international dental journal 7 3 ( 2 0 2 3 ) 3 1 1 − 3 1 8

Scientific Research Report

Validity and Reliability of the Vietnamese Version of

the Dental Fear Survey

Uyen-Anh Thi Dong a, Trung Nhu Nguyen b, Son Hoang Le c*

a
Faculty of Dentistry, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
b
Department of Orthodontics, Faculty of Dentistry, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
c
Department of Oral Surgery, Faculty of Odonto-Stomatology, University of Medicine and Pharmacy at Ho Chi Minh City,
Ho Chi Minh City, Vietnam

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: The use of questionnaires to assess patients’ dental fear is critical to dental
Received 19 May 2022 research and practice. As one of the most well-established tools in this field, the Dental
Received in revised form Fear Survey (DFS) was translated into Vietnamese (V-DFS) and employed in previous stud-
22 July 2022 ies. However, its validity and reliability have not been reported. This study aimed to deter-
Accepted 25 July 2022 mine the validity and reliability of V-DFS in adults.
Available online 25 September 2022 Methods: The DFS was translated to Vietnamese in accordance with the “Guideline for the
Process of Cross-cultural Adaptation of Self-reported Measures” to create the V-DFS. Next,
Key words: 414 students at Pham Ngoc Thach University of Medicine completed the V-DFS to examine
Dental Fear Survey its validity and reliability. The factorial validity of V-DFS was assessed using exploratory
Vietnamese version factor analysis (EFA) and structural equation modeling (SEM). The internal consistency and
Reliability test-retest reliability of the V-DFS were assessed using Cronbach’s alpha (a), intraclass cor-
Validity relation coefficient (ICC), and Spearman’s rank-order correlation coefficient (rs).
SEM Results: The rotated component matrix of the EFA revealed 3 factors: specific stimuli, antici-
patory fear and avoidance, and physiologic arousal. The statistical indices of the best-fit-
ting V-DFS model in SEM analysis satisfied the cutoff values. Cronbach’s a ranged from .82
to .94 for the 3 factors. The ICC and rs of the whole questionnaire were .86 and .86,
respectively.
Conclusions: DFS was successfully translated into Vietnamese with good validity and reli-
ability. Further research should be conducted to examine its validity in various populations
and to improve its characteristics.
Ó 2022 The Authors. Published by Elsevier Inc. on behalf of FDI World Dental Federation.
This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)

Introduction There are numerous methods to assess dental fear,

Dental fear is one of the 2 most common barriers preventing
people from undergoing oral health examinations. It can be
caused by either cognitive perceptions or catastrophic dental
experience.1 As a result of this, patients who are more fearful
of dental treatment tend to present with more serious oral
disease.2 Therefore, the early detection of dental fear can
help dentists recognise patients with this problem.
* Corresponding author. Department of Oral Surgery, Faculty of
Odonto-Stomatology, University of Medicine and Pharmacy at Ho
Chi Minh City, Ho Chi Minh City, Vietnam. 652 Nguyen Trai street,
Ward 11, District 5, Ho Chi Minh City, Vietnam.
E-mail address: lehoangson@ump.edu.vn (S.H. Le).
https://doi.org/10.1016/j.identj.2022.07.009
0020-6539/Ó 2022 The Authors. Published by Elsevier Inc. on behalf of FDI World Dental Federation. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
including self-reported, observation-based, and physiologic
assessments.3 To date, self-reported assessment using
questionnaires is still the most common method because
of some advantages. First, it is simple and convenient to
perform. Second, questionnaires for assessing dental fear
vary in purpose and structure, so clinicians can choose
the appropriate one based on their demands.4,5 Third, self-
reported assessments are less likely to depend on the
patients’ physiologic condition and the assessor.3
Since the first dental fear questionnaire, Corah’s Dental
Anxiety Survey (DAS), appeared in 1969, a number of others
have been developed, including Kleinknecht’s Dental Fear
Survey (DFS) in 1973, Stouthard’s Dental Anxiety Inventory
(DAI) in 1995, their modified versions, and some recently
introduced questionnaires.5 In a critical review, DFS was one
312 dong et al.
of the most recommended questionnaires for assessing den-
tal fear because the construct was based on an explained
behavioral approach with high reliability and validity.6 Origi-
nally written in English, the DFS has been translated into sev-
eral languages for research and use in many countries,
including Arabic, Spanish, Portuguese, Japanese, Korean,
Turkish, and Greek.7-13 Employing the DFS in a non-native
English-speaking country with different culture is classified
as the most challenging scenario.14 As a result of this, some
translated versions of DFS showed low reliability or violated
principles of construct validity.
In Vietnam, there is a limited understanding of dental fear
because of a lack of research. Some previous studies used the
Vietnamese version of the DFS (V-DFS) as a method for assess-
ing dental fear but did not evaluate reliability and validity of
the translation.15,16 A translated version with confirmed reli-
ability and validity are in demand to guarantee that the ques-
tionnaire result can be reproduceable and trustworthy.17
Therefore, using the V-DFS, for which the reliability and valid-
ity have not been investigated, makes their results less reason-
able, because differences in culture and fear perception can
affect translated versions.3 In addition, the previous translation
of the V-DFS has not been published for using in daily practice
or research. This study aimed to translate the DFS into Viet-
namese and examine the validity and reliability of the V-DFS.
Methods
This study was conducted in 2 stages. In stage 1, the original
DFS was translated into Vietnamese following the
“Guidelines for the Process of Cross-cultural Adaptation of
Self-reported Measures.”14 In stage 2, the validity and reliabil-
ity of the V-DFS were examined in adults.
Stage 1
The original DFS was translated into Vietnamese by 2
bilingual translators. The first translator was a dentist
who understood the purpose of using the DFS. The second
was an English teacher who was unaware of the aim of
the questionnaire and had no professional knowledge of
dentistry. The differences between the 2 forward transla-
tions are discussed to solve and develop a forward transla-
tion of the V-DFS. Backward translation was then
conducted by 2 native English speakers who were naÿve
to the original DFS content. The pre-final translated ver-
sion was produced based on the consensus of a committee
that included all translators and researchers. Thirty volun-
teer students were asked to answer the pre-final version
and give their opinions regarding the translated words.
Based on these comments, the prefinal version was modi-
fied to produce the final V-DFS (Appendix A. The Vietnam-
ese version of the Dental Fear Survey).
Stage 2
Participants
The participants were undergraduate students at the Pham
Ngoc Thach University of Medicine (PNTU). The second
largest medical university in Ho Chi Minh City, PNTU particu-
larly educates health care professionals, with approximately
6500 students. The students who participated in this study
were from 4 health care programmes: medicine, dentistry,
pharmacy, and nursing.
Procedure
From January to March 2021, the questionnaire was dis-
tributed and described in all classes of PNTU as an extra-
curricular activity by the academic advisers. The
questionnaire was anonymous so that students were not
hesitant to enroll in the study. Under PNTU’s rules, this
study protocol did not require permission from the ethics
committee.
In the first administration, 499 undergraduate students
voluntarily agreed to participate in the study (response rate
of 7.7%). The final V-DFS questionnaire of stage 1 was intro-
duced to the participants by a researcher (T. N. N.), the partic-
ipants self-answered the questionnaire, and the procedure
was repeated at a 3-week interval. Subsequently, a researcher
(U.-A. T. D.) screened the answers to remove some partici-
pants. Exclusion criteria were as follows: (1) incompletely
answered questionnaires, (2) no previous experience of den-
tal treatment, and (3) previous diagnosis of any psychologic
problems.
Statistical analysis
Data conversion. The collected data were input into an
Excel database and then copied to SPSS 22.0 for statistical
analysis.
Validity assessment. The V-DFS was assessed for facto-
rial validity to examine cross-cultural validation. All
answer sheets from the first survey were interpreted using
exploratory factor analysis (EFA) and structural equation
modeling (SEM). The methodology was described in detail
in “Multivariate data analysis.”18 EFA was conducted using
principal components and the varimax rotation method to
determine the latent factors of the questionnaire. Based
on this result, the rotated component matrix was input in
AMOS 20.0 (IBM) to perform SEM. The preliminary model
of the SEM analysis was assessed the goodness-of-fit (GOF)
using the following statistical indices: chi-square fit statis-
tics/degree of freedom (CMIN/df), root square mean error
of approximation (RSMEA), standardised root mean
squared residual (SRMR), comparative fit index (CFI), and
parsimony normed fit index (PNFI). According to Hair et al,
the recommended cutoff values for GOF were as follows:
CMIN/df ≤ 3; RSMEA ≤ .07; SRMR ≤ .08; and CFI ≥ .94.
Exceptionally, there is no cutoff value for PNFI, but it
should be as high as possible to increase the model fit.18
The best-fitting model was then produced by correlating
couples of the observed variables that had high modifica-
tion indices to improve the GOF.
Reliability assessment. The V-DFS reliability was exam-
ined using internal consistency and test-retest reliability.
Internal consistency was determined using Cronbach’s a test.
Test-retest reliability was determined by calculating the
intraclass correlation coefficient (ICC) and Spearman’s rank-
order correlation coefficient (rs).
 validity and reliability of the vietnamese version of the dental fear survey 313

Results
The number of students who answered the questionnaire in
the first administration was 499. After screening the answers,
85 participants were removed due to the following exclusion
criteria: uncompleted questionnaire (n = 10), no dental expe-
rience (n = 55), and psychological problems (n = 20). Conse-
quently, the V-DFS score of 414 students were used to
interpret the V-DFS validity. Of the sample, the mean age was
21.40 § 2.03 years (range, 19−32 year), and the female per-
centage was 62.8%. Amongst them, 263 participants finished
the V-DFS in the second administration, and their results
were used to interpret the V-DFS reliability. The mean value
score for each question and for the entire V-DFS question-
naire is shown in Appendix B. The Vietnamese version of the
Dental Fear Survey scores in two administrations.
In Table 1, the EFA revealed 3 latent factors of the V-DFS.
Based on the medical literature and nature of the questions,
factors 1, 2, and 3 were named specific stimuli, anticipatory
fear and avoidance, and physiologic arousal, respectively.
Statistical analysis showed that the EFA model fit the present
study data with a Kaiser−Meyer−Olkin sample adequacy of
.923, a P value for Bartlett’s test of sphericity <.001, and a total
explained variance of 64.70%. All V-DFS questions had factor
loadings higher than .40 and communality higher than .25.
The preliminary and best-fitting models are shown in Fig-
ures 1 and 2, respectively. For the preliminary model, the
model fit test was acceptable, with CMIN/df = 6.24,
RMSEA = .11, SRMR = .07, CFI = .86, and PNFI = .74. However,
there was a significantly high covariance between the error
terms of DFS1 and DFS2, DFS8 and DFS9, DFS9 and DFS10,
DFS14 and DFS15, DFS16 and DFS20, DFS17 and DFS20, and
DFS19 and DFS20. After adding the relationship between
those pairs of items, the best-fitting model showed a signifi-
cant improvement in model fit with CMIN/df = 2.98,
RMSEA = .07, SRMR = .06, CFI = .95, and PNFI = .78. The factor
loadings of each question and all correlation indices are pre-
sented in Figure 2. Notably, the factor loadings of DFS1, DFS2,
and DFS6 with their respective latent factors are low.
As shown in Table 2, the V-DFS revealed good internal
consistency for all factors, with Cronbach’s a ranging from
.82 to .94. All V-DFS items showed acceptable corrected item-
total correlations (.35−.88) and a if the item was deleted (.73
−.94). Notably, the a values if the DFS1, DFS2, DFS6, and
DFS19 items were deleted were slightly higher than the
Cronbach’s a of the individual factors; however, their cor-
rected item-total correlation values were still higher than .30.
The V-DFS showed excellent overall correlation, with an
ICC = .86 and rs = .86 (Table 3). All items of the V-DFS obtained
moderate ICC values, ranging from .55 to .77, except for DFS2
and DFS2 (ICC = .45) and DFS6 (ICC = .44). However, the scores
between the 2 administrations were significantly correlated (P
< .001). ICC values for each factor were as follows: .76 (.70−.81)
for anticipatory fear and avoidance, .71 (.64−.76) for physio-
logic arousal, and .83 (.79−.87) for specific stimuli. Regarding
Spearman’s rank-order correlation, all rs values were higher
than .50, except for DFS2 and DFS6 (rs = .47, P < .001). rs values
for anticipatory fear and avoidance, physiologic arousal, and
specific stimuli were .73, .68, and .84, respectively.
Discussion

The study results demonstrated the appropriate validity and

Table 1 – Rotated component matrix of the Vietnamese ver-
reliability of the V-DFS. The V-DFS contains 3 main factors
sion of the Dental Fear Survey (n = 414).
related to dentistry: anticipatory fear and avoidance, physio-
Items Factor loading Communality logic arousal, and specific stimuli. The best-fitting model of
1 2 3 the V-DFS not only satisfied the statistical requirements of
the SEM model fit but also had the same construction with
DFS1 .093 .587 .131 .371
DFS2 -.057 .538 .233 .347 the original DFS. The V-DFS also showed excellent internal
DFS3 .231 .135 .642 .484 consistency and good test-retest reliability.
DFS4 .206 .100 .863 .797 This study is not the first one in which the Vietnamese
DFS5 .174 .250 .751 .657 translation of DFS was utilised.15,16 One of the authors (S. H.
DFS6 .086 .297 .423 .275 L.) witnessed some patients’ confusion when choosing the
DFS7 .313 .176 .770 .722
appropriate level of dental fear in the previous Vietnamese
DFS8 .282 .754 .100 .657
translation due to ambiguous distinction between translated
DFS9 .382 .771 .119 .755
DFS10 .386 .708 .197 .689 words for level 2-3-4 of the answer. Such confusion is com-
DFS11 .551 .607 .245 .731 mon in Likert-type questionnaire and may mislead the
DFS12 .494 .619 .215 .674 results.19 Therefore, the authors agreed to make a new trans-
DFS13 .517 .623 .241 .713 lation from the beginning with new translators. Comparing
DFS14 .823 .212 .135 .741 with the translated version of previous studies, the main dif-
DFS15 .820 .134 .160 .716
ference was the words for determining levels of dental fear of
DFS16 .849 .202 .196 .801
DFS17 .845 .216 .209 .805
the answers.
DFS18 .826 .187 .225 .767 The DFS was introduced in 1973, and its construct validity
DFS19 .577 .253 .290 .481 was first reported in 1984.6 To date, the translated version of
DFS20 .720 .378 .309 .757 the DFS has been examined for construct validity in some
Eigenvalues 9.632 1.721 1.587 languages, such as Japanese (J-DFS), Korean (K-DFS), Brazilian
Percentage of explained 48.159 8.607 7.934
Portuguese (P-DFS), and Lebanese Arabic (A-DFS). In the origi-
variance
nal and translated versions of the DFS, 3 main factors related
Note. The exploratory factor analysis was conducted with principal to dental treatment were observed: anticipatory fear and
components and varimax rotation method. avoidance (DFS1, DFS2, and DFS8 to DFS13), physiologic
314 dong et al.

Fig. 1 – Preliminary model of the Vietnamese version of the Dental Fear Survey based on rotated component matrix of explor-
atory factor analysis (n = 414).

arousal (DFS3 to DFS7), and specific stimuli (DFS14 to
DFS20).6,7,10,13 However, the K-DFS showed a different facto-
rial construct that highlighted the effect of anaesthesia and
drilling on dental fear.20 Similarly, another previous study
reported that the DFS contained 6 factors that highlighted the
influence of needles and drilling on dental fear.21 However,
the participants in those studies were patients diagnosed
with dental phobia and adolescences, which could affect the
assessment of DFS factorial functions when applied to these
populations. In accordance with the original DFS and most
translated versions, this study identified 3 factors affecting
dental fear.
 validity and reliability of the vietnamese version of the dental fear survey 315

Fig. 2 – The best-fitting model of the Vietnamese version of the Dental Fear Survey (n = 414).

The best-fitting models of the Japanese, Lebanese Arabic,
and Vietnamese versions of DFS showed appropriate statistical
results for factorial validity with GOF indices that were higher
than the recommended cutoff values.18 Although some statisti-
cal indices of the V-DFS were not as good as those of other lan-
guage versions of the DFS, the salient point was that its best-
fitting model did not contain any between-construct error
covariance that appeared in other language versions of the
DFS.18 Additionally, the number of within-construct error cova-
riances of the V-DFS was much lower than those of the J-DFS
and P-DFS.7,13 In other words, the factorial validity of the V-DFS
was appropriate and complied with the fundamental psycho-
metric principles of a good questionnaire.
The reliability of the V-DFS was confirmed by analysing
internal consistency and test-retest reliability. Cronbach’s a
for each item and factor satisfied the standard requirements
of internal consistency, with a corrected item-total correla-
tion higher than .30 and factor a values higher than .80. Com-
pared with the reported Cronbach’s a of previous studies, this
study’s results were somewhat lower. In the J-DFS, K-DFS, A-
316 dong et al.

Table 2 – Internal consistency reliability of the Vietnamese version of the Dental Fear Survey.
Items First administration (n = 414) Second administration (n = 263)
Corrected Alpha if item Cronbach’s Corrected Alpha if item Cronbach’s
item-total deleted alpha item-total deleted alpha
correlation correlation
Anticipatory fear .90 .90
and avoidance
DFS1 .43 .91 .35 .91
DFS2 .36 .91 .38 .91
DFS8 .70 .88 .75 .88
DFS9 .80 .87 .82 .87
DFS10 .78 .88 .82 .87
DFS11 .80 .87 .79 .88
DFS12 .76 .88 .76 .88
DFS13 .79 .87 .80 .88
Physiologic .82 .84
arousal
DFS3 .54 .80 .60 .82
DFS4 .76 .73 .78 .77
DFS5 .67 .76 .64 .81
DFS6 .35 .84 .47 .85
DFS7 .72 .74 .73 .78
Specific stimuli .94 .94
DFS14 .80 .93 .77 .93
DFS15 .79 .93 .78 .93
DFS16 .85 .92 .87 .92
DFS17 .86 .92 .88 .92
DFS18 .84 .92 .86 .92
DFS19 .61 .94 .66 .94
DFS20 .81 .93 .80 .93

Table 3 – Test-retest reliability of the Vietnamese version of the Dental Fear Survey (n = 263).
Items Intraclass correlation coefficient F (262, 262) Spearman’s rank-order
(95% confidence interval) correlation coefficient
Anticipatory fear and avoidance .76 (.70−.81) 7.33 .73
DFS1 .56 (.47−.64) 3.53 .52
DFS2 .45 (.35−.54) 2.65 .47
DFS8 .55 (.46−.63) 3.42 .49
DFS9 .61 (.52−.68) 4.07 .58
DFS10 .64 (.56−.71) 4.55 .61
DFS11 .70 (.64−.77) 5.74 .69
DFS12 .67 (.59−.73) 4.96 .68
DFS13 .63 (.56−.70) 4.46 .59
Physiologic arousal .71 (.64−.76) 5.77 .68
DFS3 .62 (.54−.69) 4.21 .60
DFS4 .57 (.48−.65) 3.67 .54
DFS5 .55 (.46−.63) 3.49 .50
DFS6 .44 (.34−.53) 2.60 .47
DFS7 .65 (.57−.71) 4.74 .60
Specific stimuli .83 (.79−.87) 10.81 .84
DFS14 .77 (.72−.82) 7.76 .77
DFS15 .76 (.70−.80) 7.23 .76
DFS16 .70 (.63−.76) 5.60 .70
DFS17 .77 (.72−.82) 7.75 .76
DFS18 .70 (.63−.76) 5.68 .69
DFS19 .66 (.58−.72) 4.83 .65
DFS20 .75 (.69−.80) 7.12 .75
Total .86 (.83−.89) 13.35 .86

P < .001 for all items, factors, and total Vietnamese version of the Dental Fear Survey in both intraclass correlation coefficient and Spearman’s
rank-order correlation coefficient analysis.
 validity and reliability of the vietnamese version of the dental fear survey
DFS, and Greek versions of the DFS, all items were examined
for internal consistency as one group, whereas the DFS was
built on several factors.7-10 As a result, the Cronbach’s a val-
ues were too high (≥.94), indicating redundancy.22 According
to the authors’ opinion, it would be more appropriate to
examine the internal consistency of every group following
EFA results. Based on the statistical results, it is likely that
DFS1, DFS2, DFS6, and DFS19 could be removed from the V-
DFS to reduce the length of the questionnaire without affect-
ing its homogeneity.
The statistical results of the V-DFS showed that the overall
questionnaire had good reliability (ICC = .86 and rs = .86). The
ICC and rs values of each item ranged from .44 to .77 and .47
to .77, respectively. Amongst the V-DFS items, the statistical
results of DFS2 and DFS6 were quite poor, with ICC and rs
<.50. One of the most critical factors affecting the test-
retest statistical results is the time interval. Increasing the
time interval would decrease the test-retest reliability but
could reduce the effect of memory.23 A literature review
showed that most retests in previous studies were con-
ducted after a week to a month.24 In this study, the second
administration of the V-DFS was conducted 3 weeks later,
which was longer than with most translated versions of
the DFS, to ensure that the effect of memory was mini-
mised. For the DFS in the other languages, the interval
times were 1 week for the J-DFS, 2 weeks for the A-DFS and
P-DFS, and 4 weeks for the K-DFS. Generally, the reproduc-
ibility of the V-DFS was much better than that of the K-DFS
(ICC = .40; rs = .09−.49) and comparable to that of the A-DFS
(ICC = .92, rs = .70), J-DFS (ICC = .92; rs = .89−.92), and P-DFS
(ICC = .88−.90).7,8,10,13 Although the interval between tests
was the longest, the V-DFS showed good stability when
compared with the other language versions.
The study was conducted with an appropriate method:
Translating the DFS questionnaire followed a standard
guideline and interpreting the results required specialised
statistical calculations. Most previous studies interpreted
the factorial validity of the questionnaire with CFA. By
using SEM, this study results pointed out the regression
relationships between latent factors or observed variables.
It is crucial to evaluate the factorial validity and revise the
questionnaire in the future. However, there are some limi-
tations that should be overcome in the future studies or
clinical practice. First, the study participants were under-
graduate students in health sciences, so the V-DFS mean-
ing values might be somewhat lower than those of non
−health care related populations because of different
knowledge foundations.25 However, the main objective of
this study is to evaluate validity and reliability of the V-
DFS, but not to provide any reference cutoff value for diag-
nosing dental fear. Although enrolling health profession
students did not affect the study objective, carrying out
the V-DFS in the mass population is recommended to
acquire more comprehensive understanding of dental fear
in Vietnamese patients. Second, although the V-DFS was
translated under a rigorous protocol, receiving feedback
from other populations, such as people from different
majors or generations, is needed to assess dental fear
more efficiently when being used amongst a diverse popu-
lation.26 Third, because there are some minor differences
317
amongst geographic locations in the Vietnamese language,
the published V-DFS can be slightly modified to better
adapt to individual populations.
Conclusions
Within the limitations of this study, the DFS was trans-
lated into Vietnamese with good validity and reliability.
The V-DFS can be applied in clinical contexts and in fur-
ther studies to assess dental fear in Vietnamese patients.
The authors also suggest conducting further studies to
investigate validity and reliability of the DFS after remov-
ing redundant items.
Conflict of Interest
None disclosed.
Acknowledgements
The authors sincerely thank Dr Tien Huu Cao for his valuable
contributions to this study.
Supplementary materials
Supplementary material associated with this article can
be found in the online version at doi:10.1016/j.
identj.2022.07.009.
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