A Health Belief Model-Based Instrument for Assessing Factors Affecting Oral Health Behavior During Pregnancy


Hoda Bahramian 1 , Simin Zahra Mohebbi 1 , * , Mohammad Reza Khami 1 , Shirin Shahbazi Sighaldeh 2

1 Research Center for Caries Prevention (RCCP), Dental Research Institute, Department of Community Oral Health,‎ School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran

2 Department of Reproductive Health, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran

How to Cite: Bahramian H, Mohebbi S Z, Khami M R, Shahbazi Sighaldeh S. A Health Belief Model-Based Instrument for Assessing Factors Affecting Oral Health Behavior During Pregnancy, Iran Red Crescent Med J. 2017 ; 19(8):e58266. doi: 10.5812/ircmj.58266.


Iranian Red Crescent Medical Journal: 19 (8); e58266
Published Online: July 26, 2017
Article Type: Research Article
Received: December 25, 2016
Revised: February 14, 2017
Accepted: March 5, 2017




Background: Maintaining optimal oral health behavior (OHB) during pregnancy could preserve short-term and long-term health of women and their children.

Objectives: By applying the health belief model (HBM), this study aimed at developing and analyzing ‎the psychometric properties of an instrument ‎evaluating pregnant women's beliefs ‎regarding OHB.

Methods: In this instrument development study that carried out in Tehran (2015 - 2016), a preliminary 134-item questionnaire was developed, and ‎content and face validity were assessed. The construct, convergent, discriminant, and ‎criterion-oriented validity of the questionnaire were evaluated through a pilot study ‎on 221 pregnant women, attending public health centers, by performing ‎confirmatory factor analysis (CFA) and Linear Regression analysis. Cronbach’s alpha coefficient, composite reliability (CR) and intra-class correlation coefficient (ICC) were calculated to examine reliability. ‎

Results: The mean age of participants was 27.5 ± 5.6 years with mean gestational age ‎‎of 21.5 ± 8.5 ‎weeks. Based on CFA, the data fitted the HBM model. Root Mean Square Error of Approximation ‎ (RMSEA) was ‎‎0.052, Non-Normed Fit Index (NNFI) was 0.95, and Comparative Fit Index (CFI) was 0.96. The final HBM-based questionnaire with 79 items was associated with individual OHB‎ (P = 0.001 and B =‎ 0.4‎). The overall Cronbach’s alpha was 0.94 and ICC ranged between 0.84 and 0.99.

Conclusions: This valid and reliable HBM-‎based questionnaire may identify the potential ‎barriers of ‎ optimal OHB among pregnant women. ‎


Pregnant Women Oral Health Questionnaire Psychometric Factor Analysis

Copyright © 2017, Iranian Red Crescent Medical Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Background

Pregnant women are susceptible to oral health problems, and their beliefs may hinder receiving dental care and maintaining good oral hygiene (1-3). Poor oral health in pregnant women has shown associations with the risk of adverse pregnancy outcomes (4, 5), and increases the chance of dental caries in their children (6).

Pregnant women’s regular tooth brushing and dental attendances are reported to be undesirable worldwide (7-9). In Iran, less than half of women visit dentists during their pregnancy (10, 11). Unawareness about the pivotal role of good OHB during pregnancy leads to ignorance of oral health (12). One of the best-known models that can predict health-related behaviors is the health belief model (HBM) (13).

According to HBM, understanding health beliefs is a prerequisite for improving health behaviors (14). Available studies, however, have used selected questions of previously validated general oral health questionnaires for assessing beliefs of pregnant women without taking advantage of a particular instrument or behavior change model (9, 12, 15, 16). The only standard questionnaire that has already been developed to assess pregnant women's beliefs regarding OHB, have shortcomings such as lack of assessing convergent, discriminant, and ‎criterion-oriented validity (17). Since the women play a critical role in establishing proper health behaviors in their families, understanding their own OHB and its determinants is of great value. Therefore, applying HBM, this study aimed at developing and analyzing the psychometric properties of a specific instrument that measures factors affecting pregnant women's OHB.

2. Methods

This instrument development study was carried out in ‎Tehran, Iran (January 2015 to August 2016) with mixed method design in two phases of qualitative and quantitative assessment: ‎

2.1. Qualitative Phase

The instrument’s items were extracted from qualitative data of 22 pregnant women, 12 dentists, and 8 midwives involved in prenatal care at public health centers (unpublished data). Accordingly, the first version of the questionnaire was developed with 134 questions around the 6 constructs of the HBM (see Table 1).

Table 1. Major Themes and Subthemes of Factors Influencing Oral Health Behavior Among Pregnant women, Extracted from Secondary Analysis of Qualitative Data and Literature Review
Major ThemesSubthemes
Perceived sensitivityDental caries
Periodontal diseases
Dental visit need
Perceived severityMaternal health complications
Infantile health complications
Perceived barriersLack of knowledge and misbeliefs
Cost of dental care
Physiological changes
Fear and other psychological conditions
Time constraint
Dentists’ unwillingness to treat pregnant women
cultural taboos
lack of intersectoral collaboration
Perceived benefitsPhysical
Self-efficacyOral hygiene practices
Nutrition and diet
Regular dental service utilization
Cues to actionExternal

2.2. Content and Face Validity

First, the expert panel of 10 community oral health specialists, 1 reproductive health specialist and 1 epidemiologist evaluated the questionnaire for wording, grammatical points, and allocation of items in constructs. The mean age of this expert panel was 40.3 years old with at least 5 years of academic experiences, and 58% were female. Content validity ratio (CVR) values below 0.56 were removed. The threshold of the Content validity index (CVI) ‎for keeping the items was 0.7 or more (18).

For qualitative face validity, 10 pregnant women assessed the clarity of each item and the impact score was calculated (minimum 1.5) in the quantitative approach‎ (19).

2.3. Quantitative Phase

2.3.1. The Cross Sectional Study and Data Collection

With a multi-stage cluster sampling, the instrument was distributed to pregnant women attending public health centers (all governmental) in Tehran from January to March, 2016. Firstly, Tehran city was divided to 4 geographical regions and from each, 3 health centers were selected by simple random sampling. The sampling frame was the list of public health centers located in the aforementioned regions that were under ‎supervision of 3 main universities of Shahid Beheshti, Tehran, and Iran ‎University of Medical Sciences. The minimum sample size of 204 pregnant women was calculated by the following equation:

Equation 1.

“n” was the sample size, “p” prevalence of desirable oral health beliefs in pregnant women in the pilot study (0.15), “q” = (1 - p), “α” = (0.05), and “d” was the standard error (0.05). To achieve a statistical power of 80% and considering 25% attrition, it was planned to recruit a sample of 252 pregnant women. Inclusion criteria were age of 18 or more, gestational age of least 8 weeks. Four pregnant women were excluded for having a history of systemic diseases.‎

The version of the questionnaire used in this part of the study, contained 89 items measuring 6 constructs of HBM as follows:

Perceived sensitivity or “Sn1-14” (14 items), perceived severity or “Sv1-8” (8 items), perceived barriers or “Br1-34” (34 items), perceived benefits or “Bn1-8” (8 items), self-efficacy or “Sf1-8” (8 items), and cues to action or “Cu1-17” (17 items).

Except dichotomous scoring of perceived benefit, all other items were scored on a Likert scale of 1 to 5, from strongly disagree to strongly agree. Reverse scoring was applied for negative items and for perceived barrier construct. For perceived benefit, dichotomous values were recoded as 1 and 5, in order to have similar weights with other constructs. Finally, sum of the variables of the HBM was calculated. In addition, demographics including age, education, income, gestational age by weeks, parity, height, and weight were also recorded. The OHB of the participants was explored by questions about frequency of tooth brushing, flossing, using toothpaste, eating sugary junk foods, smoking, visiting the dentist before and during pregnancy, and the visit reasons. Possible answers to the questions were scored from 0 to 3, and were summed to develop individual OHB scores.

2.4. Construct Validity

To assess construct validity, confirmatory factor analysis ‎(CFA), convergent, and discriminate validity were performed (20). Fit indices including ratio of Chi-square to degrees of freedom (X2/DF), root mean square error of approximation (RMSEA), comparative fit index (CFI), and non-normed fit index (NNFI) were used. The values of at least 0.90 for CFI and NNFI, and below 0.05 for RMSEA indicated good fit (< 0.08 acceptable) (20, 21).

2.5. Convergent, divergent and Criterion-oriented validity

Methods to assess convergent validity were: Standardized estimates equal to or higher than 0.5, average variance extracted (AVE) of 0.5 or higher, and CR of 0.7 or higher (20).

The AVE for 2 constructs should exceed their maximum shared variance (MSV) and average shared variance ‎(ASV)‎ for having discriminant validity (22). Criterion-oriented validity was explored by examining the association between total HBM ‎and individual OHB score controlling for demographics.

2.6. Reliability

Cronbach’s alpha coefficient and composite reliability (CR) were ‎calculated for testing ‎internal consistency of the questionnaire with threshold of 0.7 (20). Cronbach’s alpha calculation prior to CFA revealed omission of some items to increase the scale reliability. After performing CFA, internal consistency was re-evaluated (20). Intra-class correlation coefficient (ICC) with acceptable value of at least 0.5 was calculated in a sub-sample of pregnant women (n = 30), who completed the questionnaire twice with an interval of 2 weeks.

2.7. Statistical Analysis

The CFA, convergent, and discriminant validity were performed by means of Amos SPSS version-24 (IBM Corporation, Chicago, USA) software, and Mahalanobis distance command in Amos served to detect multiple outliers. ‎The assumption test included tests of Normality, skewness, kurtosis and ‎Histogram, and Normal Q- Q Plot indicated normal distribution of the data. The IBM SPSS statistics version-24 was used to perform descriptive, chi-square, independent t test, linear regression analyses, and Cronbach’s Alpha. P values of < 0.05 were considered significant.

2.8. Ethics

This study was approved by the research ethics committee of Tehran University of Medical Sciences (code of IR.TUMS.REC.1394.855) during September 2015. All participants provided an informed written consent with the right to withdraw at any time. In the first part of the questionnaire, there was a paragraph introducing the study aim and assuring confidentiality of data by anonymous questionnaires.

3. Results

3.1. Extracted Items from Qualitative Phase, Content, and Face Validity

From 606 codes obtained from qualitative data, 311, which were most relevant, were selected for an item pool. Similar codes were merged for the 134-item questionnaire. Following the content validity, 45 items were removed, while in face validity assessment, only minor changes were applied to the 3 items. Eventually, the pre-final questionnaire consisting of 89 items was formed for assessing construct validity.

3.2. Collected Data for Construct Validity

Among all, the data of 221 women were analyzed, and 31 were excluded because of incomplete questionnaires, missing or outliers in data. The demographic variables of excluded cases, showed no difference in the remaining sample (P > 0.05). The age of the participants was on average 27.5 ± 5.6 years. About half of the women had diploma or academic education (52%). Most of them (80%) reported their income as poor or medium. The mean gestational age of pregnant women was 21.5 ± 8.5 weeks. The mean height and weight of participants before pregnancy were 161.1 ± 5.8 centimeters and 62.4 ± 10.9 kilograms. Among all, 55% had normal BMI and 41% experienced their first pregnancy (See Table 2).

Table 2. Socio-Demographic Characteristics of the Study Participants (N = 221)
Age group
< 3062
≥ 3038
Under diploma48
Academic education14
Under weight6
Normal weight55
Over weight30

3.3. Primary Internal Consistency

Cronbach’s Alpha ‎(> 0.7)‎ indicated acceptable internal consistency of multiple items for each construct. However, it was predicted that omission of 7 items would increase Cronbach’s Alpha: 2 items in perceived sensitivity (Sn6, Sn8), 1 in perceived severity (Sv5), 2 in perceived barriers (Br8, Br14), and 2 items in self-efficacy construct (Sf2, Sf8). These items were deleted and the remaining 82-item questionnaire was then analyzed by CFA to determine a model with appropriate fitness.

3.4. Construct Validity

At first, the measurement model did not fit the data. Overall, 3 items (2 items in perceived sensitivity (Sn9, Sn10) and 1 item in perceived barriers construct (Br29) showed loading factors of < 0.5. Therefore, they were omitted to form the final 79-item questionnaire. Moreover, some correlations between the variables’ errors of the same factor were added to the model based on the modification indices. After the modifications, the model fitted the data (Figure 1).

Figure 1. The Final Pattern of 79-Item Questionnaire Following Confirmatory Factor Analysis of 221 Pregnant Women Data Fitted the Health Belief Model and Its Constructs. Standardized Coefficients Were Illustrated on the Arrows
The Final Pattern of 79-Item Questionnaire Following Confirmatory Factor Analysis of 221 Pregnant Women Data Fitted the Health Belief Model and Its Constructs. Standardized Coefficients Were Illustrated on the Arrows

Error variances (e1 - e79) were ranged between 0.006 and 1.335. Sn, Sensitivity; Sv, Severity; Br, Barriers; Bn, Benefits; Sf, Self-Efficacy; Cu, Cues to Action.

X2/DF was 1.6 (P > 0.05), CFI was 0.96, NNFI was 0.95, and Root Mean Square Error of Approximation was 0.052 (90% CI 0.049 to 0.055) (Table 3). Also Table 4 represents the estimate coefficients.

Table 3. Model Fit Indices in Confirmatory ‎Factor ‎Analysis of Total HBM Model and its Constructs Before and After Applying Modifications in a Pilot Study on Iranian Pregnant Women (N = 221)
ConstructModificationΧ2/DFCFINNFIRMSEA90% CI for RMSEAP Value
Perceived sensitivityBefore1.990.870.820.0670.043 - 0.0910.113
After1.950.980.970.0660.041 - 0.0900.138
Perceived severityBefore2.270.900.840.0760.039 - 0.1130.109
After2.390.980.970.080.044 - 0.1160.08
Perceived barriersBefore2.060.670.640.070.063 - 0.076< 0.05
After2.410.900.900.080.074 - 0.86< 0.05
Perceived benefitsBefore1.710.950.930.0570.020 - 0.0880.334
After2.960.920.900.0940.067 - 0.123< 0.05
Cues to actionBefore2.170.870.840.0730.061 - 0.0850.002
After2.580.940.930.0850.073 - 0.097< 0.05
Self - efficacyBefore2.950.950.890.0940.049 - 0.143< 0.05
After0.92110.000 - 0.0790.782
Total HBM ModelBefore1.960.560.540.0560.054 - 0.059< 0.05
After1.60.960.950.0520.049 - 0.055< 0.05

Abbreviations: CFI, Comparative Fit Index; NNFI, Non-Normed Fit Index; RMSEA, Root Mean Square Error of Approximation; X2/DF, Relative Chi-square.

All the estimate coefficients were significant (P < 0.001) and were more than 0.50 (Table 4). Moreover, the AVE of all constructs exceeded 0.5, and CRs of each construct was also larger than 0.7, suggesting convergent validity (See Table 5). The AVEs of all constructs were greater than their MSV and ASV, suggesting discriminant validity (Table 5).

Table 4. ‎Estimated ‎Coefficients of the ‎Final ‎Confirmatory ‎Factor ‎Analysis ‎Model on ‎Data From ‎a Pilot ‎Study on ‎Iranian ‎Pregnant Women ‎‎(N = 221)a
ConstructsItemsUnstandardized EstimateStandard ErrorStandardized Estimate
Perceived sensitivitySn110.735
Perceived severitySv110.750
Perceived barriersBr110.715
Perceived benefitsBn110.763
Cues to actionCu110.757

Abbreviations: Bn, Benefits; Br, Barriers; Cu, Cues to action; Sf, Self-efficacy; Sn, Sensitivity, Sv, Severity.

aAll estimated ‎coefficients ‎for latent constructs were significant (P < 0.001).

Table 5. Convergent and Discriminant Validity and Reliability Indices of the Health Belief Model Constructs in a Pilot Study on Iranian Pregnant Women (N = 221)
HBM ConstructsCRAVEMSVASVCronbach’s Alpha CoefficientICC
Perceived sensitivity0.9410.6150.1070.0460.940.97
Perceived severity0.9430.7040.0990.0680.940.97
Perceived barriers0.9750.5600.0210.0130.980.96
Perceived benefits0.9220.6030.1070.0520.920.99
Cues to action0.9640.6100.0550.0260.960.98

Abbreviations: ASV, Average Shared Variance; AVE, Average Variance Extracted; CR, Composite Reliability; ICC, Intra Class Correlation Coefficient; MSV, Maximum Shared Variance.

Total HBM-based questionnaire score was significantly associated with individual OHB (standardized coefficient Beta was 0.4 and P = 0.001), controlling for age, education, income, gestational age, and parity by linear regression analysis, suggesting criterion-oriented validity.

3.5. Final Internal Consistency and Instrument’s Stability

Cronbach’s alphas computed after CFA ranged between 0.92 and 0.98 for each construct and 0.94 for total HBM. The CR of constructs ranged from 0.92 to 0.97. The ICCs of the questionnaire items ranged between 0.84 and 0.99, and ICC of the constructs between 0.93 and 0.99, indicating that the questionnaire had a good internal consistency and stability (Table 5).

The final 79-item questionnaire consisted of the following constructs with their possible score ranges:

1. Perceived sensitivity (10 items, 10 to 50), 2. Perceived severity (7 items, 7 to 35), 3. Perceived barriers (31 items, 31 to 155), 4. Perceived benefits (8 items, 8 to 40), 5. Cues to action (17 items, 17 to 85), and 6. Self-efficacy (6 items, 6 to 30).

The Total ‎HBM ‎score of the questionnaire could range from 79 to 395. Scores of 79 to 111 were considered as floor and 363 to 395 as ceiling of answers. No ceiling and floor effects existed‎, as less than 10% ‎of ‎patients scored less than 111 or more than 363 (23).

4. Discussion

This study developed a standard HBM-based instrument for assessing factors associated with OHB during pregnancy, as HBM is one of the effective models to predict oral health (14). Several studies have shown the relationship between HBM dimensions and general or oral health behavior (24-26). Health belief model-based health education programs can promote oral health performance in pregnant women (27); therefore developing a standard means to assess their current beliefs is crucial. In agreement with Solhi et al., the OHB of participants were affected by their individual perceptions (24) and the ability of HBM factors in our questionnaire to predict participants’ OHB was good.

To the best of the authors’ knowledge, this is the first study worldwide that has provided a standardized scale to assess HBM-based factors influencing OHB during pregnancy attempting to correlate the questionnaire score with OHB by performing criterion-oriented validity. This aspect was less noticed in similar studies even in other health scopes. Previously, another questionnaire, measuring oral health beliefs of Iranian pregnant women, was psychometrically evaluated that lacked a comprehensive approach in the qualitative phase and therefore according to our appraisal, the content and face validity were compromising. Moreover, its construct validity was performed by EFA instead of CFA, and convergent, discriminant, and criterion-oriented validities were not performed (17).

5.1. Strengths and Limitations

Data collection using triangulation approach, criterion-oriented, convergent, and discriminant validity assessments were among strengths of this study. However, certain limitations warrant further investigation considering factors other than beliefs, which might contribute to preventing oral health among pregnant women. In addition, mostly low-income pregnant women were considered in this study, as participants were selected form public centers, thus the study is limited in generalizability to all pregnant women. The illiteracy of some of the participants, difficulty in collecting data from usually impatient pregnant women, and low co-operation of some health centers were the study limitations. The sensitivity and specificity of the questionnaire should be evaluated in future diagnostic researches on pregnant women's oral health.

5.2. Conclusion

The present HBM-based valid and reliable questionnaire can be used in future investigations to identify barriers of optimal OHB for pregnant women, and to plan interventions that improve oral health of these vulnerable individuals.



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