p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 7 ) 1 e7

Available online at www.sciencedirect.com

Pediatric Dental Journal

journal homepage: www.elsevier.com/locate/pdj

Research Paper

The relationship of mothers' coping strategies and

health behavior with oral health care for children

Fumi Matsuo*, Shigemasa Sato

Kyushu University of Nursing and Social Welfare, 888, Tomino, Tamana-shi, Kumamoto 865-0062, Japan

article info abstract

Article history: Objectives: In the Transactional Model of Stress and Coping, coping strategies and presence of
Received 4 October 2016 social support influence health behavior. This study aimed to reveal relationships between
Received in revised form mothers' coping styles, self-health behavior, children's oral health care, and social support
27 April 2017 from dental professionals.
Accepted 5 June 2017 Methods: A total of 313 mothers participated in this study from all elementary schools in 2
Available online xxx cities in Japan. We classified participants into high and low groups with reference to self-
health behavior and oral health care. To examine the associations of mother's coping
Keywords: styles, health behavior, and the presence of social support, logistic regression analysis was
Transactional model conducted.
Coping style Results: There were significant differences in mother's coping styles associated with self-
Behavior health behavior, oral health care, and presence of social support. In logistic regression
Oral health analysis, the good self-health behavior group was more likely to use coping strategies of
Self-health obtaining information and positive interpretation, to have fewer children, and less
frequent use of avoidance-like thinking. The good oral health care group had a higher
probability of obtaining information and using problem focused coping, and a lower
probability of evading one's responsibility. Those who consulted dental offices used more
positive interpretation, while mothers who did not consult dental offices used evading
one's responsibility more frequently.
Conclusions: Mother's coping styles had different associations with self-health behavior and
children's oral health care. We may be able to use behavioral modification strategies
effectively according to whether a mother consults with dental professionals. Future
intervention studies based on this research are expected.
Copyright © 2017 Published by Elsevier Ltd on behalf of the Japanese Society of Pediatric
Dentistry.

* Corresponding author. Department of Oral Health Sciences, Kyushu University of Nursing and Social Welfare, Kumamoto 865-0064,
Japan.
E-mail addresses: f-matsu@kyushu-ns.ac.jp (F. Matsuo), satorin@kyushu-ns.ac.jp (S. Sato).
http://dx.doi.org/10.1016/j.pdj.2017.06.001
0917-2394/Copyright © 2017 Published by Elsevier Ltd on behalf of the Japanese Society of Pediatric Dentistry.

Please cite this article in press as: Matsuo F, Sato S, The relationship of mothers' coping strategies and health behavior with oral health
care for children, Pediatric Dental Journal (2017), http://dx.doi.org/10.1016/j.pdj.2017.06.001
2 p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 7 ) 1 e7
1. Introduction
Stress has long been a focus among researchers interested in
psychosocial influences on health. The Transactional Model of
Stress and Coping has generated an extensive body of literature
on coping strategies, adjustment to illness, and health
behavior [1]. This model is a framework for evaluating the
processes of coping with stressful events [2e4]. When faced
with a stressor, a person estimates the potential threat (pri-
mary appraisal), and simultaneously estimates his or her
ability to change the situation and suppress a negative
emotional reaction (secondary appraisal). According to this
model, emotional and functional effects of primary and sec-
ondary appraisals are mediated by actual coping strategies.
Coping strategies influence outcomes like healthy or un-
healthy behavior (for example, psychological well-being,
functional status, and adherence to treatment).
Original formulations of the model conceptualized coping
efforts along two dimensions: problem management and
emotional regulation [5]. Problem-focused coping strategies
are directed at changing the stressful situation such as active
coping, problem solving, and information seeking. Problem-
focused coping strategies are successful in dealing with
stressors such as treatment for cancer and diabetes [6,7]. By
contrast, emotion-focused coping efforts are directed at
changing the way one thinks or feels about a stressful situa-
tion. These strategies include seeking social support and
venting feelings, as well as avoidance and denial. In general,
not only problem-focused coping, but emotion-focused
coping will be adopted when the stressor is recognized as a
threat that one cannot control. Folkman and Lazarus et al. [8]
examined the extent to which eight different forms of coping
mediated four types of emotions during stressful events of
daily living. Typically, people use a mixture of all types of
coping strategies, and coping skills usually change over time.
Individual differences in coping styles can be considered
“moderators” of the impact of stress on coping processes and
outcomes. Problem-based coping can predict not only breast
self-examination practice [9], but also periodontal disease [10],
and active coping in relation to optimism was related to dental
health behavior and self-reported dental health [11]. A review
study found that a mother's stress is related to early childhood
caries, although when a mother has high coping skills, the
child will not develop a cavity [12]. That is, although a
mother's coping style affects her child's health, it is not
obvious how differences in coping styles affect self-health and
the child's oral health. This information would be useful for
coping skills training techniques to be incorporated into
standardized interventions for dental professionals, because
they can apply techniques for children's cavity prevention.
Social support also has important effects on outcomes. By
influencing key processes posited in the Transactional Model,
social support can influence how people adapt to stressful
events. A supportive environment can also protect against
stress by providing opportunities to explore different coping
options and to evaluate their effectiveness [13]. A relationship
between the prevention of lifestyle-related diseases and social
support has been reported in Japan [14]. There may be asso-
ciations between different aspects of social network, social
Please cite this article in press as: Matsuo F, Sato S, The relationship of mothers' coping strategies and health behavior with oral health
care for children, Pediatric Dental Journal (2017), http://dx.doi.org/10.1016/j.pdj.2017.06.001
support, and dental status. Mothers who can seek advice from
a dental professional will use different coping strategies from
those who cannot.
Therefore, we investigated coping styles of mothers with
children in 5th and 6th grade (10e12 years old) because
mothers had a poorer primary appraisal of their child's oral
health at this age compared to earlier childhood and because
children in this age group require assistance during the mixed
dentition period. Furthermore, we investigated mothers'
coping styles in relation to whether they can seek advice from
a dental professional. Our aim in this paper was to reveal re-
lationships between mothers' coping styles, self-health
behavior, and children's oral health care.
2. Material and methods
2.1. Design
A descriptive cross-sectional survey was conducted in
elementary schools in several cities in Kumamoto, Japan.
Anonymous self-administered questionnaires were distrib-
uted at school, completed at home, and collected during
February and March 2015.
2.2. Sample selection
A total of 377 families enrolled in all elementary schools in 2
cities (all 6 schools) were selected and 319 (84.6%) returned
questionnaires by the end of the data collection period. The
number of eligible responses was 313 (83.0%) because fathers
and missing replies were excluded.
2.3. Measures
Demographic data collected for parents included sex, age
(decade), job, and number of children living with them.
Coping style was measured using the Tri-axial Coping Scale
24-item version (TAC-24) [15]. This scale is a self-report measure
and evaluates a person's tendencies to adopt certain coping
strategies with three dimensions: Encounter-Avoidance, Prob-
lem-Emotion, and Behavior-Cognition Dimension. It is divided
into eight sub-scales (getting information: Encounter-Problem-
Behavior, giving up: Avoidance-Problem-Cognition, positive
interpretation: Encounter-Emotion-Cognition, plan drafting:
Encounter-Problem-Cognition, avoidance-like thinking: Avoi-
dance-Emotion-Cognition, distractive recreation: Avoidance-
Emotion-Behavior, catharsis: Encounter-Emotion-Behavior,
evading one's responsibility: Avoidance-Problem-Behavior);
the Cronbach's a value of internal consistency for the sub-
scales ranged from 0.65 to 0.84. This scale was checked by a
retest for suitability of use with Japanese people [16], and the
three-dimensional model of classifying coping behavior was
validated. Items have 5 response options (1 ¼ I'll never do that to
5 ¼ I'll certainly do that), and scores on each subscale range from 3
to 15 points.
Mothers' self-health behavior was investigated with 11
items. Seven items were based on Belloc and Breslow's Seven
Health Factors for Longevity [17], and four items were original
to this study, such as whether one has had a physical check-
 p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 7 ) 1 e7 3

up, cut down on salt, eats a lot of vegetables, sufficiently Factor (VIF) was used to check for multicollinearity. All asso-
masticates food, and were based on Health Japan 21 (the ciations were assessed with a p-value of 0.05. Descriptive
second term) [18]. Health Japan 21 (the second term) is a ten- statistics were calculated using SPSS Version 19.0 (Tokyo,
year plan begun in 2013; the policies, ideas, and specific Japan: IBM).
goals that form the basis of the plan are included in the “Basic
Direction for Comprehensive Implementation of National 2.5. Ethics
Health Promotion”. These were constructed with three
response options (1 ¼ I never do that or I'm careful not to do that, The Kyushu University of Nursing and Social Welfare Ethical
2 ¼ I often do that or I'm sometimes careful to do that, 3 ¼ I Review Board approved the study (26-009). Information about
invariably do that or I'm careful to do that and so on), and the the study aim was given to the principal in each elementary
highest (healthiest) score is set to one point. Healthiest group school. Respondents read a document about the study, and
answered I invariably do that or I'm careful to do that. The item of completed the questionnaire at home if they consented to this
“Moderate or no use of alcohol” classified the person who study. They were guaranteed confidentiality.
answered I'm careful to do that and no use into Healthiest group.
The item of “No smoking” classified the person who answered
I don't smoke into Healthiest group. The range of self-health 3. Results
behavior scores was 0e11 points.
Mothers' oral health care for children was investigated in Overall, the number of eligible responses was 313 (83.0%), and
terms of periodic fluoride treatment, being careful about using Table 1 shows the characteristics of participants. The mean
sugar, and paying attention to the child's mouth with refer- number of children was 2.45 and the standard deviation was
ence to Yamamoto et al.'s study [19]. This was constructed 0.84. Table 2 shows the coping style variables. The Cronbach's
with 3 response options (0 ¼ I never do that, 1 ¼ I often do that, a value of internal consistency for the subscales ranged from
2 ¼ I invariably do that), and a range of 0e6 points (refer to 0.67 to 0.84. Table 3 shows mothers' self-health behavior.
Table 4). There were significant differences between the healthiest
To investigate mothers' perceived social support, we asked group and others except for “Had a physical check-up.” Table 4
“Is there a person who you can consult, when a problem has occurred shows mothers' oral health care for the child. There were
to a tooth belonging to yourself or your child?”; then, we instructed significant differences among all variables. Table 5 shows
them to mark multiple responses according to the number of mothers' perceived social support. About 90% answered
the consultant (1: family member, 2: a friend, 3: neighbor, 4: a “exist,” and 61.3% answered that they consulted a dentist's
teacher at school, 5: dental office (dentist etc.), 6: clinic (doctor office when a problem had occurred to either their own tooth
etc.), 7: public office, 8: others). We paid attention to whether a or the child's. We classified participants into high and low
dental office was checked because it may be the most sup- groups with reference to means of self-health behavior and
portive environment for oral health and may influence a oral health care, and presence of social support (Table 6).
mother's choice of coping strategies. There were significant differences in mothers' coping styles
among these groups. The results of t-tests showed that there
2.4. Statistical analysis were significant differences among the high and low self-
health behavior groups in getting information, positive inter-
Initially, we calculated basic descriptive statistics and items pretation, plan drafting and evading one's responsibility.
were checked for plausibility. Chi-square tests were used to There were significant differences between the oral health
compare differences in healthiest group and others about
mother's self-health behavior and to compare differences in
the behavior about concerning mother's oral health care for
Table 1 e Characteristics of participants.
children. The internal consistency of the coping style sub-
n %
scales was calculated using Cronbach's a coefficient. We
classified participants into a high group and a low group with Age (decade)
reference to the means of self-health behavior and oral health Twenties 2 0.6
Thirties 125 39.9
care. T-tests were calculated to assess differences in coping
Forties 174 55.6
styles between the high and low groups, and between mothers
Fifties 11 3.5
who either could or could not consult a dental office. To Sixties 1 0.3
examine the association of mother's coping styles and health Number of children
behavior, logistic regression analysis was conducted by 1 33 10.5
entering each coping style measure separately. Age, number 2 139 44.4
of children, and job were selected as confounding factors in 3 114 36.4
4 23 7.3
the logistic model (Backward Elimination: Likelihood Ratio).
5 3 1.0
Ordinal or discrete variables were represented by dummy 6 1 0.3
variables. To check the interaction effect between the inde- Job
pendent variables of the six concept variables (encounter, Office worker 121 38.7
avoidance, problem, emotion, behavior, and cognition), three Family-operated business 23 7.3
dimensions were calculated, and these were entered as in- Housewife 85 27.2
Other (e.g., part-time workers) 84 26.8
dependent variables at the same time. The Variance Inflation

Please cite this article in press as: Matsuo F, Sato S, The relationship of mothers' coping strategies and health behavior with oral health
care for children, Pediatric Dental Journal (2017), http://dx.doi.org/10.1016/j.pdj.2017.06.001
4 p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 7 ) 1 e7

Table 2 e The coping style variables. Table 5 e Mother's perceived social support.
Coping style (TAC-24) Mean SD Cronbach's a Exist n (%) None n (%)
1) Getting information (EPB) 9.74 2.52 0.736 Social support 282 (90.1) 31 (9.9)
2) Giving up (APC) 6.65 2.19 0.670 Consult with n (%)
3) Positive interpretation (EEC) 10.88 2.55 0.797 (more than one answer)
4) Plan drafting (EPC) 10.38 2.35 0.735 Family member 155 (49.5)
5) Avoidance-like thinking (AEC) 8.88 2.40 0.692 A friend 83 (26.5)
6) Distractive recreation (AEB) 9.17 2.76 0.709 Neighbor 10 (3.2)
7) Catharsis (EEB) 11.13 2.63 0.839 A teacher 12 (3.8)
8) Evading one's responsibility (APB) 5.03 1.92 0.779 Dental office 192 (61.3)
Clinic 20 (6.4)
Public office 12 (3.8)
Others 8 (2.6)
Table 3 e Mothers' self-health behavior (chi-square test).
Healthiest n (%) Others n (%) 0.456e0.849), getting information (OR ¼ 1.138, 95% CI
Sleep 7e8 h (a) 73 (23.3) 240 (76.7) *** 1.021e1.267), positive interpretation (OR ¼ 1.250, 95% CI
No eating between meals (a) 65 (20.8) 248 (79.2) *** 1.106e1.413), and avoidance like thinking (OR ¼ 0.867, 95% CI
Eat breakfast regularly (a) 236 (75.4) 77 (24.6) *** 0.769e0.978). Interaction variables were not entered in this
Maintain proper weight (b) 37 (11.8) 276 (88.2) *** model. The following three variables were chosen for the final
Regular exercise (a) 17 (5.4) 296 (94.6) ***
step of oral health care for a child (Total): getting information
Moderate or no use of alcohol 195 (62.3) 118 (37.7) ***
No smoking 248 (79.2) 65 (20.8) ***
(OR ¼ 1.092, 95% CI 0.996e1.198), evading one's responsibility
Had a physical check-up (a) 166 (53.0) 147 (47.0) (OR ¼ 0.808, 95% CI 0.714e0.914), and problem focused coping
Cut down on salt (b) 56 (17.9) 257 (82.1) *** (OR ¼ 1.006, 95% CI 1.000e1.013). Problem focused coping
Eat a lot of vegetables (b) 118 (37.7) 195 (62.3) *** represents the interaction variables, and when these inter-
Sufficiently masticate food (b) 51 (16.3) 262 (83.7) *** action variables were removed, only evading one's re-
Total score mean SD
sponsibility was entered. For those who could consult a dental
4.20 1.88
office, giving up (OR ¼ 0.867, 95% CI 0.753e0.999) and positive
***p < 0.001. interpretation (OR ¼ 1.167, 95% CI 1.031e1.322) were chosen
Healthiest group answered I invariably do that (a) or I'm careful to do
for the final step. On the other hand, for those who could not
that (b).The item of “Moderate or no use of alcohol” classified the
consult a dental office, evading one's responsibility
person who answered I’m careful to do that and no use into Healthiest
group. The item of “No smoking” classified the person who (OR ¼ 0.798, 95% CI 0.631e0.963) was chosen for the final step.
answered I don't smoke into Healthiest group. Interaction variables were not entered in these two models.

4. Discussion
Table 4 e Mothers' oral health care for the child (chi-
squared test). We investigated the relationship between mothers' self-
Never n (%) Often Invariably health behavior and oral health care for children using the
n (%) n (%) coping styles questionnaire at all elementary schools in 2
Periodic fluoride 106 (33.9) 139 (44.4) 68 (21.7) *** cities (all 6 schools). These were local cities of about 60,000,
treatment and 180,000 people in the same prefecture. The participation
Being careful about 82 (26.2) 193 (61.7) 38 (12.1) *** rate was high at 83.0%, and participants had an average of 2.45
using sugar children living with them. In Japan, the average final number
Paying attention to 76 (24.3) 211 (67.4) 26 (8.3) ***
of children of married couples (completed fertility) is 1.96 [20].
the child’s mouth
Total score mean SD
We have to consider that participants in this study were living
2.58 1.24 in local cities and be aware of how this might affect the
results.
***p < 0.001.
The coping style variables mostly had satisfactory internal
consistency. There were variations in mothers' self-health
care groups in giving up and evading one's responsibility. behavior and mothers' oral health care for children. The
Furthermore, there were significant differences between following items of breakfast, smoking, and alcohol showed
mothers who either could or could not consult a dental office that many people were careful about their self-health.
in getting information, plan drafting, catharsis and evading Comparing coping styles between the high and low self-
one's responsibility. health groups, the high group was apt to use the coping
Odds ratios estimating the coping styles associated with strategies of getting information, positive interpretation, and
mothers' health behavior are presented in Table 7. None of the plan drafting, while the low group was apt to use the coping
VIF values of these models reached 10 and values ranged from strategy of evading one's responsibility. This result is consis-
1.0 to 5.0, indicating no multicollinearity in these models. The tent with previous studies [9,21]. About 66% of children un-
following four variables were chosen for the final step of self- dergo fluoride treatment, but they are influenced by mothers'
health behavior: number of children (OR ¼ 0.622, 95% CI coping strategies when they go to a dental office. Comparing

Please cite this article in press as: Matsuo F, Sato S, The relationship of mothers' coping strategies and health behavior with oral health
care for children, Pediatric Dental Journal (2017), http://dx.doi.org/10.1016/j.pdj.2017.06.001
 p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 7 ) 1 e7 5

Table 6 e T-tests assessing differences in mothers' coping styles in the high and low groups, and the presence of social
support.
n (%) Self-health behavior Oral health care for Social support
the child (consult a dental office)
High group Low group High group Low group Yes No
120 (38.3) 193 (61.7) *** 159 (50.8) 154 (49.2) 192 (61.3) 121 (38.7) ***
mean SD mean SD mean SD mean SD mean SD mean SD
Getting information (EPB) 10.38 2.46 9.34 2.48 *** 9.96 2.55 9.51 2.48 10.07 2.43 9.21 2.58 **
Giving up (APC) 6.39 2.04 6.81 2.27 6.40 2.30 6.92 2.05 * 6.56 2.14 6.79 2.28
Positive interpretation (EEC) 11.59 2.43 10.44 2.52 *** 11.10 2.67 10.65 2.41 11.03 2.46 10.64 2.67
Plan drafting (EPC) 11.03 2.25 9.97 2.34 *** 10.62 2.39 10.13 2.30 10.63 2.30 9.98 2.40 *
Avoidance-like thinking (AEC) 8.86 2.28 8.90 2.47 8.85 2.38 8.92 2.42 8.90 2.45 8.87 2.32
Distractive recreation (AEB) 9.23 2.81 9.13 2.74 9.24 2.97 9.10 2.54 9.23 2.79 9.07 2.71
Catharsis (EEB) 11.48 2.51 10.91 2.68 11.39 2.67 10.86 2.57 11.44 2.52 10.64 2.73 **
Evading one's responsibility (APB) 4.73 1.87 5.22 1.92 * 4.70 1.81 5.38 1.96 ** 4.83 1.74 5.35 2.13 *

***p < 0.001, **p < 0.01, *p < 0.05.

the coping style between the high and low oral health groups,
the low group was apt to use the coping strategies of giving up
and evading one's responsibility. Although the coping strate-
gies of getting information, positive interpretation, and plan
drafting were impartial, the problem-focused coping strategy
and not avoidance coping strategies may lead to lead healthy
behavior. Mothers who could consult a dental office were apt
to use the catharsis coping strategy. Catharsis is the purifi-
cation and purgation of emotions and is assessed by such
question items as “I have someone to hear me talk, and this calms
me down,” “I state a complaint to someone and have clear feelings”
[15]. This variable includes an implication of seeking support.
According to a previous study [22], high self-concealers (a
person's tendency to keep intimate information secret) were
more inclined than low self-concealers to seek psychological
services. After all, any form of support may be important for
good oral health care as Cohen [23] mentioned.
According to the odds ratios estimating the coping style
associated with mother's self-health behavior, fewer children,
lower avoidance-like thinking coping, higher getting infor-
mation coping and positive interpretation coping predicted
good self-health behavior. It can easily be imagined that a
mother with numerous children will be pressed for time. It
has been reported that when there are more than two chil-
dren, mothers become more likely to acknowledge maltreat-
ment of their children [24]. Thus, it is possible that mothers
with more children experience greater stress, and this causes
unhealthy behavior. On the other hand, the number of chil-
dren did not influence mothers' oral health care for children.
Additionally, mothers used different coping styles when they
had social support. Mothers who did not consult a dental of-
fice, and who were low in the use of evading one's re-
sponsibility as a coping strategy were significantly likely to
engage in good oral health care for the child. One study found
that intrinsic motivation in dental care was positively related
to responsibility [25]. In brief, a mother who has an internal
locus of control about the child's oral health, without
consulting a dental office (dental professionals), engages in
good behavior. These results parallel research findings by
Brincks et al. [26] that there was a positive relationship
between powerful others health locus of control and trust in a
physician. For patients with a tendency to internal health
locus of control, it is necessary to support them and suggest
ways they can take care of their oral health independently
[27]. Dental professionals can offer accurate information and
approaches to increase self-efficacy in patients. Additionally,
mothers who can consult a dental office, and who were high in
use of positive interpretation coping and low in use of giving
up coping were significantly likely to engage in good oral
health care for the child. That is, when a mother consults a
dental office, dental professionals can suggest that she
consider positive interpretations and never give up. Overall,
similar to prior research [12], the skill of problem-focused
coping had a positive effect on mothers' oral health care for
children. Problem-focused coping strategies include active
coping, problem solving, and information seeking. Dental
professionals can offer appropriate information and
encourage the mother to care for a child's oral health
effectively.
As with all studies, there are limitations to the findings
reported here. First, this sample was from local cities in
Japan. . Different results from those found in this study
might be obtained because there are differences in work
situations between families living in cities compared to
those in other areas. Second, although the TAC-24 was
checked by a retest, the reliability of the subscale is slightly
below the recommended value of a ¼ 0.70 [28]. Furthermore,
there are only 3 items of on mothers' oral health care for
children, and maybe the number of items should be
increased to get improve internal consistency. Finally, this
study investigated mothers' coping strategies, but not only
mothers are involved in a child's oral health. Despite these
limitations, this study made clear that there is a relationship
between coping style and health behavior, and as previous
studies have shown, coping strategies may have different
effects on children's oral health care. Therefore, different
behavioral modification strategies may be needed for
mothers who either can or cannot consult with dental pro-
fessionals. The findings of this study represent an initial
step towards further research.

Please cite this article in press as: Matsuo F, Sato S, The relationship of mothers' coping strategies and health behavior with oral health
care for children, Pediatric Dental Journal (2017), http://dx.doi.org/10.1016/j.pdj.2017.06.001
6 p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 7 ) 1 e7

Odds ratio (95% CI)

5. Conclusions

0.798 (0.631e0.963)
We found that mothers' self-health behavior and oral health

e
e
e
e
e

e
care for the child differed depending on the mother's coping
No (n ¼121)

style. This study revealed that desirable coping styles for

good oral health care for a child differed depending on the
presence of social support. Dental professionals may devise
different strategies for mothers to facilitate their child's oral
Consult a dental office

health.
0.226*
e
e
e
e
e

e
B

Conflict of interest
Odds ratio (95% CI)
Oral health care for the child

There was no conflict of interest.

0.867 (0.753e0.999)

1.167 (1.031e1.322)
e

e
e

e
Yes (n ¼ 192)

Acknowledgements

This study was supported by Nagasu and Gyokutou, Japan,

and by the Board of Education. We wish to thank the princi-
pals, teachers, students, and parents for their willingness to
0.142*

0.155*
e

e
e

e
B

cooperate in this study.

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Odds ratio (95% CI)

1.092 (0.996e1.198)

0.808 (0.714e0.914)

1.006 (1.000e1.013)

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e

e
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0.006
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e
e
B

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