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The oral health-related lifestyle of Vancouver inner city elementary school-aged children Shoajei, Azadeh 2013

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THE ORAL HEALTH-RELATED LIFESTYLE OF VANCOUVER INNER CITY ELEMENTARY SCHOOL-AGED CHILDREN  by  Azadeh Shojaei D.D.S, Isfahan Azad Dental University, 2003  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in The Faculty of Graduate Studies (Craniofacial Science) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) March 2013 © Azadeh Shojaei, 2013  Abstract  Objectives: To describe the oral health-related lifestyle of Vancouver inner city elementary school-aged children and relate different aspects of their oral health-related lifestyle with demographic and socioeconomic factors. Methods: This cross-sectional study used a structured questionnaire with some open-ended items to survey 424 school-aged children in Vancouver inner city elementary schools (53.3% boys and 46.7% girls). There were two versions of the questionnaire: the shortened version was used for grades 1-3 and included only multiple choice questions while the comprehensive version for grade 4-7 comprised both structured and openended questions. In the questionnaire, different items were used such as ordinal, interval and qualitative to acquire information about different aspects of oral health-related knowledge, attitudes and behaviours. Results:  Overall, there was a deficiency in oral-health related  knowledge and corresponding behaviours in all age groups and both genders. Thus awareness about oral health in this cohort of children needs to be improved. The oral health-related lifestyle did not differ between boys and girls except for the interdental cleaning behaviour (P=0.033). Oral health-related lifestyle did not differ according to socio-demographic characteristics except for the difference in consumption of sugar-containing drinks among age groups (P<0.001). The diet-related knowledge differed between children born inside and outside Canada (P<0.050). Conclusion: Oral health-related knowledge, attitudes and behaviours among elementary schoolaged children in inner-city Vancouver areas was deficient and professional guidance from oral health care workers concerning oral health self-care was lacking. There were no distinct socioeconomic or demographic differences in lifestyle factors among the inner city Vancouver schoolaged children.  ii  Preface The present cross-sectional survey was conducted in Vancouver inner-city elementary schools. To start the project, Behavioural Research Ethics Board approval (Certificate number: H1100621) has been received from the University of British Columbia. To facilitate the communication and subsequent collaboration with principals of inner city Vancouver elementary schools, the Support Letter was obtained from Vancouver School Board (Appendix 3).  iii  Table of Contents Abstract .................................................................................................................................................... ii Preface ..................................................................................................................................................... iii Table of Contents.................................................................................................................................. iv List of Tables .......................................................................................................................................... vi Acknowledgements ............................................................................................................................ vii Chapter 1. Introduction....................................................................................................................... 1 1.1 Literature Review .......................................................................................................................... 2 1.1.1 Social Determinants of Oral Health Behaviour ................................................................ 3 1.1.2 Child-related Determinants of Oral Health Behaviour ................................................. 4 1.1.3 Social Determinants of Child’s Oral Health Behaviours ............................................... 5 1.1.3.1 Individual socio-economic status (SES) ............................................................................................ 5 1.1.3.2 Relationship between parents’ lifestyle and their children’s lifestyle ....................................... 6 1.1.3.3 Area-based socio-economic status ...................................................................................................... 7 1.1.3.4 Family affluence ..................................................................................................................................... 9  1.1.4. Gender Differences in Oral Health-related Lifestyles................................................. 10 1.1.5. Family’s Influence ................................................................................................................... 10 1.1.5.1 Culture ................................................................................................................................................... 13 1.1.5.2 Diet habits ............................................................................................................................................. 14  Chapter 2. The Study’s Rationale, Aims and Hypotheses ...................................................... 16 2.1 Rationale ......................................................................................................................................... 16 2.2 The Study Aims ............................................................................................................................. 17 2.3 Study Hypotheses ......................................................................................................................... 17 Chapter 3. Material and Methods .................................................................................................. 18 3.1 Study Design and Sampling Framework .............................................................................. 18 3.2 Developing The Questionnaire ............................................................................................... 19 3.2.1 Questions about Family Structure ...................................................................................... 19 3.2.2 Questions about Family’s Wealth ....................................................................................... 20 3.2.3 Questions about Family’s Demographics ......................................................................... 20 3.2.4 Questions about Oral Health-related Knowledge ......................................................... 21 3.2.5 Questions about Oral Health-related Behavior ............................................................. 21 3.2.6 Question items about oral health-related attitudes and beliefs .............................. 22 iv  3.3 Pre-testing the Questionnaires ............................................................................................... 23 3.4 Data Collection .............................................................................................................................. 23 3.5 Data Analyses ................................................................................................................................ 24 Chapter 4. Results ............................................................................................................................... 27 4.1 Univariate Descriptive Statistics ............................................................................................ 27 4.1.1 Distribution of Children According to Behavioural Variables ................................. 27 4.1.2 Distribution of Children According to Diet-related Knowledge .............................. 30 4.1.3 Distribution of Children According to Demographic Characteristics .................... 33 4.1.4 Children’s Knowledge, Attitudes, Beliefs and Behaviours ......................................... 35 4.2 Bivariate Inferential Statistics ................................................................................................ 37 4.2.1 Oral-health-related Knowledge According Socio-demographic Characteristics ................................................................................................................................................................... 37 4.2.2 Oral-health Knowledge – Comparisons Between Boys and Girls ............................ 52 4.2.3 Oral Health-related Behaviour – Comparisons Between Boys and Girls .............. 53 Chapter 5. Discussion......................................................................................................................... 54 5.1 Main Study Findings and Their Comparison with Other Studies ................................ 54 5.1 Advantages and Limitations of The Study ........................................................................... 61 5.2 Implications of The Present Study ......................................................................................... 62 5.3 Conclusions .................................................................................................................................... 64 References ............................................................................................................................................. 65 Appendices ............................................................................................................................................ 81  v  List of Tables Table 3.1 Operationalization of the dependent variables………………………………………25 Table 3.2 Operationalization of the study variables (independent variables)………………….26 Table 4.1 Children distribution according to behavioural variables………………………..28-29 Table 4.2 Children distribution according to diet-related knowledge ……………………...31-32 Table 4.3 Sample distribution according to demographic characteristics…………………..33-34 Table 4.4 Self-reported data regarding children’s knowledge, attitudes, beliefs and behaviours………………………………………………………………………..……………..36 Table 4.5 Diet knowledge according socio-demographic characteristics …………………38-41 Table 4.6 Consumption of sugar containing drinks according to socio-demographic characteristics……………………………………………………………………………….43-46 Table 4.7 Consumption of sugar-containing food items according to socio-demographic characteristics……………………………………………………………………………….48-51 Table 4.8 Diet knowledge –comparisons between boys and girls……………………………...52 Table 4.9 Oral self-care – comparisons between boys and girls……………………………….53  vi  Acknowledgements I am greatly indebted to my supervisor, Dr. Jolanta Aleksejuniene, Assistant Professor, DDS, MSc, PhD, Division of Preventive and Community Dentistry, Faculty of Dentistry, University of British Columbia, for her expertise, supervision, constructive criticism, challenging comments and constant support throughout my study. She has been more than a supervisor for me, and her deep knowledge, comprehensive experience, and her continuous encouragement made my research possible.  I am also grateful to my committee members: Dr. Karen Gardner, Clinical Associate Professor, DMD, MEd, FCP, Division of Operative Dentistry, Faculty of Dentistry, University of British Columbia and Dr. Elizabeth Saewyc, Professor, PhD, RN, PHN, School of Nursing, University of British Columbia, for all their support and help during my research process. Their insights have added considerably to my graduate experience. I am also thankful to them for devoting their valuable time to reviewing my work.  I am deeply grateful to Dr. Negar Salimipour, DDS, PhD candidate in University of British Columbia, for her friendly and voluntary cooperation. Her efforts in data collection stage were of great value to me.  My warm thanks and gratitude go to Ms. Clare Davies, Department Assistant, Faculty of Dentistry, University of British Columbia, for editing my thesis.  I also thank my mother; father, other family members and friends for their support, which made it more pleasant and easier to complete my Master of Craniofacial Science program.  I can never thank enough my dear husband, Reza for his love, support, and encouragement. Without his patience and continuous encouragement, my research could have never been completed.  vii  Chapter 1. Introduction About inner city Inner city refers to the older and more populated and usually poorer central section of a city. As a general definition inner city is a general term for impoverished areas of large cities which is characterized by minimal educational opportunities, high unemployment rate, broken families and inadequate housing (The American Heritage New Dictionary of Cultural Literacy, 2005). Vancouver Inner City school allocation was established in 1988 to provide support and services to children who face difficulties to success at school for economic and related social reasons. The purpose of the Inner City Schools Program was to provide additional resources to designated schools in order to facilitate equitable educational outcomes for all students (Vancouver Board of Education, 2009). According to Vancouver School board, Vancouver School District 39 is a large, urban and multicultural school district that includes some of the most affluent and impoverished urban neighbourhoods in the country providing programs to 56,000 students in Kindergarten to Grade 12 (Vancouver School Board, assessed June 2012). This school district consists of a total of 75 Elementary schools, including 16 elementary annexes and 11 inner-city schools. The present study focused on children from seven inner-city elementary schools: Florence Nightingale, Britannia, John Henderson, Queen Alexandra, Tillicum, Mount Pleasant and Grandview elementary schools.  1  1.1 Literature Review Oral health is a part of general health and affects quality of life. Oral health, similarly to the broad definition of health, can be defined as not only an absence of disease, but also includes functional aspects and social and psychological well-being (WHO, 1998). Oral health allows an individual to speak, socialize and eat without any discomfort (WHO, 2003). Oral diseases may result in general health problems, low self-esteem, dental anxiety and poor quality of life (WHO, 2003). It is important to emphasize that poor oral health affects the growth, development, and well-being of children and consequently has a significant impact on their later life (GuarnizoHerreño, & Wehby, 2012) as well as it can have a detrimental effect on children’s performance in school and their success in later life. Self-reported problems with teeth have been associated with poor school performance among children ((David et al., 2006; Guarnizo-Herreño, & Wehby, 2012). Children who suffered from oral diseases were 12 times more likely to have restricted-activity days, including missing school, than those who did not have oral problems (US GAO, 2000). Biological, physical, environmental, behavioural and lifestyle-related factors have been considered as determinants of oral health (Eriksen et al., 2006; Selwitz et al., 2007). Lifestyle in its broader definition is an integrated system of attitudes, values, opinions and interests as well as behaviours (Berkman & Gilson's, 1978). In the narrower definition, "Lifestyle has been defined as a distinctive mode of living that is defined by a set of expressive, patterned behaviors of individuals occurring with some consistency over a period of time” (Elliott, 1993). Health-related lifestyle refers to behaviours that have been shown by epidemiological and other health research to predict disease or health (Irvin, 1990). This definition of lifestyle has also been used in a report of 'The Health of Canadians' and implied that lifestyles are the result of choices made by individuals (Lalonde, 1974). The lifestyle of an individual is seen as the result of an 2  aggregate of decisions made by the person him- or herself, decisions over which the person has considerable control. In addition, it has been shown that environmental and social factors influence health behaviours, even in affluent societies, and there are factors over which the individual person has limited or no control (Eaton et al., 2004). Oral health-related lifestyle (knowledge, beliefs, attitudes, behaviours, etc.) has been related to oral health. Oral health knowledge is considered to be an essential prerequisite for health-related behaviour (Carneiro et al., 2011). An association between knowledge and behaviour (Tolvanen et al., 2012) and between knowledge and oral health have been extensively reported (Hamilton & Coulby, 1991; Lateefat S et al., 2012). In the study by Oliveira et al. (2000), third grade schoolchildren without knowledge were twice as likely to have caries experience as compared to children having oral health-related knowledge. Evidence has also shown that oral health knowledge and positive attitudes towards it related to good oral care practices (Oliveira et al., 2000). Thus, oral health education helps to improve oral health care practices (Cialdini et al., 2005; Sgan-Cohen, 2008), i.e. if the knowledge about how to maintain oral health is properly transmitted and adopted, oral diseases can be prevented (Rodrigues et al., 2009).  1.1.1 Social Determinants of Oral Health Behaviour Understanding the factors influencing health is critical for health professionals to deliver effective treatments and prevention of diseases (Daly et al., 2002). Health behaviours have been related to social, economic, and environmental factors (Sheiham & Watt, 2000). Social determinants of health including lifestyle, social support, and socio-economic, family-related, cultural, and environmental factors determine general health (Dahlgren & Whitehead, 1992; Dahlgren, 1995) as well as oral health of individuals and populations (Petersen, 2005b; Newton 3  & Bower, 2005). Consequently, sustainable improvements in a population’s health and reduction in health inequalities can be achieved by addressing the social determinants of disease (Watt, 2005). Biological and behavioural factors as well as the social support offered by family, friends, and the community at large may determine an individual’s oral health (Dahlgren & Whitehead, 1992). Social support may be created in a child’s everyday environment e.g. their home and school (Moysés & Rodrigues, 2006). For children, parents have been identified as the most important source of social support (Wigen & Wang, 2012). Different child- and parent-related determinants of oral health and behaviour have been identified (Wickrama et al., 1999; Poutanen et al., 2007).  1.1.2 Child-related Determinants of Oral Health Behaviour Oral health status and oral health related-lifestyle have been related, e.g. a positive association between frequency of tooth brushing and personal hygiene was observed among adolescents (Dorri et al., 2009). Similarly, tooth brushing less than twice a day and/or frequent sugary snacking were found as important predictors of caries in children (David et al., 2005; Levine et al., 2007; Vaganas et al., 2009; Hietasalo et al., 2012). In Finnish children, oral disease-related behaviours at the age of three years were associated with having dental caries at the age of 10 years (Matilla et al. 2005b). In contrast, some other studies found no relationship between a child’s oral health behaviour and his/her dental health (Okada et al., 2002; Bruno-Ambrosius et al., 2005). Oral health knowledge was related with twice-daily tooth brushing among 12- to 22- year-old students in Sudan (Darout et al., 2005); a similar association was observed in British adolescents (Freeman et al., 1993). It has been shown that  4  third grade schoolchildren with insufficient oral health knowledge were twice as likely to have caries as compared to children having oral health-related knowledge (Oliveira et al., 2000).  Other health-related behaviours have also been associated with children’s oral health. In Swedish female teenagers dental caries has been related with missing breakfast and having irregular meals (Ambrosius et al. 2005). Källestål et al. (2002) found that reasons for performing oral health behaviours change as children reach adolescence, e.g. emotional factors such as aesthetic values seem to increase in importance with age, whereas cognitive factors such as knowledge become less important. A combination of oral health-related behaviours has been suggested to form an oral health-related lifestyle (Aleksejuniene et al., 2002). It has been shown that frequent ingestion of sugar containing snacks was related to less frequent tooth brushing (Rajala et al., 1980). Twice-daily tooth brushing has been related to regular use of dental floss among adolescents (Macgregor et al., 1998; Honkala et al., 2007).  1.1.3 Social Determinants of Child’s Oral Health Behaviours 1.1.3.1 Individual socio-economic status (SES)  Individual socioeconomic status is commonly conceptualized as a combination of three SES indicators: education, occupation and income (Kent & Croucher, 1998). Professionals with the highest level of education and income are usually considered as a high SES group and unskilled workers as a low SES group (Kent & Croucher, 1998). Sociologists have documented the social patterning of disease and have found a strong association between an individual’s SES and his or her health (Bruce G. Link & Jo Phelan, 1995). 5  Socioeconomic disparities in health remain strong despite reductions in acute infectious diseases (Wilson, 2009). This means that individuals with higher SES have at their disposal a broad range of flexible and multi-purpose resources that can be used to the advantage of their health, including knowledge, money, power and social connections (Link & Phelan, 1995). These same resources aid in the successful treatment of diseases (Wilson, 2009). For example, higher SES individuals as compared to lower SES individuals tend to have greater access to medical care and resources and consequently these resources help them to make adequate treatment decisions (Lutfey & Freese, 2005).  Socioeconomic differences consistently have been associated with risk behaviours, especially insufficient tooth brushing and use of sweet snacks (Honakala, 1993; Kuusela et al, 1999). Children’s poor oral health has been associated with the family’s low socio-economic status (Källestål & Wall, 2002; Peterson, 2005) as well as parents’ poor oral health-related behaviours (Matilla et al., 2005a; Okada et al., 2002).  Although the differences in oral health behaviours have lessened over time among Finnish children, boys from low socioeconomic groups with poor school performance still have the poorest oral hygiene practices in Finland (Östberg et al, 2002; Fizgerald et al., 2004). Similar gender differences have been observed in other European countries (Kuusela et al., 1997b).  1.1.3.2 Relationship between parents’ lifestyle and their children’s lifestyle  Ample evidence has shown that parental oral health-related knowledge, beliefs, and attitudes influence oral health and oral health behaviours of their children (Okada et al., 2001; Szatko et 6  al., 2004; Poutanen et al., 2007). Unfavourable oral health behaviour has been identified among children who had mothers with low-skill occupations (Poutanen et al., 2005) and low levels of education (Verrips et al., 1993; Rajab et al., 2002). In a cross sectional study of 4315 children aged three to 15 years caries was higher in children whose parents had low levels of education (Hjern et al., 2001). US report suggests that people from some ethnic minorities often have poor oral health status (US Department of Health and Human Services, 2000; Sabbah et al, 2009). It has been mentioned in a study done by Fisher-Owens, et al. (2012), that Hispanic and nonHispanic-Black people showed poor oral health status compared to non-Hispanic White people.  1.1.3.3 Area-based socio-economic status  In addition to an individual SES–based health deprivation, area-based social inequalities have been identified. There is ample evidence demonstrating that people living in socially disadvantaged environments have poorer health than their better-off counterparts (US Department of Health and Human Services, 2000). Area-based socioeconomic status reflects the socioeconomic context in which people live beyond their individual SES background (Sanders et al., 2006). However, it is important to consider that area-based socio-economic measurements tend to underestimate the effects of individual socioeconomic variation, and assume that measured social characteristics are stable and homogeneous within a specific socio-economic area (Sanders et al., 2006). Area-based SES is an important concept as people with lower SES tend to reside in certain neighbourhoods, e.g. inner city Vancouver, while their higher SES counterparts cluster in more wealthy areas, e.g. Vancouver West. This geographical distinction in residence may bring differences in area-based socio-economic inequalities, e.g. higher SES areas may have shops 7  with healthier food choices, safer and healthier environments, which are more conducive to health than what may be found in low SES geographic areas where the majority of poor and less educated families live. A review was done on existing explanations for the relationship between socio-economic status and unhealthy behaviours (Fred et al., 2010). In focusing on the mechanisms that account for the relationships between SES and health behaviours, studies from sociology, economics, and public health were considered which provided insight into the sources of health inequalities (Fred et al., 2010). These studies reported that SES disparities in health behaviour involve more than freely chosen individual lifestyles, i.e. unhealthy behaviours result from vast differences in social circumstances (Fred et al., 2010). Social environments may produce influence in health lifestyles that affect multiple behaviors e.g. oral hygiene, exercise, and diet (Cockerham, 2005). An example for that could be schools with health promotion program. Consequently, health or risk behaviours and the social environment surrounding them may increase health disparities (Wilson, 2009). Well-educated people are more likely to self-report their oral health as very good, more likely to have visited a dentist regularly and less likely to visit a dentist only when a specific problem arises than are less educated people (Australian Research Centre for Population Oral Health 2006). Unsurprisingly, oral health knowledge, attitudes and behaviour as well as oral health status have been closely linked to differences in SES. For example, children from high SES groups tended to have more positive attitudes, behaviours and oral health knowledge than their socially disadvantaged counterparts (Beal, 1989). Concomitantly, children from low SES families living in high SES neighbourhoods may receive a positive health impact from their high  8  SES neighbourhoods e.g. they can acquire health knowledge and behaviours through peer communication (Beal, 1989). 1.1.3.4 Family affluence  In adults, SES is usually measured by income, education or occupation. Most often, the SES of a parent or head of a household has also been used to identify the SES of adolescents. However, data on family SES can be difficult to collect from young children because they do not know or are not willing to disclose such information resulting in a non-response on parental occupation varying from 20% to 45% as reported by various studies (Currie et al., 1997; Wardle, Robb, & Johnson, 2002; Molcho et al., 2007). When the family affluence scale (FAS) was introduced for the first time it was used in a national context only and contained three items: whether a family had a car and a telephone and whether each child had a separate bedroom (Currie et al. 1997). Later on, this scale was revised and used cross-nationally and it was comprised of the following items: whether a family had a car and a separate bedroom for each child as well as the number of vacations a family had taken and the number of computers at home (Due et al., 2005). The FAS has been utilized in different ways and it has been employed over the last 10 years to explain socioeconomic inequalities in a wide range of health indicators while studying health behaviours in school-aged children (the HBSC study) (Currie et al., 2008). By using data from children who were able to report on parental occupation, a consistent association between the FAS score and parental social class was found which validated the FAS scale (Wardle et al., 2002). It has been shown that children with lower FAS scores consumed more soft drinks and ate more high-sugar foods compared with children who presented with higher FAS scores (Inchley et al., 2001). The high FAS also has been shown to be a predictor of frequent tooth brushing (more than once a day) and visiting the dentist regularly (Maes et al., 2006).  9  1.1.4. Gender Differences in Oral Health-related Lifestyles In general, girls have more favourable attitudes and behaviors towards oral health than boys (Östberg et al., 1999; Jimenez, R et al., 2011) and gender related differences in oral health knowledge have also been observed (Freeman et al., 1993; Östberg et al., 1999; Kuusela et al., 1997; Currie et al., 2000; Rajab et al., 2002; Farsi et al., 2004; Maes et al., 2006; Joshi et al., 2005; Källestål et al., 2006). Differences between genders also exist regarding the consumption of sugar-containing foods; e.g. girls have reported using sugary snacks and soft drinks less frequently than boys (Honkala et al., 1982; Freeman et al., 1993; Ahmed et al., 2007). Nonetheless, in terms of sugar consumption a Norwegian study found that the gender disparities observed among adolescents levelled off as the adolescents reached adulthood (Åstrøm & Samdal, 2001). In Sweden and Finland a diet associated with high risk for caries was more common among boys than among girls (Källestål et al., 2000; Poutanen et al., 2005). In contrast, other studies reported more frequent consumption of sweets and soft drinks among girls than among boys (Lian et al., 2010; Okullo et al., 2003).  1.1.5. Family’s Influence The family is a key social organization having the primary responsibility for the proper development of a child (Åstrøm, 1998; Pine et al, 2000). Adoption of consistent behavioural habits in childhood is established at home with parents, especially the mother, being the primary model for a child’s behaviour (Blinkhorn, 1981). Socialization to oral health behaviours may be considered a modelling process in which children imitate the behaviour of their parents (Bandur, 1986). Through primary socialization, a growing child learns the norms, values, and behaviours usually from his/her parents, the group in which 10  he/she is raised (Tuckett, 1980). Similarly to health behaviours, risk behaviours in children may also be family-based. For example, parents’ smoking habits, alcohol consumption, and fat intake have been associated with the corresponding behaviours of their children (Rossow & Rise, 1994). In terms of oral health habits, the associations between parents and their children have been clearly demonstrated (Vanagas et al., 2009). They demonstrated that parents with good own oral hygiene skills significantly more often understood the importance of brushing their children’s teeth. Several authors have emphasized the importance of acknowledging multi-directionality in family influences on establishment of health behaviors in children. Whereas parents provide initial opportunities for socialization for their children into oral health behaviors, it is widely recognized that parents might also be reciprocally be influenced by their children, especially their older ones (Snyder and Purdy, 1982). The similarity in oral health behaviors between parents and their offspring extending well into the adolescence has been observed (Honkala et al., 1983). Parents’ ability to effectively facilitate oral care in their children is one of the key elements that determine formation of positive oral behaviours in children (Syrjala et al., 1999). The association between a child’s oral health status and parental education (usually that of the mother) has been examined. These studies have shown that a child’s caries experience is high if parents (particularly the mother) are less educated. In general, highly educated people have established positive dental health behaviours, such as lower sugar consumption, more frequent tooth brushing, and routine visits to the dentist as compared to their less educated counterparts (Broughton, 2000; National Advisory Committee on Health and Disability, 2003). To a child’s health detriment, some parents use sugar-containing items as rewards (Hwang, 2008). Sugar-containing products are of lower cost than healthy snacks. Due to their lower cost 11  and the parents’ lack of health knowledge, unsurprisingly, lower income families tend to use sugar-containing products that are convenient for them both economically and emotionally (Hwang, 2008).  One of the factors leading to parents inadvertently contributing to oral health problems in their children is that accommodating oral health routines in the family’s daily life may be difficult. This may be especially true for lower income, single parent households where the primary financial support comes from one parent working long hours, which limits the amount of time left for supervision of a child’s behaviours (Hwang, 2008). Many studies have demonstrated that parental modeling and parental attitudes have a significant impact on the establishment of oral health habits in children (Pine et al., 2000; Adair et al., 2004). In addition, parents’ health-related attitudes, knowledge, and their own health status have been related to their children’s oral health behaviours and consequently to their children’s oral health. In an international study conducted in 17 countries, parental attitudes were associated with a child’s tooth brushing behaviours (Adair et al., 2004). In terms of intergenerational transmission (culture-based carrying-on influences) of health-risk behaviours, it has been shown that fathers’ lifestyles related to boys’ lifestyles, and mothers’ lifestyles associated to girls’ lifestyles (Wickrama et al., 1999).  A child’s tooth brushing and inter-dental cleaning behaviours have been correlated with the corresponding behaviors of their parents, especially of their mothers (Okada et al., 2002). It has been reported that a mother’s oral health-related behaviours such as proper oral self-care, active supervision of their child’s oral care, and positive attitudes towards oral health in general had a strong influence on the child’s tooth-brushing behaviour and his/her oral health (Okada et 12  al, 2001; Mahejabeen et al, 2006). Scottish parents with health-focused beliefs/attitudes about their child’s tooth-brushing behaviour had children who brushed their teeth twice a day (Pine et al., 2000). To understand child’s behaviours, it is essential to study the oral health-related behaviour of children as well as that of their parents. Adair et al. (2004) found that the most significant predictors of children’s oral health-related behaviours were parents’ attitudes towards monitoring their children’s tooth brushing and sugar-snacking habits. They suggested that parental attitudes significantly influence the establishment of healthy habits in children. Fukuda et al., (2011) demonstrated significant similarities between parents and their children in terms of use of dental floss, tooth brushing and drinking non-sugary drinks. It is important to consider that parents who lack personal oral health care habits are poor role models for their children, i.e. oral health care is a learned behaviour and if a parent or caregiver does not practice oral self-care, children are not likely to practice oral self-care either (Broughton, 2000).  1.1.5.1 Culture  Culture is often defined as coherent, shared patterns of actions or beliefs specific to certain groups of people, defining behavioural norms and interpersonal relationships (Strauss, 1990). Culture organizes norms of family life and thus cultural beliefs and practices may act as facilitators or barriers to accessing health care services (Strauss, 1990). Being part of a cultural minority group does not inevitably mean poor oral health (Riedy et al., 2001; Hilton et al., 2007). It does suggest, however, that there may be certain cultural beliefs and practices common to people in certain cultural groups that may influence their oral health status, e.g. the value placed on maintaining healthy primary teeth or expectations about preventive or  13  therapeutic activities. Consequently, cultural factors may have important implications for an individual's own health and those of others for whom they provide care, such as children (Riedy et al., 2001; Hilton et al., 2007). It is important to note that among, and within, ethnic groups there are substantial differences in beliefs and behaviours, which can lead to varying health status. Worldwide, there are numerous distinct ethnic minority and cultural groups and these cultural groups tend to maintain their beliefs, including health beliefs, after their migration to Canada (Ember M & Ember CR, 2001). Ethnic groups might have their own set of beliefs and attitudes towards oral health care, therefore it is important to understand cultural beliefs, values and practices (Ember M & Ember CR, 2001). A survey in ethnic minority subpopulations in England (Gould, 2001) found that children from some ethnic minority groups, especially Pakistani and Bangladeshi children, were less likely to have ever visited a dentist. Of these ethnic minorities, the individuals who visited a dentist were more likely to do so because of existing dental problems rather than from any motivation to seek professional help for preventive reasons (Gould, 2001). Epidemiological studies have suggested that Asians living in Britain, particularly children, have a poor oral health-related lifestyle (Bedi et al., 2000).  1.1.5.2 Diet habits  Poor diet has been frequently associated with the aetiology of dental caries at any age, especially, among school children (Hooley et al, 2012; Watt & Rouxel, 2012). For young children who are unable to make independent decisions, diet is determined by family values, traditions and lifestyle (Petersen, 2003).  14  In recent years, there has been a trend among school-aged children to have irregular meal times and to engage in unhealthier snacking (Vereecken et al., 2004). High consumption of sweets and soft drinks is common among school children in many European countries (Vereecken et al., 2004). In the Middle East, consumption of sugar-containing foods and drinks is also high (Vigild et al, 1999; Sayegh et al., 2005) and is more frequently observed among boys than girls (Ahmed et al., 2007). Hupkens et al., (1998) demonstrated that a mother’s high socio-economic status related to her children having a healthy diet enriched by a low intake of sweets, soft drinks, chips and white bread.  15  Chapter 2. The Study’s Rationale, Aims and Hypotheses  2.1 Rationale During the transition from childhood to adolescence, health behaviours are formed (Kuusela et al., 1997b; Kwan et al., 2012). Pre-adolescence and adolescence have been shown to be a period when health education is important as much biological and psychological development occurs during this time (Durward & Wright, 1989). Adolescence is also a period of intense psychological changes, where cognitive development is rapid and beliefs developed in this stage of life will influence an individual’s future life (Declerck , 2009). During pre-adolescence and adolescence, young people acquire health-related attitudes and behaviours that carry over into adulthood. It has been shown that patterns of tooth brushing (Kuusela et al., 1997a), physical activity and diet behaviour are established during childhood and adolescence and such patterns remain relatively stable throughout later life (Kelder et al., 1994), e.g. individuals who brushed their teeth more than once a day at the age of 12 years tended to maintain this behaviour through adolescence. Similarly, dietary habits are also established during adolescence (Sweeting & Anderson, 1994). A number of studies have examined the oral health knowledge and behaviours of children from low income areas (Lim et al, 2008; Koerber et al., 2006; Bedi et al., 2000; Hamilton & Coulby, 1991); however no studies had been done on the children residing in the low income areas of Vancouver. The inner city of Vancouver comprises areas where families with low income and from many ethnic groups reside (Vancouver School Board, assessed June 2012). Available evidence about inner city populations from other countries has demonstrated that inner city children are form a high-risk population (Laher, 1990; Canadian International Development Agency, 1998; Toronto District Health Council, 1999) and so a relatively high prevalence of oral disease might be expected. Therefore, the inner city of Vancouver might be an area where 16  children as well as their parents might have a poor oral-health lifestyle. Moreover, there have been no previous studies about oral health-related research about this age group in British Columbia. It is therefore unclear whether the family structure and SES status of Vancouver’s inner city schoolchildren relate to these children’s oral health-related knowledge, attitudes and behaviours.  2.2 The Study Aims  The aims of the present study were: 1) to describe the oral health-related lifestyle of elementary school-aged children attending Vancouver’s inner-city schools 2) to relate different aspects of the oral health-related lifestyle with demographic and socioeconomic factors.  2.3 Study Hypotheses 1) Children from higher SES families have a better oral health-related lifestyle as compared to children from lower SES families. 2) Oral health-related knowledge, beliefs, attitudes and behaviors differ between boys and girls.  17  Chapter 3. Material and Methods  3.1 Study Design and Sampling Framework The present study was approved by the University of British Columbia Research Ethics Board (H11-00621) and by the Vancouver School Board. The present cross-sectional survey was conducted in seven of Vancouver’s eleven inner-city elementary schools. The pre-selected schools comprise culturally and ethnically diverse communities and have high rates of immigrant children (Vancouver School Board, assessed June 2012). The following inner city Vancouver elementary schools participated in the present study: Florence Nightingale, Britannia, John Henderson, Queen Alexandra, Tillicum, Mount Pleasant and Grandview. We approached the parents or guardians of inner city Vancouver school children to obtain informed parental consent for the study. A total of 424 out of 820 children were recruited (the response rate 52%). Then, all school children with parental consents were asked to complete a comprehensive questionnaire comprising 60 items and to take another questionnaire comprising 68 items home for their parents. The questionnaire for children (grades 1-3) was abbreviated to consider the developmental level of children at this age, thus this questionnaire included only simple multiple-choice questions. After multiple reminders, only 68 parental questionnaires were returned, i.e. the return was rate 16 %.  18  3.2 Developing The Questionnaire Most of the questionnaire items were pre-selected from previously validated questionnaires from a number of studies (World Health Organization, year, Kawamara & Takase, 2008; Ernesto, 2007; Poutanen & Lahti, 2005). In order to accommodate the present audience, some of the questionnaire items were revised. The questionnaire was designed to be administered anonymously and included both structured and open-ended questions concerning different aspects of oral health or disease related lifestyle. The questionnaire included inquiries about the following themes: (a) demographic information, (b) socio-economic status, (c) oral hygiene practices, (d) dietary habits, (e) knowledge, attitudes and practices related to oral health and (f) self-assessment of oral health status. After the questionnaires were developed, they were tested in a pilot study and then revised accordingly. A few duplicate questions were included in the questionnaire to test for reliability. Reliability was measured by employing Cohen’s Kappa and values ranging from 0.72 to 0.77 for different questionnaire items. Given the targeted audience of young children, an internal reliability of 70% or more was considered satisfactory.  3.2.1 Questions about Family Structure This section included inquiries about a child’s family structure and the ethnicity of his/her parents/guardians. The measurements for this section were designed on nominal variables. The children were asked about their family structure, i.e. about the number of family members they lived with. The structured answers for this inquiry were: mother, father, stepmother, stepfather, siblings, grandparents or other family members living with them (Children were asked to specify). The ethnicity questions included seven structured answers: Aboriginal, Chinese, European, Filipino, Vietnamese, Indian and other. 19  3.2.2 Questions about Family’s Wealth The Affluence Scale (FAS) was chosen to measure a family’s wealth. The questions for this section were taken from the HBSC (Health Behaviour in School-aged Children) WHO Collaborative Cross- National Study in Adolescent Health Study (Currie, 1998). The present study measured each child’s SES based on principles of the FAS with some small modifications. From the aforementioned study, we pre-selected relevant items which were nonsensitive, simple to answer and relevant to current Canadian economic circumstances. The measurements in this section were on nominal variables and the following questions were included: “number of cars in a family” and “child’s having or not having own bedroom”.  3.2.3 Questions about Family’s Demographics This part consisted of six questions and inquired about age, gender, parent’s/guardian’s ethnicity, job, family income and parents’ education. The measurements in this section were either on nominal variables or had open-ended answers (qualitative measurements). The grouping into low, medium or high socio-economic status groups was done qualitatively based on socio-economic status measures (separate bedroom for child, number of cars in family, whether parents working or not and what kind of job parents have) and consensus between two examiners, e.g. a child will be allocated into a high SES group if he/she has a separate bedroom, the family has two or more cars and at least one of the parents has a professional job.  20  3.2.4 Questions about Oral Health-related Knowledge This section comprised both structured (ordinal and interval variables) and open-ended questions. The open-ended questions were chosen in order to avoid leading questions and subsequently to reduce the measurement bias. Examples of open-ended questions (qualitative measurements):   What do you think causes “rotten teeth”?    How do you clean between your teeth?  Examples of ordinal variable measurements: “How often do you brush your teeth”? The structured answers were: never, not every day, once a day, twice a day, after every meal. Other ordinal item measurements included inquiries regarding the frequency of consumption of different sugar-containing food items and drinks. These questions were taken from a similar study (Hamilton & Coulby, 1991; Heft et al., 2003). An example of an interval response measurement: “A child should stop brushing if gums bleed” The question was taken from a similar previous study (Zhu et al., 2003) with some modifications. The child is asked to place a mark on a line labelled with ‘completely wrong’ at one end and ‘completely true’ at the other end.  3.2.5 Questions about Oral Health-related Behavior Questions included inquiries about brushing activity such as frequency of brushing and dietary habits such as frequency of consuming sugar-containing foods or drinks (Heft et al., 2003; Hietesalo et al., 2008). Ordinal items were chosen.  21  Example of an ordinal variable measurement: How often do you brush your teeth?” The structured answers were: never, not every day, once a day, twice a day or more, and after every meal. The interval response measurements were designed employing the Visual Analog Scale (VAS). For example, the child read the statement “I take good care of my teeth” and answered by placing a mark on a 100 mm line where one end is labeled with ‘never’ and the other end is labeled ‘always’. For more examples, please refer to the Appendix 1.  3.2.6 Question items about oral health-related attitudes and beliefs This section included inquiries about attitudes and beliefs; the questions for this section were taken from a previous study by Poutanen & Lahti, (2005). Subsequently, some modifications to both questions and answers were made. In order to collect more accurate information and subsequently enable parametric statistics, the responses for these inquiries were designed on a VAS instead of the original ordinal variable measurements. The questionnaire items (statements) assessed participants’ attitudes, beliefs about oral hygiene practices and attitudes about dentists and regular dental visits. VAS–based questions had answers ranging from ‘completely wrong’ to ‘very true’ and included the following statements: “People, who take good care of their teeth, do not have toothaches.” “If I do not see a dentist often my teeth will rot.” “Brushing teeth helps to stop teeth from being yellow.” “When one tooth is rotten, other teeth will rot too.”  22  3.3 Pre-testing the Questionnaires In the pilot study, the questionnaires were first peer-reviewed for content validity and revised accordingly. Next, in May 2011, a pilot study with 25 children at one of the elementary schools (Grandview Elementary) was done in order to test for the questionnaires’ readability and absence of ambiguity. In addition, as the questionnaires included some questions to be answered on a VAS, it was important to test the response and be sure that the children understood how to answer the questions using this method. The pilot study showed that, when the VAS was explained, the children did not have any problems answering the questions in this way. After the pilot study was completed, the questionnaires were revised where required. In order to simplify the wording for children, some revisions were necessary.  The final revised  comprehensive questionnaires including mainly structured and some open-ended questions are presented in the Appendix 1. Subsequently, the study protocol was prepared and the data collection began.  3.4 Data Collection Data was collected in two periods: May 2011 to the end of June 2011 and from September 2011 to the end of January 2012. Data has been gathered by a trained research team (all dentists). The questionnaires were administered in ordinary classroom settings and our team supervised all school-aged children participating in the present study during completion of the questionnaire. Younger children, i.e. grades one to three, were assisted individually by one team member to fill out the questionnaire. In order to avoid report bias, teachers were not allowed to help children complete the  23  questionnaires. In order to reduce information bias due to missing answers, all questionnaires were checked for missing answers prior to releasing the child.  3.5 Data Analyses All analyses were performed employing the SPSS 18.00 software. Univariate analyses (desriptive statistics) were used to report frequency distributions regarding different study variables. Bivariate analyses (inferential statistics) were employed to test whether oral healthrelated lifestyle is associated with socio-demographic characteristics (Chi-square or Fisher’s Exact Test and independent sample t-test).  24  The study variables are presented in Tables 3.1 and 3.2 Table 3.1 Operationalization of the dependent variables Dependent variables  Operationalization What is dental floss used for? Open ended question.  Knowledge about oral hygiene  Reasons for tooth decay. Open ended question Should stop brushing if gums bleed. A Visual Analog Scale (VAS) from never to always. Water is bad for the teeth. No (0) Yes (1)  Knowledge about diet  Juice is bad for the teeth. No (0) Yes (1) Milk is bad for the teeth. No (0) Yes (1) Tooth brushing frequency: Never (0), Not daily (1), Once a day (2), Twice a day (3), After every meal (4).  Brushing behaviour  Diet behaviour  Attitudes/Beliefs  Diet behaviours. Frequency of taking any of the following: candy, chocolate, soft drinks, cakes or muffins. Never (0), Less than once a week (1), 1-2 times a week (2), 3-6 times a week (3) and every day (4). Only a dentist can stop cavities in teeth. A VAS from completely wrong to very true. I take care of my teeth. A VAS from completely wrong to very true. I brush my teeth to make my parents happy. A VAS from completely wrong to very true.  25  Table 3.2 Operationalization of the study variables (independent variables)  Variable  Operationalization of a variable  Gender  Boy (1), Girl (2)  Years lived in Canada  Number of years lived in Canada  Family members a child lives with  Mother (1), Father (2), Stepmother (3), Stepfather (4), Brother (5), Sister (6), Other (7).  Ethnic groups  Aboriginal (1), Chinese (2), European (3), Filipino (4), Vietnamese (5), Indian (6), Other (7). No (0), Yes (1).  A child has his/her own bedroom Number of cars family has  The number of cars a family owns.  Family Socioeconomic Status  Father/Guardian work? No (0) Yes (1) Mother/Guardian work? No (0) Yes (1)  26  Chapter 4. Results 4.1 Univariate Descriptive Statistics 4.1.1 Distribution of Children According to Behavioural Variables Table 4.1 shows the distribution of children according to oral health-related behaviour, such as the frequency of tooth brushing, history of the last dental visit, frequency of eating and drinking sugarcontaining items and cleaning between teeth. Only a small proportion of children did not brush their teeth every day and the majority of children brushed their teeth at least once a day. Regarding the last dental visit, more than half of the children visited a dentist during the last year, but around one third of them did not know or did not remember when their last dental visit was. Only 8.0 % of children reported that they never drank juice; almost one fourth of them drank juice every day and more than half of the children reported that they drank juice less than once a week or only 1-2 times a week. More than one third of children never drank Coca Cola, Pepsi or Slurpee, while one third of them drank these cariogenic drinks less than once a week. A few of them (4.7%) drank them every day. Regarding the consumption of candies, chocolate and sweets, only a few of the children never ate these items.  27  Table 4.1 Children distribution according to behavioural variables Study Variables  Number  %  424  100  Not every day  11  6.3  Once a day  117  22.9  Twice a day  40  66.0  After every meal  7  4.0  Last year  256  57.8  More than one year ago  23  5.2  Does not know/does not remember  164  37.0  8  4.6  Less than once a week  43  24.6  1-2 times a week  55  31.4 16.6  3-6 times a week  29  Every day  40  Total number of children Frequency of brushing  Last dental visit  Frequency of drinking juice Never  22.9  Frequency of eating candy/chocolate/sweets Never  31  7.4  Less than Once a week  118  28.1  1-2 times a week  155  36.9  3-6 times a week  63  14.9  Every day  53  12.6  28  (Continued) Table 4.1 Children distribution according to behavioural variables Study Variables  Number  %  44  10.4  Less than once a week  166  39.2  1-2 times a week  118  27.8  3-6 times a week  55  13.0  Every day  40  9.4  136  32.2  141  33.4  97  23.0  28  6.6  20  4.7  5  2.9  61  34.2  109  62.3  Frequency of eating cookies/cakes/muffins Never  Frequency of drinking Coca cola/Pepsi/Slurpee Never Less than once a week 1-2 times a week 3-6 times a week Every day  Cleaning between teeth No Yes, always Yes, sometimes  29  4.1.2 Distribution of Children According to Diet-related Knowledge Table 4.2 presents the distribution of children according to oral health-related knowledge. The structured answers related to consumption of different food items were as follows: “yes”, no” and “do not”. Of all, 95% of children stated that water is good for teeth, but 5% believed that water is bad for teeth. Almost half of children reported that juice is not bad for their teeth. The majority of children reported that milk is not bad for teeth and 87% of them considered soft drinks to be bad for teeth. Children from grades 4-7 also were also asked about other food items. The majority of them (91%) reported that candy bar is not good for teeth, and very few (6%) reported it to be good for teeth. Of all, 8% of children reported popcorn as good for teeth, while the majority (92%) reported it either as bad for teeth or did not know whether it is good or bad for their teeth. When children were asked about “nuts” almost 27% of them reported that nuts are not good for teeth, 30% did not know whether nuts are good or bad for teeth and 43% stated that nuts are good for teeth. More than half of the children reported that raisins are good for teeth, while 22% stated that they are not good for teeth and one fourth of them did not know if raisins are good or bad for teeth. Half of the children reported cheese to be good for teeth, while almost 20% stated that cheese is not good for teeth and the rest of the children did not have any knowledge about whether cheese is good or bad for teeth.  30  Table 4.2 Children distribution according to diet-related knowledge Study Variables  Number  %  424  100  No  403  95.0  Yes  21  5.0  No  203  48.0  Yes  220  52.0  No  55  13.0  Yes  368  87.0  No  360  85.1  Yes  63  14.9  No  80  18.9  Yes  95  22.4  No  117  27.6  Yes  57  13.4  No  159  90.9  Yes  10  5.7  Does not know  6  3.4  No  126  72.0  Yes  14  8.0  Does not know  35  20.0  Total number of children Water is bad for teeth  Juice is bad for teeth  Soft drinks are bad for teeth  Milk is bad for teeth  Coffee w/o sugar is bad for teeth  Tea w/o sugar is bad for teeth  Candy bar is good for teeth  Popcorn is good for teeth  31  (Continued) Table 4.2 Children distribution according to diet-related knowledge  Study Variables  Number  %  No  47  26.9  Yes  75  42.9  Does not know  53  30.2  No  38  22.0  Yes  93  53.4  Does not know  43  24.6  No  33  18.9  Yes  94  53.7  Does not know  48  27.4  No  76  43.4  Yes  47  26.9  Does not know  52  29.7  No  124  70.9  Yes  23  13.1  Does not know  28  16.0  No  20  11.4  Yes  138  78.9  Does not know  17  9.7  Nuts are good for teeth  Raisins are good for teeth  Cheese is good for teeth  Muffin is good for teeth  Ice cream is good for teeth  Fruits are good for teeth  32  4.1.3 Distribution of Children According to Demographic Characteristics Table 4.3 illustrates the sample distribution according to demographic characteristics. Of all the children (n=424), 53% were boys and 47% were girls. The children were divided into three age groups; 32% were six years old, 27% were 7-8 years old and 41% were between 9 to 13 years old. The majority of children were born in Canada. Of all, around 40% of the children came from families of four family members and one third of them were from households consisting of five or more people. The assessment of a child’s socio-economic status was based on the joint assessment of the following aspects: parent’s employment, the child having a separate bedroom and the number of cars in the family (Table 4.3). Table 4.3 Sample distribution according to demographic characteristics Study Variables  Number  %  424  100  Boy  226  53.3  Girl  198  46.7  6 years  134  31.6  7-8 years  116  27.4  9-13 years old  174  41.0  No  91  24.6  Yes  278  75.4  Total number of children Gender  Age groups  Born in Canada  33  (Continued) Table 4.3 Sample distribution according to demographic characteristics Ethnicity Aboriginal  19  8.4  Chinese  22  9.7  European  24  10.6  Filipino  47  20.8  Vietnamese  29  12.8  Indian  36  15.9  Other  49  21.7  Number  %  2-3 people  115  27.4  4 people  162  38.4   5 people  144  34.2  No  71  16.9  Yes  350  83.1  No  111  26.3  Yes  311  73.7  No  241  56.8  Yes  183  43.2  No Cars  98  23.4  One Car  208  49.8  Two or more Cars  112  26.8  Study Variables Household size  Socio-economic status Father employed  Mother employed  Child has a separate bedroom  Number of cars in a family  34  4.1.4 Children’s Knowledge, Attitudes, Beliefs and Behaviours Table 4.4 describes the children’s answers regarding their knowledge, attitudes, beliefs and behaviours. There was a wide range of answers to the majority of inquiries with a minimum of “0%”, i.e. no agreement to a maximum of “100%” denoting a complete agreement with the oral health-related lifestyle-related statement. The majority of children considered themselves to be from families of middle wealth, measured on a scale from “0%” (poorest) to the “100%” (richest) as they marked around the 50% mark. There was a strong belief among the children that brushing teeth helps to avoid cavities (mean = 90%), people who take good care of teeth do not have toothaches (mean=77%) and that people who brush their teeth have good breath (mean=78%). There was no self-reported impediment to the oral health related quality of life as the majority of children did not consider their oral health to be a problem, i.e. children did not avoid talking (mean=19%) or smiling (mean=30%) because of any problems with their teeth. However, a common erroneous belief, was found in that only 5% of the children were completely  certain  that  one  should  not  stop  brushing  if  one’s  gums  bleed.  35  Table 4.4 Self-reported data regarding children’s knowledge, attitudes, beliefs and behaviours Questionnaire Items  Min-Max  Mean ± SD*  Child compares own family financial status with other families  0-100  51.5±16.5  People who take good care of teeth do not have toothaches  0-100  76.8 ±26.4  Child takes good care of his/her teeth  9-100  77.1±20.9  Child takes good care of teeth so his/her mouth feels clean  0-100  74.2±27.7  Child brushes teeth because he/she wants to smell good  0-100  59.3±33.8  If a child doesn’t see a dentist often, his/her teeth will rot  0-100  61.9±33.1  Child should stop brushing if gums bleed  0-100  47.7±35.5  Child brushes teeth to make parents happy  0-100  52.8±37.0  Child brushes teeth to be liked by friends  0-100  37.8±36.9  Child avoids smiling because of teeth  0-100  30.2±31.6  Child avoids talking because of teeth  0-100  18.8±28.0  There are people with good or bad teeth no matter what they do  0-100  40.6±34.6  People who brush teeth have good breath  0-100  77.6±26.5  Brushing teeth helps to avoid cavities  37-100  90.1±15.2  Brushing helps teeth from being yellow  0-100  88.2±20.9  People who brush look better  0-100  66.0±32.8  Child can avoid rotten teeth  0-100  67.3±32.9  When one tooth is rotten, the other teeth will rot too  0-100  47.3±33.3  Only a dentist can stop cavities  0-100  50.8±39.1  * 0% most negative answers  100% most positive answer)  36  4.2 Bivariate Inferential Statistics 4.2.1 Oral-health-related Knowledge According Socio-demographic Characteristics Table 4.5 presents information about the children’s knowledge of how diet relates to oral health in relation to their socio-demographic characteristics. Overall, there were only a few significant differences. There was a statistically significant difference between the knowledge of children born in Canada as compared to children born outside Canada; the latter did not have adequate knowledge about the detrimental effect to teeth of muffins and ice cream (P< 0.05).  37  Table 4.5 Diet knowledge according socio-demographic characteristics Demographic characteristics  Are these good for your teeth?* Candy %  Popcorn %  Nuts %  Raisins %  Cheese %  Muffins %  Ice cream %  Fruits %  Yes  no  dnk  yes  No  dnk  yes  no  Dnk  yes  no  dnk  Yes  no  dnk  yes  No  dnk  yes  no  dnk  yes  no  dnk  5.4  90.2  4.3  7.6  70.7  21.7  56.6  25.3  18.1  56.0  18.7  25.3  56.5  19.6  23.9  25.0  46.7  28.3  15.2  64.1  20.7  78.3  14.1  7.6  6.1  91.5  2.4  8.5  73.2  18.3  50.0  24.4  25.6  50.0  25.6  24.4  50.0  18.3  31.7  28.0  40.2  31.7  11.0  78.0  11.0  79.3  8.5  12.2  Gender Boys Girls  P= 0.779  Chi square#  P= 0.843  P= 0.535  P=0.535  P= 0.513  P= 0.690  P= 0.116  P= 0.347  Age group 7-8 years  16.7  66.7  16.7  8.3  66.7  25.0  33.3  33.3  33.3  50.0  3.33  16.7  33.3  33.3  33.3  25.0  58.3  16.7  16.7  66.7  16.7  75.0  16.7  8.3  9-13 years old  4.9  92.6  2.5  8.0  72.4  19.6  43.6  26.4  30.1  53.7  21.0  25.3  55.2  17.8  27.0  27.0  42.3  30.7  12.9  71.2  16.0  79.1  11.0  9.8  P= 0.006  Chi square  P= 0.899  P= 0.774  P= 0.564  P= 0.274  P= 0.493  P= 0.924  P= 0.836  Born in Canada No  7.3  85.4  7.3  7.3  73.2  19.5  39.0  36.6  24.4  37.5  32.5  30.0  58.5  19.5  22.0  14.6  61.0  24.4  22.0  53.7  24.4  80.5  7.3  12.2  Yes  4.7  92.9  2.4  7.9  71.7  20.5  44.9  23.6  31.5  59.1  18.9  22.0  52.8  18.1  29.1  30.7  38.6  30.7  11.0  75.6  13.4  78.7  12.6  8.7  P= 0.258  Chi square#  P= 0.982  P= 0.257  P=0.051  P= 0.668  P= 0.031  P= 0.028  P= 0.554  Ethnicity Aboriginal Chinese European  6.7  86.7  6.7  73.3  0.0  26.7  33.3  26.7  40.0  73.3  13.3  13.3  66.7  6.7  26.7  26.7  40.0  33.3  6.7  73.3  20.0  73.3  6.7  20.0  0.0  100.0  0.0  75.0  18.8  6.3  75.0  12.5  12.5  75.0  25.0  0.0  62.5  12.5  25.0  25.0  50.0  25.0  12.5  87.5  0.0  87.5  12.5  0.0  7.7  92.3  0.0  76.9  15.4  7.7  46.2  38.5  15.4  61.5  30.8  7.7  46.2  53.8  0.0  30.8  53.8  15.4  7.7  92.3  0.0  69.2  7.7  23.1  *dnk” do not know; # Chi square or Fisher’s Exact Test  38  (Continued) Table 4.5 Diet knowledge according socio-demographic characteristics Demographic characteristics  Are these good for your teeth?* Candy %  Popcorn %  Nuts %  Raisins %  Cheese %  Muffins %  Ice cream %  Fruits %  Yes  no  dnk  yes  No  dnk  yes  no  Dnk  yes  no  dnk  Yes  no  dnk  yes  No  dnk  yes  no  dnk  yes  no  dnk  Filipino  2.6  94.7  2.6  71.1  5.3  23.7  34.2  23.7  42.1  28.9  28.9  42.1  50.0  15.8  34.2  23.7  44.7  31.6  10.5  71.1  18.4  84.2  7.9  7.9  Vietnamese  12.5  83.3  4.2  66.7  4.2  29.2  45.8  20.8  33.3  58.3  8.7  21.7  58.3  16.7  25.0  25.0  41.7  33.3  16.7  62.5  20.8  83.3  12.5  4.2  3.4  96.6  0.0  69.0  13.8  17.2  44.8  27.6  27.6  51.7  17.2  31.0  51.7  17.2  31.0  31.0  34.5  34.5  10.3  72.4  17.2  86.2  3.4  10.3  7.5  85.0  77.5  75.0  5.0  20.0  37.5  35.0  27.5  50.0  25.0  25.0  50.0  20.0  30.0  27.5  45.0  27.5  20.0  60.0  20.0  67.5  22.5  10.0  Ethnicity  Indian Other  P= 0.685  Chi square#  P= 0.502  P= 0.324  P=0.021  P= 0.193  P= 0.995  P= 0.537  P= 0.257  Household size 2-3 people  10.2  79.6  10.2  10.2  61.2  28.6  49.0  30.6  20.4  55.1  28.6  16.3  55.1  22.4  22.4  26.5  44.9  28.6  12.2  73.5  14.3  77.6  16.3  6.1  4 people  3.3  95.1  1.6  8.2  72.1  19.7  37.7  36.1  26.2  53.3  21.7  25.0  59.0  18.0  23.0  32.8  42.6  24.6  16.4  73.8  9.8  78.7  9.8  11.5   5 people  4.6  95.4  0.0  6.2  80.0  13.8  43.1  15.4  41.5  52.3  16.9  30.8  47.7  16.9  35.4  21.5  43.1  35.4  10.8  66.2  23.1  80.0  9.2  10.8  P= 0.012  Chi square  P= 0.289  P= 0.029  P= 0.387  P= 0.455  P= 0.595  P= 0.320  P= 0.666  Father works No  6.7  90.0  3.3  10.0  66.7  23.3  36.7  36.7  26.7  31.0  34.5  34.5  33.3  20.0  46.7  20.0  43.3  36.7  16.7  66.7  16.7  70.0  16.7  13.3  Yes  5.6  91.0  3.5  7.6  72.9  19.4  44.4  24.3  31.3  58.3  18.8  22.9  57.6  18.8  23.6  27.8  43.8  28.5  12.5  71.5  16.0  81.3  10.4  8.3  Chi square#  P= 0.972  P= 0.781  P= 0.376  P= 0.024  P= 0.023  P= 0.569  P= 0.812  P= 0.384  *dnk” do not know; # Chi square or Fisher’s Exact Test  39  (Continued) Table 4.5 Diet knowledge according socio-demographic characteristics Demographic characteristics  Are these good for your teeth?* Candy %  Popcorn %  Nuts %  Raisins %  Cheese %  Muffins %  Ice cream %  Fruits %  Yes  no  dnk  yes  No  dnk  yes  no  Dnk  yes  no  dnk  Yes  no  dnk  yes  No  dnk  yes  no  dnk  yes  no  dnk  No  10.0  87.5  2.5  7.5  75.0  17.5  45.0  25.0  30.0  59.0  23.1  17.9  62.5  15.0  22.5  27.5  40.0  32.5  17.5  67.5  15.0  75.0  10.0  15.0  Yes  4.4  91.9  3.7  8.1  71.1  20.7  42.2  27.4  30.4  51.9  21.5  26.7  51.1  20.0  28.9  26.7  44.4  28.9  11.9  71.9  16.3  80.0  11.9  8.1  Mother works  P= 0.394  Chi square#  P= 0.886  P= 0.940  P= 0.534  P= 0.446  P= 0.868  P= 0.649  P= 0.431  Own bedroom No  4.0  92.9  3.0  8.1  69.7  22.2  43.4  21.2  35.4  57.1  16.3  26.5  54.5  12.1  33.3  22.2  43.4  34.3  13.1  68.7  18.2  80.8  9.1  10.1  Yes  7.9  88.2  3.9  7.9  75.0  17.1  42.1  34.2  23.7  48.7  28.9  24.7  52.6  27.6  19.7  32.9  43.4  23.7  13.2  73.7  13.2  76.3  14.5  9.2  P= 0.514  Chi square  P= 0.693  P= 0.098  P= 0.136  P= 0.015  P= 0.177  P= 0.660  P= 0.539  Number of cars No Cars  11.8  85.3  2.9  8.8  70.6  20.6  38.2  35.3  26.5  52.9  20.6  26.5  52.9  17.6  29.4  26.5  41.2  32.4  14.7  73.5  11.8  73.5  5.9  20.6  One Car  4.5  90.9  4.5  10.2  65.9  23.9  45.5  23.9  30.7  54.0  21.8  24.1  56.8  15.9  27.3  27.3  40.9  31.8  12.5  71.6  15.9  77.3  14.8  8.0  3.8  94.2  1.9  3.8  82.7  13.5  40.4  26.9  32.7  51.9  23.1  25.0  50.0  23.1  26.9  26.9  48.1  25.0  13.5  67.3  19.2  84.6  9.6  5.8  Two or more cars  *dnk” do not know; # Chi square or Fisher’s Exact Test  40  (Continued) Table 4.5 Diet knowledge according socio-demographic characteristics Demographic characteristics  Are these good for your teeth?* Candy % Yes  no  Popcorn % dnk  yes  P= 0.470  Chi square#  No  dnk  P= 0.315  Nuts % yes  no  Raisins % Dnk  P= 0.767  yes  no  dnk  P= 0.998  Cheese % Yes  no  dnk  P= 0.867  Muffins % yes  No  dnk  Ice cream % yes  P= 0.906  no  dnk  P= 0.918  Fruits % yes  no  dnk  P= 0.111  SES groups Lowest  9.0  87.6  3.4  6.7  75.3  18.0  42.7  28.1  29.2  51.1  25.0  23.9  48.3  21.3  30.0  28.1  41.6  30.3  16.9  67.4  Middle  2.8  93.3  4.2  8.5  66.2  25.4  40.8  25.4  33.8  57.7  15.5  26.8  59.2  16.9  23.9  22.5  47.9  29.6  7.0  77.5  Highest Chi square#  15.7 15.5  73.0  14.6  12.4  83.1  8.5  8.5  93.3  6.7  0.0  20.0 0.0  100  P= 0.344  0.0  13.3  80.0  6.7  P= 0.426  53.3  26.7  20.0  P= 0.842  46.7  33.3  20.0  P= 0.499  60.0  13.3  26.7  P= 0.689  40.0  33.3  26.7  P= 0.678  20.0  60.0  P= 0.345  P= 0.309  *dnk” do not know; # Chi square or Fisher’s Exact Test  41  Table 4.6 shows the children’s consumption of sugar-containing drinks in relation to their sociodemographic characteristics. Only a few statistically significant differences were found; namely there was a statistically significant difference among different age groups in terms of drinking cariogenic drinks such as Coke, Pepsi or Slurpee. Around half of the 6-year-olds, one third of the 7-8 year-olds and 15% of the 9-13 years old children never drank Coke/Pepsi/Slurpee (P<001). Regarding the frequency of drinking juice, almost half of the 6-year-olds and one third of the 7-8 years olds reported that they drank juice every day, while among 9 -13 year-old children, one out of five, drank juice everyday (P<001).  42  Table 4.6 Consumption of sugar-containing drinks according to socio-demographic characteristics  Consumption of sugar-containing drinks Demographic characteristics  Coke/Pepsi/Slurpee % never Less than once a week  Juice %  1-2 times/week  3-6 times/week  everyday  never  Less than once a week  1-2 times/week  3-6 times/week  everyday  Gender Boys  32.2  30.5  24.2  7.2  5.9  6.3  16.0  26.9  15.1  35.7  Girls  33.5  36.4  21.1  5.3  3.8  7.7  15.8  28.2  20.1  28.2  P= 0.505  Chi square#  P= 0.423  Age group 6 years  52.6  18.0  16.5  6.8  6.0  8.2  7.5  20.9  17.2  46.3  7-8 years  34.5  30.2  25.0  6.0  4.3  6.0  14.7  34.5  13.8  31.0  9-13 years old  15.0  47.4  26.6  6.9  4.0  6.3  24.1  30.5  19.0  20.1  P<001  Chi square  P<001  Born in Canada No 33.3  31.2  21.5  10.8  3.2  6.3  14.7  25.3  22.1  31.0  31.6  34.2  23.0  5.6  5.6  5.9  17.4  29.3  16.1  31.3  Yes  Chi square#  P= 0.417  P= 0.694 43  (Continued) Table 4.6 Consumption of sugar-containing drinks according to socio-demographic characteristics  Consumption of sugar-containing drinks Demographic characteristics  Coke/Pepsi/Slurpee % never Less than once a week  Juice %  1-2 times/week  3-6 times/week  everyday  never  Less than once a week  1-2 times/week  3-6 times/week  everyday  Ethnicity Aboriginal  41.5  17.1  24.4  14.6  2.4  4.9  17.1  22.0  17.1  39.0  Chinese  30.6  36.7  20.4  4.1  8.2  12.2  14.3  32.7  12.2  28.6  European  40.8  32.4  12.7  7.0  7.0  8.3  18.1  19.4  19.4  34.7  Filipino  33.7  30.6  29.6  2.0  4.1  6.1  19.4  31.6  14.3  28.6  Vietnamese  21.7  41.7  20.0  11.7  5.0  10.0  11.7  25.0  15.0  38.3  Indian  32.7  26.9  25.0  7.7  7.7  3.8  5.8  28.8  21.2  40.4  29.9  40.3  24.7  3.9  1.3  3.8  19.2  32.1  21.8  23.1  Other Chi square#  P= 0.090  P= 0.525  # Chi square or Fisher’s Exact Test  44  (Continued) Table 4.6 Consumption of sugar-containing drinks according to socio-demographic characteristics  Consumption of sugar-containing drinks Demographic characteristics  Coke/Pepsi/Slurpee %  Juice %  Never  < once a week  1-2 times/we ek  3-6 times/week  everyday  never < once a week  1-2 times/week  3-6 times/week  everyday  2-3 people  36.1  29.5  23.0  7.4  4.1  7.3  17.1  30.1  14.6  30.9  4 people  34.7  34.7  21.0  5.7  4.0  5.7  16.5  22.7  19.3  35.8   5 people  28.1  34.0  24.8  6.5  6.5  7.8  13.6  32.5  16.9  29.2  Household size  P= 0.819  Chi square#  P= 0.604  Father works No  37.5  37.5  15.3  6.9  2.8  4.2  19.4  29.2  12.5  34.7  Yes  31.4  32.2  24.7  6.4  5.4  7.2  14.9  28.0  18.4  31.5  P= 0.360  Chi square#  P= 0.550  Mother works No  33.9  36.4  16.5  6.6  6.6  5.0  17.4  21.5  20.7  35.5  Yes  32.1  32.1  25.1  6.4  4.3  7.3  15.2  30.4  16.1  31.0  Chi square#  P= 0.357  P= 0.276  45  (Continued) Table 4.6 Consumption of sugar-containing drinks according to socio-demographic characteristics  Consumption of sugar-containing drinks Demographic characteristics  Coke/Pepsi/Slurpee %  Juice %  Never  < once a week  1-2 times/we ek  3-6 times/week  everyday  never < once a week  No  33.2  35.5  20.3  6.6  4.3  6.2  Yes  32.3  29.7  26.2  6.2  5.6  7.7  1-2 times/week  3-6 times/week  everyday  16.3  27.2  17.5  32.7  14.8  29.1  16.8  31.6  Own bedroom  P= 0.515  Chi square#  P= 0.951  Number of cars No Cars  35.5  1 Car  31.7  ≥ 2 cars  32.8  31.8  21.8  9.1  1.8  9.1  14.5  26.4  17.3  32.7  32.6  22.2  6.8  6.8  3.6  18.5  25.7  18.5  33.8  34.5  25.0  3.4  4.3  10.3  11.1  35.0  15.4  28.2  P= 0.492  Chi square#  P= 0.117  SES groups Lowest  34.4  33.6  20.6  6.5  5.0  6.8  15.6  26.6  18.3  32.7  Middle  32.5  30.5  27.2  5.3  4.6  7.9  14.5  31.6  15.1  30.9  Highest  23.7  39.5  21.1  10.5  5.3  2.6  21.1  23.7  18.4  34.2  Chi square#  P= 0.742  P= 0.864  46  Table 4.7 shows the pattern of sugar-containing food consumption (candies, chocolate, sweets, cookies, cakes or muffins) according to socio-demographic characteristics. There were no statistically significant differences among different age or SES groups except for the consumption of sugar-containing foods, e.g. one out of five six year-old children ate candies, chocolate or sweets on an everyday basis, while this percentage decreased in 7-8 year olds and only a few 9-13 year-old children ate these sugarcontaining items every day (P<001). A similar pattern was observed when children were asked about the frequency of eating cookies, cakes or muffins (P<001).  47  Table 4.7 Consumption of sugar-containing food items according to socio-demographic characteristics  Consumption of sugar-containing food items Demographic characteristics  Candies/chocolates/sweets % Never  Cookies/cakes/muffins %  < Once a week  1-2 times a week  3-6 times a week  Everyday  Never  < Once a week  1-2 times a week  3-6 times a week  Everyday  Gender Boys  8.1  27.7  33.6  16.2  14.5  11.4  39.2  27.8  13.9  7.6  Girls  7.7  28.4  40.4  13.0  10.6  9.6  37.3  30.1  11.5  11.5  P= 0.478  Chi square#  P= 0.565  Age group 6 years  10.7  15.3  41.2  10.7  22.1  14.3  22.6  29.3  12.8  21.1  7-8 years  7.8  31.0  30.2  14.7  16.4  11.2  37.1  27.6  17.2  6.9  9-13 years old  4.6  35.8  38.2  18.5  2.9  6.9  53.4  27.0  10.3  2.3  P<001  Chi square  P<001  Born in Canada No 5.3  26.6  33.0  20.2  14.9  7.4  34.0  31.9  19.1  7.4  8.6  30.6  37.2  12.3  11.3  11.2  41.8  27.3  10.9  8.9  Yes  Chi square#  P= 0.225  P= 0.158  # Chi square or Fisher’s Exact Test 48  (Continued) Table 4.7 Consumption of sugar-containing food items according to socio-demographic characteristics  Consumption of sugar-containing food items Demographic characteristics  Candies/chocolates/sweets % Never  Cookies/cakes/muffins %  < Once a week  1-2 times a week  3-6 times a week  Everyday  Never  < Once a week  1-2 times a week  3-6 times a week  Everyday  Ethnicity Aboriginal  4.9  19.5  48.8  7.3  19.5  7.3  26.8  48.8  7.3  9.8  Chinese  14.9  23.4  34.0  12.8  14.9  16.3  38.8  26.5  6.1  12.2  European  14.1  16.9  42.3  12.7  14.1  15.5  35.2  22.5  12.7  14.1  Filipino  5.1  36.7  29.6  15.3  13.3  9.2  33.7  33.7  14.3  9.2  Vietnamese  3.3  28.3  35.0  21.7  11.7  6.7  43.3  30.0  15.0  5.0  Indian  1.9  28.8  44.2  9.6  15.4  11.5  38.5  23.1  21.2  5.8  10.4  32.5  32.5  18.2  6.5  9.0  47.4  21.8  11.5  10.3  Other  P= 0.070  Chi square#  P= 0.238  Household size 2-3 people  7.4  27.0  28.7  20.5  16.4  11.4  31.7  30.9  14.6  11.4  4 people  5.7  26.4  42.0  12.1  13.8  9.7  38.1  30.7  10.8  10.8   5 people  10.5  29.4  37.3  13.7  9.2  11.1  43.1  24.8  14.4  6.5  Chi square#  P= 0.125  P= 0.521  # Chi square or Fisher’s Exact Test 49  (Continued) Table 4.7 Consumption of sugar-containing food items according to socio-demographic characteristics  Consumption of sugar-containing food items Demographic characteristics  Candies/chocolates/sweets (%)  Cookies/cakes/muffins (%)  Never  < Once a week  1-2 times a week  3-6 times a week  Everyday  Never  No  9.7  33.3  26.4  16.7  13.9  12.5  Yes  7.3  26.4  39.4  14.3  12.7  10.2  < Once a week  1-2 times a week  3-6 times a week  Everyday  45.8  26.4  8.3  6.9  36.9  28.9  13.9  10.2  Father works  P= 0.338  Chi square#  P= 0.435  Mother works No  8.4  27.7  38.7  10.1  15.1  14.0  34.7  28.1  13.2  9.9  Yes  7.6  27.8  35.8  16.5  12.2  9.1  39.3  29.0  13.1  9.5  P= 0.515  Chi square#  P= 0.632  Own bedroom No  9.5  28.9  35.6  15.0  11.1  11.3  39.1  28.1  12.5  9.0  Yes  5.6  26.0  38.3  14.8  15.3  9.7  36.7  29.6  13.8  10.2  Chi square#  P= 0.379  P= 0.934  # Chi square or Fisher’s Exact Test 50  (Continued) Table 4.7 Consumption of sugar-containing food items according to socio-demographic characteristics  Consumption of sugar-containing food items Demographic characteristics  Candies/chocolates/sweets (%)  Cookies/cakes/muffins (%)  Never  < Once a week  1-2 times a week  3-6 times a week  Everyday  Never  10.1  24.8  33.9  19.3  11.9  10.9  6.4  25.6  39.7  11.9  16.4  8.5  34.2  34.2  16.2  6.8  < Once a week  1-2 times a week  3-6 times a week  Everyday  32.7  34.5  15.5  6.4  11.8  33.5  28.1  14.9  11.8  6.8  51.3  25.6  7.7  8.5  Number of cars No Cars One Car Two or more cars  P= 0.103  Chi square#  P= 0.030  SES groups Lowest  9.3  29.3  31.3  13.9  16.2  12.2  34.7  29.0  13.7  10.3  Middle  6.6  25.7  46.7  12.5  8.6  9.9  40.1  28.3  12.5  9.2  Highest  2.6  23.7  34.2  31.6  7.9  2.6  52.6  28.9  10.5  5.3  Chi square#  P= 0.004  P= 0.506  # Chi square or Fisher’s Exact Test  51  4.2.2 Oral-health Knowledge – Comparisons Between Boys and Girls Table 4.8 illustrates the distribution of boys and girls according to their knowledge about different food items. As we can see in the table, there were no significant differences in terms of diet knowledge between the two genders.  Table 4.8 Diet knowledge –comparisons between boys and girls Good for teeth  Boys (%)  Girls (%)  yes  no  dnk*  Yes  no  dnk  P values #  5  90  4  6  92  2  0.779  Raisins  56  19  25  50  26  24  0.535  Pop corn  8  70  22  8  74  18  0.843  Nuts  48  28  31  45  24  31  0.822  Cheese  56  20  24  50  18  32  0.513  Muffins  25  47  28  28  40  32  0.690  Ice cream  15  64  21  11  78  11  0.116  Fruits  78  14  8  79  8  13  0.347  Candy bar  # Chi square or Fisher’s Exact Test, *dnk: does not know  52  4.2.3 Oral Health-related Behaviour – Comparisons Between Boys and Girls It is apparent from Tables 4.6 and 4.7 that there were no significant differences between the two genders in terms of the frequency of consumption of sweets, snacks and soft drinks. Table 4.9 presents a comparison of oral hygiene practices between boys and girls. There were no statistically significant differences in tooth brushing frequency between the two genders, but girls cleaned between their teeth more frequently than boys (P=0.033).  Table 4.9 Oral self-care – comparisons between boys and girls Oral self-care Gender  Frequency of tooth brushing not every day  ≥twice a day  once a day  Interdental cleaning  after every meal  no  yes ,sometimes  yes, always  Boys  5.4  25.0  68.5  1.1  4.3  67.4  28.3  Girls  7.3  20.7  64.6  7.3  0  42.7  57.3  #Chi square  P=0.182  P= 0.033  # Chi square or Fisher’s Exact Test  53  Chapter 5. Discussion 5.1 Main Study Findings and Their Comparison with Other Studies Oral health disparities in Canada are of great concern (Lawrence et al., 2009). Therefore it is important to consider the present findings in the context of social determinants of oral health. The systematic review by Reisine and Psoter (2001) concluded that that young children from low socio-economic families are at greater risk for dental caries. The role of behaviours and their contribution to oral health disparities should be considered. Individualistic approach, i.e. focusing on changing individual behaviours without considering the social environment/determinants may even increase health disparities (Marmot & Bell, 2011). Therefore we should tailor our preventive actions targeting social environments (families, peer groups, schools) where these behaviours occur (Marmot & Bell, 2011). Cultural beliefs and behaviours have been associated with oral health disparities (Butani et al., 2008). Given the multi-ethnic nature of the inner-city community it is also important to consider the potential differences among diverse cultural groups as their oral health-related behaviours may differ. As it relates to establishment of healthy diet, it is important to take into account the possibilities of low-income families, i.e. these families have limited financial and material resources that may hinder them to make healthy diet choices. Demographic research in inner-city Vancouver found out that this vulnerable community has multiple areas of disadvantage (Lynam JM et al, 2011). On the other hand, the social school environment can be used to support healthy eating patterns by providing subsidies for healthy snacks and drinks in school areas (Hashim, et al. 2009).  54  The present cross-sectional study is the first study about oral health-related lifestyle in elementary school-aged children from inner city Vancouver.  The total sample size  comprised 424 children, among which 53% were boys and 47% were girls. All lifestylerelated information was collected by means of a self-administered structured questionnaire. The questions used for the present study have been validated in previous studies (Harikiran et al, 2008; Smyth 2007; Poutanen et al, 2007; Zhu L & Petersen P.E, 2003). A school-based approach for collecting data about the children was chosen and we expected to acquire a high response rate. However, the 52% response rate achieved in the present study is relatively low despite the multiple attempts used to recruit participants. The relatively low response rate might at least partly be explained by the teacher’s long-term job action, which coincided with the time the study was performed. As parental/guardian consents were necessary, the teachers’ job action and their unwillingness to assist in any extracurricular activities possibly led to lower response rates. The present study found that the majority of children did not consider their dental health to be a problem or to affect their quality of life in any way, i.e. most of the children responded that they did not avoid talking or smiling because of problems with their teeth. The present finding is not in accordance to similar studies performed in children, which reported having a lack of oral health influencing an oral health-related quality of life (Harikiran et al., 2008; Petersen et al. 2001; Varenne et al., 2006). However, these differences in oral health-related quality of life among children from different countries should be interpreted with caution mainly due to differences in the quality of life related measurements employed in these studies.  55  Although a number of oral health–related lifestyle aspects were assessed, none related to socio-demographic characteristics (gender, age, ethnicity, SES groups), i.e. there were no gender or socioeconomic differences in knowledge, attitudes or beliefs and only a few statistically significant associations were found. For example, older children as compared to younger ones tended to have better knowledge and more positive health behaviours. Given that only a few socio-demographic differences were found among inner city Vancouver elementary school-aged children, i.e. no distinct high risk groups based on sociodemographic characteristics could be identified, the whole cohort of inner city school-aged children should be considered as a high-risk subpopulation. Two main approaches, namely a high-risk and a population-based strategy, have been suggested for health promotion in populations. The high-risk strategy focuses only on individuals who are considered to be at high risk for a specific disease. Consequently, the aim of a high-risk prevention strategy is to limit all prevention-based activities to the individuals who are considered to be at the highest risk without interfering with the rest of the population. This high-risk strategy is cost-effective for populations where the highest burden of a disease is found in only a small proportion of the population., When no distinct high-risk groups can be identified and the whole population or subpopulation carries a similar burden of a specific disease or the whole population/subpopulation presents with similar deficiencies in their health-related lifestyles, a population-based approach to health promotion is more relevant. The population-based prevention strategy focuses on the whole population, i.e. preventive activities are tailored to all, as opposed to addressing only the needs of high-risk groups in any given population (Rose G, 1992).  56  The present findings showed that there was a lack of adequate oral health-related knowledge, attitudes and beliefs in the whole cohort of inner city Vancouver elementary school-aged children. Thus the cohort of inner city Vancouver children should be considered as a subpopulation on which a population-based strategy for oral health promotion should be focused. The present findings identifying specific deficiencies in children’s knowledge, attitudes, beliefs or behaviours could form the basis for future preventive activities in this population. Overall, the children had insufficient or inadequate diet knowledge i.e. they did not know what is good and what is bad for their teeth. For example, almost half of the children either considered cheese and nuts to be bad or did not know that cheese and nuts are two healthy snacks despite that cheese and nuts are commonly recommended by dental professionals as healthy snacks (Tinanoff & Palmer, 2000). Similarly, popcorn has been categorized as a non-cariogenic food item (Tinanoff & Palmer, 2000), but only 8% of children reported popcorn to be good for their teeth, while the majority of them (92%) reported it as being either bad for their teeth or they did not know whether it is good or bad for their teeth. Approximately half of the children did not know that drinking juice or eating raisins or muffins are detrimental to teeth. This finding is in contrast to the study by Al-Omiri et al, 2006, showed that the majority of children considered sweets and soft drinks bad for dental health. Our study results supported the findings of a previous study done by Lian et al.,(2010) which reported that carbonated drinks was most favorable among the respondents and the majority (77%) of the secondary school students in the study claimed they drink carbonated drinks and 26.3% have it at least once per day (Lian et al, 2010).  57  Obviously, a substantial proportion of Vancouver inner-city elementary school-aged children lack or have inadequate knowledge of what constitutes a good oral health lifestyle. It is important to consider that modifying the knowledge or behaviours of children who lack knowledge (“do not know”) is easier than modifying the behaviours of children who already acquired inadequate knowledge (“wrong” answers). Having inadequate knowledge leads to inappropriate behaviours, and subsequently this contributes to deterioration of dental health. For example, a commonly found belief among children is that they should stop brushing their teeth if their gums bleed. This inadequate belief is detrimental as the opposite is true, i.e. if gums show signs of bleeding; children should brush effectively as their bleeding gums indicate that tooth brushing is insufficient or inadequate. Perhaps, the children have acquired this erroneous belief from their parents, despite that bleeding gums, particularly in children, indicates deficient oral hygiene and these children should brush their teeth properly, to prevent their gums bleeding in the future. The way in which children practice oral hygiene at home is important, as oral self-care should be established as a habit in order to retain healthy teeth. The present study showed that regular tooth brushing was already established as a habit in the majority of the children examined; as nine out of ten children reported that they brush their teeth at least once a day and only a small proportion of the children reported that they did not brush their teeth daily. However, interdental cleaning does not seem to be a common habit among inner city Vancouver elementary school-aged children. The present study showed a significant difference in cleaning between the teeth among two genders (P= 0.033); which supported the finding of a previous study (Ahmed et al., 2007).  Regarding cleaning between teeth,  34% of children reported always cleaning between their teeth which is a substantially higher  58  percentage compared to the Harikiran et al., (2008) study that reported that only 5% of school children used dental floss for cleaning their teeth. This obvious disagreement in findings between the two studies may be explained by the difference in how children were asked about their interdental cleaning. The present study asked if children clean between their teeth or not, but there was no inquiry about how this interdental cleaning was actually performed. Possibly children from the present study considered cleaning between teeth as part of regular tooth brushing but not as an additional oral self-care activity involving dental floss. Future studies are needed in order to understand how and if the interdental cleaning is performed in the cohort of Vancouver inner city school-aged children. The parents’ support for establishing health-promoting habits in their children is of key importance for maintaining good health in the long term (Poutanen et al, 2006). However, only 37% of children in the present study reported that their parents or other family members monitored their brushing, i.e. 63% brushed their teeth on their own without any support or supervision from their parents. The same trend was seen in a study by Al-Omiri et al, 2006, which reported that only 26% of the children were watched by their parents while brushing. Although children of this age try to be independent and are willing to perform their daily care without a family member’s interference, we should keep in mind that parents’ failure to support their child’s oral self-care could result in inadequate oral self-care, and consequently poor oral health. Of all, 83% of the children stated that their parents had shown them how to brush. This percentage may be over-reported due to social desirability, i.e. the children may have wanted to present their parents in a more positive light. In a study done by Varenne et al., (2006) a substantial proportion of children (48%) reported their parents as their first source  59  of dental health information and only 4% of children mentioned their dentist as a source of information. A lack of guidance from dentists regarding oral health self-care was also found in the present study. Seemingly, family members represent the primary source of information for their children about oral health, thus one way to raise children’s oral health awareness would be to educate parents/guardians about oral health and subsequently focus on the parental responsibility for children’s oral health. However, reaching parents of children may be a challenge as the present study showed a relatively low level of parental interest, e.g. only 15% of parental questionnaires were returned. Other medical studies have also identified a similar challenge and also reported a relatively low level of parental involvement (Bullen et al., 1988; Kerebel et al., 1985). For maintaining healthy teeth in children, parental support is very important, as it is parents who are responsible for meals and snacks. In addition, the benefits of the available school infrastructure should be utilized, i.e. the school environment can offer a health - supportive environment where children can acquire and subsequently bring home health-related information. For example, the school staff with the help of health educators could develop and send home healthy meal menu plans to help improve diet at home. In addition, the school staff may work with nutrition experts to develop a healthy school lunch menu (including snacks available in school). This effort, together with a strong parental support, may facilitate the development of healthy-eating patterns among children that could be carried into their adult lives. The importance of professional help should not be underestimated. There was a clear lack of professional help, at least in terms of assisting with the maintenance of healthy teeth; the majority of the children (67%) in the present study reported that their dentist did not explain how the children should to take care of their teeth. A lack of professional guidance has been 60  also reported in other studies e.g. high numbers of children reported that they have never received oral health care instructions from their dentists (Al-Omiri et al, 2006, Zhu et al, 2003). Thus an important recommendation for dentists is that they include professional guidance on oral self-care as part of a patient’s routine dental appointment.  5.1 Advantages and Limitations of The Study Limitations and advantages of the present study have to be considered. In order to decrease the potential inter-examiner disagreement, only one calibrated examiner was assisting children in completing the questionnaires and teachers were not allowed to help. Given that lifestyle was self-reported, some information may be under or overestimated. With regards to dental knowledge and oral hygiene habits, over-reporting may be expected, while the consumption of sugar-containing foods and drinks may be under-reported, both type of potential measurement bias mainly might occur due to social desirability. However, as questionnaires were completed anonymously, the social desirability should be minimal, as respondents had no reason to answer in a socially desirable way. In order to adjust for the developmental stage of the children, questionnaires were pretested for readability and comprehension. Except for a few items, which were subsequently revised, the pilot study showed that the questionnaire items were written in a language that was understood by even the youngest subjects. Therefore, we did not expect bias to be caused by lack of comprehension. Another limitation is the relatively low response rate (52%). However, even this response rate was achieved after multiple attempts to recruit subjects for the study. The parental  61  consent form included a paragraph where parents refusing to participate in the study could write a reason for their refusal. The most common reason for refusal to participate was that parents had their own dentist, thus they were not motivated to have their children enrolled in the present study. In order to increase the response rate, future studies should consider the recruitment of children assisted by local community members e.g. youth and or social workers. Community members will be helpful as they know their community values better than health professional workers. Another limitation of the present study is the cross-sectional nature of its study design, which does not allow for inferences of causal associations. Given that the present study aimed to examine patterns of oral health-related lifestyle in an inner city children age cohort, but not to relate lifestyle variables with the children’s dental health, the limitation to infer causally is not of substantial importance or relevance. For studies aiming to explore causal associations between lifestyle and dental health, longitudinal study designs should be recommended, as these will enable researchers to study causal relationships and long-term consequences of lifestyle factors to dental health.  5.2 Implications of The Present Study Health promotion has been defined as “the process of enabling people to increase control over and to improve their health” (WHO, 1986). An important part of health promotion is education, including information, motivation, and training skills (WHO, 1999). Health education is a prerequisite for healthy choices and behaviour, and for enabling self-care (Glanz et al., 2010). The present study provides the necessary information for a needs-based  62  oral health promotion program in inner city Vancouver as the study mapped the oral healthrelated lifestyle of inner city school-aged children. Consequently, the present study provides the basis for education of future dental professionals regarding the needs of their future patients, as well as for community-based oral health education. Understanding attitudinal and other lifestyle factors that underlie school-aged children’s decisions about maintaining oral health is of key importance (Kida & Astrom, 1998). Motivating children to avoid frequent daily intake of sugar-containing foods or drinks and to engage them in quality oral self-care, as well as to increase their understanding of decision-making in the domain of food choices, should be used to guide the development of future educational programs tailoring school-aged children. The present study also lays the basis for future comparisons where lifestyle factors can be monitored as time trends, i.e. the present study findings provide the baseline data for future studies. The baseline data is also necessary for development and subsequent monitoring of oral health promotion programs in this cohort of inner city school-aged children. The present data also offers important information for policy makers and or health educators aiming to prevent lifestyle related diseases. In order to maintain healthy teeth long-term, oral health education programs should be reinforced to promote oral health care as a lifelong practice. Certainly, the support from the parents and school for children in this process is crucial.  63  5.3 Conclusions The cohort of inner city Vancouver children should be considered as a population of risk as any distinct socioeconomic or demographic differences among children in lifestyle factors were not found. 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Yes  (0) No  If yes, what is his job?......................................  F.G.ses  Does your Mother/Guardian work? Yes  No  If yes, what is her job? ....................................  M.G.ses  1. No  bedroom  Do you have your own bedroom?  2.Yes  cars Does your family have a car? 1. Yes  0. No  If yes, how many? ……………  WHEN DID YOU SEE A DENTIST LAST TIME? ..........................................  Dentist1  WHY DID YOU SEE A DENTIST? .................................................. ……………………………………………………………………….  Dentist2  Which is BAD for YOUR TEETH? Water Juices Soft drinks (Coca Cola, Fuzzy drinks(Slurpees), energy drinks) Milk  (1)  (0) Yes Yes Yes Yes  No No No No  water juice soft.dr milk  81  WHO taught you HOW TO BRUSH YOUR TEETH?(Check one box next to each person on the list)  (1) Parents/Family Dentist Friend School  Yes Yes Yes Yes  Fam.teach Dent.teach Fr.teach Sch.teach  (0) No No No No  Who CONTROLS how you Brush YOUR TEETH Nobody I do it myself Father Mother Other family member….....  How often do you eat candies/chocolates/sweets?  Every day 3-6 times a week 1-2 times a week Less than once a week Never  0 1 2 3 4  contr.brush  4 3 2 1 0  diet1  How often do you DRINK Coca Cola, Pepsi, slurpees, energy drinks?  diet2  Every day 3-6 times a week 1-2 times a week Less than once a week Never  4 3 2 1 0  Every day 3-6 times a week 1-2 times a week Less than once a week Never  4 3 2 1 0  diet11  Every day 3-6 times a week 1-2 times a week Less than once a week Never  4 3 2 1 0  diet12  How often do you EAT COOKIES, CAKES, MUFFINS?  How often do you DRINK JUICE?  Thanks for your time filling this questionnaire!  82  Appendix 2. Shortened version of the questionnaire  QUESTIONNAIRE for Schoolchildren (Grade 4-7) boy girl  Year of birth: ....................................................  1 2  Were you born in Canada? Yes  No  If No, how many years have you lived in Canada?.............  Gender  yrs. ca  Now we would like to ask about YOUR FAMILY Who do you live with? Mother Father Brother(s) Sister(s) Guardian  Fam.n Moth Fath Step.m Step.f Sib.Broth Sib.Sist     how many? ………  how many? ………  who? ……………..  Father(Guardian) is  Mother(Guardian) is  1. Aboriginal 2. Chinese 3. European (specify….......) 4 .Filipino 5. Vietnamese 6. Indian 7. Other (specify...........)  1.Aboriginal 2.Chinese 3.European (specify…......) 4. Filipino 5. Vietnamese 6. Indian 7. Other (specify.............)  F/G.ethnic M/G.ethnic  Yes  No   If yes, what is his job?......................................  F.ses  Does your mother work? Yes  No   If yes, what is her job? ......................................  M.ses  Does your father work?  Does your guardian work? Yes  No  If yes, what is his/her job? ...................................... Your families money needed for living comes from:  Mothers job  Fathers job  Guardians job  Other ……………………..  G.ses Moth.inc Father.inc G.inc Other.inc  Do you have your OWN BEDROOM?  Bedroom  No (0)  Yes (1)  You think YOUR FAMILY when compared to OTHER FAMILIES is Poorest Does your family have a car? Yes   Richest No   If yes, how many? ……………  Fam.ses Cars  83  Now we would like to know how you take care of your teeth Why do you Take CARE of your TEETH?  T.care6  How often do you BRUSH your TEETH?  Toothbr 1. 2. 3. 4. 5.  Never Not daily Once a day Twice a day or more After every meal  Now we would like to ask about DENTAL VISITS  WHEN was YOUR LAST DENTAL VISIT? ....................................  Dent.1  People who take care of their teeth DO NOT have TOOTHACHE (pain)  T.care2  Completely Wrong  Very True  How often do YOU DRINK JUICE?  Every day 3-6 times a week 1-2 times a week Less than once a week Never People who TAKE CARE of their TEETH, DO NOT NEED to SEE the DENTIST Yes No I don’t know  4 3 2 1 0 1 2 3  Diet.12  T.care3  I take CARE of my TEETH Never  Always  T.care1  I take CARE of my TEETH, because MY MOUTH feels CLEAN  Completely Wrong Definition: Rotten teeth are also known as cavities or tooth decay. What do you think causes CAVITIES (rotten teeth)?  Very True  T.care4  Know.1  84  I Brush TEETH, because I want my BREATH to SMELL GOOD  Completely Wrong  Very True  T.care5  If you DO NOT SEE the DENTIST OFTEN, your TEETH will ROT (cavities in teeth)  Completely Wrong  Very True  Dent. 3  QUESTIONS about Tooth Brushing WHO taught you HOW TO BRUSH YOUR TEETH?(Check one box next to each person on the list) Parents/Family Dentist Friend School Nobody (0)   1. Yes  1. Yes  1. Yes  1. Yes    2. No  2. No  2. No  2. No  Fam.teach Dent.teach Fr.teach Sch.teach Nobody  What can you do to clean BETWEEN your TEETH? between  I should STOP BRUSHING if my GUMS BLEED Know.5 Never Which is BAD for YOUR TEETH? Water Juices Soft drinks (Coca Cola, Fuzzy drinks(Slurpees), energy drinks) Milk Coffee without sugar Tea without sugar  Always  Yes Yes Yes Yes Yes Yes  No No No No No No  What is Dental Floss?  Water Juice Soft.dr Milk Coffee Tea Know.4  To make my PARENTS HAPPY, I BRUSH my TEETH Parent.acc  Completely Wrong  Very True  To be LIKED by my FRIENDS I BRUSH my TEETH Friend.acc  Completely Wrong  Very True  85  I Avoid Smiling because of My Teeth  Never  Ql.smil  Always  I Avoid Talking because of My Teeth  Never  Always  There are people with GOOD TEETH NO MATTER WHAT THEY DO, and others with BAD TEETH NO MATTER WHAT THEY DO Completely Wrong  Ql.talk  Know.6  Very True Betw.th  Do you clean BETWEEN your teeth? No (0) If YES, HOW do you clean BETWEEN your teeth?  Yes  (1)  People who BRUSH their TEETH have GOOD BREATH Breath  Completely Wrong  Very True  BRUSHING your TEETH helps STOP CAVITIES (rotten teeth) Th.decay  Completely Wrong  Very True  BRUSHING TEETH helps STOP TEETH from being YELLOW Discolor  Completely Wrong  Very True  People who BRUSH their TEETH look BETTER Appear  Completely Wrong  Very True  PEOPLE TAKE GOOD CARE OF TEETH BECAUSE they WANT………………………………….  Who CONTROLS your tooth brushing at home?  Nobody I do it myself Father Mother Other family member….....  Know.9  0 1 2 3 4  contr.brush  86  How often do You EAT CANDIES, CHOCOLATES and SWEETS? Every day 4 3-6 times a week 3 1-2 times a week 2 Less than once a week 1 Never 0 How often do you DRINK Coca Cola, Pepsi, slurpees, energy drinks? Every day 4 3-6 times a week 3 1-2 times a week 2 Less than once a week 1 Never 0 Are these GOOD or BAD for your TEETH?(Check one box beside each item) Candy Bars  1. Yes  3. No  2. Don’t Know Popcorn  1. Yes  3. No  2. Don’t Know Nuts  1. Yes  3. No  2. Don’t Know Raisins  1. Yes  3. No  2. Don’t Know Cheese  1. Yes  3. No  2. Don’t Know Muffins  1. Yes  3. No  2. Don’t Know Ice Cream  1. Yes  3. No  2. Don’t Know Fruits  1. Yes  3. No  2. Don’t Know  Diet.1  Diet.2  Diet.3 Diet.4 Diet.5 Diet.6 Diet.7 Diet.8 Diet.9 Diet.10  How often do you EAT COOKIES, CAKES, MUFFINS? 4 3 2 1 0 4 3 2 1 0  Diet.11  WHEN DO YOU EAT or DRINK SUGARY FOODS? Do not eat or drink them at all 0 During meals only 1 Between meals 2 At any time of the day 3 Which is BAD for YOUR TEETH? Water Yes No Juices Yes No Soft drinks (Coca Cola, Fuzzy drinks(Slurpee’s), energy drinks) Yes No Milk Yes No Coffee without sugar Yes No Tea without sugar Yes No  Diet.13  How often do you DRINK JUICE?  Every day 3-6 times a week 1-2 times a week Less than once a week Never Every day 3-6 times a week 1-2 times a week Less than once a week Never  Diet.12  Water Juice Soft.dr Milk Coffee Tea  YOU can AVOID TOOTH DECAY (cavities in teeth) ILC.1 Never  Always  87  When ONE TOOTH has A CAVITY(is rotten) OTHER TEETH will get cavities too  Completely Wrong  ELC.3  Very True  ONLY DENTISTS CAN STOP CAVITIES IN TEETH  Completely Wrong  ELC.2  Very True  I ENJOY being together with OTHER CHILDREN at SCHOOL  Never  Always  SE. 1  It is EASY for me TO MAKE NEW FRIENDS Never  Always  SE.2  I like TO KNOW WHAT IS HAPPENING AROUND ME SOC.1 Never  Always  I FEEL that I AM Others are NOT NICE TO ME SOC.2 Never  Always  What is life like for you? Bad Great/Wonderful Comparing to your friends, your teeth are … I think my teeth are BETTER than my friend’s teeth 2 I think my teeth are THE SAME as my friend’s teeth 1 I think my teeth are WORSE than my friend’s teeth 0  Sat.life  S-OH  PLEASE CHECK IF YOU ANSWERED ALL QUESTIONS! Thanks for your time filling this questionnaire!  88  Appendix 3. Vancouver School Board Support Letter  89  

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