.
© 2015 Indian Journal of Public Health | Published by Wolters Kluwer - Medknow
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Jain, et al.: Assessment of validity and reliability of GOHAI
include the Oral Health Impact Profile (OHIP),5 the Oral
Impacts on Daily Performance (OIDP),6 and the wellestablished Geriatric Oral Health Assessment Index
(GOHAI).7 The use of these indicators represents one of
the most detailed methods for the measurement of oral
health impact on quality of life.8 They have been used
in many international cross-sectional and longitudinal
studies, as well as in comparative studies in different
countries, allowing valid comparisons of the concerns
of the population about their oral health status, when
evaluated both objectively and subjectively and based
on standardized criteria.9
The GOHAI7 was developed by Atchinson and Dolan
in 1990 and used in North America for elderly patients.
Its reliability (internal consistency) was satisfactory,
and all hypotheses designed to assess construct and
concurrent validity were confirmed in Swedish,10 Malay,11
Arabic,12 and German13 studies. The GOHAI is fairly
compact, having only 12 items. The GOHAI was initially
designed to assess the oral health of older adults but has
been recently used in the African-American population
of all ages in the USA.8 The GOHAI is an index that
incorporates different dimensions of oral health, and
it avoids problems connected with weighing, which
introduces complications and subjectivity.14
Before introducing an index such as GOHAI in a different
population with different culture, it is essential to carry out
a rigorous translation and validation process.15 Transferring
such indicators from one country to another presents
problems at two levels. Direct translations may present
linguistic problems because some words and phrases
have no direct translation and questions conceived in the
context of one language may not be understood in the same
way in the other language. Further, languages exist within
social and cultural frameworks that are frequently unique
and some questions may therefore become different or
meaningless in a different culture and location.16
For all these reasons, it was decided to develop a Hindi
version of GOHAI for use in the Indian population. The
aim of this study was to test its validity and reliability.
Materials and Methods
Study population
A total of 500 people aged 55 years or more, who attended
Terna Dental College, over a period of 4 months (from
November 2013 to February 2014) were invited to
273
participate in the study. Terna Dental College is a private
dental college, located in the urban area of Nerul, Navi
Mumbai, Maharashtra. The sample size was based on the
literature available, which mentions that in assessing the
reliability and validity of an index or scale, the minimum
necessary sample size for coefficient alpha is commonly
suggested as 300, or sometimes 500. The general view on
this subject is that the sample coefficient alpha obtained
from larger samples tends to produce a more accurate
estimate of the population coefficient alpha.17 Thus we
decided to recruit 500 subjects for this study. Eighty
subjects were excluded from the study because their
questionnaire was incomplete, leaving 420 subjects to
be included in the final analysis.
Ethical considerations
Ethical clearance was obtained from the Institutional
Review Board and verbal consent was obtained from the
participants. The questionnaire forms on which information
was recorded were identified by numbers, not names.
Questionnaire
The data were collected through a self-administered
questionnaire. The questionnaire included
sociodemographic characteristics such as age, gender,
educational level, occupation, and income. The
Kuppuswamy scale modified for 2012 was used to
calculate socioeconomic status.18 Information was also
collected regarding the use of tobacco products, visits to
the dentist, and tooth-brushing habits. Subjects were also
asked about the perception of their general and oral health,
whether they were satisfied with their dental condition,
their assessment of the need of the dental treatment, pain
or discomfort due to temperomandibular joint (TMJ)
disorders, burning mouth sensation, the sensation of TMJ
clicking, and bad oral habits such as biting objects.
GOHAI
The 12 items of the GOHAI assessed the dimensions of
physical functions (eating, speaking, and swallowing),
psychosocial functions (worry or concern about oral
health, dissatisfaction with appearance, self-consciousness
about oral health, avoidance of social contact because of
oral problems), and pain or discomfort (use of medication
to relieve pain, oral discomfort). Subjects were asked if
they have always, often, sometimes, seldom, or never
experienced any of those problems in the previous
3 months. Questions were worded sometimes in positive
and sometimes in negative directions, to require the
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Jain, et al.: Assessment of validity and reliability of GOHAI
respondents to consider their answers. Reponses were
rated on a five-point Likert scale. When the data were
transferred to the computer, the responses were recoded
so that the responses indicating good conditions and no
problems carried the highest scores. Thus, the scale score
was such that a low value indicated an oral health problem.
A summary score (Add-GOHAI) ranging 12-60 was
calculated for each subject, and a simple count score (SC
GOHAI) was calculated by counting the number of items
with responses “sometimes,” “often,” or “always,” which
shows the negative impact of oral health conditions on
quality of life. In the GOHAI questionnaire, questions 3, 5,
and 7 are worded positively so that “sometimes,” “often,”
and “always” show positivity or satisfaction toward oral
health condition. As we were measuring negative impact,
we needed to reverse the score for these three questions.
Add-GOHAI and SC GOHAI scores were used to assess
the concurrent, convergent, and discriminant validity of
the scale by comparing it with different variables.
The process of adapting the GOHAI index for the elderly
into a Hindi version and evaluating its psychometric
properties involved three main steps: Translation of the
English version into Hindi, a pilot study, and a main study
for validity and reliability testing.19
Translation process and pilot study
Reliability
Cronbach’s alpha was calculated to assess the degree
of internal consistency and homogeneity between the
items.20,21 For test-retest reliability, 50 participants
repeated the GOHAI after 1 week. Spearman’s
correlation coefficient was used to measure the
test-retest reliability and to measure inter-item and
item-scale correlation.
Validity
Concurrent validity assessed the degree to which GOHAI
scores were related to the following self-reported items:
General health, oral health, need for dental care, and
satisfaction with oral health status. An attempt was made
to assess the ability of GOHAI to distinguish between
groups of people with different responses to these selfreported items. Convergent validity was evaluated by
assessing the association between GOHAI score and the
objective assessment of oral health status (number of
missing teeth, decayed teeth), and self-reported symptoms
such as TMJ pain, burning mouth sensation, and bad
breath, which have hypothesized effects on OHRQoL.
Discriminant validity was evaluated by examining the
association between GOHAI score and self-reported bad
oral habits that were hypothesised not to be associated
with OHRQoL.21,22
The GOHAI was translated into Hindi by two dentists
who were fluent in both English and Hindi. The Hindi
draft was then back-translated into English by two other
people who were also fluent in English and Hindi. The
back-translated version was then compared with the
original English version to verify if the questions were
properly translated.19 All of the back-translated items
were worded similarly to the original ones and were
comparable in their meaning. The final Hindi version
was then pilot-tested on a sample of 50 subjects, after
which further minor language modifications were made.
Statistical Package for the Social Sciences (SPSS version
17 Inc., Chicago, IL, USA) was used to analyze the
data. Frequency distributions were produced. Medians,
mean, and standard deviations (SDs) of the dependent
variables (Add-GOHAI and SC GOHAI scores) were
estimated and compared among different groups using
the Mann-Whitney U test or the Kruskal-Wallis test as
appropriate. Spearman’s correlation coefficient was
used to measure item-scale correlation. A P value of
<0.05 was considered statistically significant.
Clinical examination
Results
The researcher assessed the number of decayed, missing,
filled, and crowned teeth. The examination was done
using World Health Organization (WHO) criteria.20 All
the oral examinations were performed on the same day
that the questionnaire was administered.
Data analysis
The general approach involved was assessment of
the reliability of GOHAI measures and assessment of
concurrent, convergent, and discriminant validity.
Participants’ characteristics
The total sample consisted of 420 participants, among
whom 257 (61.2%) were males and 163 (38.8%) were
females. The participants’ ages ranged 55-84 years.
Around 45% of the study population belonged to the
upper lower socioeconomic class. Only 1.7% of the
participants reported that they had excellent oral health,
while more than half of the subjects perceived themselves
to be in need of dental treatment.
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Jain, et al.: Assessment of validity and reliability of GOHAI
Reliability
For assessing data on the reliability of the Hindi version
of GOHAI, Cronbach’s alpha (0.77) showed a high
degree of internal consistency and homogeneity between
items. Inter-item and item-scale correlations varied
between 0.740 and 0.811. Test-retest reliability was
assessed by repeating the administrations of GOHAI to
50 participants. For the 12 items, the weighted kappa
coefficient varied from 0.49 to 0.80, with a Spearman
correlation coefficient of 0.82 between two successive
GOHAI scores.
Validity
Concurrent validity was evaluated by examining the
correlation between self-perceived general and oral
health status and two GOHAI summary scores [Table 1].
Add-GOHAI scores decreased with poorer perceived
general and oral health. As self-reported general and
Table 1: Concurrent validity: Correlation between self-reported
general and oral health and the geriatric oral health assessment
index (GOHAI) scores
Item
Spearman correlation coefficient
Add-GOHAI
SC GOHAI
−0.20
0.21
−0.76
0.77
Self-perceived general health
1=Excellent, 2=Very good,
3=Good, 4=Fair, 5=Poor
Self-perceived oral health
1=Excellent, 2=Very good,
3=Good, 4=Fair, 5=Poor
275
oral health decreased, SC scores (number of negative
impacts) increased, indicating poor health and OHRQoL.
Furthermore, people who perceived themselves as
needing dental care and those who were not satisfied
with their oral health status had significantly lower mean
Add-GOHAI scores and higher SC GOHAI scores,
indicating poorer OHRQoL.
Convergent validity
Lower Add-GOHAI scores were associated with selfreported TMJ pain, burning mouth sensation, and bad
breath, a finding that supports convergent validity
[Table 2]. Participants who had one or more missing or
decayed teeth had lower Add-GOHAI scores than those
who had no missing or decayed teeth.
Discriminant validity
It was evaluated by examining the association between
GOHAI scores and self-reported bad oral habits, which
were hypothesized not to be notably associated with
OHRQoL and thus have no effect on the GOHAI scores.
Table 3 shows that there was no statistically significant
difference in GOHAI scores between those who reported
bad oral habits and those who did not. Moreover, GOHAI
could not discriminate between participants according to
the number of filled or crowned teeth.
GOHAI scores were also studied among groups known
to have different levels of health. Those belonging
Table 2: Convergent validity: Difference in the mean scores of GOHAI (Add-GOHAI and SC GOHAI) according to different health-related
questions and objective assessment of oral health
Item
n
Add-GOHAI Mean ± SD (median)
P value
SC GOHAI Mean ± SD (median)
P value
44.18±6.3 (46.3)
42.29±8.5 (44.2)
0.04
5.00±2.3 (4.5)
5.71±2.84 (5)
0.162
42.53±8.5 (41.2)
41.69±7.4 (43.1)
0.222
5.59±2.8 (6)
6.11±2.6 (5.7)
0.138
41.64±8.6 (45.2)
41.10±9.0 (44.2)
43.77±6.5 (42.1)
44.17±7.4 (46.1)
0.009
6.17±2.8 (5.9)
5.42±2.6 (4.8)
5.9±2.9 (5.6)
4.97±2.5 (5)
0.002
43.40±7.9 (45.2)
40.70±8.9 (46.2)
0.001
5.3±2.6 (4.8)
6.29±2.9 (5.9)
0.002
41.43±9.7 (45.2)
42.93±7.6 (46.3)
0.001
5.91±3.0 (5.4)
5.54±2.6 (5.3)
0.017
41.24±8.4 (43.6)
43.26±8.2 (47.2)
0.007
5.99±2.8 (5.5)
5.42±2.7 (5.2)
0.032
Self-reported TMJ pain
No
392
Yes
28
Self-reported burning mouth sensation
No
365
Yes
55
Self-reported bad breatha
Often
26
Sometimes
154
Rarely
100
Never
140
Self-reported satisfaction
Yes
153
No
267
Missing teeth
>1
285
0
135
Decayed teeth
>1
245
0
175
Mann–Whitney U test, aKruskal–Wallis test, significant at P < 0.05
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276
to low socioeconomic status had significantly lower
Add-GOHAI and higher SC GOHAI scores. GOHAI
discriminated between the subjects according to tooth
brushing and visits to the dentist. Those who regularly
brushed their teeth and visited a dentist had higher AddGOHAI scores than others [Table 4].
Discussion
This study examined the validity and reliability of the
Hindi version of GOHAI in a selected group of people
in Mumbai, Maharashtra. The GOHAI, which was
originally developed and tested among well-educated,
elderly Americans,7 has also been demonstrated to be
suitable for geriatric poorly educated populations. 8
Hindi is official language of the Union Government
of the Republic of India. The population of Mumbai is
multiethnic; hence, language use varies not only across
different areas but also among the different ethnic groups.
Due to the cultural diversity, there was much deliberation
over the best way to express the GOHAI items in Hindi.
This necessitated pretests of the translations.
Problems of validity stemming from cultural or language
differences appear to be more complex, and populations
with different cultural backgrounds may respond
differently to the same GOHAI items. Thus, it is important
that the GOHAI be tested in diverse populations in terms
of culture, language, and geography. In this study, the first
step consisted of using a standardized translation process.19
Translation and back-translation were conducted to ensure
the accuracy and interpretability of the questions. This
allowed the creation of a Hindi version that exhibited
satisfactory psychometric properties.
As did Locker et al.,23 we found that GOHAI was
very successful at detecting oral disorders, with a few
participants having a very high score of 55-57. This is
because GOHAI places great emphasis on functional
limitations and pain or discomfort, which are more
immediate and more common outcomes of oral disorders
in the elderly population.
The item measuring problems with the ability to swallow
comfortably was originally developed to measure the
Table 3: Discriminate validity: Difference in the mean scores of GOHAI (Add-GOHAI and SC GOHAI) according to variables that have no
predicted effect on OHRQoL
Item
Self-reported bad oral habit
No
Yes
Filled teeth
>1
0
Crowned teeth
0
>1
n
Add-GOHAI Mean ± SD (Median)
P value
SC-GOHAI Mean ± SD (Median)
P value
343
77
42.41±8.6 (44.3)
42.44±7.1 (44.3)
0.508
5.72±2.8 (5.1)
5.38±2.4 (4.9)
0.423
197
223
42.44±8.1 (42.1)
42.40±8.6 (42.2)
0.717
5.64±2.7 (5.1)
5.68±2.8 (5.2)
0.696
324
96
42.06±8.3 (42.1)
43.63±8.4 (43.1)
0.645
5.86±2.8 (5.5)
4.99±2.7 (4.8)
0.588
Mann-Whitney U test, Significant at P < 0.05
Table 4: Association between the variables with predicted effect on OHRQoL and GOHAI scores
Item
Socioeconomic status
Upper class
Upper-middle class
Lower-middle class
Upper-lower class
Lower class
Tooth brushing
>1 per day
Not regular
Never
Visit to dentist
Regular
Occasional
Only in problem
n
Add-GOHAI Mean ± SD (Median)
P value
SC GOHAI Mean ± SD (Median)
P value
9
117
79
191
24
46.67±4.2 (45.9)
44.3±6.4 (43.9)
43.28±8.3 (43.1)
41.25±8.9 (41)
38.17±10.3 (38.1)
0.001
4.0±1.5 (4)
5.45±2.2 (5.1)
5.41±2.8 (5.2)
5.84±3.0 (5.6)
6.71±3.3 (6.4)
0.075
267
140
13
42.64±8.6 (43.1)
42.14±7.6 (42.6)
40.92±11.8 (41.2)
0.691
5.47±2.8 (5.2)
5.94±2.7 (5.8)
6.54±3.1 (6.3)
0.150
49
111
260
43.63±8.5 (42.9)
41.07±9.5 (40.9)
42.67±7.7 (41.8)
0.170
5.24±2.7 (5.1)
6.02±2.9 (6.1)
5.58±2.7 (5.2)
0.231
Kruskal–Wallis test, Significant at P < 0.05
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Jain, et al.: Assessment of validity and reliability of GOHAI
problems that people with xerostomia might encounter.
Xerostomia is more common in older adults, which is
evident in this study from the fact that a higher proportion
of the study population reported having difficulty in
swallowing. Similar results were not obtained in a study
done in France among 18-45-year-old individuals.16 This
might be due to the younger age group involved in this
study.
Socioeconomic data suggest that more than half of the
sample belonged to the upper lower class. Self-rating of
oral health was particularly poor and perception of dental
care needs was high, indicating a substantial negative
impact of oral conditions. This is in accordance with
previous findings showing that populations with lower
socioeconomic status experienced a greater negative
impact of oral conditions on functioning and well-being.24
The perception of oral health and the level of acceptance
of oral conditions may vary according to the country and
the socioeconomic status, irrespective of the objective
dental status.12,25
The results showed that the Hindi version of GOHAI
exhibits satisfactory psychometric properties. The
analysis reported that the Hindi GOHAI demonstrates
good internal consistency. The Cronbach’s alpha
coefficient was similar to the values obtained in previous
surveys.7,23-25 Results concerning stability indicated
good reproducibility concerning the global score of
GOHAI (Spearman correlation coefficient r = 0.82), as
in the Chinese version where 47 elderly persons were
interviewed after 1 week.16,25 Calabrese et al.26 obtained a
lower score (r = 0.61) from 23 older adults. In this study,
subjects filled in the GOHAI administered by a dentist for
the first time and 8 weeks later by a physician. A longer
period between the two administrations and a change in
way the questionnaire was administered between the two
sections might explain this lower correlation coefficient.
The concurrent validity of the Hindi version of the GOHAI
was comparable to that of the original English version.7
Analysis demonstrated the expected associations between
the GOHAI scores and the reported oral and general
health status, perceived need for dental treatment, and selfsatisfaction with oral health. The lower Add-GOHAI scores
were associated with poor perceived oral and general health,
need for dental care, and low satisfaction with oral health.
Regarding convergent validity, this study supported
others5,12 in showing that people with TMJ pain, burning
277
mouth sensation, self-reported bad breath had lower
Add-GOHAI scores than those who did not have these
symptoms. Bad oral habits did not have any significant
effect on the GOHAI scores. However, socioeconomic
status was another factor that influenced the GOHAI
scores.12,27,28
This study found a significant relationship between the
GOHAI and certain clinical measures, including numbers
of decayed and missing teeth. However, associations
between the GOHAI scores and the number of filled or
crowned teeth were not significant. Missing and decayed
teeth affect eating, esthetics, and speech, and cause pain
and discomfort. On the other hand, fillings and crowns
are designed to restore as much of the lost functions and
esthetics as possible, accounting for the fact that those
with filled or crowned teeth did not score significantly
worse on the GOHAI than on others.
Conclusion
In conclusion, the Hindi translation of the GOHAI
demonstrated acceptable validity and reliability when used
for people in Mumbai, India. It could therefore be a valuable
instrument for measuring ORHQoL for people in this region.
Further research is needed to determine the stability of
GOHAI over different time periods and to examine it as a tool
to evaluate dental treatment outcomes in Indian populations.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Indian Journal of Public Health, Volume 59, Issue 4, October-December, 2015