Professional Documents
Culture Documents
1602
j Dent Res 76(9) 1997 Oral Hygiene Habits in 23 Countries 1603
standardized methods are needed. For this purpose, a HBSC Study). The philosophy and methods of the project have
special WHO research program, the Cross-National Survey, been described in more detail elsewhere (Aar0 and Wold, 1985;
was developed, which also included oral health habits. The King et al., 1996).
first data for this survey were collected in four European
countries (Austria, England, Finland, and Norway) in
1983/1984 (Aar0 et al., 1986). In the second phase Study design
(1985/1986), 11 European countries and in the third phase In the fourth phase of this study program, 1993/1994, 24
(1989/1990) 15 countries participated in the survey European countries (Austria, Belgium, the Czech Republic,
(Nutbeam and Aar0, 1991). The oral health habits in the first Denmark, Estonia, Finland, France, Germany, Greenland,
survey (Honkala et al., 1988) and in the second survey Hungary, Israel, Latvia, Lithuania, Northern Ireland, Norway,
(Honkala et al., 1990) have been reported earlier. Poland, Russia, Scotland, the Slovak Republic, Spain, Sweden,
The overall aim of the Cross-National Survey was to Switzerland, the Netherlands, and Wales) and Canada took part
increase understanding of the health behavior and lifestyles in the study program (Wold et al., 1994). However, the
of young people. Further objectives of the study were to Netherlands and Switzerland were excluded because the
promote cross-disciplinary research into young people's common guidelines for data collection were not followed. In
health behavior and to support international networking some countries, the sample represented only certain regions: in
that promotes scientific progress (Aar0 and Wold, 1985; France, the regions of Toulouse and Nancy; in Germany, the
Aar0 et al., 1986). state of Nordrhein-Westfalen; and in Russia, the St. Petersburg
The aim of this study was to describe the oral hygiene region. In Belgium, two samples were drawn, one (n = 1733)
habits (toothbrushing and flossing) of 11-year-old representing the Flemish-speaking population (57% of the whole
schoolchildren in 22 European countries or regions (Austria, population) and the other (n = 1935) the French-speaking
Belgium, the Czech Republic, Denmark, Estonia, Finland, population (43% of the whole population). For Belgian data,
France, Germany, Greenland, Hungary, Israel, Latvia, weighted mean figures were used. In all other countries, the
Lithuania, Northern Ireland, Norway, Poland, Russia, sample was collected according to the research protocol (Wold et
Scotland, the Slovak Republic, Spain, Sweden, and Wales) al., 1994) and was therefore nationally representative. A cluster
and Canada. A further aim was to compare the associations sample design was used, in which the first level of sampling
between these habits and gender, age, country, school occurred at school or school class level, and then all students in
performance, and family economy in these countries. appropriate age groups were surveyed (King et al., 1996).
The data were collected by means of standardized
questionnaires administered to 11-, 13-, and 15-year-old
Materials and methods schoolchildren in school classrooms. Pupils responded
This study is part of a large, international comparative survey of anonymously during a class period, with either a teacher or
schoolchildren's health and life-styles (Health Behaviour in researcher overseeing the process. The ethical clearance for the
School-aged Children-A WHO Cross-National Survey, the study was obtained by each national participant from the
1604 Kuusela et al. j Dent Res 76(9) 1997
ethical committees of their respective institutions. Overall, in purely economic terms to mean something more holistic, such
every participating country, each age category was to consist of as family well-being (Piette et al., 1993).
about 1300 schoolchildren, except in Greenland (sample was
about 450). Since the population of Greenland is relative small,
the entire in-school population for each age group was Validity and reliability
surveyed (King et al., 1996). In studies involving several countries in the management of the
survey, there are problems in ensuring consistency in data
collection, and therefore direct comparisons of behaviors
Variables between and among countries have to be made with caution
Oral hygiene habits were determined with two structured (Nutbeam and Aar0, 1991). If valid international comparisons
questions. To the question "How often do you brush your are to be made, it is of the utmost importance that the data be
teeth?", five alternatives were given: more than once a day, once comparable. Special concern should be exercised with
a day, at least once a week but not daily, less than once a week, prevalence figures based on only single questions. To make the
never. In the analyses, the answers were recoded into three comparisons as reliable as possible in the HBSC study program,
categories: more than once a day, once a day, and less than once we applied the standardized methods for procedures of
a day. To the question "How often do you use dental floss?", sampling and data collection (Aar0 et al., 1986; King et al., 1996).
three altematives were given: daily, weekly, rarely or never. No Terms used to describe behaviors like toothbrushing frequency
information about flossing was gathered in Scotland and Wales. are easy to translate and are understood similarly everywhere
One group of countries needed an alternative-"Don't know (King et al., 1996). Several separate studies or set procedures
what flossing is"-in their questionnaires for flossing. The have been undertaken for the examination of both the reliability
proportions of don't-know answers were quite high (from 32 to and the validity of the national and cross-national data (Piette et
77%) in Belgium, France, Germany, Lithuania, and Poland; thus, al., 1993). The relevance of the questions was studied during the
those countries were excluded from the analyses. Estonia, pilot surveys. The validity of all the studied questions has also
Latvia, and Russia were also excluded because of the high been studied earlier in Finland (Honkala, 1984).
proportions of reported daily users (from 17 to 46%), even
though dental floss is not commonly available in those
countries. Analyses
The study also included information about age, gender, All data were cleaned and re-ordered where necessary to a
school performance, and family economy as indicators of socio- consistent format at the co-ordinating center in the University of
economic status, because all of these factors are known to Bergen, Norway. The cleaning implied exclusion of cases that
associate with dental health habits (Honkala, 1984). This study did not meet the age criteria and cases where more than 25% of
was based on only 11-year-olds for age to be controlled as a the answers were missing across selected key behavioral
confounding factor. However, we used the two oldest age questions (Nutbeam and Aar0, 1991). The proportion of pupils
groups for calculating the odds ratio for age. The 13-year-olds excluded through this process varied from 3% to 7% among the
and 15-year-olds did not differ very much from each other in participating countries. The final population of the cleaned data
their brushing habits. Only in Hungary, Poland, and Spain was consisted of 102,641 schoolchildren (Table 2), the number of 11-
the difference between the proportions of twice-a-day brushers year-olds being 35,138 (King et al., 1996).
greater than 10%. Therefore, the older adolescents were The variations in the distributions of the variables studied in
compared together with the 11-year-olds. The question this study were analyzed by cross-tabulations according to
concerning school performance was: "In your opinion, what gender, age, child's self-reported school performance, and self-
does your class teacher think about your school performance reported family economy. Statistical significances were
compared with your classmates'? He/she thinks I am: very measured by the chi-square test. A logistic regression model
good, good, average, below average." In the analyses, answers was used to estimate the odds ratios for brushing teeth less than
were recoded into three categories: good, average, and poor. twice a day according to gender (males compared with
Self-reported school performance in different countries with females), age (11-year-olds/13- to 15-year-olds), family
different school systems might mean different things. However, economy (poor and average/good), and school performance
despite differences between and among countries in terms of (poor and average/ good).
school systems, economic development, or spending power, the
adolescents face many of the same difficulties, to which they
seem to react similarly (Piette et al., 1993). Non-respondents
Family economy was asked in the question: "How well off There were two sources of non-response in the study: (1)
do you think your family is?" The alternatives given were: very schools or classes that refused to participate and (2) individual
well-off, well-off, average, not very well-off, not at all well-off, I pupils who refused to participate (informed consent) or were
don't know. In the analyses, the following categories were used: absent on the day the questionnaire was administered
good, average, and poor. There were no data available from (Nutbeam and Aar0, 1991). No attempt was made to follow up
Spain concerning family economy. For self-reported and self- with pupils who were absent on the day of the survey. In those
evaluated family economy, the expression "well-off" has been countries where it was possible to calculate the number of
used for clarifying the socio-economic status of families. In pupils who did not participate, the response rates varied
English, "well-off" could be interpreted more broadly than in between 75% and 90%.
j Dent Res 76(9) 1997 Oral Hygiene Habits in 23 Countries 1605
Table 2. Number of 11-year-old children in the sample Table 3. Percentages of children who brush their teeth more than
once a day (gender-standardized) in different countries
Country Total Sample Sample of 11-year-olds
Austria 5,217 1,614 Country Toothbrushing > 1/day
Belgium 9,702 3,668 Sweden 83
Canada 6,758 2,289 Denmark 82
Czech Republic 3,585 1,094 Germany 76
Denmark 3,912 1,219 Austria 74
Estonia 3,516 1,170 Norway 73
Finland 4,187 1,714 Czech Republic 63
France 4,004 1,461 Israel 63
Germany 3,275 1,104 Canada 61
Greenland 1,322 457 France 61
Hungary 5,775 2,072 Poland 60
Israel 4,299 1,301 Northern Ireland 59
Latvia 3,818 1,307 Scotland 59
Lithuania 5,428 1,783 Wales 59
Northem Ireland 3,970 1,346 Greenland 56
Norway 4,988 1,614 the Slovak Republic 56
Poland 4,527 1,473 Hungary 46
Russia 4,001 1,353 Spain 45
Scotland 4,959 2,007 Belgium 45
the Slovak Republic 3,374 1,088 Estonia 40
Spain 4,570 1,507 Latvia 38
Sweden 3,584 1,225 Finland 34
Wales 3,870 1,272 Lithuania 34
Russia 34
TOTAL 102,641 35,138
-I"
earlier by videotape, but these
Austria -L "'
, ,have little relevance if the re-
commended frequency has
Czech Rep ,
not been adopted (Honkala et
-7-7-7X al., 1986). From the behavioral
Canada standpoint, the most import-
,,-,,,,ant aspect of brushing is its
-.,,
Israel - frequency. Only after the
twice-a-day brushing habit
Scotland -
f"I