453

Journal of Oral Science, Vol. 50, No. 4, 453-459, 2008

Original

Translation and validation of the Arabic version of

the Geriatric Oral Health Assessment Index (GOHAI)
Shaher Daradkeh1) and Yousef S. Khader2)
1)Ministry

of Health, Irbid, Jordan

and Medical Sciences Sector, Higher Council for Science and Technology,
Department of Community Medicine, Public Health and Family Medicine, Faculty of Medicine,
Jordan University of Science and Technology, Irbid, Jordan
2)Health

(Received 16 June and accepted 22 October 2008)

Abstract: Our aim was to translate the original

English version of the Geriatric Oral Health Assessment
Index (GOHAI) into Arabic and assess its validity and
reliability for use among people in North Jordan. After
translation into Arabic and back-translation to check
the translation quality, a total of 288 participants
completed the Arabic version of the GOHAI
questionnaire. Individual GOHAI items were recoded
and summed as originally recommended. The
questionnaire sought information about sociodemographic characteristics and self-reported
perception of general and oral health. Clinical
examination included assessment of periodontal status,
and number of decayed teeth, missing teeth, filled teeth
and crowned teeth. Reliability, internal consistency,
and concurrent, convergent and discriminant validity
of GOHAI scores were examined. Mean GOHAI score
was 40.9 (SD = 10.6, range: 12 to 60). Cronbachs alpha
for the GOHAI score was 0.88, indicating a high degree
of internal consistency and homogeneity between the
GOHAI items. The test-retest correlation coefficient for
add-GOHAI scores was 0.72, indicating good stability.
Add-GOHAI scores increased with poorer perceived
general and oral health. Convergent validity, construct
validity and discriminant validity of the GOHAI were
demonstrated. The Arabic translation of the GOHAI
Correspondence to Dr. Yousef S. Khader, Health and Medical
Sciences Sector, Higher Council for Science and Technology,
Department of Community Medicine, Public Health and Family
Medicine, Faculty of Medicine, Jordan University of Science and
Technology, Irbid 22110, Jordan
Tel: +962-795435025
Fax: +962-2-7201064
E-mail: yousef.k@excite.com

demonstrated acceptable validity and reliability when

used for people in North Jordan. It could therefore be
used as a valuable instrument for measuring oral
health-related quality of life for people in this region.
(J. Oral Sci. 50, 453-459, 2008)

Keywords: validity; reliability; oral health; quality

of life; Arabic; Jordan.

Introduction
Measures of oral health-related quality of life (OHQoL)
are essential for epidemiological and clinical studies in order
to provide accurate data for health promotion, disease
prevention programs and allocation of health resources (1).
Other uses of such measures were described by Fitzpatrick
et al. (1) and Slade and Spencer (2). Most of the OHQoL
instruments (2-6) that have been shown to have adequate
validity and reliability are based on three main dimensions:
physical symptoms, perception of well-being and functional
capacity. Among the most commonly used instruments is
the Geriatric Oral Health Assessment Index (GOHAI)
(3). This has been validated and widely used in North
America. Its internal consistency is satisfactory and its
concurrent and construct validity have been confirmed
(7). Swedish (8), Malay (9), Chinese (10) and French (11)
versions have shown acceptable reliability and validity.
However, none of the indicators of OHQoL have been
validated in Arabic for use among people in North Jordan.
It is important that an adopted instrument should be
culturally relevant and valid for the local population while
demonstrating acceptable psychometric properties (1214). It is therefore essential to carry out a rigorous translation
and validation process of the instrument when used in

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another population with a different culture. Therefore,

this study was conducted to translate the original English
version of the GOHAI into Arabic and validate it to
evaluate the impact of oral disease on the quality of life
of people in north Jordan

Methods

they were satisfied with their dental condition, their

assessment of their need for dental treatment, pain or
discomfort due to temporomandibular joint (TMJ)
disorders, burning mouth sensation, sensation of TMJ
clicking, and bad oral habits such as biting objects. Because
of the high illiteracy rate in North Badia, the questionnaire
was completed through personal interview.

Study population
A total of 300 consecutive people who had attended
North Badia Comprehensive Health Center for any reason
over a period of two months were invited to participate in
this study. After providing verbal consent to participate,
290 (96.7%) people were clinically examined. Two subjects
were excluded from the study because their questionnaire
answers were incomplete, leaving 288 to be included in
the analysis.

Translation and scoring of the GOHAI

The GOHAI was translated into Arabic by two dentists
who were fluent in both English and Arabic. The Arabic
draft was then back translated into English by another two
people fluent in both Arabic and English. The backtranslated version was compared with the original English
version to verify that the questions were properly translated.
All of the back-translated items were worded similarly to
the original ones and were comparable in their meaning.
The Arabic draft was then discussed by three dentists who
found that it would aid understanding to rephrase the
questions in the form of simple statements instead of
question format without changing their meaning. For
example, GOHAI item 1 How often do you limit the
kinds or amounts of food you eat because of problems with
your teeth or dentures? was restated as: Because of
problems with my teeth or dentures, I limit the kinds or
amounts of food I eat.
Individual GOHAI items were recoded and summed as
originally recommended. Two summary scores were
calculated. Add-GOHAI was calculated as the sum of
values of responses to the 12 items for each participant with
the resulting score ranging from 12-60. Simple count
score (SC-GOHAI) was calculated by counting the number
of GOHAI items with responses sometimes, often, or
always. Less than 5% of values were missing, and these
were replaced with the median of all values in the series.

Questionnaire
In addition to the 12 items of the GOHAI, the
questionnaire included socio-demographic characteristics
such as age, sex, educational level, marital status,
employment, and income. Subjects were also asked about
their perception of their general and oral health, whether

Clinical examination
The researchers assessed periodontal status and number
of decayed teeth, missing teeth, filled teeth, and crowned
teeth. Sterile dental mirrors and standardized periodontal
probes were used to measure probing pocket depth (PPD)
and clinical attachment level (CAL). PPD was measured
from the gingival margin to the bottom of the crevice to
the nearest millimeter (mm). If the cement-enamel junction
(CEJ) was exposed, CAL was measured by reading off the
distance from the CEJ or the margin of fixed restoration
to the base of the pocket. In other cases it was measured
indirectly by subtracting the distance from the gingival
margin to the CEJ from the pocket depth, with the tip of
the probe used to feel for the CEJ level. In both cases, CAL
was measured to the nearest mm.
PPD and CAL were measured at six sites (mesio-facial,
mid-facial, disto-facial, mesio-lingual, mid-lingual, and
disto-lingual) per tooth for all teeth, excluding third molars.
The number of decayed teeth, filled teeth, and missing teeth
for each participant were recorded. Periodontitis was
defined as presence of four or more teeth with PPD 4 mm
and CAL 3 mm at one site or more.

Reliability
Cronbachs alpha was calculated to assess the degree of
internal consistency and homogeneity between items (15).
Pearsons correlation coefficient was used to measure
item-scale correlation to assess the correlation between the
individual items and their scale score. To assess test-retest
reliability, 30 participants repeated the GOHAI one week
after the questionnaire was first administered. Test-retest
reliability was measured using Pearsons correlation
coefficient for individual items and for the overall GOHAI
score.

Validity
Concurrent validity was investigated by examining the
degree to which the GOHAI scores were related to the
scores of four self-reported items: general health, oral
health, need for dental care, and satisfaction with oral
health status. We assessed the ability of the GOHAI to
distinguish between groups of people with different
responses to these self-reported items, which it should

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theoretically be able to do. Convergent validity was

evaluated by examining the association between GOHAI
scores and objective assessment of oral and dental status
(number of missing teeth, number of decayed teeth, and
the presence or absence of periodontal disease) and selfreported symptoms with hypothesized effects on oral
health-related quality of life: TMJ pain, burning mouth
sensation, and bad breath). It was predicted that subjects
who did not have one of such symptoms would have better
oral health-related quality of life and thus higher GOHAI
scores compared with subjects who had that symptom
(11,16). Discriminant validity was evaluated by examining
the association between GOHAI scores and self-reported
bad oral habits that were hypothesized not to be notably
associated with oral health-related quality of life (16) and
thus to have no effect on GOHAI scores.

Table 1 Socio-demographic and important characteristics of

participants

Statistical analysis
Statistical Package for Social Sciences (SPSS, version
11.5) software was used to analyze data. Frequency
distributions were produced. Means and standard deviations
of the dependent variables (Add-GOHAI and SC-GOHAI
scores) were estimated and compared among different
groups of the study population using a t-test or one-way
ANOVA as appropriate. Pearsons correlation coefficient
was used to measure item-scale correlations. Responses
to the 12-item questionnaire were subjected to factor
analysis using squared multiple correlations as prior
communality estimates. The principal components method
of factor extraction and varimax method of factor rotation
were used in factor analysis. A P-value of less than 0.05
was considered statistically significant.

Results
Participants characteristics
A total of 288 participants (155 men and 133 women)
agreed to participate and completed the GOHAI
questionnaire. Their socio-demographic characteristics
are shown in Table 1. Their mean age ( SD) was 33.4 (
13.2) years. A total of 134 (48.6%) respondents were 30
years of age or younger and 184 (63.9%) were married.
Monthly income was 160 JD or less (1 $ = 0.7 JD) for 106
(50.7%) respondents, and only 44 (15.3%) had attained
more than high school education. More than two thirds of
participants (70.7%) reported that they visited the dentist
only when they had pain and 118 (42.6%) reported that
they brushed their teeth once or more per day.

Self-perceived general and oral health

Table 2 shows the distribution of respondents according
to different self-reported ratings of health. Seventy-one

(24.8%) respondents reported that they had excellent

general health and 95 (33.2%) reported that they had very
good general health. Only 11.5% of the participants
reported that they had excellent oral health and 18.1%
perceived their oral health as being very good. Three
quarters of the subjects perceived themselves as needing
dental treatment. Only 36.9% of participants were satisfied
with their oral health status.

Oral health
Oral health examination showed that 65.6% of subjects
had at least one decayed tooth, 61.8% had at least one
missing tooth, 49.0% had one or more filled teeth, and
16.3% had one or more crowned teeth. Periodontal disease
was present in 33.3% of the subjects.

Acceptability of and responses to the Arabic

version of the GOHAI
The frequency of missing responses for GOHAI items
ranged from 0.1% to 3.8%.Using the add scoring method,
only one subject had a minimum score of 12, indicating
the greatest possible impact from oral conditions, and 9

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Table 2 Distribution of participants according to self-reported

health-related ratings

(3.1%) subjects had the maximum score of 60 indicating

no impact. When the SC scoring method was used, 21
(7.3%) subjects had a score of zero and 11 (3.8%) subjects
had the maximum score of 12. The most common negative
impact (sometimes, often, or always) was sensitivity of teeth
or gums to hot, cold, or sweets.
Mean GOHAI score was 40.9 (SD = 10.6, range: 12 to
60). The mean number of negative impacts (sometimes,
often, or always) was 6.1 (SD = 3.5, range: 0 to12).

Factor analysis, reliability, and validity

Only one component was extracted. The factor loadings
ranged from 0.51 to 0.78 for all items except for item 5.
Cronbachs alpha for the GOHAI was 0.88, indicating a
high degree of internal consistency and homogeneity

between the GOHAI items. The item-scale correlation

coefficients ranged from 0.53 to 0.77 for all items except
item 5, which had a correlation coefficient of 0.27. The
mean values of the individual GOHAI items were close
to each other. Test-retest correlation coefficients ranged
from 0.41 to 0.75 for all individual items except item 5,
which had a test-retest coefficient of 0.01. The test-retest
correlation for the total add-GOHAI score was 0.72
indicating good stability.
Concurrent validity for the GOHAI was evaluated by
examining the correlation between self-perceived general
and oral health status and the two GOHAI summary scores
(Table 3). Add-GOHAI scores increased with poorer
perceived general and oral health. As self-reported general
and oral health decreased, SC score (number of negative
impacts) increased, indicating poorer health and oral
health-related quality of life. Furthermore, people who
perceived themselves as needing dental care or those who
were not satisfied with their oral health status had a
significantly lower mean GOHAI and higher mean SCGOHAI scores, indicating poorer oral health-related quality
of life.
As predicted, lower add-GOHAI scores were associated
with self-reported TMJ pain, burning mouth sensation, and
bad breath, a finding that supports convergent validity
(Table 4). Participants who had one or more missing or
decayed teeth had lower add-GOHAI scores than those who
had no missing or decayed teeth. Those with periodontal
disease had lower add-GOHAI scores than those without
periodontal disease (P < 0.005), supporting construct
validity of the add-GOHAI.
Discriminant validity was evaluated by examining the
association between GOHAI scores and self-reported bad
oral habits which were hypothesized not to be notably
associated with oral health-related quality of life and thus
have no effect on the GOHAI scores. Table 5 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. Results were as expected.
Respondents who were older than 30 and those with a low
level of education had lower add-GOHAI and higher SCGOHAI scores. GOHAI discriminated between the subjects
according to tooth brushing; those who regularly brushed
their teeth had higher add-GOHAI scores than others
(Table 6).

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Table 3 Concurrent validity: Correlation between self-reported general and

oral health and the Geriatric Oral Health Assessment Index (GOHAI)
scores

Table 4 Convergent validity: Differences in the average of the Geriatric Oral Health
Assessment Index (GOHAI) scores (Add-GOHAI and SC-GOHAI) according to
self-reported responses to different health-related questions and objective assessment
of oral health

Table 5 Discriminant validity: Differences in the average of the Geriatric Oral

Health Assessment Index (GOHAI) scores (Add-GOHAI and SC-GOHAI)
according to variables that have no predicted effect on oral health related
quality of life

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Table 6 Association between variables with predicted effect on oral health-related quality
of life and the GOHAI score

Discussion
This study examined the validity and reliability of the
GOHAI Arabic version in a selected group of people in
north Jordan. The GOHAI, which was originally developed
and tested in well-educated, elderly Americans (3) has also
been demonstrated suitable in younger, poorly educated
populations.
When used among Jordanian people, the Arabic version
of the GOHAI showed acceptable validity and reliability.
However, it was noticeable that the proportion of subjects
reporting discomfort when eating anything (Q5) was lower
than that reporting other problems. This item was also
atypical in other ways. It had a low item-scale correlation
and was poorly correlated with other items. The most
likely explanation is that this item was one of three items
worded in a positive direction while the remaining items
were worded in a negative direction, which might have
caused a misunderstanding. The three positively worded
items had the lowest item-scale correlations.
Factor analysis extracted only one component. Factor
loadings ranged from 0.51 to 0.78 for all items except for
item 5, suggesting that the Arabic version of GOHAI
demonstrated good internal consistency. Cronbachs alpha
coefficient (0.88) was comparable to that obtained from
the French version (0.86) (12) and higher than those for
versions of the GOHAI in other languages, which varied
from 0.74 to 0.81 (3,8-10,17). Item-scale correlations
varied from 0.27 to 0.77 in the Arabic version, compared
with 0.28 to 0.61 in the Chinese version (10) and 0.40 to
0.78 in the French version (11).
When 30 subjects retook the questionnaire one week after
it was first administered, the test-retest correlation
coefficient between the add-GOHAI scores was 0.72. This
finding was similar to that reported for the Malay version
(0.72) (9) and lower than that reported for the French
version (0.87) (11).

Self-rating of oral health was poor and perception of need

for dental treatment was very high, indicating a substantial
negative impact of oral conditions among this population.
The low socio-economic status of this population may
explain the relatively large negative impact of oral
conditions on functioning and well-being.
Concurrent validity of the Arabic GOHAI version was
comparable to that of the original English GOHAI version
(3). The analysis demonstrated the expected associations
between the GOHAI score and the reported oral and
general health status, perceived need for dental treatment,
and self satisfaction with oral health. Lower add-GOHAI
scores were associated with poorer perceived oral and
general health, need for dental care, and low satisfaction
with oral health.
Regarding convergent validity, this study supported
others (2) in showing that people with TMJ pain, burning
mouth sensation, or self reported bad breath had lower addGOHAI scores than those who did not have these
symptoms. Bad oral habits did not have any significant
effect on the GOHAI score. However, education and
employment were important factors influencing the GOHAI
score, as reported previously (7,17).
This study found significant relationships between the
GOHAI and certain clinical measures including number
of missing teeth, number of decayed teeth, and periodontal
status. However, associations between the GOHAI score
and the number of filled or crowned teeth were not
significant. Missing and decayed teeth affect eating,
esthetics, and speech, and dental decay may cause pain and
discomfort. Periodontal diseases cause tooth mobility,
tooth loss, limiting the ability to eat comfortably and
resulting in esthetic and speech problems. On the other
hand, fillings and crowns are designed to restore as much
of the lost function and esthetics as possible, accounting
for the fact that those with filled and crowned teeth did

459

not score significantly worse on the GOHAI than others.

In conclusion, the Arabic translation of the GOHAI
demonstrated acceptable validity and reliability when used
for people in north Jordan. It could therefore be a valuable
instrument for measuring oral health-related quality of
life for people in this region. Further research is needed
to examine the stability of the GOHAI over different
periods of time and to examine it as a tool to evaluate dental
treatment outcomes in the Jordanian population.

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