Introduction
The kingdom of Saudi Arabia (KSA) is a relatively ‘young’ nation comprised of 13 provinces. Development in this nation has been rapid, with corresponding changes in the wealth and lifestyle of the population. By the year 2007, the population of Saudi Arabia was estimated at 27,601,038 and the population growth rate stood at 2.06% (MOC&I, 2007). The statistics presented in the same report indicated that people aged between 0-14 years contributed to an average of 38.2% of the total population in Saudi Arabia while those in the 15-64 years age bracket covered a total of 59.4%. In addition to this, the results of the last census show that the number of females (8.24364 million) citizens, constitute 49.9 percent of the total population.
According to statistics presented by the NCBI website, most humans in all regions of the world suffer in one way or the other from oral diseases such as dental caries and periodontal disease. Among teenagers worldwide, dental caries has been noted as the leading chronic disease that most affects this age group. Even though the disease has significantly decreased in developed countries, the situation is still worse in many developing countries. This is so due to a variety of factors including the consumption of foodstuff high in refined carbohydrates. The disease is known to have a multifactor nature comprising of social, cultural, behavioral, dietary, and biological factors which makes dental caries the most prevalent disease among schoolchildren in different parts of Saudi Arabia. An epidemiological survey conducted in 1987 (Oral Health Survey Phase I) on oral diseases presented a foundation for extensive research on the dental health status of the population in the central province of Saudi Arabia. According to the findings thereafter, it was noted that among the 12-year-old age group, 41.8% of the total population was free of dental caries in their permanent teeth. As such, the mean DMFT value for males was 1.61 while that of the female counterpart constituted 1.68 (ALShammery et al, 1991). The results of a study conducted 14 years after the aforementioned Survey of Saudi Arabia indicated that the presence of dental caries was commonplace among intermediate schoolchildren in Riyadh.
The sharp increase in oral diseases among adolescents could be attributed to the various changes that the population has gone through in terms of their way of life as well as the habits and behaviours of young Saudi children since the first survey in 1987. In addition, young people’s oral health is predominantly shaped by health behaviours and the impact of chronic and long-term conditions and is mediated by social inequalities including gender (Hawkins et al, 1999). Therefore, a study to examine the patterns of health behaviour among Saudi teenagers is required
The aim of this study is to describe the oral health status of 12-year old urban and semi-urban Lao schoolchildren and how oral health is linked to socio-behavioural risk factors. The purpose of this study shall be to better understand the factors that contribute to poor oral health schools. High prevalence rates of dental related diseases particularly among school age children in Saudi Arabia is a cause for alarm and direct attention is needed to come up with effective strategies and programs to prevent or alleviate the problem. This study seeks to assess the nutrition programs currently in place in the schools and the curriculum currently implemented. The importance of the paper is to address the significance of the issue of oral disease prevention today as well as come up with a feasible plan of action that can be implemented so as to alleviate the problem. The information provided by the study shall be useful to parents, educators, policy makers and even the students themselves. By being more aware of the problems at hand, implementation of better practices shall follow so as to contribute to the overall wellness and development of the students. The results obtained from the study shall be quantifiable and shall assist in the quest to significantly reduce the rate of oral health problems all the while protecting, promoting or maintaining the health of the individual within school children in Saudi Arabia.
Health behavior
While adopting good health behaviours have been known to be an effective tool in combating various diseases, many people still have not yet understood the importance of this aspect. Initiatives such as moderation of alcohol intake, not smoking, healthy eating and involvement in physical activity or exercise can reduce the risks of developing serious illnesses such as cancer, heart disease, type 2 diabetes dental caries and periodontal disease. However, promoting the adoption of healthier behaviour presents challenges, both at the individual and population levels. Gochman (1982) defines health related behaviour as;
“Overt behavioural patterns, actions and habits that relate to health maintenance health restoration and to health improvement” (92)
The initiation and maintenance of health behaviours result from an interaction of social, psychological, biological and environmental factors (Kuusela, 1997). Adolescents who brush their teeth more than once a day by 12 years of age are more likely to continue to do so throughout their teenage years (Levin and Currier, 2010). However, those who don’t and involve themselves in risky habits such as smoking and poor physical health head towards illnesses or premature deaths (WHO, 2003). For these reasons, adolescence is a crucial stage for the development of a healthy lifestyle.
There is also plenty of evidence to indicate that most health-risky behaviours is higher among those with lower levels of education and income (Lantz et al., 2006; Jarvis & Wardle, 2006; Lynch, Kaplan & Salonen, 1997; National Centre for Health Statistics, 1998). In addition to this, risk behaviours such as unbalanced diet, sedentary lifestyle, tobacco smoking, and hazardous alcohol drinking tend to cluster together within the same individuals.
Oral health behaviours
Europe
The majority of studies on oral hygiene behaviours in adolescents are cross sectional. However, there are some studies which recorded the oral hygiene behaviours of adolescents at different points in time during adolescents (Koerber et al, 2005).
On the other hand, 26% to 33 % of boy in Finland, Lithuania, and Russia attested to brushing their teeth more than once a day. Tooth brushing was less frequent among boys than among girls in all countries except in France where 61% of both boys and girls brushed their teeth twice a day. However, using dental floss was rare. More Canadian schoolchildren flossed their teeth daily than in other countries. Children in Hungary, Finland, and the Slovak Republic rarely flossed. Furthermore, 11 year old children as compared to those aged between 13-15 years were strongly associated with less than twice-a-day tooth brushing frequency in Canada, Finland, Hungary, Northern Ireland, Sweden, and Wales.
In Austria and in Lithuania, the situation was reversed (Kuusela et al, 1997). Rise et al (1991) claimed that Finnish, Norwegian and Swedish school children recorded a higher percentage of girls than boys in relation to brushing their teeth more than once a day. However, the proportion among girls increased as they grew older while that of the boys remained constant.
Figure1 presents the proportion of 11-year-olds brushing their teeth more than once a day from the 2001/02 Health Behaviour in School-aged Children (HBSC) survey. The average for all the HBSC countries is 56 per cent for boys and 67 per cent for girls. Wales (66%) is rated 13th overall, with levels similar to Scotland (65%) but less than England (72%).
Switzerland has the highest ratio of 11-year-olds brushing their teeth more than once a day at 84% and Malta has the lowest at 26%. In general, across HBSC countries, the difference between age groups is minor (62 % at age 11 and 63 % at age 15). Nevertheless, in regards to brushing their teeth more than once a day, girls were noted to do it significantly more than the boys. In Wales, 72 per cent of 11-year-old girls brush their teeth more than once a day, further increasing to 78 per cent at age 13 and 81 per cent at age 15. This is unlike the 59 per cent figure relating to the boys across all three age groups.
In regards to daily fruit consumption, Wales is rated 30th (of 35countries) overall. This rating is moderately lower than that in England and considerably lower than those in Scotland and Ireland. Portugal has the highest levels of daily fruit consumption at 55% overall. Greenland has the lowest at 23%.
Across all HBSC countries the proportion of young people reported to have been eating fruit every day tends to decline with age; an average of 38% of 11-year-olds eat fruits daily in comparison to 29% of 15-year-olds. Additionally, girls consume more fruits than boys. For instance, in Wales, 31 % of girls and 23% of boys report eating fruit every day at the age of 11, declining to 24 % and 19 %, respectively, at age 15.
On the other hand, Young people in the Flemish speaking region of Belgium are ranked the highest with 52 % eating vegetables daily compared to a low of 14 % in Spain. Wales is ranked 31st out of the 35 HBSC countries, with 20 % of 11-year-olds reporting that they eat vegetables every day. As per the frequency of fruit consumption, fewer young people in Wales report eating vegetables every day than their counterparts in England and Scotland.
Girls were more likely to report eating vegetables every day in all HBSC countries. In Wales, daily vegetable consumption increased slightly between the ages of 11 and 15 for both sexes (19 % to 22 % for boys and 22 % to 26 % for girls).
Israel has the highest proportion (52 %) of young people who consume soft drinks every day compared to a low of 6 % in Finland. In Wales, the proportion of young people preferring sugary soft drinks rises with age for boys from 33 % at age 11, 39 % at age 13 and 41 % at age 15. As for girls, consumption increases from 32 % at age 11 to 39 % at age 13 and then drops to 35 % at age 15. A similar pattern emerges in England and Scotland.
Koerber et al (2005) reported in his study that at least 80% of African –American teenagers reported tooth brushing at least twice daily and 98% reported brushing at least once daily. Only four percent reported brushing less than daily any time during the study. However, a substantial proportion (31%) reported brushing less than twice daily at least once during the period. Additionally, daily tooth brushing was greater in late 5th grade compared to 6th grade. The frequency of brushing less than twice daily declined from the 6th grade to the 7th.
the Far East
In Chinese schools, a study conducted indicated that an average of 22% of the children in the 12-year-old group brushed their teeth at least twice a day. However, 62% brushed once a day while 16% never brushed or brushed less frequently. The use of fluoridated toothpaste was confirmed by 42 percent of the children in this age group. Additionally, 20 % of 12 year old had seen a dentist within the past 12 months and 17% drink milk with sugar once a day (Petersen & Esheng, 1998). In 2001 Wong et al documented that 77% of Chinese children claimed that they brushed their teeth twice or more daily and almost all of the children (99%) said that they used toothpaste when they brush their teeth. Furthermore, the reported tooth brushing habit was better among the girls (61% twice or more daily) than boys. Toothpicks were commonly used by people in Hong Kong and Japan (Lind et al 1987; Chen et al, 1997).
Petersen et al (2001) conducted a study in Southern Thailand and found that 66% of the adolescents (12yrs) saw a dentist within the previous year and 24% of adolescents reported that visits were due to troubles in teeth. 88% claimed to brush their teeth at least once a day.
Africa
Blay et al (2006), claim that female adolescents in Ghana consumed more sugary snacks and sodas daily than their male counterparts. This was also the case for children with parents who have higher education levels. Varenne et al (2006) found that among adults, the use of chew sticks was often practiced for oral hygiene in urban as well as rural areas; tooth brushing with the use of toothpaste was also common in urban areas.
Meanwhile, the use of fluoridated toothpaste was very low and varied significantly by location and gender. The consumption of sugar-free products in the country is somewhat low but it appears to be higher in urban than rural areas. Dental visits were infrequent and mostly carried out for emergency care and tooth extraction.
The most common means of tooth cleaning is using a toothbrush. Dental floss and mouth rinse are also used either with tooth brushing as oral hygiene aid or as the main means for tooth cleaning. In different communities, alternative tools have been used for this purpose such as chewing sticks (Miswak).
In Africa for example, chewing sticks were found to be the most commonly used means for teeth cleaning (Omar and Pitts 1991; Clerehugh et al, 1995). The use of the ‘Miswak’ is also popular among people in Arab countries, India, and Pakistan.
the Middle East
The health behaviors of schoolchildren in Europe have been described in various parts of many surveys. However, little is known about the oral health behavior of children in Middle East countries (AL-Tamimi & Petersen, 1998). 31% of the children in Jordan reported having brushed their teeth at least twice a day.
In their study in Kuwait, Vigild et al (1999) found that 53% of 12-year-old children visited a dentist because of toothaches due to the consumption of sugary foods and drinks which was extremely high. Also, they found that children whose parents had higher education levels had visited a dentist within the last 12 months and frequently brushed their teeth while those whose parents had low levels of education brushed less often and rarely visited the dentist.
A study in Al-Hassa, Saudi Arabia indicated that only 24.65% of the students brushed their teeth more than twice per day, while 44.6% used ‘Miswak’ as an alternative method of dental cleaning. In Medina, a total of 61% of the adolescents reported having brushed their teeth at least once a day. 16 % of the surveyed population claimed to use the ‘Miswak’ chewing stick as a means of a dental cleaning (AL-Tamimi & Petersen, 1998).
Wyne & khan (1995) documented that in the 75% of school children in Riyadh who were using various canned products and packed fruit juices, 41% of children were not brushing their teeth. Chewing sticks were practiced by more than half of Saudi people (AL-Khateeb et al, 1990).
Almas et al (2003) found 7% of male intermediate school students (age 12-15 years) and 3% of females never cleaned their teeth. In secondary schools, 14% of male and 3.5% of female students never cleaned their teeth too. The daily oral hygiene habit was prevalent among 19% male and 20% female students in intermediate and 25.4% male and 19% female students in secondary schools.
A toothbrush was most commonly used by both male and female students at intermediate (28.9% male, 44.5% female) and secondary school (28.8% male and 63.7% female). The use of Miswak was less prevalent as compared to the toothbrush and was used by almost 24% of secondary school male students.
Furthermore, toothpaste was commonly used with a toothbrush in both groups of students. 11.3% of male secondary school students did not use anything with a toothbrush. Toothpaste was used with Miswak by 4% male and 11% female students in intermediate and 4.6% male and 8.3% female students in secondary schools.
Brushing teeth once a day was common among 42.6% male and 27.6% female at intermediate and 61.4% male and 26.8% female students at secondary schools. ‘Miswak’ was used more than 3 times a day by male students (53.1%) in intermediate and 55.8% in secondary schools. On the other hand, female students using ‘Miswak’ at least once a day was commonly ranging from 49.5%-55.2% respectively.
Risk behaviors
Risk behaviors such as smoking and drinking seem to be an important issue among adolescents. In the search for identity and autonym which is characteristic of adolescence; risk behavior frequently comes into play when young people experiment with limit and test capacities. There is a higher probability of being involved in risky behavior when bonds between the adolescent and their family or school environment are weak (Oetting & Donnermeyer, 1998).
These behaviors are influenced by factors relating to individual characteristics (such as maturation stage and coping strategies) and social environment (peer group or culture) (Di Clement, 1996). Findings from HBSC (2006) showed that daily smoking was least likely in England (5.1%), followed by Ireland (6.5%), Wales (6.7%), and Scotland (7.1%). Furthermore, girls (70.4%) were more likely than boys (4.5%) to report that they smoked daily; gender differences were significant among 13 and 15-year-olds in both Scotland and Wales, but not for any age group in England or Ireland.
Regarding age, there were significant differences between age groups in the percentages of young people that smoked daily, with 15-year-olds (13.7%) most likely to report daily smoking followed by 13-year-olds (4.5%) and 11-year-olds (0.7%). Significant age differences were found for both genders in each country
Oral and general hygiene behaviors
Poor personal hygiene is one of the ten leading behaviors risk factors contributing to the global burden of disease (Pruss et al, 2002). Promoting optimal hygiene behavior is important as they are cost-effective ways of reducing and preventing diseases. For instance, hygiene behaviors such as handwashing using soap significantly reduce the prevalence of diarrhea (Borghi et al, 2002).
There are similarities between the patterns of oral and general hygiene behaviors. The results of a recent study on hygiene behaviors of adolescents revealed that the common social and psychological factors, such as sex, alcohol affiliation, and smoking habits, were associated with tooth brushing and hand washing after toilet and before eating (Tran et al, 2006).
The similarities between patterns of oral and general hygiene behaviors and the fact that they both affect one’s health through prevention would suggest that these two behaviors are interrelated.
Studies have looked in detail at the relationship between oral and general hygiene behaviors. Dorri et al (2009), claim that among Iranian adolescents, there seems to be a significant correlation between general and oral hygiene behaviors. In addition, Hodge et al (1982) found a close association between tooth brushing and general hygiene among English adolescents from varying social backgrounds.
Young adults who brushed and flossed their teeth more frequently tended to perform handwashing more often after toilet use (Macgregor and Balding, 1987; Macgregor et al, 1997). Furthermore, a study conducted in Kenya confirmed the association between tooth brushing and personal hygiene habits among 14-17 year adolescents (Nzioka et al, 1993). Also, in Finland, a strong correlation between the frequency of tooth brushing and hand washing was noted (Pippola-Hatakka et al, 1992).
Curtis (2007) suggests that factors such as social, cultural, community influence are not the dominant ones for gender differences in hygiene practice and suggest that hygiene behaviors precede cultural acceptance of the practice. Therefore, there could be subtler motivations for hygiene behaviors. Contagion, grooming, religion, and order, whether intuitive or acquired by learning from others or self-experience, are possible explanations for cleanliness.
Some factors influence health behaviors and the following section reviews the influence of these factors among adolescents.
Factors influencing health behaviors
Gender
Dorri et al (2009), state that in terms of practicing apt oral hygiene and general hygiene, girls were significantly more likely to succeed than boys. For example, females brush their teeth more frequently than males do (Honkala et al, 1997). The data from the HBSC (2006) survey in Great Britain and Ireland demonstrate that girls were considerably more likely than boys to brush their teeth more than once a day. In Wales, 72% of 11year old girls brush their teeth more than once a day, increasing to 78 % at age 13 and 81% at age 15, compared to 59 % of boys across all three groups (11yrs, 13yrs, 15yrs).
Moreover, Maes et al (2006) state that boys have lower tooth brushing rates compared to girls, not only in Scotland but in all countries. The gender difference was large in Northern Ireland (25%), Hungary (20%), the Slovak Republic (19%), Finland (18%), and Poland (18%) and quite small in Sweden (5%), Denmark (8%), Norway (9%), and Latvia (10%).
Kuusela et al (1997) found that boys flossed more frequently than girls. There were significant differences between boys and girls in Canada (30% and 20% respectively), Norway (20 and 13% respectively), and Northern Ireland (18 and 11 %, respectively).
Regular use of dental services has been considered to be important health behavior. In particular, this means seeking preventive dental care well before symptoms appear. Females are usually more frequent users of dental care services than males (Honkala et al, 1997). On the other hand, leisure-time physical exercise is one of the health-related behavior that is typically more prevalent among men than women (Steptoe et al, 1997). For instance, a survey in Britain and Ireland (HBSC) reveal that boys were more likely to report being physically active and playing games on a computer or games console than girls (Brooks et al, 2006).
Health behaviors and social environment
Studies have shown that behavioral patterns are formed, influenced, and changed by social and societal conditions (Honkala, 1993). The immediate environment strongly predicts health behaviors; and the economic cultural process within the wider environment directly or indirectly influences the choices and decisions young people make concerning health behaviors (Kuusela et al, 1997).
The existence of socioeconomic inequalities in health has been well established (Lynch, 1997). Attempts to explain these inequalities have often referred to the fact that behavioral factors, such as smoking, physical activity, and diet are differentially distributed by socio-economic levels. Many studies in a variety of industrial countries have shown that smoking, poor dietary habit, and low amounts of physical activities are associated with depreciative socio-economic status (Lynch et al, 1997).
There is evidence of a moderately consistent pattern relating socioeconomic status with physical activity and fruit consumption, both of which confer health benefits in the short and longer-term (HBSC, 2006). Furthermore, a study conducted by lynch et al (1997) has shown that poor adult health behavior is related to a poor socio-economic status in life, low levels of education, and blue-collar employment.
Higher education status as inferred by high occupational status may explain the great incidence in health-promoting behavior of young people in less poor families (HBSC, 2006). These findings suggest that childhood, adolescents, and adulthood are all potentially important stages for attempts to alter the health-related behavioral profiles of adults. Dental visits correlate with the occupational and educational status of the parents in Finland (Honkala et al, 1997).
The high prevalence of major health risk behaviors among people of lower socioeconomic position accounts for much of their increased risk of negative health outcomes (Williams, 1990). In other words, a prominent hypothesis is thatdifferencese in personal health risk behaviors or lifestyle choices across socio-economic strata can largely explain observed socio-economic disparities in health (Macintyre, 1997). Young people with low family influence were, in general, more likely to report daily smoking and weekly consumption of beer, cider, and wine. Cannabis use was most consistent among boys in Ireland and girls in England (HBSC, 2006). Additionally, adolescences with low family affluence (10.3%) were more likely to report that they smoked daily compared to those with medium (6.3%) and high family affluence (5.1%). This was particularly clear among girls.
Social context
The life circumstances of young people are inevitably linked with their ability to establish and maintain good health, as well as navigate their exposure to health risk behaviors.
Parental behaviors
As well as socio-demographic factors, parental oral health behavior is a known predictor of oral health behaviors during adolescents Astrom&Jakobsen, (1996). Their study has provided practical support for the hypothesis that the dental health behavior of parents and their adolescent children is significantly associated, at least with the use of dental floss, tooth brushing, and consumption of nonsugared mineral water. This reveals that parents represent important social models for their children even at an age when they are particularly open to other socializing agents. There were no significant interactions with gender (of the adolescent), suggesting that parents are equally important models for both sexes. Nevertheless, according to the present results, conformity in adolescent and parental behavior appears to be more likely when parents are similar in their behaviors than when they are conflicting. Aside from parental behavior and socio-demographic factors, few other dimensions of the family and home environment have been studied about oral health behavior. Levin and Currie (2009) found mealtime routines and positive parent-child relationships are highly associated with the prevalence of twice-a-day tooth brushing.
Peers
Petraitis et al (1995) acknowledge that peers can contribute to the development of an individual’s identity through their influence on social norms and values. Such influence can extend to health behaviors. Almost every study that has examined the relationship between physical activity and social support has indicated a strong positive association using both cross-sectional and prospective study designs (Steptoe et al, 1997). There is also evidence that social support is more influential for women than it is for men (Steptoe et al, 1997). Voorhees (2005) found protective effects of behavior-specific social networks: adolescent girls who have more physical activities friends report higher activity levels themselves. The most recent comprehensive review of the literature on peers and adolescent smoking identified the number of friends who smoke as the single most commonly cited peer risk factor (Hoffman et al, 2006).
Aspects of peer relations other than peer smoking have less often been a research focus, even though the need for a more inclusive perspective on the role of peers in smoking etiology has been noted (Ennett et al. 2008; Kobus 2003). Both smoking and non-smoking aspects of peer relations need consideration. Examples of the latter include peer interaction, social status, and attributes of the larger peer networks in which friendships are embedded, all of which have been identified as having developmental significance for adolescents (e.g., Crosnoe 2000; Giordano 2003; Hartup 1996; Savin-Williams and Berndt 1990). The tracking data for physical activity and healthy food choices offer convincing evidence that students change their behaviors over time but that the change is relative to the behavior of their peers (Kelder et al, 1994). Understanding how the process of peer influence can contribute to both health risk and health promotion behaviors is likely to be of critical importance to the development of future effective health promotion policies (HBSC, 2006).
The rationale for this study
Growing concern over the long-term effects of unhealthy behaviors such as unhealthy eating and smoking among children and young people has highlighted the need to monitor young people’s health behaviors. Up to now, few studies are available on health-related behaviors of female Saudi schoolchildren in Riyadh. Additionally, all the studies available are focused on tooth brushing frequency, dietary habits, and dental attendance. However, there is no data available on risk behaviors or general behaviors among female schoolchildren in Riyadh.
Conclusion
That being said, the purpose of this study was to provide information on the current pattern of health behaviors among a sample of female school children aged 12 -18 years in Riyadh. The results from this study will be valuable in several ways. First, it will help in developing and implementing an oral health promotion program. Also, the result will be used to compare the health behaviors of female schoolchildren in the region with the health behaviors of similarly aged schoolchildren in other regions or countries.
Moreover, trying to investigate the various factors that influence the health behaviors among the young generation may prove to be useful towards the development of concrete and efficient policies on the same in Riyadh.