Model specification in oral health-related quality of life research

The aim of this study was to analyze conventional wisdom regarding the construction and analysis of oral health-related quality of life (OHRQoL) questionnaires and to outline statistical complications. Most methods used for developing and analyzing questionnaires, such as factor analysis and Cronbach's alpha, presume psychological constructs to be latent, inferring a reflective measurement model with the underlying assumption of local independence. Local independence implies that the latent variable explains why the variables observed are related. Many OHRQoL questionnaires are analyzed as if they were based on a reflective measurement model; local independence is thus assumed. This assumption requires these questionnaires to consist solely of items that reflect, instead of determine, OHRQoL. The tenability of this assumption is the main topic of the present study. It is argued that OHRQoL questionnaires are a mix of both a formative measurement model and a reflective measurement model, thus violating the assumption of local independence. The implications are discussed.