Background: A vicious cycle exists between dental anxiety, oral health behaviors and oral health status. Based on previous research, psychological factors of the Health Belief Model (HBM) are associated with oral health behaviors and oral health, and are likely involved in this cycle. However, little is known about the relationship between HBM factors and dental anxiety of adolescents. The purpose of this cross-sectional study was to investigate the relationship between health belief factors, oral health and dental anxiety based on the constructs of the HBM. Methods: 1207 Grade 2 students from 12 secondary schools in Hong Kong were randomly selected and measured for the decayed, missing and filled permanent teeth (DMFT) index. Data for oral health behaviors, HBM constructs and dental anxiety were collected using questionnaires. The hierarchical entry of explanatory variables into logistic regression models estimating prevalence odds ratios (POR) were analyzed and 95% confidence intervals (95% CI) for DMFT and dental anxiety were generated. Path analysis was used to evaluate the appropriateness of the HBM as predictors for oral health behaviors, DMFT and dental anxiety. Results: Based on the full model analysis, individuals with higher perceived susceptibility of oral diseases (POR: 1.33, 95% CI: 1.14–1.56) or girls or whose mother received higher education level were likelier to have a DMFT≥1, while those with higher perceived severity (POR: 1.31, 95%CI: 1.09–1.57), flossing weekly, DMFT≥1 or higher general anxiety level statistically increases the possibility of dental anxiety. The results from path analysis indicated that stronger perceived susceptibility, greater severity of oral diseases, less performing of oral health behaviors and a higher score of DMFT were directly related to increased dental anxiety level. Other HBM variables, such as perceived susceptibility, self-efficacy beliefs, cues to action and perceived barriers, might influence dental anxiety through oral health behaviors and caries status. Conclusions: Clarifying the propositional structures of the HBM may help the future design of theory-based interventions in reducing dental anxiety and preventing dental caries.
Keywords: Dental anxiety; Health belief model; Path analysis; Oral health behavior; Oral health; Adolescent
Supplementary Information Supplementary information accompanies this paper at https://doi.org/10.1186/s12889-020-09784-1.
A vicious cycle of dental anxiety, oral health behavior and oral health status has been hypothesized [[
Dental anxiety among youth is a common problem in dental practice. The prevalence of dental anxiety among adolescents ranges from 9.4 to 19% [[
Psychosocial factors, such as "intention", "social influences", and "self-efficacy", have been identified as important modifiable determinants of tooth brushing frequencies of adolescents [[
The objectives of the study were (a) to identify psychological factors contributing to oral health and dental anxiety based on the HBM and (b) to explore the direct and indirect associations of the HBM factors on oral health and dental anxiety via oral health behaviors among Hong Kong adolescents. To the best of our knowledge, this is the first study employing a theoretical model to explore HBM constructs involved in dental anxiety via oral health behaviors and oral health status. A well-known conceptual model of influences on health-related behaviors has been described by Janz and Becker et al. [[
The study was approved by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (HKU/HA HKW IRB) (IRB HKU: UW18–029). We hypothesized the prevalence of dental anxiety in the adolescent population as 19.5% based on previous studies [[
The questionnaire was filled by participants under the supervision of the teacher-in-charge in order to prevent student interaction and maintain data integrity. Age and the gender of participants were requested. The following oral health-related behaviors were measured: frequency of tooth brushing (1. Less than twice a day; 2. Twice or more a day), flossing frequency (1. Never or less than once a week; 2. Once or more a week), sugar consumption (1. Several times a week or daily; 2. Rare) and dental visits (1. No regular dental visit; 2. Have an annual dental visit). Each beneficial behavior scored 1 while discouraged behavior scored 0. The oral health behavior (OHB) score was calculated by summing up the scores of the four beneficial behaviors (ranged from 0 to 4), with a higher score indicating a higher level of oral health behavior.
The constructs of the HBM were measured using a validated questionnaire, Oral Health Behavior Questionnaire for Adolescents based on the Health Belief Model (OHBQAHBM), which consists of 35 items related to 6 interrelated components of the HBM; Perceived Susceptibility (2 items), Perceived Benefits (7 items), Perceived Barriers (6 items), Cues to Action (3 items), Perceived Severity (7 items) and Self-efficacy (10 items) [[
Dental anxiety was assessed using a validated questionnaire, the Modified Child Dental Anxiety Scale consisting of 8 questions [[
Two trained and calibrated dentists conducted dental examinations in schools using dental mirrors with added lights and Community Periodontal Index probes. Dental caries diagnosis was determined according to the criteria of WHO [[
The percentage of missing values of the questionnaire was 0.3–7.0%. For eligible participants, an MCAR (missing completely at random) analysis in SPSS was undertaken to test whether data were missing at random. The p-value for the MCAR analysis were all > 0.05, signifying that our data were missing completely at random. The expectation maximization algorithm was used to replace the missing values with predicted values.
Correlation tests confirmed weak associations among the HBM factors, oral health and dental anxiety (Spearman's Rho correlation range 0.1–0.4). Variables were not excluded due to collinearity. The comparison of DMFT and dental anxiety between different groups was assessed using chi-square test. The column proportion test was performed to identify whether the prevalence of DMFT and severe dental anxiety in that column was significantly different from other columns. Unadjusted associations between independent variables related to DMFT/ severe dental anxiety were estimated through the odds ratio (OR) and 95% confidence interval (CI). A normality distribution test for general anxiety score, DMFT and HBM variables was used. Since the data were not normally distributed, a Mann-Whitney U test was used to compare the median between groups. Blocks of explanatory variables were entered into a binary logistic regression model using a hierarchical methodology, as predicated by our conceptual model (Fig. 1). The dependent variable of these models were DMFT ≥1 or DMFT = 0 and the existence of severe dental anxiety. The HBM construct factors were entered into Model 1. The modifying factors were entered into Model 2 and oral health behaviors entered into Model 3. For DMFT, the severe dental anxiety level was entered into Model 4. The full model of DMFT (Model 5) comprised the factors in Model 1–4. For severe dental anxiety, DMFT was entered into Model 4 and general anxiety entered into Model 5. The full model of dental anxiety (Model 6) comprised all factors. It is important to note that the full model was built based on a priori selection of covariates according to the conceptual model (Fig. 1) as opposed to covariate selection based upon bivariate statistics. The degree of attenuation was calculated by the 1–[ln (adjusted OR)/ln (unadjusted OR)] formula [[
Graph: Fig. 1 Theoretical model for the study of the health belief model to predict oral health status and dental anxiety (Adapted from Janz & Becker, 1984 [[
To explore the relationship between HBM variables, general anxiety, OHB and DMFT, a path analysis was performed using AMOS 22.0. All variables in the path analysis model were included as continuous variables. The univariate distributions of all variables in the theoretical path model were checked for normality and the skewness and kurtosis values were also measured. Because of the presence of non-normally distributed variables, the path model was evaluated using the Bollen-Stine bootstrapping procedure [[
Of the 1207 eligible participants, 1159 participated in clinical examinations and returned questionnaires (response rate = 96%). The mean age of the participants was 14.32 ± 0.68 and the proportion of girls were 46.6%. The prevalence of severe dental anxiety [[
Table 1 The relationship between dental anxiety and oral health behaviors, oral health status, HBM variables and general anxiety
Variable Total group DMFT = 0 DMFT≥1 OR (95% CI) No or mild dental anxiety Severe dental anxiety OR (95% CI) Gender % Boys 619 (53.4) 369 (57.9) 250 (47.9)* 1 546 (54.7) 73 (45.9)* 1 Girls 540 (46.6) 268 (42.1) 272 (52.1)* 1.50 (1.19–1.89) 453 (45.3) 86 (54.1)* 1.42 (1.02–1.99) Father's education level % Elementary school 84 (7.8) 39 (6.6) 45 (9.3) 1 68 (7.3) 16 (10.5) 1 High school 741 (68.7) 400 (67.3) 341 (70.3) 0.74 (0.47–1.16) 634 (68.5) 107 (69.9) 0.72 (0.40–1.28) College or above 254 (23.5) 155 (26.1) 99 (20.4)* 0.55 (0.34–0.91) 224 (24.2) 30 (19.6) 0.57 (0.29–1.11) Mother's education level % Elementary school 128 (11.7) 54 (8.9) 74 (15.0)* 1 108 (11.5) 20 (12.9) 1 High school 740 (67.5) 410 (67.9) 330 (66.9) 0.59 (0.40–0.86) 633 (67.2) 107 (69.0) 0.91 (0.54–1.53) College or above 229 (20.9) 140 (23.2) 89 (18.1)* 0.46 (0.30–0.72) 201 (21.3) 28 (18.1) 0.75 (0.41–1.40) Monthly family income % HK$15,000 or below 183 (18.1) 91 (16.3) 92 (20.3) 1 147 (16.9) 35 (24.6)* 1 HK$15,001 -50,000 688 (67.9) 383 (68.5) 305 (67.2) 0.79 (0.57–1.09) 595 (68.4) 93 (65.5) 0.66 (0.43–1.01) HK$50,001 or above 142 (14.0) 85 (15.2) 57 (12.6) 0.66 (0.43–1.03) 128 (14.7) 14 (9.9) 0.46 (0.24–0.89) Tooth brushing behaviors % Once a day or less often 372 (32.1) 201 (31.6) 171 (32.8) 1 310 (31.0) 61 (38.4) 1 Twice or more a day 787 (67.9) 436 (68.4) 351 (67.2) 0.95 (0.74–1.21) 689 (69.0) 98 (61.6) 0.72 (0.51–1.02) Flossing behavior % Never or less than once a week 924 (79.7) 503 (79.0) 421 (80.7) 1 790 (79.2) 132 (83.0) 1 At least once a week 235 (20.3) 134 (21.0) 101 (19.3) 0.47 (0.67–1.20) 208 (20.8) 27 (17.0) 0.78 (0.50–1.21) Sugar consumption % Rare or less than once a week 212 (18.3) 509 (79.9) 438 (83.9) 1 191 (19.1) 20 (12.6)* 1 Several times a week or daily 947 (81.7) 128 (20.1) 84 (16.1) 1.30 (0.97–1.78) 807 (80.9) 139 (87.4)* 1.64 (1.00–2.70) Annual dental visit % No 889 (76.7) 478 (75.0) 411 (78.7) 1 724 (74.9) 127 (82.5)* 1 Yes 270 (23.3) 159 (25.0) 111 (21.3) 0.81 (0.62–1.08) 243 (25.1) 27 (17.5)* 0.63 (0.41–0.98) Variable Total group DMFT = 0 DMFT ≥1 p No or mild dental anxiety Severe dental anxiety Perceived susceptibility (Mean ± SD)a 2.7 ± 0.9 2.5 ± 0.9 2.8 ± 0.9 < 0.001 2.6 ± 0.9 2.9 ± 0.9 < 0.01 Perceived severity (Mean ± SD)a 3.7 ± 0.9 3.7 ± 0.9 3.7 ± 0.9 0.24 3.7 ± 0.9 3.8 ± 0.8 0.03 Perceived benefits (Mean ± SD)a 3.7 ± 0.6 3.7 ± 0.6 3.7 ± 0.6 0.54 3.7 ± 0.6 3.7 ± 0.6 0.65 Perceived barriers (Mean ± SD)a 2.3 ± 0.8 2.2 ± 0.8 2.4 ± 0.8 0.001 2.2 ± 0.8 2.4 ± 0.8 0.02 Cues to action (Mean ± SD)a 2.1 ± 0.9 2.1 ± 0.9 2.1 ± 0.9 0.90 2.1 ± 0.9 2.0 ± 0.9 0.22 Self-efficacy (Mean ± SD)a 3.5 ± 1.0 3.5 ± 1.0 3.4 ± 1.0 0.27 3.5 ± 1.0 3.3 ± 1.0 < 0.05 General anxiety score (Mean ± SD)a 4.8 ± 5.2 – – – 4.4 ± 5.0 7.4 ± 5.5 < 0.001 Variable Total group DMFT = 0 DMFT ≥1 OR (95% CI) No dental anxiety Dental anxiety OR (95% CI) Oral health (DMFT) % DMFT = 0 637 (55.0) – – – 569 (57.0) 67 (42.1)* 1 DMFT ≥1 522 (45.0) – – – 439 (43.0) 92 (57.9)* 1.82 (1.30–2.56)
*Note. P-value < 0.05 (column proportion test)
The Hosmer-Lemeshow test showed a good model fit of all the logistic regression analysis. For an unadjusted model of HBM variables, every increase of one unit in perceived susceptibility resulted in 1.44 times the odds for DMFT ≥1 (Table 2, Model 1). The addition of modifying factors to HBM variables attenuated the effect of perceived susceptibility on DMFT by 14% (Table 2, Model 2), while the addition of oral health behavior variables to HBM variables attenuated the odds by 8% (Table 2, Model 3). The OR was attenuated by 3% with the addition of severe dental anxiety (Table 2, Model 4). A strong perceived susceptibility persisted as a risk indicator for DMFT ≥1 in the final model, which included all covariates. In the full model, the odds of perceived susceptibility was attenuated by 25% (Table 2, Model 5). In addition, girls, low education level of mothers and having severe dental anxiety were also significantly associated with DMFT ≥1 in the full model (Table 2, Model 5).
Table 2 Multivariable models evaluating risk indicators for DMFT ≥1 among adolescents
Model 1 (POR, 95% CI) Model 2 (POR, 95% CI) Model 3 (POR, 95% CI) Model 4 Model 5 (POR, 95% CI) Perceived susceptibility 1.44 (1.25–1.65)* 1.36 (1.16–1.59)* 1.39 (1.21–1.61)* 1.42 (1.24–1.63)* 1.31 (1.12–1.54)* Perceived severity 1.00 (0.87–1.15) 0.94 (0.80–1.11) 1.01 (0.87–1.16) 0.98 (0.85–1.14) 0.92 (0.78–1.09) Perceived benefits 0.98 (0.79–1.20) 1.05 (0.83–1.33) 0.97 (0.79–1.20) 0.98 (0.79–1.20) 1.05 (0.83–1.33) Perceived barriers 1.16 (0.97–1.39) 1.16 (0.95–1.42) 1.15 (0.95–1.39) 1.13 (0.95–1.36) 1.16 (0.93–1.44) Cues to action 0.96 (0.84–1.10) 1.00 (0.86–1.17) 0.98 (0.85–1.13) 0.97 (0.85–1.12) 1.02 (0.87–1.19) Self-efficacy 1.02 (0.89–1.15) 1.00 (0.87–1.16) 1.01 (0.88–1.16) 1.02 (0.90–1.16) 1.00 (0.86–1.17) Sex Boy – 1 – 1 Girl – 1.63 (1.25–2.12)* – 1.64 (1.24–2.17)* Father's education level Elementary school – 1 – 1 High school – 0.76 (0.46–1.25) – 0.73 (0.44–1.21) College or above – 0.66 (0.37–1.21) – 0.64 (0.35–1.17) Mother's education level Elementary school – 1 – 1 High school – 0.58 (0.38–0.89)* – 0.58 (0.38–0.91)* College or above – 0.56 (0.32–0.98)* – 0.54 (0.31–0.96)* Family income per month HK$15,000 or below – 1 – 1 HK$15,001 -50,000 – 1.00 (0.69–1.43) – 1.02 (0.71–1.49) HK$50,001 or above – 1.01 (0.61–1.68) – 1.07 (0.64–1.79) Tooth brushing behavior Once a day or less often – – 1 1 Twice or more a day – – 0.96 (0.73–1.28) 0.94 (0.68–1.30) Flossing behavior Never or less than once a week – – 1 1 At least once a week – – 0.99 (0.73–1.35) 1.01 (0.71–1.42) Sugar consumption Rare or less than once a week – – 1 1 Several times a week or daily – – 1.23 (0.69–1.26) 1.09 (0.75–1.57) Annual dental visit No – – 1 1.08 (0.76–1.53) Yes – – 0.93 (0.69–1.26) Dental anxiety level No or mild 1 1 Severe 1.66 (1.17–2.35)* 1.51 (1.03–2.21)* −2 Log likelihood 1558 1261 1508 1549 1218 Nagelkerke R2 0.042 0.072 0.042 0.051 0.080
Note: *p < 0.05
In the unadjusted model, the increase in perceived susceptibility, perceived severity, perceived barriers and significantly resulted in a higher chance of severe dental anxiety (Table 3, Model 1). In the full model, only perceived susceptibility and perceived severity remained significantly associated with severe dental anxiety. The odds of perceived susceptibility and perceived severity on severe dental anxiety were 1.27 and 1.38, which were attenuated by 11% and intensified by 10% after adjusting for confounding factors, respectively (Table 3, Model 6). In addition, tooth brushing behavior, DMFT and general anxiety remained statistically associated with severe dental anxiety in the full model (Table 3, Model 6).
Table 3 Multivariable models evaluating risk indicators for severe dental anxiety among adolescents
Model 1 (POR, 95% CI) Model 2 (POR, 95% CI) Model 3 (POR, 95% CI) Model 4 (POR, 95% CI) Model 5 (POR, 95% CI) Model 6 (POR, 95% CI) Perceived susceptibility 1.31 (1.07–1.59)* 1.38 (1.11–1.72)* 1.27 (1.04–1.56)* 1.25 (1.02–1.53)* 1.26 (1.03–1.54)* 1.27 (1.01–1.60)* Perceived severity 1.34 (1.08–1.66)* 1.40 (1.09–1.78)* 1.39 (1.11–1.73)* 1.35 (1.08–1.68)* 1.25 (1.00–1.56)* 1.38 (1.07–1.78)* Perceived benefits 1.02 (0.76–1.37) 1.00 (0.73–1.38) 0.97 (0.72–1.32) 1.02 (0.75–1.37) 1.01 (0.74–1.37) 0.93 (0.66–1.30) Perceived barriers 1.36 (1.06–1.73)* 1.29 (0.98–1.70) 1.30 (0.99–1.70) 1.34 (1.04–1.71)* 1.33 (1.04–1.71)* 1.17 (0.86–1.59) Cues to action 0.85 (0.70–1.05) 0.92 (0.74–1.15) 0.89 (0.72–1.10) 0.86 (0.70–1.05) 0.88 (0.72–1.09) 0.97 (0.77–1.22) Self-efficacy 0.89 (0.74–1.06) 0.88 (0.72–1.08) 0.95 (0.77–1.16) 0.89 (0.74–1.06) 0.95 (0.79–1.14) 1.06 (0.84–1.33) Sex Boy – 1 – – – 1 Girl – 1.30 (0.89–1.89) – – – 1.14 (0.76–1.70) Father's education level Elementary school – 1 – – – 1 High school – 0.79 (0.42–1.50) – – – 0.87 (0.45–1.68) College or above – 0.76 (0.34–1.69) – – – 0.80 (0.35–1.81) Mother's education level Elementary school – 1 – – – 1 High school – 1.36 (0.75–2.48) – – – 1.50 (0.80–2.80) College or above – 1.30 (0.58–2.87) – – – 1.75 (0.77–4.01) Family income per month HK$15,000 or below – 1 – – – 1 HK$15,001 -50,000 – 1.09 (0.76–1.57) – – – 0.76 (0.47–1.22) HK$50,001 or above – 1.02 (0.62–1.70) – – – 0.51 (0.24–1.09) Tooth brushing behavior Once a day or less often – – 1 – – 1 Twice or more a day – – 0.76 (0.51–1.13) – – 0.63 (0.40–0.99)* Flossing behavior Never or less than once a week – – 1 – – 1 At least once a week – – 0.97 (0.62–1.54) – – 0.97 (0.58–1.61) Sugar consumption Rare or less than once a week – – 1 – – 1 Several times a week or daily – – 1.64 (0.98–2.75) – – 1.53 (0.86–2.74) Annual dental visit No – – 1 – – 1 Yes – – 0.77 (0.48–1.23) – – 0.76 (0.44–1.29) Oral health DMFT = 0 – – – 1 – 1 DMFT≥1 – – – 1.66 (1.17–2.35)* – 1.58 (1.07–2.35)* General anxiety – – – – 1.09 (1.06–1.12)* 1.07 (1.04–1.11)* −2 Log likelihood 899 757 864 890 1441 1151 Nagelkerke R2 0.043 0.065 0.053 0.056 0.090 0.113
Note:*p < 0.05
The model was firstly based on the conceptual model and secondly modified according to the regression results. Three paths were added to the model: one path between perceived susceptibility and dental anxiety; and one path between perceived severity and dental anxiety; furthermore, one path linked the perceived susceptibility to oral health (DMFT). The final model is depicted in Fig. 2 and Table 4. The model was well fitted (TLI = 0.99; CFI = 1.00; RMSEA = 0.01; SRMR = 0.01; Bollen-Stine bootstrap p = 0.35). Regarding the direct effect, a significant path was noted from general anxiety to dental anxiety (β = 0.44, p < 0.01). Consistent with the regression results, higher perceived susceptibility (β = 0.56, p = 0.03) and greater perceived severity (β = 0.72, p < 0.01) were associated with greater dental anxiety. Significant direct paths were also found to OHB from perceived susceptibility (β = − 0.07, p = 0.04), self-efficacy (β = 0.20, p < 0.01), perceived barriers (β = − 0.25, p < 0.01) and cues to action (β = 0.08, p = 0.01). Regarding the direct effects of OHB and DMFT on dental anxiety, both were significant (β = − 0.74, p < 0.01; β = 0.28, p = 0.02).
Graph: Fig. 2 Path analysis of psychological factors as predictors for dental anxiety. Standardized direct path coefficients are presented. Note. Significant differences indicated by ∗∗p < 0.01; ∗p < 0.05
Table 4 Standardized and unstandardized path coefficients of the path analysis model
Effects Standardized path coefficient (β) Unstandardized path coefficient SE 95% CI Bootstrapping p R2 Oral health behaviors Perceived susceptibility −0.07 −0.07 0.03 −0.12 to −0.00 0.04 0.14 Perceived severity −0.01 −0.01 0.03 − 0.08 to 0.05 0.72 Perceived benefits 0.06 0.09 0.05 −0.01 to 0.17 0.08 Perceived barriers −0.21 −0.25 0.04 −0.33 to − 0.17 < 0.01 Cues to action 0.08 0.08 0.03 0.02 to 0.13 0.01 Self-efficacy 0.23 0.20 0.03 0.15 to 0.25 < 0.01 Oral health (DMFT) Oral health behaviors −0.05 −0.08 0.06 −0.20 to 0.04 0.09 0.04 Perceived susceptibility 0.17 0.30 0.18 −0.06 to 0.66 0.16 Dental anxiety Perceived susceptibility 0.07 0.56 0.24 0.05 to 1.03 0.03 0.14 Perceived severity 0.09 0.72 0.23 0.31 to 1.18 < 0.01 General anxiety 0.32 0.44 0.04 0.36 to 0.52 < 0.01 Oral health (DMFT) 0.07 0.28 0.13 0.04 to 0.54 0.02 Oral health behaviors −0.09 −0.74 0.23 −1.18 to −0.30 < 0.01
Note: 95% CI, 95% confidence interval of the unstandardized path coefficient; SE, standard error of the unstandardized path coefficient
For indirect effects exerted through OHB and DMFT, perceived susceptibility (β = 0.14, p < 0.01), self-efficacy beliefs (β = − 0.16, p < 0.01), cues to action (β = − 0.06, p < 0.01) and perceived barriers (β = 0.19, p < 0.01) were statistically significant. The dotted line of Fig. 2 denoted the insignificant paths, but for conceptual reasons, it was decided to retain the paths. The final model explained 14% of variances in oral health behaviors and 14% of variances in dental anxiety.
This study suggests that HBM factors are risk indicators for caries and dental anxiety among Hong Kong adolescents. After adjusting for socio-demographic factors and behavior covariates, the association of perceived susceptibility with DMFT score and perceived severity in relation to dental anxiety was maintained.
We believe that this is the first study to examine the complex predictors regarding oral health and dental anxiety after accounting for the impact of HBM variables in a path analysis model of data. Our findings suggested that perceived susceptibility, perceived barriers, self-efficacy and cues to action could predict oral health behaviors. The results were in accordance with other studies that perceived barriers, self-efficacy and cues to action played a role in predicting oral health behaviors [[
What's more, our findings suggested that oral health beliefs (including HBM constructs) were associated with dental anxiety directly or indirectly via OHB and oral health. In recent decades, pressure has been placed on therapeutics to reduce patients' anxiety in the long term without pharmacological use [[
However, the HBM variables predicted only 14% of the variance in both oral health behaviors and dental anxiety, leaving 86% of the variance unaccounted for. This suggested that HBM factors owned the ability to predict dental anxiety as well as oral health behaviors. But it also indicated that there are other important determinants of healthy behaviors and dental anxiety not yet accounted for by HBM. This points to the need to investigate other determinants that were not accounted for by HBM, such as demographic variables. In addition, most HBM researchers assumed that the individual determinants were only directly related to healthy behaviors and no indirect or mediating effects exist between the variables [[
One of the major limitations of our study is the cross-sectional study design of the work. Given the nature of the design, a causal relationship between psychological factors and dental anxiety cannot be determined. Thus, future work is necessary to test this relationship using a longitudinal study design. Another limitation of our study is the use of self-reported measures to assess oral health behaviors. There is a possibility that social desirability may introduce bias. The third limitation of our findings is that it may not be generalizable to older adolescents as differences in psychological and physical status exist between early adolescents and late adolescents [[
The present study suggests directions and further steps to be taken to reduce dental anxiety and improve oral health status in adolescents. The need for cognitive-behavioral interventions is further evidenced by the fact that 2/3 of adolescents brushed their teeth as recommended (at least twice a day) but only 20.0% of adolescents flossed weekly. Most adolescents had a high frequency of sugar intakes and did not have plans for annual dental visitation. Moreover, our study found a relatively high prevalence of dental anxiety (40.5%) and DMFT ≥1 (45.0%). A high prevalence of dental anxiety has been shown to result in increased dental avoidance and poorer oral health outcomes. Our analysis of dental anxiety and oral health from a cognitive theory model perspective, such as the HBM, provides a clearer explanation for one of the mechanisms involved in oral health and dental anxiety among adolescents. Thus, there is a tangible application for the implementation of theory-based behavioral interventions targetting the promotion of oral health behaviors in schools as an alternative strategy in reducing dental anxiety and prevent oral diseases in adolescents.
The author would like to thank all the participating adolescents.
BX: data collection, data analysis and writing of the manuscript. HMW: design of the study and revision of the manuscript. APP: critical review of the data analysis and results. CPJM: critical review of the manuscript. All the authors read and approved the final manuscript.
The study was financially funded by grants from the Research Grants Council of the Hong Kong Special Administrative Region, China (Project No. 17115916). The funding body has not influenced the study design, collection, analysis and interpretation of data, or how the manuscript was written.
The datasets used and/or analyzed for the current study are available from the corresponding author on reasonable request.
The study was approved by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (HKU/HA HKW IRB) (IRB HKU: UW18–029). The mean age of the participants was 14.32 ± 0.68. Written informed consent from parents were obtained prior to their child's participation.
Not applicable.
The authors declare that they have no competing interests.
Graph: Additional file 1. Questionnaire.
• HBM
- Health Belief Model
• DMFT
- Missing and filled permanent teeth
• POR
- Prevalence odds ratios
• CI
- Confidence interval
• OHB
- Oral health behavior
• CFI
- Comparative fit index
• GFI
- Goodness-of-fit index
• TLI
- Tucker-Lewis index
• RMSEA
- The root mean square error of approximation
• SRMR
- The standardized root mean squared residual
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By Bilu Xiang; Hai Ming Wong; Antonio P. Perfecto and Colman P. J. McGrath
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