International Dental Journal (2003) 53, 289–298
Oral health knowledge, attitudes and behaviour of children and adolescents in China Ling Zhu Beijing, China
Poul Erik Petersen Geneva, Switzerland
Hong-Ying Wang, Jin-You Bian and Bo-Xue Zhang Beijing, China
Objectives: A national representative study to describe oral health behaviour, illness behaviour, oral health knowledge and attitudes among 12-year-old and 18-year-old Chinese, to analyse the oral health behaviour profile of the two age groups in relation to province and urbanisation, and to assess the relative effect of socio-behavioural risk factors on dental caries experience. Methods: The total number of 4,400 of each age group were selected and data were collected by clinical examinations (WHO criteria) and self-administered structured questionnaires. Results: 44.4% of the respondents brushed their teeth at least twice a day but only 17% used fluoridated toothpaste. Subjects who saw a dentist during the previous 12 months or two years were 31.3% and 35.3% for 12-year-olds and 22.5% and 20.2% for 18-year-olds, respectively. Nearly one third (29%) of 12 yearolds and 40.5% of 18-year-olds would visit a dentist in case of signs of caries but only when in pain. Nearly half of the participants (47.2%) had never received any oral health care instruction. Significant variations in oral health practices were found according to province and regular dental care habits were more frequent in urban than in rural areas. The risk of dental caries was high in the case of frequent consumption of sweets and dental caries risk was low for participants with use of fluoridated toothpaste. Conclusion: Systematic community-oriented oral health promotion programmes are needed to target lifestyles and the needs of children, particularly for those living in rural areas. A prevention-oriented oral health care policy would seem more advantageous than the present curative approach.
Key words: Epidemiology, oral health knowledge, oral health behaviour, oral health habits
Correspondence to: Dr. Poul Erik Petersen, World Health Organization, Non-Communicable Disease Prevention and Health Promotion, Oral Health Programme, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland. Email:
[email protected] © 2003 FDI/World Dental Press 0020-6539/03/05289-10
During the past two decades, many industrialised countries have experienced a dramatic decline in dental caries prevalence of children and adolescents14. The reasons for the improved oral health are complex but may involve a more sensible approach to sugar consumption, improved oral hygiene practices, fluorides in toothpaste, topical fluoride application, effective use of oral health services and establishment of school-based preventive programmes510. In parallel with the changing oral disease patterns there have been significant improvements in oral health awareness, dental knowledge and attitudes of children and parents1113. Conversely, increasing levels of dental caries have been observed in several developing countries, especially for those countries where preventive programmes have not been implemented1416. In China, surveys of oral health status have been conducted in different provinces or local communities. Some variation in the occurrence of oral disease is found, for example in recent studies the mean dental caries experience of 12-year-olds was reported at 0.4 1.9 DMFT1722. The analysis of oral health habits, knowledge and atti-
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tudes of children was initiated in the late 1980s and these studies were carried out in some provinces among urban children19,22. However, such oral health behaviour data of children are scarce for rural population groups. Since the introduction of the national Love Teeth Day campaigns in 1988, a number of health education projects have been implemented at province and community-levels throughout the country. National oral health behaviour data are needed for national planning and evaluation of health promotion programmes and systematic analysis of oral health behaviour may help the specification of oral health messages as well as development of behaviour modification strategies relevant to China. Therefore, the second national oral health survey was designed in order to provide nation-wide information for the analysis of both oral health status and oral health knowledge, attitudes and behaviour of the Chinese population of ages 12, 18, 3544, and 6574 years. The results from the clinical investigation of oral health conditions have been described separately17,23. The purpose of this report is to describe the pattern of oral health behaviour, illness behaviour, oral health knowledge and attitudes among 12-year-old and 18-yearold Chinese at the national level; to analyse the oral health behaviour profile of the two age groups in relation to province and urbanisation, and to assess the relative effect of socio-behavioural risk factors on caries experience. Study population and methods
The present study is part of the 2nd comprehensive national oral health survey, which was completed in China in 199617. The study population and principles of sampling have been detailed in previous reports17,24. The participants of this survey were chosen by multistage International Dental Journal (2003) Vol. 53/No.5
stratified cluster random sampling involving 11 provinces and within each province the total number of 400 subjects of the WHO standard ages was identified from randomly selected schools. The schools were chosen from at least three locations in each province and district and in urban and rural areas, respectively. For the present study, the survey comprised 8,800 participants, i.e. 4,400 in each age group and the final sample was balanced by gender and urbanisation. Oral epidemiological data were collected by clinical examinations according to WHO methodology and criteria and all examiners were trained and calibrated to acceptable standard 17,24. Examinations were carried out in daylight. In addition, structured questionnaires were used for self-administration whereby the participants were asked about demographic background, oral health knowledge and attitudes, self-care practices, and utilisation of dental services. The questionnaires were filled out by the respondents themselves in the classroom and the data collection was supervised by survey staff specially trained for this activity. The supervisors had at least tertiary education level and they were carefully instructed in the rationality and meaning of questions. Prior to the data collection the questions were pre-tested among comparable groups of children in order to assess reliability and validity. In each province one dentist was in charge of the organisation of clinical examinations as well as administration of questionnaires. Processing of data was performed by use of EPI-INFO v5.0 (Chinese version) whereby data were checked for logical errors. The data entry took place in every province and the staff members were carefully trained on how to use the data input program. Double data entry was carried out. All questionnaires were collected from each province, checked for logical errors by use of EPI-INFO and the files were
then transferred to the National Committee for Oral Health in Beijing for central data analysis. The national data file was constructed by the Department for Epidemiology, Peking University, Faculty of Medical Science, Beijing. The data were finally converted for analysis by means of the Statistical Package for the Social Sciences (SPSS 10.0) in the WHO Collaborating Centre for Community Oral Health Programmes and Research, University of Copenhagen. Bivariate and multivariate analyses of the data on oral health knowledge, attitudes and behaviour were based on frequency distributions. The Chisquare test was used in the statistical evaluation of the bivariate frequency distributions. For the assessment of the relative effect of behavioural factors on dental caries experience, multiple dummy regression analysis and logistic regression analysis were performed. Dental caries experience index (DMFT) was the dependent variable in the dummy regression analyses. In the logistic regression model the dependent variable was represented by the dichotomous presence or absence of caries (i.e. DMFT=1 or more, or DMFT=0); thereby the regression coefficient indicates the Odds Ratio (OR=P/1-P) of caries. For the statistical evaluation of the regression coefficients, the t-test was used in the dummy regression whereas the Wald-test was chosen in the logistic regression. Results
Oral hygiene habits
Tables 12 summarise the findings concerning tooth brushing habits of 12- and 18-year-olds. No significant differences in tooth brushing behaviour were found according to gender. In all, nearly half of the respondents claimed to brush their teeth at least twice a day and such practice was reported more often in urban than in rural areas. The majority of children and adolescents brushed their teeth in the
291 Table 1 The percentages of 12- and 18- year-old Chinese according to frequency of tooth brushing, occasion of brushing, use of toothpaste and age of starting brushing in relation to urbanisation
Urban (n=2200)
12 years Rural (n=2200)
Total (n=4400)
Urban (n=2200)
18 years Rural Total (n=2200) (n=4400)
Frequency of tooth brushing seldom or no brushing brushing once a day brushing at least twice a day
7.2 33.7 59.1***
26.3 42.8 31.0
16.8 38.2 45.0
2.0 45.8 52.1***
9.5 54.9 35.6
5.8 50.3 43.9
Occasion of tooth brushing in the morning in the evening after meals after dessert/sweets
94.9 64.6*** 13.6 21.0
88.6 43.6 1.4 14.5
91.8 54.2 16.0 17.8
94.0 60.4*** 14.2 17.0
88.8 51.6 20.4 21.0
91.4 56.1 17.3 18.9
Use of toothpaste non-fluoridated fluoridated
77.3 22.7***
89.1 10.9
83.2 16.8
87.5 12.5***
92.6 7.4
90.0 10.0
Started brushing teeth before schooling when attending primary school after completing primary school
70.6 28.9 0.5
29.0 69.8*** 1.2
50.0 49.1 0.9
54.3*** 41.0 4.7
18.7 69.6*** 11.6
36.7 55.2 8.1
*** p
