Abstracts

Introduction

Access to health services, including those for oral health, depends upon socioeconomic, cultural, environmental and individual factors ¹1. Yu SM, Bellamy HA, Schwalberg RH, Drum MA. Factors associated with use of preventive dental and health services among U.S. adolescents. J Adolesc Health 2001; 29: 395-405. ^{, 2}2. Slack-Smith LM, Mills CR, Bulsara MK, O'Grady MJ. Demographic, health and lifestyle factors associated with dental service attendance by young adults. Aust Dent J 2007; 52: 205-9. . Moreover, cultural and lifestyle differences also influence the degree to which services are sought. According to Freeman ³3. Freeman R. The determinants of dental health attitudes and behaviours. Br Dent J 1999; 187: 15-18. , oral health behaviors are also influenced by adolescents' social contacts, tending to adopt behavior similar to their peers. Among adolescents, it has been shown that low socioeconomic status and poor mental health can increase the risk of adopting health risk behaviors ⁴4. Viner RM, Haines MM, Head JA, Bhui K, Taylor S, Stansfeld SA et al. Variations in associations of health risk behaviors among ethnic minority early adolescents. J Adolesc Health. 2006; 38: 55-8. . Additionally, unhealthy habits such as smoking, eating sweets and physical inactivity are associated with fewer visits to dentists and greater curative needs ⁵5. Freddo SL, Aerts DRGC, Abegg C, Davoglio RS, Vieira PC, Monteiro L. Oral hygiene habits and use of dental services among teenage students in a city in southern Brazil. Cad. Saúde Pública 2008; 24: 1991-2000. . The age group of adolescents has drawn the attention of the World Health Organization, because adolescence is a period marked by considerable physical, sexual, cognitive and emotional changes ⁶6. World Health Organization. Global school-based student health survey (GSHS). Available in http://www.who.int/chp/gshs/en/ (Acessed in 2010 oct 10).
http://www.who.int/chp/gshs/en/... . It is a period when habits and behavior change, remaining in the future and influencing both their general and oral health. This is why adolescence represents an essential time for health promotion ²2. Slack-Smith LM, Mills CR, Bulsara MK, O'Grady MJ. Demographic, health and lifestyle factors associated with dental service attendance by young adults. Aust Dent J 2007; 52: 205-9. . In Brazil, a large section of the population has very poor access to dental and health services. As an example, a national study performed in 2003 showed that 22% of Brazilians, aged from 15 to 74 years, had never been to a dentist ⁷7. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Projeto SB Brasil 2003: condições de saúde bucal da população brasileira 2002-2003: resultados principais. Brasília: Ministério da Saúde 2004. Available in http://cfo.org.br/wp-content/uploads/2009/10/04_0347_M.pdf (Acessed in 2010 oct 10).
http://cfo.org.br/wp-content/uploads/200... . This percentage was 14% among adolescents, increasing to 22% in more impoverished areas. Among all adolescents studied, 30% reported toothaches as the reason for seeking dentists and only 34% made a dental appointment for routine/maintenance purposes ⁷7. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Projeto SB Brasil 2003: condições de saúde bucal da população brasileira 2002-2003: resultados principais. Brasília: Ministério da Saúde 2004. Available in http://cfo.org.br/wp-content/uploads/2009/10/04_0347_M.pdf (Acessed in 2010 oct 10).
http://cfo.org.br/wp-content/uploads/200... . Based on the WHO recommendations, Brazil has introduced health investigation strategies into the schools, prioritizing the 7^th grade of primary education. Because of this new initiative and the lack of information about factors affecting dental care among Brazilian adolescents, the present study was conducted, aiming to investigate factors associated with the use of dental services among adolescents in the 7^th grade of primary schools included in the public school network of a city of the Greater Porto Alegre area, the capital of the state of Rio Grande do Sul, in Southern Brazil.

Methods

Sample

This is a school-based cross-sectional study. Participants were selected by cluster sampling. The city was divided into 15 administrative areas and all were included in the study. Firstly, schools were randomly selected, followed by classes. All students from the selected classes participated in the study. The sample calculation was based on a target population of 2,282 school adolescents from Gravataí, a city of the Greater Porto Alegre area, in Southern Brazil. Considering that the study is part of a larger research project with other objectives, the larger estimate of prevalence for multiple outcomes (50%), a confidence interval of 95% and maximum error of ± 3% were taken into consideration as reference, so that a sample of 728 subjects was obtained. Applying a design effect of 1.5 and adding 20% to compensate for losses, the sample size increased to 1,312 adolescents. This number represented about half of the schoolchildren enrolled. Because of this, it was decided that half plus one of the groups would be randomly selected from each of the 15 administrative regions of Gravataí, observing the proportionality of students per group. The sample totaled 1,366 schoolchildren and all members of the randomly selected groups were included in the study. At the end of the data collection, a response rate of 85.7% was obtained and the population studied was comprised of 1,170 adolescents.

Data collection

Data were collected in the schools by trained research assistants, using a self-assessment questionnaire which contained information about sex; age; self-reported ethnicity; family socioeconomic conditions; physical activity, classified according to the International Physical Activity Questionnaire – IPAQ ⁸8. International Physical Activity Questionnaire – IPAQ. Available in http://www.ipaq.ki.se/ (Acessed Oct 10, 2010).
http://www.ipaq.ki.se/... ; tobacco, alcohol and other drug use in life; experiences at home and at school; feelings of depression; oral health, based upon the Global School-Based Student Health Survey – GSHS ⁶6. World Health Organization. Global school-based student health survey (GSHS). Available in http://www.who.int/chp/gshs/en/ (Acessed in 2010 oct 10).
http://www.who.int/chp/gshs/en/... ; and perception of body image, using the Body Shape Questionnaire – BSQ, validated in Brazil by Cordás and Castilhos ⁹9. Cordás TA, Castilho S. Imagem corporal nos transtornos alimentares: instrumento de avaliação: Body Shape Questionnaire. Psiquiatr Biol 1994; 2: 17-21. . According to Cooper et al. ¹⁰10. Cooper PJ, Taylor MJ, Cooper Z, Fairburn CG. The developmentand validation of the Body Shape Questionnaire. Int J Eat Disord 1987; 6: 485-94. , the BSQ score is classified into four groups: 1) not concerned about body image (<81 points), 2) slightly concerned (from 81 to 110 points), 3) moderately concerned (from 111 to 140 points), and 4) extremely concerned (>140 points). For the purposes of this study, adolescents were grouped into “not concerned about body image” (up to 110 points) and “concerned about body image” (above 110 points).

Explanatory variables were divided into socio-demographic, psychosocial and lifestyle-related. Socio-demographic factors include sex, ethnicity (white, non-white) and economic status (B, C, D+E). The classification criterion of the ABEP (Brazilian Association of Market Research Companies) was used to define the economic status, considering the following five categories: A, B, C, D, and E ¹¹11. Associação Brasileira de Empresas de Pesquisa - ABEP. Critério de classificação econômica Brasil . Available in http://www.abep.org/novo/Content.aspx?SectionID=84 (Acessed in 2010 oct 10).
http://www.abep.org/novo/Content.aspx?Se... . This classification takes into consideration household goods such as cars, televisions and washing machines. Category A is the highest and it was excluded as there were no schoolchildren classified in this category. Additionally, adolescents classified in categories D and E were grouped, as only six belonged to category E.

Psychosocial factors included concern about body image ( yes, no ); the group of variables related to social support (in the previous 30 days) – involvement in fights ( yes, no ); frequency with which parents knew where their children were in their leisure time, categorized into always/nearly always, sometimes/rarely, or never, according to the frequency of the variable; number of close friends, which followed the same criterion for categorization and was divided into 3 or more friends, 1 or 2 friends, or none –; and one variable related to feelings of depression in the previous year, described as feeling of sadness (yes, no).

Lifestyle variables referred to alcohol, tobacco and other drug use in life (yes, no), which considered if adolescents had already consumed these substances; practice of physical activity (yes, no) for which a cut-off point of 300 minutes or more per week was established, categorizing those who were below this limit as insufficiently active ¹²12. Prochaska JJ. Sallis JF, Long B. A physical activity screening measure for use with adolescents in primary care. Arch Pediatr Adolesc Med 2001, 155: 555-9. ; initiation of sexual life (yes, no); oral hygiene habits: frequency of teeth cleaning ( > 2 times/day and < 2 times/day) and daily use of dental floss (yes, no); type of dental service (private; non-private) and the reason for going to the dentist (preventive treatment, curative treatment); in the last two cases, children who did not use dental services were excluded.

The outcome was categorized according to the frequency of use of dental services, considering two categories: visits with a time interval < 12 months ( < 1 time/year) and visits with a time interval > 12 months (>1 time/year). The second category also included those who did not go to dental services.

Statistical analysis

Data were analyzed by Cox regression modified for cross-sectional studies, using the STATA 6.0 software. Univariate and multivariate analyses were conducted. Analyses were performed from a hierarchical conceptual model designed by the authors, supported by the literature on hierarchical models ¹³13. Victora CG, Huttly S, Fuchs S, Olinto MT. The role of conceptual frameworks in epidemiological analysis: a hierarchical approach. Int J Epidemiol 1997; 26: 224-7. . This model includes four stages that show the hierarchy of influence of independent variables on the outcome ( Figure 1 ). In the first stage, sociodemographic variables were included; in the second stage, the psychosocial variables; in the third, lifestyle variables; and in the fourth, variables related to oral health habits and behaviors. A level of significance ≤ 0.10 was established as the cut-off point to select the variables which would be maintained in the following stage. Prevalence ratios with a p-value < 0.05 were considered to be statistically significant.

Ethical Aspects

This is one of the subprojects of the study entitled “The Health of Schoolchildren in the Public School Network of the city of Gravataí, RS, Brazil”. The research protocol was approved by the Research Ethics Committee of the Lutheran University of Brazil – ULBRA (2004-375H). Parents or legal guardians of the students signed an Informed Consent Form. The authors declared that there were no conflicts of interest.

Results

Of all 1,170 adolescents, 21.8% belonged to economic category B, 58.8% to category C and 19.3% to category D+E; 52.5% of the adolescents were females and 52.6% reported they were white ( Table 1 ). The average age was 14 years (sd: 1.13 years) and 68.9% of them used dental services at least once a year. Those who did not go to these services represented 10.4% of the sample.

In the univariate analysis, the outcome was associated with socioeconomic status, concern with body image, involvement in fights and the frequency with which parents knew where their children were in their leisure time. The same occurred with tobacco use in life, frequency with which they brushed their teeth and use of dental floss.

The results of the multivariate analysis showed that use of dental services was less frequent among those with a lower socioeconomic status, those who reported concern with body image, those involved in fights; and those whose parents did not know where they were in their leisure time. A similar result was found among adolescents who brushed their teeth less than twice a day, compared with those who brushed their teeth two or more times a day; those who did not use dental floss daily, compared with those who did; and those who reported seeking dental services for curative treatment, compared with those who sought it for preventive reasons ( Table 2 ).

Discussion

This study set out to increase understanding of factors associated with the use of dental services. By using a hierarchical conceptual model, it explored the relationship between psychosocial variables and the use of dental services, which had not been previously reported. There was a significant relationship between the use of dental services and concern about body image, involvement in fights, and the frequency with which parents knew where their children were in their leisure time, in addition to the commonly reported relationship between socioeconomic status, tooth brushing frequency, use of dental floss and reasons for going to the dentist.

In both univariate and multivariate analyses, the use of dental services in the previous year was much less frequent among adolescents with a lower economic status, a fact which, in spite of having been already expected, deserves some attention. Individuals who were poorer, apart from using dental services less frequently, did not primarily seek them for preventive reasons ¹⁴14. Antunes JLF, Torpocov TN, Andrade FP. Trends and patterns of cancer mortality in European countries. Eur J Cancer Prev 2003; 12: 367-72. , which also reduces the possibility of their treatment needs being detected early, resulting in a worse prognosis of the illnesses diagnosed ¹⁵15. Roberts-Thomson KF, Stewart JF. Access to dental care by young South Australian adults. Aust Dent J 2003; 48: 169-74. .

In this study, no association was found between the outcome and the sex and ethnicity variables in both analyses. These findings are different from those of other studies ¹1. Yu SM, Bellamy HA, Schwalberg RH, Drum MA. Factors associated with use of preventive dental and health services among U.S. adolescents. J Adolesc Health 2001; 29: 395-405. ^{, 15}15. Roberts-Thomson KF, Stewart JF. Access to dental care by young South Australian adults. Aust Dent J 2003; 48: 169-74. . It is possible that the influence of sex in the use of services could not be found, due to the adolescents investigated being still dependent on adult care for making appointments. As regards ethnicity, the fact that no association with the outcome was found may have occurred due to the social homogeneity of the sample. All participants were public school students of the public school network and most of them belonged to the same economic category. Other studies found differences in the use of services of oral health between ethnic groups, which was less frequent among black people, although also observing that this result was associated with the socioeconomic condition ¹⁶16. Ronis DL, Lang WP, Antonakos CL et al. Preventive oral health behaviour among African-Americans and whites in Detroit. J Public Health Dent 1998; 58: 23-40. ^{, 17}17. Gilbert GH, Shah GR, Shelton BJ, Heft MW, Bradford EH Jr, Chavers LS. Racial differences in predictors of dental care use. Health Serv Res 2002; 37: 1487-507. .

In the multivariate analysis, the use of services was found to be lower among adolescents who were concerned about their body image and were involved in fights and whose parents did not know where they were in their leisure time. An individual's body image corresponds to the way that he/she perceives himself/herself as regards his/her own body. Moreover, the idea that this individual imagines others to have about him/her is reflected in his/her self-image and self-esteem. Dissatisfaction with one's body image can cause feelings of rejection and isolation, resulting in difficulties of living socially and with peers. A negative self-image and low self-esteem can influence the health of individuals. Oral health is linked to self-care, which is related to self-esteem. Providing a positive view of one's body-image reinforces self-confidence, with repercussions on the adolescent's health condition. In this sense, schools have a key role to play, as they are able to act positively on the development of actions of health promotion, encouraging interpersonal relationships and providing opportunities for self-expression and building self-esteem. At the same time, they can promote social interaction and integration and the adoption of protective behavior.

The frustration experienced by adolescents about their body and about family relations can trigger unhealthy behavior. Becoming involved in fights can be a way for an adolescent to express dissatisfaction with himself/herself and with the attention received from his/her family or social group, using the exposure to risk situations and negligence of self-care as a means of protesting and drawing attention to himself/herself. Unsatisfactory social support can be related to negative health behavior, and less social support is associated with lower use of dental services ¹⁸18. Krasnik A, Sawitz A, Keiding N, Hansen E. Determinants of general practice utilization in Denmark. Dan Med Bull 1997; 44: 542-6. . During adolescence, identification with parents and friends and acceptance by the peer group contribute to structuring the personality and have a protective effect ³3. Freeman R. The determinants of dental health attitudes and behaviours. Br Dent J 1999; 187: 15-18. ^{, 19}19. Resnick MD, Bearman PS, Blum RW, Bauman KE, Harris KM, Jones J et al. Protecting adolescents from harm: findings from the National Longitudinal Study on Adolescent Health. JAM 1997; 278: 823-32. . Moreover, living among people can act as a way to monitor and encourage the adoption of healthier behavior, such as practicing physical activities and making preventive appointments, which in its turn contributes to a better quality of life. The absence of these protection mechanisms can leave adolescents more vulnerable to risk behavior and factors.

The family context exerts great influence on establishing habits and behavior in adolescence, and parents who are more present and that accompany the daily activities and development of their children, including knowing where they spend their leisure time, are usually more attentive to their health and encourage the adoption of healthy behavior. The existence of family links, where adolescents feel understood by their parents, can lead to the adoption of healthier attitudes toward their oral health, including greater use of dental floss and preventive use of dental services ²⁰20. Davoglio RS, Aerts DRGC Abegg C, Freddo SL, Monteiro L. Factors associated with oral health habits and use of dental services by adolescents.. Cad. Saúde Pública 2009; 25: 655-67. . On the other hand, a hostile and indifferent family context can generate feelings of abandonment and neglect, causing depression ²¹21. Baggio L, Palazzo LS, Aerts DRGC. Suicide planning among teenage students: prevalence and associated factors. Cad. Saúde Pública 2009; 25: 142-50. , which in its turn can lead to negligence of self-care actions ²²22. Dolic M, Bailer J, Staehle HJ, Eickholz P. Psychosocial factors as risk indicators of periodontitis. J Clin Periodontol 2005; 32: 1134-40. . During adolescence, seeking dental services is, in the majority of cases, a decision that does not rest exclusively on the youth, but also depends on the performance of parents, who are responsible for selecting the health service which will be used and setting up appointments.

Tobacco use lost significance, in spite of having shown an association with the outcome in the univariate analysis, when controlled for other variables related to lifestyle. This could be indicating that the manner in which tobacco consumption was measured may have failed to distinguish between the individuals who have the smoking habit and those who do not, as it took into account whether adolescents had already used this substance at any time in their life, which does not necessarily mean that consumption has persisted and become a habit.

The frequency with which dental services are used with a time interval longer than one year was higher among those who had worse oral hygiene habits, i.e. who brushed their teeth less than twice a day and did not use dental floss daily, an association which was maintained after controlling for confounding factors. This can also be related to the fact that those who made fewer appointments primarily sought dental services for curative reasons, revealing the coexistence of risk behavior. The maintenance of oral health is related to habits of adequate hygiene and preventive care, both for preventing the occurrence of dental caries by bringing fluoride to the oral cavity through toothpastes and for maintaining periodontal integrity ²³23. Löe H, Switzerland B. Oral hygiene in the prevention of caries and periodontal disease. Int Dent J 2000; 50: 129-39. . However, the coexistence of factors which characterize an unhealthy lifestyle leaves the youth more vulnerable, as oral diseases are highly related to lifestyle ²⁴24. World Oral Health Report 2003: Continuous improvement of oral health in the 21st century - the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2003; 31: 3-23. .

The present study had good external validity as it used a representative sample. Moreover, it also showed good internal validity, because of the use of pre-tested questionnaires, the training of the research group and the supervision of field work. However, this study had some limitations: data were cross-sectional, the directions of the relationships identified could not be determined, and those not enrolled in a school were excluded from this study. The use of self-assessment questionnaires might have affected the results as it assumed that respondents had good reading and understanding skills.

Conclusion

The schoolchildren who reported the lowest economic status, insufficient family support, involvement in fights, concern with their body image, brushing their teeth less than twice a day and no daily use of dental floss sought dental services less frequently than their peers, suggesting that the use of such services by adolescents depends on the interaction of several social and individual factors, in addition to the family context.

The investigation and understanding of how adolescents use dental services and the factors associated with this use, apart from providing support to organize the health system, contribute to the adoption of protective behavior and elimination of risk factors, thereby reducing their vulnerability to health problems, including oral health. Dealing with the latter means developing actions of health promotion and education that involve the family, school and community, apart from inter-sectoral public policies aimed at improving the living conditions of the population.

Acknowledgments: Authors would like to thank the support and contribution of Emeritus Professor Aubrey Sheiham.

Contribution of each author: All authors contributed to the data analysis and writing of the present paper.

Conflict of interest: None of the authors had any conflicts of interest.

References

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