Development and validation of a structured questionnaire to assess the Knowledge, Attitude and Practice (KAP) regarding the effect of yoga on periodontal health among Indian adults.

Ethical approval and consent

Ethical approval was obtained from the Institutional Review Board of Kasturba Medical College (KMC) and the Kasturba Hospital Institutional Ethics Committee (IEC-841/2020, obtained on 6th February 2021) which is the Institutional Ethics Committee of Manipal Academy of Higher Education. Informed consent was obtained from all participants via electronic mode using the Google form. The first page of the Google form gave information about the study and obtained consent from the participants following which they were able to move to the subsequent pages containing the questions. The participants were completely anonymized and delinked.

Research design and study population

This questionnaire study was conducted between February 2021 and May 2022 among Indian adults. Ethical clearance was obtained for the study from the institutional ethical committee. The study was a pilot study designed to determine the psychometric properties of the KAP questionnaire. The content validation of the questionnaire was performed by five exponents in the field of yoga and health care. Following content validation, the reliability of the questionnaire was tested. The questionnaire was subsequently distributed as a Google form to collect data for assessment of additional psychometric properties to develop a validated and reliable questionnaire.

Sample size and sampling method

Sample size was determined based on the rule of thumb that states that five respondents are required for each item as suggested by Kline R.B.²⁴ Convenience and snowball sampling methods were adopted to include patients reporting to the Department of Periodontology, Manipal College of Dental Sciences, for dental health problems. The contact details were obtained from participants’ acquaintances as a part of snowball sampling. A web-based questionnaire was sent (Online survey by Google Forms) to the prospective participants along with a letter of invitation to participate. Indian adults who were willing to participate in this study and had knowledge of the English language were included, while those not willing to participate were excluded. Anticipating a 50% lack of response, the questionnaire was sent to twice the required participants.

Questionnaire development

The Knowledge, Attitude, and Practice questionnaire was developed (Stage One) using a deductive approach and a psychometric evaluation of the questionnaire was performed to evaluate reliability and validity (Stage Two).

Stage One: Item and domain development

Using a deductive approach, questionnaire items were developed from the literature on yoga in managing periodontal disease and its influence on systemic diseases. Eight articles were referenced and conceptual definitions of knowledge, attitude, and practice regarding yoga and periodontal disease were derived.^23,25–31 Knowledge was defined as the awareness of what yoga is and its role in managing systemic diseases, stress, and oral diseases. The definition of attitude was given as the manner in which an Indian adult would think and behave toward the possibility of the application of yoga in addressing systemic and oral diseases. Practice was defined as the scheme followed by Indian adults who demonstrate an understanding of the use of yoga in dealing with systemic and oral diseases.

An initial questionnaire with appropriate items was developed based on related literature in English language to fit the categories and the total number of items in the questionnaire was 36. The initial KAP questionnaire was reviewed by an expert panel comprising experts on yoga and periodontal health to validate the content. The test-re-test reliability of the questionnaire was calculated by administering the scale to 30 participants twice within one month. There were 27 items and 4 domains in the final questionnaire; (1) demography of participants; (2) knowledge regarding yoga and oral health; (3) attitude towards yoga and oral health; and (4) practice towards implementing yoga for oral health. Periodontal disease and health was the primary area of focus in the oral health aspect of the questionnaire can be found in the Extended data.

Stage Two: Psychometric evaluation

A sample size of 135 was determined based on the rule of thumb given by Kline R.B.²⁴ and repeated in the study by Selvaraj et al.³² The questionnaire was administered online and informed consent was obtained via electronic mode. The descriptive analysis and assessment of Item response theory³³ were performed using the JMETRIK software (version 4.0.0, Charlottesville, Virginia, USA).

Item Response Theory (IRT)

A sample size of 135 participants was considered acceptable for IRT analysis of the knowledge domain. For the knowledge domain, one-parameter logistic item response theory (1-PL IRT) analysis was carried out with the response as either right or wrong as a dichotomous output. The analysis was performed in JMETRIK using the RASCH function of the ltm package. A range of difficulty (−4 to +4) was considered as the cut-off value for the psychometric Property evaluation of the domain.³⁴

Internal consistency reliability

The internal consistency (IC) of the items was calculated using the coefficient of Cronbach’s alpha and correlation between items.

Characteristics of the study population

The majority of the participants were in the age group of 31-40 years (39.7%) followed by 23-30 years (25.6%) of age. 50.8% of the participants were female and 56.3% had completed their post-graduate education. Most of the participants in the study had no history of systemic illnesses (80.9%). Diabetes had the highest percentage of occurrence (5.5%) amongst the remaining 19.1%. Oral health care was found to be an ancillary consideration as the question on frequency of visits to the dentist for consultation regarding oral or gum health was met with the answer from the majority (63.8%) that they visited the dentist only in the presence of dental problems, 12.6% said that they visited the dentist once in a year and 11.1% had never visited a dentist. 88.9% had no behavioral risk factors such as alcohol consumption, tobacco usage, and a sedentary lifestyle. Alcohol consumption, including regular consumption (5%), occasional drinking (1%), and alcohol consumption along with smoking (2.5%), was the leading behavioral risk factor.

Questionnaire development

Total items developed using deductive approach and content validation (Stage One)

After consulting relevant literature, an initial questionnaire with 36 items was developed using the deductive approach. Five experts performed content validation of each scale to ensure content relevance, representativeness, and technical quality. The Scale level Content Validity Index/Average (S-CVI/Ave) for the questionnaire was 0.88. The Scale level Content Validity Index/Universal Agreement (S-CVI/UA) was 0.414. The Free Marginal Kappa was 0.53, indicative of moderate agreement, Fixed Marginal Kappa was -0.13, and the percentage agreement was 76.55%. Item reduction was performed to 30 after eliminating six questions after Content validation. The detailed results of the content validation are given as a supplementary file in the extended data of the data availability statement. The Content Validation Index (CVI) was found to be satisfactory.

Test-re-test reliability

Item scoring was finalized and the questionnaire was subjected to test-re-test reliability assessment. Unweighted Kappa Coefficient was used to assess the reliability of the items with binary responses. One question in the Knowledge category had poor agreement (K2: -0.036) and two had slight agreement (K3: 0.151, K4: 0.081). All the other questionnaire questions had a moderate, substantial, or near-perfect agreement.

Intraclass correlation coefficient (ICC) was used for assessing the questions in the practice and attitude category with categorical variables. The interpretation of the ICC was given as acceptable if values were above 0.40, but probably improvable; ICCs above 0.60 or greater indicated satisfactory stability; ICCs greater than 0.80 specified excellent stability. The ICC for all the assessed questions was greater than 0.60 suggesting satisfactory stability.

Three questions from the knowledge category were thus eliminated after the test- re-test reliability assessment as the questions had demonstrated only poor or slight agreement in the tests.

Psychometric evaluation of the questionnaire (Stage Two)

The 27-item questionnaires were administered to 300 participants through the online platform to compensate for the expected non-response. From this, 199 responses were obtained, and all the responses were evaluated to assess the psychometric properties of the questionnaire. The one-parameter model for the knowledge domain of the respondents revealed an acceptable range of difficulty for all the questions with the values ranging from 1.01 to 2.16 (Table 1).

Internal consistency measured using Cronbach’s alpha for knowledge, attitude and practice items were reported to be 0.632, 0.923, and 0.591, respectively and that of KAP total was 0.632 (Table 2a). Guttman Split-Half Coefficient was satisfactory for knowledge (0.600) and attitude (0.781) (Table 2b).

Association of KAP with demographic variables

An independent t-test was performed to assess the association between demographic variables such as age, gender, education, and KAP regarding the application of yoga in oral health. A significant association was seen between the level of education and KAP of yoga and oral health (Table 3).

Standardization of scores

For the Indian population, the 27 item questionnaire scores were standardized (The questionnaire has been given as a supplementary file as part of extended data in the data availability statement). For the questionnaire, scores below 33 indicated low KAP, 34-40 indicated medium KAP and scores greater than 41 indicated good KAP of yoga for overall health, including oral health with a focus on periodontal health. The current study’s total KAP was 37.1859, indicating a medium KAP (Table 4).

Frequency of responses in Knowledge, Attitude and Practice questions

82.4% of the participants felt that oral health is a mirror of general health and 92% were aware of the general symptoms of periodontal disease, such as bleeding gums, loose teeth, and receding gums. Although 53.3% had known that stress at work or in life could contribute to oral diseases, 35.7% were not aware of the significance of stress on oral health. 81.9% of the participants agreed that physical activity/lifestyle changes would help control chronic diseases, while only 60.8% felt the same about the influence of physical activity/lifestyle changes on gum diseases. 98% of the participants knew that yoga is a group of physical, mental, and spiritual practices of disciplines that originated in ancient India and 86.9% were knowledgeable about specific ‘asanas’ to reduce stress, blood sugar level, blood pressure and inflammation. Only 57.3% recognized that there are scientific studies that have proven the benefits of yoga on systemic health and oral/gum health.

The majority of the participants agreed that yoga is necessary for a healthy life (51.8%-Strongly agree, 32.7% agree), that yoga practice can help in managing lifestyle diseases like obesity, hypertension, cancer (50.3%-Strongly agree, 39.7% agree) and that yoga practice can improve memory and concentration (58%-Strongly agree, 32.2% agree). The participants also felt that yoga could help manage mental ill health like depression, stress (57.3%-Strongly agree, 36.2% agree) and facilitate healing, relaxation and reduction in pain (47.7%-Strongly agree, 39.7% agree). The majority of the participants were of the attitude that gum disease/periodontal disease is caused due to stress, defective immunity of the body in addition to poor oral hygiene (25.6%-Strongly agree, 44.7% agree) and that the effect of yoga on periodontal and oral health may be due to its effect on immunity and inflammation (Strongly agree-20.6%, Agree-38.2%). However, they were sceptical about the role of yoga in managing gum diseases/periodontal diseases (Neutral-46.7%, Disagree-5.5%, Strongly disagree-0.5%) and its effect on salivary flow and dry mouth, which often result in periodontal diseases (Neutral-47.2%, Disagree-3.5%, Strongly disagree-0.5%).

Amongst the practice questions, 42.7% of the respondents practiced yoga, with 52.9% practicing yoga regularly. Lack of time was the most common reason for the non-practice of yoga (29.8%). 54.1% practice yoga for less than 30 minutes and 43.2% are focused on the various asanas and 27% perform meditation. Many of the participants (97.6%) practice yoga for the improvement of general health while 27.1% focus on yoga for specific ailments. 97.6% find yoga beneficial in improving general health or specific ailment. 88.2% of the participants have not considered the practice of yoga for the health of their gums which is primarily due to a lack of awareness regarding the effects of yoga on oral health (68%), but 66.7% have noticed that the health of the gums improve with the practice of yoga. 70.9% of the participants are very willing to recommend yoga for the improvement of general health/specific ailment to others and only 4.5% are not willing. However, only 35.7% are willing to recommend yoga to improve the health of gums to others and 15.1% are unwilling to do so.