DOI: 10.1111/idh.12319
ORIGINAL ARTICLE
1
Department of Oral Hygiene, College
of Dental Medicine, Kaohsiung Medical Abstract
University, Kaohsiung City, Taiwan Objectives: This study aimed to develop and validate a new instrument based on the
2
Department of Medical Research, Kaohsiung
health belief model and to use the instrument to investigate the determinants of regu-
Medical University Hospital, Kaohsiung City,
Taiwan lar dental attendance among primary schoolchildren.
3
School of Dentistry, College of Dental Methods: A cross-sectional study was conducted using a newly developed measure-
Medicine, Kaohsiung Medical University,
ment scale based on the HBM, 4 health-promoting schools participated in the study
Kaohsiung City, Taiwan
4
Division of Family Dentistry, Department and 958 students studying in grades 4–6 completed the questionnaire. The psycho-
of Dentistry, Kaohsiung Medical University metric properties of the instrument were analysed, and a path analysis model was used
Hospital, Kaohsiung City, Taiwan
5
to identify the determinants of regular dental attendance.
Division of Pediatric Dentistry, Department
of Dentistry, Kaohsiung Medical University Results: The instrument had good internal consistency (Cronbach’s α = 0.826–0.925)
Hospital, Kaohsiung City, Taiwan and a factor structure identical to HBM. Overall, the schoolchildren’s health beliefs on
6
Department of Healthcare Administration
caries treatment were positive. The determinants of regular dental visit were school
and Medical Informatics, College of Health
Sciences, Kaohsiung Medical University, location (β = −0.13), mother’s education level (β = 0.15), susceptibility (β = −0.18) and
Kaohsiung City, Taiwan
barriers (β = −0.11).
7
Department of Public Health, College
of Health Sciences, Kaohsiung Medical
Conclusion: This study provided evidence that HBM is applicable to children’s dental
University, Kaohsiung City, Taiwan visiting behaviour and their health beliefs towards adherence to caries treatment.
Correspondence
Although children had a positive attitude towards dental visits, environmental obsta-
Chen-Yi Lee, Department of Oral Hygiene, cles would interfere with dental visits. The newly developed instrument could be used
College of Dental Medicine, Kaohsiung
Medical University, Kaohsiung City, Taiwan.
to identify high-risk children and help design oral health interventions for these chil-
Email: cylee@kmu.edu.tw dren. Moreover, policy makers should increase the accessibility of dental resources to
enhance the utilization of dental care among schoolchildren.
KEYWORDS
caries, child, dental visit, health belief model, health-promoting school
1 | INTRODUCTION water fluoridation practice nor licensed paraprofessionals such as den-
tal nurses/hygienists/therapists to offer services to school students or
Since the 1990s, the Taiwan government has funded various pro- individuals in the community; unstable structure of the dental public
grammes to improve children’s oral health. Moreover, in Taiwan, health system and the disparity of dental resources produce a com-
health-promoting schools (HPSs) have advocated oral health promo- plex problem that potentially influences the dental care-seeking be-
tion since 2001,1 such as daily practice of tooth brushing after meal, haviours of patients.
dental flossing and weekly use of fluoride mouthwash. After years of Children’s oral health is influenced by child-
, family-and
effort, the decayed, missing and filled teeth (DMFT) index at 12 years community-level factors.3 Importantly, various aspects of childhood
of age has significantly declined from 4.95 in 1990 to 2.50 in 2012. oral health are considered pivotal in determining the oral health trajec-
However, a high percentage of children continue to have untreated tories in later life, especially adult oral health.4,5 Childhood socioeco-
2
dental decay in their primary and permanent teeth. Taiwan has no nomic status and parental oral health-related beliefs were associated
Int J Dent Hygiene. 2017;1–8. wileyonlinelibrary.com/journal/idh © 2017 John Wiley & Sons A/S. | 1
Published by John Wiley & Sons Ltd
|
2 LEE et al.
tive fit index (CFI), Tucker-Lewis index (TLI) and root mean square error <3 months 88 26.0
of approximation (RMSEA) were also used to evaluate the model fit. 3-6 months 227 67.0
The following cut-off values were used for establishing adequate fit: >6 months 19 5.6
GFI > 0.90, CFI ≥ 0.95, TLI ≥ 0.95 and RMSEA < 0.05.17 Missing 8 0.8
What were the reasons for your last dental visit? (multiple choice)
provided 4 factors with eigenvalues above 1.0 (10.815, 3.750, 2.719 the health beliefs showed significant interrelationships among each
and 1.423). The 4-factor model accounted for 52.0% of the total vari- other.
ance. The first factor (severity) accounted for 30.0%, the second fac-
tor (barriers) for 10.4%, the third factor (benefits) for 7.6% and the
fourth factor (susceptibility) for 4.0%. No cross-loading items were 4 | DISCUSSIONS
found. Factor analysis revealed a 4-factor structure identical to the
HBM. This study developed a valid and reliable questionnaire based on
the HBM to measure 4 concepts (susceptibility, benefits, barriers
and severity) that influence dental visits among primary schoolchil-
3.3 | Description and comparisons of the health
dren. The instrument has good internal consistency and construct
beliefs
validity. Factor analysis revealed a 4-factor structure identical to the
After transforming the score of each item, the following results were HBM, which revealed that “severity” was the most important factor
obtained. The schoolchildren’s health beliefs towards caries treatment influencing schoolchildren’s health beliefs towards caries treatment.
were mostly positive (53.1-92.1%), a proportion of children were non- The 4 factors were correlated, as proven by the path analysis model
committal for some items (6.1-33.4%), and a small percentage showed (Figure 1). The study results provided evidence that HBM is appropri-
negative beliefs (1.8-13.5%; Table 2). The distributions of the suscep- ate for explaining adherence to a dental regimen by children.
tibility and barrier scales were positively skewed; the mean (SD) of the In the path analysis model of sociodemographic variables, the
sum scores was 7.76 (3.68) and 16.81 (6.66), respectively. The distri- significant paths that affected dental visiting behaviour were school
butions of the benefits and severity scales were negatively skewed; location and mother’s education level; the non-significant paths
the mean values of sum of the scores were 46.05 (7.28) and 52.54 were grade, sex and father’s educational level. Similar to our finding,
(8.02), respectively. most research9 showed that the child’s gender had no significant
We further assigned the students into the “discomfort” group com- effect on adherence to regular dental visits. Moreover, the grade
prising students who had never visited a dentist or visited only when level had an insignificant effect in this study, possibly because of the
they felt uncomfortable (n = 611) and the “regular” group comprising influence of schools through recommendations for dental checkups
students who regularly visited a dentist (n = 339). A comparison of the and school examination schedules.9 Furthermore, we found that the
sample characteristics (Table 3) and health beliefs (Table 4) between mother’s more than the father’s education level was significantly as-
these groups revealed that students from different schools had signif- sociated with children’s dental visiting behaviour. This might be be-
icant differences related to regular dental visit, with W primary school cause mothers care more than the fathers about children’s oral (and
showing the highest percentage (41.3%) and G primary school show- general) health, and previous studies reported that mother’s sense
ing the lowest (16.1%). Girls (40.0%) had a significantly higher percent- of coherence (SOC) was significantly associated with children’s oral
age of regular dental visits than did boys (31.6%). Moreover, the higher health-related quality of life.18,19 Higher education level possibly
the educational level of the parent, the higher was the percentage of indicates more knowledge about oral health or a better attitude to-
the child’s regular dental visit (Table 3). All the health beliefs in the wards caries treatment and prevention. Similar to our findings, pre-
“regular” group were significantly more positive than those in the “dis- vious findings have indicated that adherence to regular dental visits
comfort” group (Table 4). depends on the willingness of the parents and caregivers20 or on
the parents’ educational level.21,22 Another significant path that af-
fected dental visiting behaviour was school location; a more remote
3.4 | Path analysis model
location indicated fewer dental resources. Difficulty accessing den-
Figure 1 illustrates the path analysis model. The model fit to the data tal services (eg longer travel time due to traffic) and limited availabil-
was satisfactory, with the following values: χ2 = 45.727, df = 15, ity of professional dental services for young and disabled children
P < .0001; RMSEA
= 0.05, 95% confidence interval (CI)
= 0.034, possibly resulted in a low proportion of regular dental visits. We also
0.067; GFI = 0.986; TLI = 0.957; and CFI = 0.977. Among the direct found a significant positive relationship between the father’s and
effects, significant paths were noted from school location (β = −0.13, mother’s educational levels, and both showed a significant negative
P < .001) to regular dental visiting behaviour. The remoter the school relationship with school location. This indicated that parents with
location, the lesser the probability of regular dental visits; the higher lower education levels tended to live in areas with fewer dental re-
the mother’s educational level, the higher the probability of the child sources, thereby indirectly influencing dental visiting behaviours.
visiting a dentist regularly (β = 0.15, P < .001); the higher the score on Previous studies revealed that lower parental social class was sig-
the susceptibility scale, the lower the probability of regular dental vis- nificantly associated with lower dental self-efficacy, external dental
its (β = −0.18, P < .001); and the higher the score on the barrier scale, health locus of control (LoC)23,24 and poorer parenting practice.24
the lower the probability of regular dental visits (β = −0.11, P = .005). Further research to address these issues is recommended.
Regarding the indirect effects, a significantly positive correlation The scores for the 4 scales (susceptibility, benefits, barriers
was found between the parents’ education levels, and both variables and severity) showed that schoolchildren had positive health be-
showed a significant negative correlation with school location. Finally, liefs towards dental caries. In the path analysis model, we found
LEE et al. 5 |
T A B L E 2 Attitude towards each item, factor structure of health beliefs and corresponding factor loadings
Susceptibility
1. When I find caries, I will not see a dentist. 0.737 656 (68.7) 228 (23.9) 71 (7.4)
2. When I find caries, I do not want to see a dentist. 0.748 658 (68.8) 193 (20.2) 105 (11.0)
3. When I find caries, I will see a dentist after a long time. 0.772 688 (72.5) 158 (16.6) 103 (10.9)
4. When I find caries, I will see a dentist after a long time, when 0.759 729 (76.3) 128 (13.4) 99 (10.4)
the caries has become serious.
Benefits
1. I think treating caries can make teeth healthier. 0.525 832 (87.2) 74 (7.8) 48 (5.0)
2. I think treating caries can make learning enjoyable. 0.571 506 (53.1) 318 (33.4) 129 (13.5)
3. I think treating caries can prevent it from becoming more 0.566 834 (87.6) 74 (7.8) 44 (4.6)
serious.
4. I think treating caries can prevent me from worrying about the 0.640 753 (79.1) 132 (13.9) 67 (7.0)
caries problem.
5. I think treating caries can prevent toothache problems. 0.721 817 (85.5) 93 (9.7) 45 (4.7)
6. I think treating caries can make teeth look good. 0.675 655 (68.4) 231 (24.1) 71 (7.4)
7. I think treating caries can keep breath fresh. 0.654 696 (73.0) 189 (19.8) 69 (7.2)
8. I think treating caries can help me avoid spending more time on 0.684 767 (80.6) 124 (13.0) 61 (6.4)
dental treatment in the future.
9. I think treating caries can help me avoid spending more money 0.665 726 (75.9) 152 (15.9) 78 (8.2)
on dental treatment in the future.
10. I think treating caries can prevent inconvenient eating. 0.636 788 (82.4) 121 (12.7) 47 (4.9)
11. I think treating caries helps me avoid ridicule by classmates. 0.599 548 (57.3) 304 (31.8) 104 (10.9)
Barriers
1. I think it is difficult for me to visit a dentist when I have caries. 0.607 699 (73.0) 195 (20.4) 63 (6.6)
2. I did not have a toothache during caries formation, so I did not 0.556 715 (74.7) 173 (18.1) 69 (7.2)
visit a dentist.
3. I think I do not have enough time to visit a dentist. 0.845 599 (62.7) 258 (27.0) 99 (10.4)
4. I think my parents do not have time to take me to a dentist 0.829 603 (63.1) 229 (24.0) 123 (12.9)
when I have caries formation.
5. I think going to a dentist is a waste of time, troublesome, and 0.608 789 (82.5) 111 (11.6) 56 (5.9)
not interesting.
6. I am afraid of undergoing tooth treatment, so I do not see a 0.678 725 (75.8) 161 (16.8) 70 (7.3)
dentist.
7. I am afraid of my teeth being extracted, so I do not want to be 0.699 692 (72.5) 167 (17.5) 96 (10.1)
treated for caries.
8. I think we have no money at my home, so I do not see a 0.592 750 (78.5) 155 (16.2) 51 (5.3)
dentist.
9. I think the dental clinic is far from my home, so I do not see a 0.561 759 (81.3) 152 (16.3) 23 (2.5)
dentist.
Severity
1. If I do not see a dentist for treatment of caries, for me that is… 0.605 651 (68.8) 255 (27.0) 40 (4.2)
2. If I do not see a dentist to treat caries and experience a 0.796 818 (86.4) 105 (11.1) 24 (2.5)
toothache, for me that is…
3. If I do not see a dentist for treatment of caries and my teeth do 0.735 749 (79.3) 158 (16.7) 37 (3.9)
not look good, for me that is…
4. If I do not see a dentist for treatment of caries and have bad 0.800 811 (85.8) 106 (11.2) 28 (3.0)
breath, for me that is…
(Continues)
|
6 LEE et al.
T A B L E 2 (Continued)
5. If I do not see a dentist for treatment of caries and cannot 0.693 771 (81.5) 125 (13.2) 50 (5.3)
sleep well, for me that is…
6. If I do not see a dentist for treatment of caries and need to 0.725 754 (79.9) 148 (15.7) 42 (4.4)
spend more time on treatment, for me that is…
7. If I do not see a dentist for treatment of caries and need to 0.650 750 (79.4) 152 (16.1) 42 (4.4)
spend more money on treatment, for me that is…
8. If I do not see a dentist for treatment of caries and cannot eat 0.724 793 (83.9) 115 (12.2) 37 (3.9)
my favourite food, for me that is…
9. If I do not see a dentist for treatment of caries and my tooth 0.702 699 (74.0) 179 (19.0) 66 (7.0)
has to be extracted, for me that is…
10. If I do not see a dentist for treatment of caries and prosthetic 0.828 836 (88.5) 84 (8.9) 25 (2.6)
treatment is needed, for me that is…
11. If I do not see a dentist for treatment of caries and experience 0.876 870 (92.1) 58 (6.1) 17 (1.8)
swelling, for me that is…
12. If I do not see a dentist for treatment of caries and the growth 0.790 854 (90.2) 71 (7.5) 22 (2.3)
of my teeth is affected, for me that is…
T A B L E 3 Comparison of dental visiting behaviour according to that the susceptibility and barrier scores were significant indicators
sample characteristics that affected dental visiting behaviour, whereas the benefits and
severity scores showed no significant direct effects. Nevertheless,
Dental visiting behaviour
(n, %) benefits and severity could reduce susceptibility and barriers, while
indirectly improving regular dental attendance. Moreover, the per-
Discomfort Regular
ceived susceptibility and barriers scores were interrelated (Figure 1).
Variables (n = 611) (n = 339) P
The direct effect of susceptibility indicated the tendency to delay
School
dental treatment. Therefore, the results seemed to imply that even
W 381 (58.7) 268 (41.3) <.0005
though schoolchildren had positive attitudes towards dental treat-
E 119 (73.0) 44 (27.0) ment, they tended not to visit dentists unless they had a toothache,
Y 85 (79.4) 22 (20.6) because of perceived barriers. These barriers possibly produced a
G 26 (83.9) 5 (16.1) negative effect with regard to parents’ adherence to recommended
Grade dental visits for their children; these results were similar to those of
4 188 (61.8) 116 (38.2) .306 previous studies.21,25-27
5 205 (67.7) 98 (32.3) Overall, the results imply that environmental factors significantly
6 218 (63.6) 125 (36.4) affected behaviour. Although children had a positive attitude towards
dental visits, environmental obstacles such as school location, moth-
Sex
er’s attitude, lack of time and lack of dental resources, or the child’s
Male 329 (68.4) 152 (31.6) .007
attitude-related obstacles including fear, would interfere with dental
Female 281 (60.0) 187 (40.0)
visits. However, the questionnaire collected information focused on
Father’s educational level
children’s oral health beliefs. Further research to address parental or
Junior high school or lower 153 (77.7) 44 (22.3) <.0005
caregiver oral health beliefs is recommended.
Senior or vocational high 237 (67.3) 115 (32.7) This study provided evidence that HBM is applicable to children’s
school
dental visiting behaviour and their health beliefs towards adherence to
College or higher 192 (52.5) 174 (47.5)
caries treatment. The determinants of regular dental visit were school
Mother’s educational level
location, mother’s education level, perceived susceptibility and per-
Junior high school or lower 149 (77.6) 43 (22.4) <.0005 ceived barriers. The HBM can respond to children’s adherence to den-
Senior or vocational high 265 (68.7) 121 (31.3) tal regimens that guide children’s schemas concerning the values of
school
and expectations from regular dental visits. With respect to practical
College or higher 173 (50.7) 168 (49.3) applications, the susceptibility scale could be used to detect high-risk
Compared by using the χ2 test. children who “did not visit a dentist even if they had tooth decay.” The
LEE et al. |
7
School location
Grade Sex
–0.23***
Mother’s
–0.24*** education level
– 0.13***
0.61***
Father’s 0.15***
education level
Regular dental
– 0.18*** attendance
Susceptibility
–0.23***
0.58***
Benefits –0.11***
F I G U R E 1 Path analysis model relating –0.31*** –0.36***
health beliefs and sociodemographic
variables to dental visiting behaviour. Barriers
0.51***
Standardized path coefficients are
presented. Non-significant paths are –0.42***
represented by dashed lines. Significance: Severity
***P < .001
The health belief model was applied to investigate children’s attitude The authors thank the Bureau of Education of the Kaohsiung City
towards dental visits. Path analysis was used to explore the causes Government for the permission to conduct the survey in the selected
for delay in seeking dental treatment and the determinants of regular schools, the teachers who helped in this research and most impor-
dental visits. tantly, the participating children.
|
8 LEE et al.
CO NFLI CT OF I NTE RE S T 14. Collins SM. An overview of health behavioural change theories
and models: Interventions for the dental hygienist to improve cli-
All authors declare that they have no conflict of interest. This research ent motivation and compliance. Canadian Journal of Dental Hygiene.
did not receive any specific grant from funding agencies in the public, 2011;45:109‐115.
15. Walker KK, Steinfort EL, Keyler MJ. Cues to action as motivators for
commercial or not-for-profit sectors.
children’s brushing. Health Communication. 2015;30:911‐921.
16. Kasmaei P, Amin Shokravi F, Hidarnia A, et al. Brushing behavior
among young adolescents: Does perceived severity matter. BMC
O RCI D
Public Health. 2014;14:8.
C-Y Lee http://orcid.org/0000-0002-8234-1524 17. Hu LT, Bentler PM. Cutoff criteria for fit indexes in covariance struc-
ture analysis: Conventional criteria versus new alternatives. Struct Eq
Model Multi J. 1999;6:1‐55.
18. Khatri SG, Acharya S, Srinivasan SR. Mother’s sense of coherence and
REFERENCES oral health related quality of life of preschool children in Udupi Taluk.
1. Liao LL, Liu CH, Chang FC, Cheng CC, Niu YZ, Chang TC. Evaluation Community Dent Health. 2014;31:32‐36.
of the health-promoting school supporting network in Taiwan. J Sch 19. Fernandes JB, Costa DC, Coelho VS, Sá-Pinto AC, Ramos-Jorge J,
Health. 2015;85:487‐495. Ramos-Jorge ML. Association between sense of coherence and oral
2. Ministry of Health and Welfare, R.O.C. (Taiwan). Health Promotion health-related quality of life among toddlers. Community Dent Health.
Administration Annual Report. http://health99.hpa.gov.tw/media/ 2017;34:37‐40.
public/zip/21771.zip. 2014. 20. Ashkenazi M, Cohen R, Levin L. Self-reported compliance with pre-
3. Fisher-Owens SA, Gansky SA, Platt LJ, et al. Influences on children’s ventive measures among regularly attending pediatric patients. J Dent
oral health: A conceptual model. Pediatrics. 2007;120:e510‐e520. Educ. 2007;71:287‐295.
4. Nicolau B, Thomson WM, Steele JG, Allison PJ. Life-course epidemi- 21. Leroy R, Bogaerts K, Hoppenbrouwers K, Martens LC, Declerck D.
ology: Concepts and theoretical models and its relevance to chronic Dental attendance in preschool children – a prospective study. Int J
oral conditions. Commun Dent Oral Epidemiol. 2007;35:241‐249. Pediatr Dent. 2013;23:84‐93.
5. Shearer DM, Thomson WM, Broadbent JM, Poulton R. Maternal oral 22. Quinonez RB, Pahel BT, Rozier RG, Stearns SC. Follow-up preven-
health predicts their children’s caries experience in adulthood. J Dent tive dental visits for Medicaid-enrolled children in the medical office.
Res. 2011;90:672‐677. J Public Health Dent. 2008;68:131‐138.
6. Broadbent JM, Zeng J, Foster Page LA, Baker SR, Ramrakha S, 23. Duijster D, van Loveren C, Dusseldorp E, Verrips GHW. Modelling
Thomson WM. Oral health-related beliefs, behaviors, and outcomes community, family, and individual determinants of childhood dental
through the life course. J Dent Res. 2016;95:808‐813. caries. Eur J Oral Sci. 2014;122:125‐133.
7. Peterson-Sweeney K, Stevens J. Optimizing the health of infants 24. Duijster D, Jong-Lenters M, de Ruiter C, Thijssen J, van Loveren C,
and children: Their oral health counts!. J Pediatr Nurs. 2010;25: Verrips E. Parental and family-related influences on dental caries in
244‐249. children of Dutch, Moroccan and Turkish origin. Commun Dent Oral
8. John JR, Mannan H, Nargundkar S, D’Souza M, Do LG, Arora A. Epidemiol. 2015;43:152‐162.
Predictors of dental visits among primary school children in the rural 25. Goettems ML, Ardenghi TM, Demarco FF, Romano AR, Torriani DD.
Australian community of Lithgow. BMC Health Services Research. Children’s use of dental services: Influence of maternal dental anxi-
2017;17:264‐273. ety, attendance pattern, and perception of children’s quality of life.
9. Badri P, Saltaji H, Flores-Mir C, Amin M. Factors affecting children’s Commun Dent Oral Epidemiol. 2012;40:451‐458.
adherence to regular dental attendance: A systematic review. J Am 26. Kelly SE, Binkley CJ, Neace WP, Gale BS. Barriers to care-seeking
Dent Assoc. 2014;145:817‐828. for children’s oral health among low-income caregivers. Am J Public
10. Camargo MB, Barros AJ, Frazao P, et al. Predictors of dental visits Health. 2005;95:1345‐1351.
for routine check-ups and for the resolution of problems among pre- 27. Naidu R, Nunn J, Forde M. Oral healthcare of preschool children in
school children. Rev Saude Publica. 2012;46:87‐97. Trinidad: A qualitative study of parents and caregivers. BMC Oral
11. Kikken JB, Vanwilk AJ, Tencate JM, Veerkamp JS. Child dental anx- Health. 2012;12:27.
iety, parental rearing style and dental history reported by parents.
European Journal of Paediatric Dentistry. 2013;14:258‐262.
12. Champion VL, Skinner CS. The health belief model. In: Glanz K, Rimer How to cite this article: Lee C-Y, Ting C-C, Wu J-H, Lee K-T,
BK, Viswanath K, eds. Health behavior and health education: Theory, Chen H-S, Chang Y-Y. Dental visiting behaviours among primary
research, and practice, 4th edn. San Francisco: Jossey-Bass Publisher;
schoolchildren: Application of the health belief model. Int J Dent
2008: 45‐66.
13. Hollister MC, Anema MG. Health behavior models and oral health: A Hygiene. 2017;00:1–8. https://doi.org/10.1111/idh.12319
review. Journal of Dental Hygiene. 2004;78:6.