Ciininninity Dem Oral Epidemiol I99.<: 21: I4K .

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Communify Dentistryand Oral Epidemiology

tSSN ().MIt-566l

Cross validation of a Brazilianversion of fhe Dental Fear Survey

Jose Cesar',Antonio Bento A, de Moraes^,Peter Milgrom^ andRonald A, Kleinknecht"'Department of Psychology, MethodistUniversity of Piracicaba. SP. 'School of Dentistryof Piracicaba. State University of Campinas,SP-Brazil; ^Department of Dental Public HealthSciences. University of Washington. Seaffle.WA. ""Department of Psychology. WesternWashington University. Bellingham, WA, USA

Cesar .1, dc Moracs ABA, Milgrom P, Kleinknecht RA: Cross validation ol" aBrazilian version of the Dental Fear Sttrvcy. Community Dent Oral Epidemiol 1993;21; 148 50. (r, Munksgaard, 1993

Abstract - The Dental Fear Survey (DFS), a paper and pencil instriimenl forassessing dental fear and avoidance, has been widely used and validated in fearstudies in the US. However, before such instruments are used in countries andcultures dissimilar to the one in which it was developed, they should be cross-validated in Ihat culture. The present study is an examination of the DFS responsecharacteristics in a group of 374 Brazilian university students. Factor analysis of theDFS revealed three factors essentially identical to those found ainong universitystudents in the US and in Sitigapore, as well as among US adult dental patients.Fliglier DFS scores were significantly associated longer intervals since last dentalvisit. These results are taken as evidence thai Ihe DFS performs in this Braziliansample very tnuch as it does in other samples; and is thus, a valid indicator ofdental Tear al least among Brazilian university students.

Key words; cross-cultural comparison; dentalcare; fear; dental anxiety; personality tests;Brazil

Peter Milgrom, DDS, Department of DentalPublic Health Sciences, SM-35, University ofWashington. Seattle, WA 98195, USA

Accepted for publication 12 August 1992

Fear of denial treatment continues lo bea signiiicant barrier lo the optimalutilization/provision ofdental health ser-vices. This fear-tnotivatcci avoidance ofdentistry is now well documented withinNorth America (1), as well as in numer-ous countries aroutid the world includingSingapore (2), United Kingdotn (3), andSweden (4).

Efforts to amclioralc the Fear and re-duce its adverse effects on patienls arc inpart dependent upoti proper identifica-tion and diagnosis of dental fear cases.One instrument widely used in denial set-tings to assess denial fear is the DenialFear Survey (DFS) (5). Although thisscale has been validated in numerousstudies in Ihc US (6, 7), before being used

in countries and cultures different fromthe one on which it was originally devel-oped, this scale must be cross-validatedoti the specific population addrcs.sed.This cross validation is essential to ensutethai the constructs assessed by this scalein its nalivc population are also found inthe culture into which it is being intro-duced. Thai is, one can nol assume thatthe scale performs similarly in diversecultures with different customs, values,and systems o("detilal care delivery.

Recently MILGR(»I and colleaguescross-validalcd the DFS in two diversesamples of Singaporeans (2). In ihalsludy results suggested Ihat the DFS per-formed very similarly to how it did inthe US. The present sludy is a further

examination of the robustness of theDFS as applied in a sample of Brazilianuniversity students.

Methods and materialsSample

The subjects were a convenience sampleof 51 men and 323 women undergraduatepsychology students enrolled in theMethodist University of Piracicaba in thestate of Sao Paulo, Brazil. Women areover-represented in this sample wilh re-spect to the Brazil population. The meanage of the students was 23.2 yr (SD =4.6 yr). The students who completed ihestudy represent 374 of 449 (83'y;i) under-graduate psychology students at the Uni-

Dctititl fear iti Brctzil 149

versity. The students come from the Bra-zilian social middle class with patetitshaving professional occupations and Ihcstudents having studied in private sec-ondary schools. Nearly 15% ol" Ihc slu-dents had been lo Ihe denlist within ei-ther 6 months (181, 48.5%) or I yr (96,25.7%). The remaining students had seena dentist within 2 yr (29. 7.8'/-o), 3 yr (9,2.4%), or longer than 3 yr (58, 15.5%).The treatment at the last visit was asfollows;

Treattnetit tt

Examination, preventive 86 23.0'> iRestorative ireatmenl 193 51.6%Extraction, endodonties &relief ol" pain 62 16.6%Other treatment 33 8.8'y;,

When more than one treatment was re-ported, only the tnost complex wascoded.

Table 1. Factor loadines for totaled Dl-S factor tnatri.x

Ucni stem

Pttt off making appointmentCaticelled/failed lo appear

Arousal during treattnenl;Muscle tensenessIncrease btcathitig tatcPerspiration increaseNauseaHeart rate increase

Fear of stitiiuli;Making an appoinlmenlApproaching dental ofiiceSitting in waiting roomSitting in denial chairStnell of dental officeSeeing the denlisiSecitig ancstiietic needleFeeling anesthetic needleSeeing the drillHearing the drillL'celing the drillHaving teeth cleanedOverall fear of dentistty

Faclor I l-actor II Faclor 111

0.3080.131

0.4790.3700.3890.0690.339

0.1610.3040.4100..S260.537O..'^270.7020.7510.8200.805O.SI 10.4220.604

0.6640.471

0.2460.2580.2110.1910.312

0.7950.8000.7050.6270.4870.5770.2S40.1950.3180.3180.2290.1650.497

0.2530.493

0.6030.6970.5690.7370.682

0.2020.2460.3000.3410.2830.2430.2930.2620.2030.1580.2220.2940.3S6

Eigenvalues 4.348 3.444

Survey Instrumentation

The DFS is a 20-ilem Likert-like ques-tionnaire thai uses representative five-point ratings ofdental avoidance, soma-tovisceral arousal during dental treat-ment, and the amount of fear evokedby various stimuli associated with dentaltreatment. There is a final summary itemthai asks; "All things considered, howfearful of dentistry are you?'" The DFShas been validated and cross-validated indiverse samples within the US (7), andSoutheast Asia (1). For the present study,the questionnaire was translated intoBrazilian Portuguese by a bilingual na-tive speaker and then back-translated,pretested, and revised.

Data Analysis

In order lo examine the validity of theD F S in Brazilian, two approaches weretaken. The results were subjected lo fac-tor analysis to determine whether ihcconstructs demonstrated in other lan-guage forms of the DFS were found inthis form. In addition, the DFS scoreswere examined in relalion lo ihe limitigof the last visit to the dentist and previoustreatment. The hypothesis was thai high-er DFS scores would be associated withlonger intervals since a dental visit andmore painful, invasive treatment at thelast visit. Statistical analyses were con-ducted using SAS 5.18 excepting that the

reliability analysis was conducted usingSPSS 4.1.

Results

The DFS mean was 40.7 (SD = 15.0).Our previous work has shown ihal DFSscores exceeding 60 are indicative of highdental fear. In the present sample, greaterihan \1>% had scores in this range. DFSscores did not differ by gender (maleM = 43.9 (SD = 14.3); female M = 40.2(SD = 15.1), P> .Q5) but did differ byage, with older students reported higherDFS scores (r = 0.136, F<.01). The in-ternal consistency was estimated usingcoefficient alpha = 0.95.

Faclor structure

Using a principal components factormethod with varimax rolalion, the factoranalysis yielded ihrcc factors with eigen-values exceeding one. Item steins withtheir respective factor loadings are shownin Table I. These tlitec rotated factorsexplained 66.3'y.iof scale variance. FaclorI. accounting for some 27.3% of Ihe scalevariance, is defined by items pertainingto fear elicited by proximity lo specificdental stimuli such as "feeling injeclionof anesthetic."" Factor II. accounting for21.7% of scale variance, is defined byitems in which subjects reporl having

avoided denial Ircalment and fear gencr-aled by their proximity lo sitch treat-mctii. Faclor HI. accounling for 17.3"''not scale variance, pcrUiins lo specificphysiological reactions while undergoingdenial Itcatmctit such as perspiration andincreased heart rale.

Relalionship DFS scores to utilization

Trcalmenl at the lasl denial visit wascharacterized as primarily non-invasive(examination, preventive) or invasive (re-storative, extraclioti, endodonlics, reliefol" pain or olhcr trealment) by combinitigthe categories of previous treatmcni rc-ported earlier in the paper. When cat-egory of previous ireatmenl was dividedinto primarily non-itivasive versus inva-sive care, the DFS scores for the non-invasive cate group were slightly lowerthan those for the invasive care group(M = 38.8 versus 41.7); F = 2.87. 1,372.P = .09). Preplanned posl-hoc l-lcsts re-vealed Ihal the subgroup thai receivedendodontic care or cate for relief ol" painhad Ihe highest score (M -= 43.6) whichwas significantly different from the gt ottpthai received noti-invasivc services(/'<.O5) bul nol different from ihc sub-group that last received reslorafive care.

When DFS scores were examined inrelalion to the liming ol" ihe lasl visit loihc dcnlisl, Ihc tesults were as follows:

150 CESAR I;T .\I..

Titne since last visit tt DFS titcitn

Within 6 months 181 39.4Within 1 yr 96 41.2I 3yr 38 47.7Over 3 yr 58 39.6

Differences among the groups were ex-amined with a one-way ANOVA and re-vealed a significant difference (I- = 3.36,df 3,369, 7 = 0.019). Posl-hoc t-lestsshowed that the differences between the6-inonth group and the I-3-yr group andbetween the within 1-yr group and theI 3-yr group are significant {P<.05).There was no difference between the 6-monlh and l-yr interval (P>.05). Asomewhat larger pioportion of the long-term avoidcrs versus the other subjectsreported extractions and endodontieswith lower proportions receiving restor-alive care (/-•<.05).

Discussion

Reports of denial fear among Universitystudents in this Brazilian satnple seemclearly to parallel in many ways reportsof students and older adults from olhcrcountries and cultures. The factor struc-ture of the DF"S based on responses ofthese 374 Brazilian students is virtuallyidenlical to that found for students inthe US (7) and in Singapore (2). Thissimilarity suggests Brazilian students in-terpret the questions relative their dentalcxperietices as do subjects in the othercultures studies. Further, this suggeststhat the DFS is a valid instrument forassessing dctilal fear in this culture.

Further supportive evidence of the va-

lidity of the DFS in this sample is thefinding thai higher scores were associatedwilh longer intervals between dctilal vis-its. This finding of higher reported fearbeing associated wilh greater avoidanceis also cotisislent with results of our studyof Singaporean sludcnls (8).

A final piece of dala obtained herethat supports the validity of the DFS asa dental fear as.sessmenl instrument isthat subjects whose last dental visit in-volved more invasive, and assumedlytnore painful and fear provoking Ireat-ment, reported greater fear than thosewhose prior visits were prophylactic innature. A great deal of evidence existsdocumenting ihat much ofdental fear isgenerated by painful dental experiences(5, 7). There are, of course, other factorsthat contribute to dental fear, whichprobably vary according to the intensityof the fear experienced.

Thus, in most ways the DFS operatesin this Brazilian sample of students asit does in olhcr cultures. However, onedifference is worthy of note. In this sam-ple no differences were found betweenmales and fetnales. In most studies ol"reported fears, including denial fear, fe-males reliably reporl greater fear thanmales (1,7). Why there was no differencehere is unclear. We do not know if thislack of difference is due to an artifact ofthe study and its sample such as the factthat there were relatively few males inthe sample, or whether this lack of genderdifference is more characteristic of thebroader Brazilian culture. Nonetheless,ihc other results in this study are consis-tent with the literature and suggest thaithe DFS can serve as a vahd instrument

to further examine such factors in futurestudies.

The DFS appears to operate amongthis Brazilian sample, very much as itdoes among college sludenls in Singa-pore and among sludenls and olderadults in the US. The consistent factorstructure and that higher scores were as-sociated wilh greater dental avoidanceserve to support the generalizibilily ofthis instrument to Brazilian students andperhaps, to the larger population as well.Other studies are being conducted to rep-licate and extend these findings.

References

1. Mn.GROM P. 1-tSHT L. Mt l.NlfK S.Wi;iNSti:iN p. The ptevalctice and practicemanagement consequences of dental tearin a major U.S. city. JADA 1988; 116:641 7.

2. Mit.ciKOM P, Ki.t;tNKNiit ttf RA. Ui.rtoi rJ. Ltu H-H, Tt;o C-S. A cross-culturalcross validation of the Denial Fear Surveyin Soulh East Asia. Behav Res Ther 1990;28: 227 33.

3. WARDLJ: J. Fear ol" dentistry. Br J MedPsyehol 1982; 55: 119 26.

4. l-lAKliBHRG M. BliRGGRtiN U. CARLSSONSG. Prevalence of denial anxiety in anadult population in a tnajor urban area inSweden. Cotntnunity Detit Oral Epidetniol1992; 20: 97 101.

5. Ki.i:iNKNECiiT RA. Kuii'AC RK. ALEXAN-DLR LD. Origins and eharacleristics ofdental fear. JADA 1973; 86: 842 8.

6. Kt.tnNKNiiCiir RA, BiiRNsititN DA. Theassesstnent ol" dental fear. Behav Ther1978; 9: 626-34.

7. Ki.i;iNi;NiiCMT RA. MCOLYNN F D .TiioRNDiKi; R. HARKAVY .1. Factor anal-ysis of the Dental l-"car Survey with crossvalidation. JADA 1984; 108: 59 61.

8. Tt;o CS. FooNG "W. Lut HH, "VK;Nt:nsAH, F.Li.iot I J, Mti.GROM P. Ptevalence ofdental fear in young adult Singaporeans.Itit Dent J 1990; 40: 37 42.