Accepted: 17 September 2017

DOI: 10.1111/idh.12319

ORIGINAL ARTICLE

Dental visiting behaviours among primary schoolchildren:

Application of the health belief model

C-Y Lee1,2  | C-C Ting3 | J-H Wu1,4 | K-T Lee1,4 | H-S Chen1,5 | Y-Y Chang6,7

1
Department of Oral Hygiene, College
of Dental Medicine, Kaohsiung Medical Abstract
University, Kaohsiung City, Taiwan Objectives: This study aimed to develop and validate a new instrument based on the
2
Department of Medical Research, Kaohsiung
health belief model and to use the instrument to investigate the determinants of regu-
Medical University Hospital, Kaohsiung City,
Taiwan lar dental attendance among primary schoolchildren.
3
School of Dentistry, College of Dental Methods: A cross-­sectional study was conducted using a newly developed measure-
Medicine, Kaohsiung Medical University,
ment scale based on the HBM, 4 health-­promoting schools participated in the study
Kaohsiung City, Taiwan
4
Division of Family Dentistry, Department and 958 students studying in grades 4–6 completed the questionnaire. The psycho-
of Dentistry, Kaohsiung Medical University metric properties of the instrument were analysed, and a path analysis model was used
Hospital, Kaohsiung City, Taiwan
5
to identify the determinants of regular dental attendance.
Division of Pediatric Dentistry, Department
of Dentistry, Kaohsiung Medical University Results: The instrument had good internal consistency (Cronbach’s α = 0.826–0.925)
Hospital, Kaohsiung City, Taiwan and a factor structure identical to HBM. Overall, the schoolchildren’s health beliefs on
6
Department of Healthcare Administration
caries treatment were positive. The determinants of regular dental visit were school
and Medical Informatics, College of Health
Sciences, Kaohsiung Medical University, location (β = −0.13), mother’s education level (β = 0.15), susceptibility (β = −0.18) and
Kaohsiung City, Taiwan
barriers (β = −0.11).
7
Department of Public Health, College
of Health Sciences, Kaohsiung Medical
Conclusion: This study provided evidence that HBM is applicable to children’s dental
University, Kaohsiung City, Taiwan visiting behaviour and their health beliefs towards adherence to caries treatment.

Correspondence
Chen-Yi Lee, Department of Oral Hygiene,
College of Dental Medicine, Kaohsiung
Medical University, Kaohsiung City, Taiwan.
Email: cylee@kmu.edu.tw
Although children had a positive attitude towards dental visits, environmental obsta-
cles would interfere with dental visits. The newly developed instrument could be used
to identify high-­risk children and help design oral health interventions for these chil-
dren. Moreover, policy makers should increase the accessibility of dental resources to
enhance the utilization of dental care among schoolchildren.

KEYWORDS
caries, child, dental visit, health belief model, health-promoting school

1 |  INTRODUCTION
Since the 1990s, the Taiwan government has funded various pro-
grammes to improve children’s oral health. Moreover, in Taiwan,
health-­promoting schools (HPSs) have advocated oral health promo-
tion since 2001,1 such as daily practice of tooth brushing after meal,
dental flossing and weekly use of fluoride mouthwash. After years of
effort, the decayed, missing and filled teeth (DMFT) index at 12 years
of age has significantly declined from 4.95 in 1990 to 2.50 in 2012.
However, a high percentage of children continue to have untreated
2
dental decay in their primary and permanent teeth. Taiwan has no
water fluoridation practice nor licensed paraprofessionals such as den-
tal nurses/hygienists/therapists to offer services to school students or
individuals in the community; unstable structure of the dental public
health system and the disparity of dental resources produce a com-
plex problem that potentially influences the dental care-­seeking be-
haviours of patients.
Children’s oral health is influenced by child-­
, family-­and
community-­level factors.3 Importantly, various aspects of childhood
oral health are considered pivotal in determining the oral health trajec-
tories in later life, especially adult oral health.4,5 Childhood socioeco-
nomic status and parental oral health-­related beliefs were associated

Int J Dent Hygiene. 2017;1–8. wileyonlinelibrary.com/journal/idh   © 2017 John Wiley & Sons A/S. |  1
Published by John Wiley & Sons Ltd
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2       LEE et al.
with children’s oral health-­
related beliefs, which in turn predicted
6
toothbrushing and dental service use. Poor oral health has a signif-
icant effect on children’s growth and development, overall well-­being
and quality of life.7 Parents’ adherence to regular dental attendance
for their young children plays an important role in improving and main-
8,9
taining children’s oral health. Despite the recommendation, most
children’s first dental visit appears to happen only when they have
visible caries lesions or experience dental trauma,10 which could cause
greater dental anxiety.11 Moreover, adherence studies related to den-
tal regimens and preventive practices have received little attention.9
One of the most acknowledged theoretical explanatory models
of individual behaviour change in the public health domain, which
can be used to tailor personal messages, is the health belief model
12
(HBM). It was first proposed in the 1950s by Hockbaum and adopted
in the 1970s by the US Public Health Service. The HBM is a value-­
expectancy theory that assesses the values individuals place on the
desire to avoid illness or stay well (value), combined with their belief
that a health action can prevent illness (expectation). The HBM was
spelled out in terms of the following 4 constructs representing the
perceived threat and net benefits: perceived susceptibility, severity,
benefits and barriers. These concepts were proposed as accounting
for people’s “readiness to act.” The HBM is used to assist individuals in
assuming responsibility for their behaviours13 and has been utilized as
a model for oral health.14 However, few studies have applied HBM in
oral health attendance perspectives, that is, dental visiting behaviours,
mostly focusing on tooth brushing and dental flossing behaviours.15,16
The aims of the present study were twofold. First, it intended to
develop and validate a new questionnaire based on the HBM that can
be used to assess perceived susceptibility, benefits, barriers and se-
verity regarding children’s health beliefs on caries treatment. Second,
a path analysis was conducted to test the hypothesis that sociode-
mographic characteristics, school location and children’s oral health
beliefs are determinants of their dental visiting behaviours.
2 |  STUDY POPULATION AND
METHODOLOGY
2.1 | Participants and procedure
This study was approved by the Kaohsiung City Government and the
HPS programme directed by the Taiwan Ministry of Education. The
study was conducted in Kaohsiung—the third largest municipality in
Taiwan, with an approximately 2.78 million population. The study
design was cross-­sectional, using purposive sampling. Four HPSs (W,
E, Y and G) located in different districts were selected for high car-
ies rate by the Kaohsiung government to participate in this study. W
primary school was located in an urban district (Fengshan, 351 621
inhabitants) with 118 dental clinics. E primary school was located near
the town centre of an urban district (Qianzhen, 195 196 inhabitants)
with 51 dental clinics. Y primary school was located in a rural district
(Qishan, 38 818 inhabitants) near a small town with 11 dental clinics.
G primary school was located in a remote district (Yanchao, 30 666
inhabitants) with only 3 dental clinics.
Considering the literacy required to complete a self-­rating ques-
tionnaire, this study chose fourth-­, fifth-­and sixth-­grade students
as participants. W (a large school), E (a smaller school) and Y primary
schools had 717, 235 and 109 students, respectively, in grades 4 to 6.
G primary school was a small school with only 31 eligible students. In
total, 1092 students were eligible for inclusion in this study, which was
conducted from February to May 2013.
The contents of the questionnaire included the following: sociode-
mographic characteristics, dental visiting behaviours and an instrument
newly developed by the authors. The teachers distributed informed
consent forms to their students and asked them to take the form home
for their parents to sign. The questions related to sociodemographic
characteristics were filled out by the teachers, before handing out the
questionnaires to their students who completed them during class.
The questionnaire was pretested in February 2013. Since E primary
school was appointed by Kaohsiung government to direct the proj-
ect, the participants for the pretest were randomly selected from one
class each for grades 4, 5 and 6 in that school. Seventy-­two pretest
questionnaires were completed, and after modifying the content of
the questionnaire, it was formally tested from March to May 2013.
Finally, 958 valid questionnaires were collected; the response rate was
94.3%. The research protocol was approved by the Human Experiment
and Ethics Committee of the Chung-­Ho Memorial Hospital, Kaohsiung
Medical University (KMUHIRB-­EXEMPT[I]-­20150067).
2.2 | Instrument development
The instrument was designed based on the HBM, focusing on the
health beliefs towards caries treatment. Considering that schoolchil-
dren in grades 4–6 were unwilling to answer a long questionnaire,
only the 4 major concepts of HBM (susceptibility, benefits, barriers
and severity) were adopted while designing the questionnaire. The
original questionnaire comprised 37 items regarding caries-­related
dental visits.
Based on the reliability analysis (corrected item-­total correlation
<0.3) and factor analysis (factor loading <0.4), one item was added
(“When I find caries, I will see a dentist only when the caries has be-
come serious”) and 2 items were removed (“I think it’s no big deal if my
caries is not treated” from the benefits scale and “I thought my caries
did not affect my daily life, so I did not visit a dentist” from the barriers
scale) from the questionnaire after the pretest and subsequent investi-
gation. Finally, 36 items were retained in the questionnaire. The items
were originally developed in Chinese. The English version presented in
this study was translated from Chinese for the purpose of publication
and has not been tested for psychometric properties in an English-­
speaking population.
The susceptibility scale focused on “deterioration of dental caries
due to delay in visiting a dentist” and consisted of 4 items answered
on a 5-­point Likert scale ranging from 1 (highly impossible) to 5 (highly
possible), with the total score ranging from 4 to 20. The benefits scale
focused on “benefits of visiting a dentist when caries formed” and
consisted of 11 items that were answered on a 5-­point Likert scale
of 1 (strongly disagree) to 5 (strongly agree); the total score ranged
LEE et al.
from 11 to 55. The barriers scale focused on “barriers to visit a dentist
when caries formed” and consisted of 9 items that were answered on
a 5-­point Likert scale of 1 (strongly disagree) to 5 (strongly agree); the
total score ranged from 9 to 45. The severity scale focused on “the
severity of caries deterioration due to delay in visiting a dentist” and
consisted of 12 items that were answered on a 5-­point Likert scale of
1 (not serious at all) to 5 (very serious); the total score ranged from 12
to 60. Higher scores indicated higher perceived susceptibility, more
perceived benefits and barriers, and greater perceived severity.
2.3 | Data analyses
An exploratory factor analysis using the principal components method
with promax rotation was conducted to explore the factor structure
of the items developed based on HBM, which represent the construct
validity of the questionnaire. Cronbach’s alpha was calculated to es-
timate internal consistency of the scales. To further understand the
health beliefs to schoolchildren, the descriptive analysis of each item
was classified as positive, non-­committal or negative attitudes, which
were defined as follows. “Positive attitude” implies a score of 1 (highly
impossible) or 2 (impossible) for each item on the susceptibility scale,
4 (agree) or 5 (strongly agree) on the benefits scale, 1 (strongly disa-
gree) or 2 (disagree) on the barriers scale and 4 (serious) or 5 (very se-
rious) on the severity scale. “Non-­committal attitude” implies a score
of 3 (undecided) for each item in all the scales. “Negative attitude” im-
plies a score of 4 (possible) or 5 (highly possible) for each item on the
susceptibility scale, 1 (strongly disagree) or 2 (disagree) on the benefits
scale, 4 (agree) or 5 (strongly agree) on the barriers scale and 1 (not
serious at all) or 2 (not serious) on the severity scale. The sum of the
scores for each scale was calculated for each item and scale.
Chi-­square test was used to compare sociodemographic charac-
teristics according to dental visiting behaviour. The independent t test
was used to compare the health beliefs. All the above-­mentioned anal-
yses were performed using the Statistical Package for Social Sciences
(SPSS, version 20). To investigate the relationship between dental
visiting behaviour, health beliefs and sociodemographic characteris-
tics, a path analysis model was developed and tested by using Amos
20. To ensure adequate fit of the models, rigorous evaluation criteria
were adopted. A χ2 test was chosen as the statistical test of model fit
(α = 0.05). Because this test can be sensitive to minor deviations in a
model fit in large samples, the goodness-­of-­fit index (GFI), compara-
      3|
31 (3.2%) from G school. Among the respondents, 309 (32.3%) were
from grade 4, 303 (31.6%) from grade 5 and 346 (36.1%) from grade 6.
Among these students, 469 (49.0%) were girls and 488 (51.0%) were
boys. Regarding the fathers’ education level, 202 (21.1%) completed
junior high school or lower, 354 (37.0%) completed senior or voca-
tional high school, 367 (38.3%) completed college or higher, and 35
(3.7%) had missing values. Regarding the mothers’ educational level,
196 (20.5%) completed junior high school or lower, 388 (40.5%) com-
pleted senior or vocational high school, 343 (35.8%) completed col-
lege or higher, and 31 (3.2%) had missing values.
Regarding children’s dental visiting behaviours, most (61.3%) of
the students reported that they visited a dentist only when they have a
toothache or discomfort and 35.4% of the students reported having a
regular dental attendance. Among the reasons for the last dental visit,
caries was the most common (36.7%), followed by regular examina-
tion (29.2%), toothache (28.4%) and primary tooth extraction (26.9%;
Table 1).
3.2 | Internal consistency reliability and factor
structure of health beliefs
Internal consistency for each scale was evaluated on the basis of
Cronbach’s alpha. The coefficients of susceptibility, benefits, barriers
and severity were 0.826, 0.846, 0.873 and 0.925, respectively. Table 2
shows the factor structure of the health beliefs. The Kaiser-­Meyer-­
Olkin measure of sampling adequacy was 0.930, and the result of
Bartlett’s test of sphericity yielded acceptable results (P < .001). These
2 measures of psychometric adequacy suggested that the correlation
matrix was suitable for factor analysis. All of the pattern coefficients
(factor loadings) of each factor were higher than 0.5. The communality
coefficients (h2) ranged from 0.320 to 0.682. The scree plot suggested
4 factors, and the principal components analysis with promax rotation
T A B L E   1   Dental visiting behaviours among schoolchildren
Variables n %
When will you visit a dentist?
Never 24 2.5
Toothache or discomfort 587 61.3
Regular dental attendance 339 35.4

tive fit index (CFI), Tucker-­Lewis index (TLI) and root mean square error <3 months 88 26.0
of approximation (RMSEA) were also used to evaluate the model fit. 3-­6  months 227 67.0
The following cut-­off values were used for establishing adequate fit: >6 months 19 5.6
GFI > 0.90, CFI ≥ 0.95, TLI ≥ 0.95 and RMSEA < 0.05.17 Missing 8 0.8
What were the reasons for your last dental visit? (multiple choice)

3 | RESULTS Caries 352 36.7

Regular dental attendance 280 29.2

3.1 | Sample characteristics and dental visiting Toothache 272 28.4

behaviour Primary tooth extraction 258 26.9
Dental trauma 47 4.9
Among the 958 valid questionnaires, 657 (68.6%) were collected from
Others 36 3.8
W school, 163 (17.0%) from E school, 107 (11.2%) from Y school and
 |
4       LEE et al.
provided 4 factors with eigenvalues above 1.0 (10.815, 3.750, 2.719
and 1.423). The 4-­factor model accounted for 52.0% of the total vari-
ance. The first factor (severity) accounted for 30.0%, the second fac-
tor (barriers) for 10.4%, the third factor (benefits) for 7.6% and the
fourth factor (susceptibility) for 4.0%. No cross-­loading items were
found. Factor analysis revealed a 4-­factor structure identical to the
HBM.
3.3 | Description and comparisons of the health
beliefs
After transforming the score of each item, the following results were
obtained. The schoolchildren’s health beliefs towards caries treatment
were mostly positive (53.1-­92.1%), a proportion of children were non-­
committal for some items (6.1-­33.4%), and a small percentage showed
negative beliefs (1.8-­13.5%; Table 2). The distributions of the suscep-
tibility and barrier scales were positively skewed; the mean (SD) of the
sum scores was 7.76 (3.68) and 16.81 (6.66), respectively. The distri-
butions of the benefits and severity scales were negatively skewed;
the mean values of sum of the scores were 46.05 (7.28) and 52.54
(8.02), respectively.
We further assigned the students into the “discomfort” group com-
prising students who had never visited a dentist or visited only when
they felt uncomfortable (n = 611) and the “regular” group comprising
students who regularly visited a dentist (n = 339). A comparison of the
sample characteristics (Table 3) and health beliefs (Table 4) between
these groups revealed that students from different schools had signif-
icant differences related to regular dental visit, with W primary school
showing the highest percentage (41.3%) and G primary school show-
ing the lowest (16.1%). Girls (40.0%) had a significantly higher percent-
age of regular dental visits than did boys (31.6%). Moreover, the higher
the educational level of the parent, the higher was the percentage of
the child’s regular dental visit (Table 3). All the health beliefs in the
“regular” group were significantly more positive than those in the “dis-
comfort” group (Table 4).
3.4 | Path analysis model
Figure 1 illustrates the path analysis model. The model fit to the data
was satisfactory, with the following values: χ2 = 45.727, df = 15,
P < .0001; RMSEA 
= 0.05, 95% confidence interval (CI) 
= 0.034,
0.067; GFI = 0.986; TLI = 0.957; and CFI = 0.977. Among the direct
effects, significant paths were noted from school location (β = −0.13,
P < .001) to regular dental visiting behaviour. The remoter the school
location, the lesser the probability of regular dental visits; the higher
the mother’s educational level, the higher the probability of the child
visiting a dentist regularly (β = 0.15, P < .001); the higher the score on
the susceptibility scale, the lower the probability of regular dental vis-
its (β = −0.18, P < .001); and the higher the score on the barrier scale,
the lower the probability of regular dental visits (β = −0.11, P = .005).
Regarding the indirect effects, a significantly positive correlation
was found between the parents’ education levels, and both variables
showed a significant negative correlation with school location. Finally,
the health beliefs showed significant interrelationships among each
other.
4 | DISCUSSIONS
This study developed a valid and reliable questionnaire based on
the HBM to measure 4 concepts (susceptibility, benefits, barriers
and severity) that influence dental visits among primary schoolchil-
dren. The instrument has good internal consistency and construct
validity. Factor analysis revealed a 4-­factor structure identical to the
HBM, which revealed that “severity” was the most important factor
influencing schoolchildren’s health beliefs towards caries treatment.
The 4 factors were correlated, as proven by the path analysis model
(Figure 1). The study results provided evidence that HBM is appropri-
ate for explaining adherence to a dental regimen by children.
In the path analysis model of sociodemographic variables, the
significant paths that affected dental visiting behaviour were school
location and mother’s education level; the non-­significant paths
were grade, sex and father’s educational level. Similar to our finding,
most research9 showed that the child’s gender had no significant
effect on adherence to regular dental visits. Moreover, the grade
level had an insignificant effect in this study, possibly because of the
influence of schools through recommendations for dental checkups
and school examination schedules.9 Furthermore, we found that the
mother’s more than the father’s education level was significantly as-
sociated with children’s dental visiting behaviour. This might be be-
cause mothers care more than the fathers about children’s oral (and
general) health, and previous studies reported that mother’s sense
of coherence (SOC) was significantly associated with children’s oral
health-­related quality of life.18,19 Higher education level possibly
indicates more knowledge about oral health or a better attitude to-
wards caries treatment and prevention. Similar to our findings, pre-
vious findings have indicated that adherence to regular dental visits
depends on the willingness of the parents and caregivers20 or on
the parents’ educational level.21,22 Another significant path that af-
fected dental visiting behaviour was school location; a more remote
location indicated fewer dental resources. Difficulty accessing den-
tal services (eg longer travel time due to traffic) and limited availabil-
ity of professional dental services for young and disabled children
possibly resulted in a low proportion of regular dental visits. We also
found a significant positive relationship between the father’s and
mother’s educational levels, and both showed a significant negative
relationship with school location. This indicated that parents with
lower education levels tended to live in areas with fewer dental re-
sources, thereby indirectly influencing dental visiting behaviours.
Previous studies revealed that lower parental social class was sig-
nificantly associated with lower dental self-­efficacy, external dental
health locus of control (LoC)23,24 and poorer parenting practice.24
Further research to address these issues is recommended.
The scores for the 4 scales (susceptibility, benefits, barriers
and severity) showed that schoolchildren had positive health be-
liefs towards dental caries. In the path analysis model, we found
LEE et al.       5 |
T A B L E   2   Attitude towards each item, factor structure of health beliefs and corresponding factor loadings

Factor structure Attitude (n, %)

Dimensions and items F1 F2 F3 F4 Positive Non-­committal Negative

Susceptibility
1. When I find caries, I will not see a dentist. 0.737 656 (68.7) 228 (23.9) 71 (7.4)
2. When I find caries, I do not want to see a dentist. 0.748 658 (68.8) 193 (20.2) 105 (11.0)
3. When I find caries, I will see a dentist after a long time. 0.772 688 (72.5) 158 (16.6) 103 (10.9)
4. When I find caries, I will see a dentist after a long time, when 0.759 729 (76.3) 128 (13.4) 99 (10.4)
the caries has become serious.
Benefits
1. I think treating caries can make teeth healthier. 0.525 832 (87.2) 74 (7.8) 48 (5.0)
2. I think treating caries can make learning enjoyable. 0.571 506 (53.1) 318 (33.4) 129 (13.5)
3. I think treating caries can prevent it from becoming more 0.566 834 (87.6) 74 (7.8) 44 (4.6)
serious.
4. I think treating caries can prevent me from worrying about the 0.640 753 (79.1) 132 (13.9) 67 (7.0)
caries problem.
5. I think treating caries can prevent toothache problems. 0.721 817 (85.5) 93 (9.7) 45 (4.7)
6. I think treating caries can make teeth look good. 0.675 655 (68.4) 231 (24.1) 71 (7.4)
7. I think treating caries can keep breath fresh. 0.654 696 (73.0) 189 (19.8) 69 (7.2)
8. I think treating caries can help me avoid spending more time on 0.684 767 (80.6) 124 (13.0) 61 (6.4)
dental treatment in the future.
9. I think treating caries can help me avoid spending more money 0.665 726 (75.9) 152 (15.9) 78 (8.2)
on dental treatment in the future.
10. I think treating caries can prevent inconvenient eating. 0.636 788 (82.4) 121 (12.7) 47 (4.9)
11. I think treating caries helps me avoid ridicule by classmates. 0.599 548 (57.3) 304 (31.8) 104 (10.9)
Barriers
1. I think it is difficult for me to visit a dentist when I have caries. 0.607 699 (73.0) 195 (20.4) 63 (6.6)
2. I did not have a toothache during caries formation, so I did not 0.556 715 (74.7) 173 (18.1) 69 (7.2)
visit a dentist.
3. I think I do not have enough time to visit a dentist. 0.845 599 (62.7) 258 (27.0) 99 (10.4)
4. I think my parents do not have time to take me to a dentist 0.829 603 (63.1) 229 (24.0) 123 (12.9)
when I have caries formation.
5. I think going to a dentist is a waste of time, troublesome, and 0.608 789 (82.5) 111 (11.6) 56 (5.9)
not interesting.
6. I am afraid of undergoing tooth treatment, so I do not see a 0.678 725 (75.8) 161 (16.8) 70 (7.3)
dentist.
7. I am afraid of my teeth being extracted, so I do not want to be 0.699 692 (72.5) 167 (17.5) 96 (10.1)
treated for caries.
8. I think we have no money at my home, so I do not see a 0.592 750 (78.5) 155 (16.2) 51 (5.3)
dentist.
9. I think the dental clinic is far from my home, so I do not see a 0.561 759 (81.3) 152 (16.3) 23 (2.5)
dentist.
Severity
1. If I do not see a dentist for treatment of caries, for me that is… 0.605 651 (68.8) 255 (27.0) 40 (4.2)
2. If I do not see a dentist to treat caries and experience a 0.796 818 (86.4) 105 (11.1) 24 (2.5)
toothache, for me that is…
3. If I do not see a dentist for treatment of caries and my teeth do 0.735 749 (79.3) 158 (16.7) 37 (3.9)
not look good, for me that is…
4. If I do not see a dentist for treatment of caries and have bad 0.800 811 (85.8) 106 (11.2) 28 (3.0)
breath, for me that is…
(Continues)
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6       LEE et al.

T A B L E 2   (Continued)

Factor structure Attitude (n, %)

Dimensions and items F1 F2 F3 F4 Positive Non-­committal Negative

5. If I do not see a dentist for treatment of caries and cannot 0.693 771 (81.5) 125 (13.2) 50 (5.3)
sleep well, for me that is…
6. If I do not see a dentist for treatment of caries and need to 0.725 754 (79.9) 148 (15.7) 42 (4.4)
spend more time on treatment, for me that is…
7. If I do not see a dentist for treatment of caries and need to 0.650 750 (79.4) 152 (16.1) 42 (4.4)
spend more money on treatment, for me that is…
8. If I do not see a dentist for treatment of caries and cannot eat 0.724 793 (83.9) 115 (12.2) 37 (3.9)
my favourite food, for me that is…
9. If I do not see a dentist for treatment of caries and my tooth 0.702 699 (74.0) 179 (19.0) 66 (7.0)
has to be extracted, for me that is…
10. If I do not see a dentist for treatment of caries and prosthetic 0.828 836 (88.5) 84 (8.9) 25 (2.6)
treatment is needed, for me that is…
11. If I do not see a dentist for treatment of caries and experience 0.876 870 (92.1) 58 (6.1) 17 (1.8)
swelling, for me that is…
12. If I do not see a dentist for treatment of caries and the growth 0.790 854 (90.2) 71 (7.5) 22 (2.3)
of my teeth is affected, for me that is…

Only factor loadings >0.30 are presented.

T A B L E   3   Comparison of dental visiting behaviour according to that the susceptibility and barrier scores were significant indicators
sample characteristics that affected dental visiting behaviour, whereas the benefits and
severity scores showed no significant direct effects. Nevertheless,
Dental visiting behaviour
(n, %) benefits and severity could reduce susceptibility and barriers, while
indirectly improving regular dental attendance. Moreover, the per-
Discomfort Regular
ceived susceptibility and barriers scores were interrelated (Figure 1).
Variables (n = 611) (n = 339) P
The direct effect of susceptibility indicated the tendency to delay
School
dental treatment. Therefore, the results seemed to imply that even
W 381 (58.7) 268 (41.3) <.0005
though schoolchildren had positive attitudes towards dental treat-
E 119 (73.0) 44 (27.0) ment, they tended not to visit dentists unless they had a toothache,
Y 85 (79.4) 22 (20.6) because of perceived barriers. These barriers possibly produced a
G 26 (83.9) 5 (16.1) negative effect with regard to parents’ adherence to recommended
Grade dental visits for their children; these results were similar to those of
4 188 (61.8) 116 (38.2) .306 previous studies.21,25-27
5 205 (67.7) 98 (32.3) Overall, the results imply that environmental factors significantly

6 218 (63.6) 125 (36.4) affected behaviour. Although children had a positive attitude towards
dental visits, environmental obstacles such as school location, moth-
Sex
er’s attitude, lack of time and lack of dental resources, or the child’s
Male 329 (68.4) 152 (31.6) .007
attitude-­related obstacles including fear, would interfere with dental
Female 281 (60.0) 187 (40.0)
visits. However, the questionnaire collected information focused on
Father’s educational level
children’s oral health beliefs. Further research to address parental or
Junior high school or lower 153 (77.7) 44 (22.3) <.0005
caregiver oral health beliefs is recommended.
Senior or vocational high 237 (67.3) 115 (32.7) This study provided evidence that HBM is applicable to children’s
school
dental visiting behaviour and their health beliefs towards adherence to
College or higher 192 (52.5) 174 (47.5)
caries treatment. The determinants of regular dental visit were school
Mother’s educational level
location, mother’s education level, perceived susceptibility and per-
Junior high school or lower 149 (77.6) 43 (22.4) <.0005 ceived barriers. The HBM can respond to children’s adherence to den-
Senior or vocational high 265 (68.7) 121 (31.3) tal regimens that guide children’s schemas concerning the values of
school
and expectations from regular dental visits. With respect to practical
College or higher 173 (50.7) 168 (49.3) applications, the susceptibility scale could be used to detect high-­risk
Compared by using the χ2 test. children who “did not visit a dentist even if they had tooth decay.” The
LEE et al. |
      7

T A B L E   4   Comparison of health beliefs

Dental visiting behaviour (Mean ± SD)
according to dental visiting behaviour
Discomfort Regular
Variables (n = 611) (n = 339) t P

Susceptibility 8.52 ± 3.81 6.39 ± 3.03 9.429 <.0005

Benefits 45.46 ± 7.25 47.09 ± 7.29 −3.253 .001
Barriers 18.09 ± 6.71 14.56 ± 5.95 8.255 <.0005
Severity 51.73 ± 7.95 53.98 ± 7.96 −4.138 <.0005

Compared by using the independent t test.

School location
Grade Sex
–0.23***
Mother’s
–0.24*** education level
– 0.13***
0.61***
Father’s 0.15***
education level

Regular dental
– 0.18*** attendance
Susceptibility
–0.23***
0.58***
Benefits –0.11***
F I G U R E   1   Path analysis model relating –0.31*** –0.36***
health beliefs and sociodemographic
variables to dental visiting behaviour. Barriers
0.51***
Standardized path coefficients are
presented. Non-­significant paths are –0.42***
represented by dashed lines. Significance: Severity
***P < .001

severity and benefit scales could be useful in designing and evaluating

oral health educational programmes. The barrier scale could help un-
derstand the obstacles that keep children from visiting a dentist when
they have tooth decay. The questionnaire based on HBM could thus
be used as a tool to identify children who need oral health interven-
tion. Finally, from the perspective of HPSs, the oral health education of
teachers at schools could facilitate the cooperation between children’s
families and dental care services, and the government should improve
the schoolchildren’s access to dental resources to enhance the utiliza-
tion of treatment and preventive dental care.
5 | CLINICAL RELEVANCE
5.2 | Principal finding
Most of the children had a positive attitude towards dental visits;
however, environmental factors such as location of the school and
lack of dental resources can hinder regular dental visits.
5.3 | Practical implications
The instrument could be useful in identifying high-­risk children,
in designing and evaluating oral health educational programmes
and in understanding the barriers of seeking dental treatment for
caries.

5.1 | Scientific rationale for study AC KNOW L ED G EM ENTS

The health belief model was applied to investigate children’s attitude The authors thank the Bureau of Education of the Kaohsiung City
towards dental visits. Path analysis was used to explore the causes Government for the permission to conduct the survey in the selected
for delay in seeking dental treatment and the determinants of regular schools, the teachers who helped in this research and most impor-
dental visits. tantly, the participating children.
 |
8       LEE et al.
CO NFLI CT OF I NTE RE S T
All authors declare that they have no conflict of interest. This research
did not receive any specific grant from funding agencies in the public,
commercial or not-­for-­profit sectors.
O RCI D
C-Y Lee  http://orcid.org/0000-0002-8234-1524
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How to cite this article: Lee C-Y, Ting C-C, Wu J-H, Lee K-T,
Chen H-S, Chang Y-Y. Dental visiting behaviours among primary
schoolchildren: Application of the health belief model. Int J Dent
Hygiene. 2017;00:1–8. https://doi.org/10.1111/idh.12319