Perception Of Oral Health Status Research Articles

Self-Rated Oral Health and Associated Factors among an Adult Population in Rural India-An Epidemiological Study.

Background: To determine the perception of oral health status and its associated factors among adults living in rural areas in Karnataka state, India. Methods: A cross-sectional study was conducted among adults in the age group of 35–54 years old residing in villages in a southern state in India. The main outcome measure was poor self-rated oral health (SROH) among adults in rural India. Results: About 873 adults participated in the study. The prevalence of poor SROH was 15.2%. Adults of age 40–44 years, females, those in lower socioeconomic conditions, and those with high caries experience (DMFT ≥ 4) and periodontal disease were associated with poor SROH. Those who had visited a dentist in the previous one year were 1.9 times more likely to report poor oral health. Conclusions: Nearly 15% of rural people reported poor oral health. Socioeconomic conditions, sex, age, smoking, and dental visiting were associated with poor SROH. People’s perception of poor oral health was associated with severe periodontitis and DMFT ≥ 4. A dose–response relationship was observed between experience with dental caries and poor SROH.

THE PERCEPTION OF CAREGIVERS OF POOR ORAL HEALTH OF THEIR CHILDREN AND ITS RELATED CLINICAL CONDITIONS.

ABSTRACTObjective: To determine the association between the perception of caregivers regarding the oral health of their children and socio-demographic characteristics, report of dental pain, and clinical oral conditions.Methods: A cross-sectional study was conducted with 570 children aged two to five years old, enrolled at public preschools, and with their caregivers. Data regarding perceptions of oral health status in children, socio-demographic characteristics, and dental pain were collected from a questionnaire. Three examiners (Kappa>0.7) evaluated children’s oral health status using the dmft index, pufa index, and the Andreasen classification for traumatic dental injury (TDI). The occurrence of open bite and overjet was also investigated. Descriptive analyses, and unadjusted and adjusted logistic regression were used, considering a 5% significance level.Results: A total of 24.7% of children had poor oral health status, which increased 4.92-fold (95% confidence interval [95%CI] 3.05-7.93) when children had dental caries, and 3.78-fold (95%CI 1.63-8.76) when there were consequences from dental caries. The perception of poor oral health was also associated to open bite (Odds Ratio [OR] 1.98; 95%CI 1.16-3.38) and TDI (OR 1.68; 95%CI 1.06-2.68). No associations were found between the perception of caregivers and socio-demographic variables or overjet.Conclusions: The perception of caregivers of poor oral health in their children was associated to dental caries, its consequences, TDI, and open bite.

Cross sectional survey to assess the self perception of oral health status reported by IGNOU students versus clinical diagnosis

Introduction: Oral health is considered as a gateway /reflection to general health and thus it is of pivotal importance for everyone. With the advent of the 21st century, oral health awareness and prevention of oral diseases has become the agenda nationally and internationally. Despite, various awareness campaigns via mode of audio aids, audio-visual aids, and street play etc. oral health diseases are on a constant increase. Materials and Method:Descriptive cross sectional survey was carried out on 259 IGNOU students to assess: Self-perceived dental & periodontal status versus clinically diagnosed dental and periodontal health. Assessment of questionnaire using large value population survey. Establish a relationship between dental health status and understanding the public perception of oral health. Results: Total 259 patients 16 males and 4 females) 136 males and 123 females with the mean age of 19±2.3 years participated in the survey. The overall consensus of the patients were that 52% (134) of the participants perceived that they have a bad dental health status compared to 50.5% (131) who were clinically found to have bad dental health status, (p < 0> Conclusion:Self-assessment questionnaires were of moderate value in evaluating oral health status each within the individual and public levels, although perception levels of health were beyond that of disease and illness. Literature also reflects that occasional level of awareness of the general public will influence care-seeking behaviour and will signify the importance of oral health promotion and is also crucial for public health actions. Keywords: Self- assessment, Oral health, Clinical diagnosis

Parents' perceptions and related factors of the oral health status of Brazilian children enrolled in public preschools.

This study aimed to evaluate parents' perceptions of the oral health status of children enrolled in public preschools and associated factors. This was a cross-sectional study with data collected via self-administered questionnaire. A total of 474 questionnaires were distributed in public preschools in the city of Canoas, Rio Grande do Sul, the southernmost state of Brazil. Poisson regression models were used in the multivariate analysis (p < 0.05). The study included 171 (36%) valid questionnaires. The prevalence of parents who perceived the oral health status of their children as negative was 29.8% (n = 51). Mother being unemployed (vs employed) increased by 16% the likelihood of parents perceiving the oral health status of their children as negative (prevalence ratio [PR] 1.16; 95% confidence interval [CI] 1.02-1.31. Parents having (vs having not) observed difficulties in the child's ability to eat increased by 27% the likelihood of perceiving the child's oral health status as negative (PR 1.27; 95% CI 1.08-1.48), while child's tooth brushing 1-2 (vs 3 or more) times a day and family income up to 2 (vs 3 or more) minimum wages increased it by 14% (PR 1.14; 95% CI 1.03-1.27 for both). Current or past use (vs no use) of pacifiers increased by 12% the likelihood of parents' negative perceptions (PR 1.12; 95% CI 1.00-1.25). We can conclude that unemployed mothers, low-income families, parents having observed child's feeding difficulties, child's tooth brushing 1-2 times a day, and current or past use of pacifiers contributed significantly to parents' negative perception of the child's oral health status. These factors are essential for the planning, implementation, monitoring, and evaluation of actions aimed at controlling the oral health of children enrolled in public preschools.

Perception of oral health status of adolescents and young adults undergoing substance abuse treatment.

Objective: to determine the oral health status perception of adolescents and young adults in drug dependence treatment. Material and Method: a qualitative research model was proposed. The theoretical sample by saturation consisted of adolescent population and young adults hospitalized in the Portal Amarillo center (the National Drug Information and Reference Center, Montevideo, Uruguay). Inclusion criteria: a) being between 15 and 24 years old. b) being in treatment for drug abuse. Exclusion criteria: a) non-lucid patients. b) non-collaborating patients. Results: participants considered oral health as having clean, white and aligned teeth; and oral disease as the presence of caries, bleeding gums and communicable diseases; chewing, aesthetics and taste were seen as altered functions. Before becoming drug consumers, oral hygiene was regular, after meals and as instructed; once addiction began, hygiene was very irregular at best (if they remember to do it), and without reinforcement of the instruction. Prior to drug consumption, participants were students or held a job; they had a good family life, with a partner or in search of one. After consumption, they report self-marginalization, loss of contact with partners and children, isolation from the family and social discrimination. Addiction makes it difficult for them to access dental care, except in urgent situations. Conclusions: Young people in treatment for drug dependence are aware that addiction damages oral health, deteriorating aesthetics, affecting oral functions, self-esteem and quality of life.

Differences between caregiver-perceived and dentist-assessed oral health status of patients among intellectual disabilities.

This study compared the caregiver-perceived and dentist-determined oral health status of patients with intellectual disabilities to determine factors that affect caregiver-perception of patients' oral health. 297 patients [mean (SD) age = 51.9 (12.5) years] and 56 professional caregivers [42.1 (8.2) years] from three institutional facilities took part. Data were acquired via self-administered questionnaires by caregivers and oral examination by dentists. Oral hygiene condition, numbers of decayed and missing teeth, and periodontal disease reported by caregivers and dentists were compared using paired t-test and Pearson correlation. Demographic and dental factors of the patients and caregivers were analyzed using chi square and Fisher's exact tests. Caregivers underestimated decayed and missing teeth compared to dentists (p⟨0.05). Oral hygiene condition and periodontal disease were similarly rated by the two groups. Tooth brushing, diet type, sex, and overall oral health status of the patients were associated with caregiver perception (p⟨0.05). Career length and time since caregivers last received dental care were also related factors (p⟨0.05). Professional caregivers of adult patients with intellectual disabilities had different perceptions of oral health status based on patient and caregiver circumstances.

Prevalence of self‐reported gingival bleeding in a representative sample of the Brazilian adolescent population

To estimate the prevalence of self-reported gingival bleeding in a representative sample of 12- to 17-year-old Brazilian adolescents. Sociodemographic and oral health information were obtained through a self-administered questionnaire of the Study of Cardiovascular Risk Factors in Adolescents. The adolescents answered "yes" or "no" to the question "Do your gums bleed?" 74,589 of the 102,327 eligible adolescents answered the questionnaire and 18.4% (95% CI 17.5-19.3) reported having bleeding gums. The prevalence of self-reported gingival bleeding varied as following: 21.4% (95% CI 20.3-22.6) in girls and 15.3% (95% CI 14.3-16.4) in boys; 20.5% (95% CI 19.2-21.8) in older and 17.5% (95% CI 16.4-18.6) in younger adolescents; 20.6% (95% CI 18.5-22.9) in Black people and 17.1% (95% CI 16.1-18.1) in White people. Regarding mother's level of education, the prevalences were 18.1% (95% CI 16.2-20.3), 17.6% (95% CI 16.4-18.9) and 19.3% (95% CI 17.9-20.9) for high, middle and low levels, respectively. For socioeconomic status, the equivalent figures were 16.4% (95% CI 14.3-18.7), 18.4% (95% CI 17.5-19.4) and 23.0% (95% CI 17.3-29.9). Nearly one in five Brazilian adolescents reported having gingival bleeding, which might not be a serious condition, but reflect the disease and the adolescents' perception of oral health status.

노인의 식품선호도와 주관적 구강건강상태의 관련성

Objectives: The purpose of the study is to investigate the correlation with subjective oral health status and food preference in elderly people. Methods: Data were extracted from the fifth Korea National Health and Nutrition Survey 2010-2012. The survey data included general characteristics of the subjects, food preference, and subjective oral health status. Food preference was analyzed by assigning score to 63 food categories. The subjective oral health status consisted of toothache within a month, self-perception of oral health, chewing difficulty, mastication difficulty, and speaking difficulty. Data were analyzed by frequency analysis, descriptive statistics, test, t-test, and ANOVA using SPSS 22.0 program. Results: Elderly men had a tendency to have a liking for all food categories except for fruit. Difficulty in chewing and mastication was shown in those who had older age, lower education, lower monthly income, and national basic livelihood security. Difficulty in speaking was found in those who had older age, lower education, and national basic livelihood security. Self perception of oral health status was closely related to food preference for pulses and potatoes, fish, vegetables and others(p

Creencias y prácticas de salud bucal de padres de párvulos: estudio cualitativo

Among oral pathologies, dental caries is the one that is easy to prevent with dental hygiene measures. Since the 1990's, oral health education has aimed at instilling the habit of tooth brushing twice a day with fluoride toothpaste to prevent this disease. However, there is a need to understand the effect of the context on the expected outcomes. ObjectiveThis study aimed to determine the oral health practices of parents of pre-school children in an urban community of the Metropolitan Region of Chile, Lo Prado. MethodThis was a qualitative study with a descriptive design, and a non-probabilistic sample of 14 parents, using in-depth interviews. ResultsThe analysis of the results was performed starting from transcription and codification of the descriptions made by the mothers, generating categories: (1) Oral health care, (2) persons in charge of teaching the tooth brushing habit, (3) use of fluoride dentifrices, (4) perception of oral health status, (5) associated positive or negative stimuli, and (6) the need for more information on oral health issues. ConclusionsOral health is perceived to correlate with a good appearance, and to attain it, a good oral hygiene is considered important, along with a reduction in the amount of carbohydrates ingested. Women are the ones that are socially in charge of the establishment and maintenance of this habit.

Parental Perceptions of Oral Health Status in Preschool Children and Associated Factors.

The aim of the present study was to evaluate parental perceptions of oral health status in preschool children. A cross-sectional study was carried with 843 Brazilian children between 3 and 5 years of age. Parents/guardians answered a self-administered questionnaire on the health of their children and sociodemographic data. Parental perceptions of their child's oral health were determined by the responses to the following question: "How would you describe your child's oral health?" The Brazilian version of the Early Childhood Oral Health Impact Scale (B-ECOHIS) was answered by parents/guardians and used to measure the impact of oral health-related quality of life (OHRQoL) on preschool children and their families. Three examiners performed oral exams on the children (K= 0.85-0.90). Descriptive analytical statistics were carried out, followed by logistic regression for complex samples (α=5%). The following variables were significantly associated with parental perceptions of children's oral health: parental perception of general health as poor (OR=18.25; 95% CI: 3.36-98.96), negative impact on family's OHRQoL (OR=13.82; 95% CI: 4.27-44.72), child aged five years (OR=7.40; 95% CI: 1.49-36.63) and the interaction between history of toothache and dental caries (OR=10.02; 95% CI: 1.17-85.61). Thus, parental perceptions of oral health are influenced only by clinical conditions with symptoms, such as dental caries with toothache. Other oral conditions, such as malocclusion or traumatic dental injury, were not associated with parental perceptions of their child's oral health.

Child and adolescent perceptions of oral health over the life course.

To elicit perceptions of oral health in children and adolescents as an initial step in the development of oral health item banks for the Patient-Reported Oral Health Outcomes Measurement Information System project. We conducted focus groups with ethnically, socioeconomically, and geographically diverse youth (8-12, 13-17 years) to identify perceptions of oral health status. We performed content analysis, including a thematic and narrative analysis, to identify important themes. We identified three unique themes that the youth associated with their oral health status: (1) understanding the value of maintaining good oral health over the life course, with respect to longevity and quality of life in the adult years; (2) positive association between maintaining good oral health and interpersonal relationships at school, and dating, for older youth; and (3) knowledge of the benefits of orthodontic treatment to appearance and positive self-image, while holding a strong view as to the discomfort associated with braces. The results provide valuable information about core domains for the oral health item banks to be developed and generated content for new items to be developed and evaluated with cognitive interviews and in a field test.

Impact of Malocclusion on Quality of Life in Sudanese Dental Students

Introduction: Both psychological and social factors come to play when analyzing oral health-related quality of life, and recent developments have shown that more focus has been placed on patients’ own perceptions of oral health status and oral health care systems to understand their needs, fulfillment with treatment, and ultimately the perceived overall quality of health systems.Objective: To assess the impact of orthodontic treatment needs on oral health-related quality of life of dental students.Materials &amp; Method: A cross-sectional study was done on a random sample of 100 dental students aged 17-23 years at the University of Medical Sciences &amp; Technology in Sudan. Each subject was assessed for orthodontic treatment need using Dental Health Component (DHC) of Index of Orthodontic Treatment Needs (IOTN). Each subject was given an Oral health-related quality to life questionnaire to complete the Oral Health Impact Profile (OHIP).Result: The oral health-related quality of life was generally good. Those with ‘definite need for treatment’ showed higher impact on oral health in relation to functional limitation and physical pain, than those who had ‘borderline need’, ‘little need’, or ‘no need for treatment’. Males with ‘borderline’ and ‘definite need for treatment’ generally showed higher impact on oral health than the female counterpart. However, this was not statistically significant. Conclusion: Malocclusion does not seem to affect the oral health-related quality of life to a significant degree.

Validation of the CPQ 8-10ESP in Mexican School children in urban areas

The current indicators used to gather information on oral health in children are basically clinical indexes that register mainly dental caries, periodontal disease, and malocclusion. These indexes should be complemented with emotional and social aspects related to the individual experience and perception of oral health status. In order to obtain this information, valid instruments capable of evaluating the impact of oral health as it relates to the quality of life (OHRQoL) are required. The objective of the Child Perceptions Questionnaire (CPQ8-10) is to assess OHRQoL in children aged eight to ten years. CPQ8-10 consists of 25 questions divided into four domains: oral symptoms, functional limitation, emotional well-being, and social well-being. The aim of this study was to validate the translated Spanish version of the Child Perceptions Questionnaire (CPQ8-10ESP) in use with Mexican urban children. Three hundred fifteen students in Mexico City aged eight- to ten-years-old participated in this study. The CPQ8-10ESP questionnaire was self-administered in the classroom. Clinical data about caries and malocclusion were obtained. To assess test-retest reliability, the questionnaire was reapplied to a subgroup of children. Cronbach's alpha reliability coefficient was 0.89 for the total CPQ8-10ESP scale. The intraclass correlation coefficient was 0.67; a statistically significant difference was found in the CPQ8-10ESP mean score between children with caries and malocclusion; a significant correlation between general well-being ratings with all domains was found (p<0.001). General perception of oral health was associated with both oral symptoms (p=0.049) and emotional well-being (p=0.022) domains, as well as with the total scale (p=0.015). The CPQ8-10ESP version showed good validity and reliability for use with Mexican schoolchildren from urban areas.

Southern Nevada assisted living residents’ perception of their oral health status and access to dental care

Oral health is an integral component of general health, and quality of life. The purpose of this study was to determine the perceptions of oral health status and acces\s to dental care by Southern Nevada Assisted Living Facilities Residents. A cross-sectional questionnaire study design was used to survey residents between 34 and 99 years old residing in Assisted Living Facilities. Seventy respondents (42 males and 28 females) completed a survey that included personal oral hygiene, access to care, and demographic information. Data analyses included descriptive statistics and chi-square. Mean age was 75.78 years, and the majority had a college education (n = 41). Four currently smoked cigarettes. Twenty-nine (males = 14; females = 15) reported having dental insurance. Eleven respondents had seen a dentist twice a year, while 33 reported a visit less than 6 months. Forty-one reported the facility did not provide oral health care with majority (n = 64) indicating that accessing oral health care was difficult. Self-rated response to oral hygiene, a majority (n = 64) reported their oral hygiene as fair and five reported their oral hygiene as poor. Assisted living residents in Southern Nevada reported difficulty accessing dental services within and outside of the facility. Oral care models to address this unique population should be explored.

Perceived oral health status and treatment needs of dental auxiliaries

Objective: To determine the perceived oral health status and treatment needs of Nigerian dental therapists in training and dental technology students.Methods: A descriptive cross-sectional study of students from Federal School of Dental Therapy and Technology Enugu, Nigeria was conducted using self-administered questionnaire to obtain information on demography, self-reported oral health status, knowledge of impact of oral health on daily life activity, dental attendance and perceived dental need.Results: The perception of oral health status and treatment need of the two groups of dental auxiliaries was the same. Fewer respondents (27.3%) rated their oral health as excellent, while 50.4% rated their oral health as good. Majority (95.5%) agreed that oral health is a part of general health and 94.6% agreed that oral health has a role in daily life.Out of 81.4% that had previous dental treatment, scaling and polishing accounted for 66.1%. Presently, 48.8% think they need dental treatment ranging from scaling and polishing (33.9%), tooth restoration (10.3%), to extraction (1.2%).Conclusion: This survey revealed that most of the students are aware that oral health is a component of general health and that it has an impact on an individual's daily life. More than half of the students perceived their oral health as good, but only a few knew that there is a need for a preventive approach to oral health as evident by the percentage that perceived scaling and polishing as a treatment need.

Psychological distress and self-perception of oral health status among an immigrant population from Ethiopia

Objectives. To examine the association between psychological distress (PD) and perception of oral health status among a group of Ethiopian immigrants compared to the ‘gold standard’ of clinical diagnosis. Design. Three hundred and forty Ethiopian immigrants, aged 18 years or more, were interviewed using a version of the Self-Reporting Questionnaire (World Health Organization) for the assessment of psychological status and perceived dental and periodontal health status. Clinical data for dental and periodontal health status were used as the ‘gold standard’ against the self-perceived assessment scores among the PD and no psychological distress (NPD) groups. These were compared for sensitivity and specificity. Results. One hundred and thirty-five subjects (40%) presented PD. Seventy-eight percent of the PD subjects reported a negative dental health status, as compared to 42% of the NPD subjects. Seventy-three percent of the PD subjects reported a negative periodontal health status, as compared to 44% of the NPD subjects (p<0.001). The sensitivity for self-perceived dental health status among the PD subjects was found to be 0.78 and the specificity was found to be 0.40, as compared to 0.59 and 0.69, respectively, among the NPD subjects (p<0.001). The sensitivity for self-perceived periodontal health status among the PD subjects was found to be 0.78 and the specificity was found to be 0.40, as compared to 0.59 and 0.58, respectively, among the NPD subjects (p<0.001). Conclusion. Results demonstrate that PD may modify self-perception of health status. Self-perceived health and disease should be an integral element in the continuum of professional clinical health assessment and subsequent health care planning. The relevance of PD is evident in this immigrant ethnic group and should be considered and further studied in other at-risk minority communities.

Parental perception of oral health status of children in mainstream and special education classrooms

The aim of this study was to compare parental perceptions of oral health status and access to dental services by children in 34 special education and 16 mainstream public elementary school classes in San Mateo County, California. A self-administered parental survey was utilized and included questions about demographics, oral health, and dental utilization. The overall response rate was 58.8%. After adjusting for age and gender of the child, compared to mainstream, parents of students in special education classes were significantly more likely to report their children to have worse oral health (OR = 2.4, 95% CI 1.54, 3.67), be lacking a past year dental visit (OR = 1.96, 95% CI 1.01, 3.84), and have missed school days due to dental reasons (OR = 2.5, 95% CI 1.55, 4.17). Both groups rated their children's oral health inferior to the overall health rating (p < .001). The authors concluded that disparities exist between the two groups in parental perceptions of their children's oral health status and dental service utilization.

Are immigrant populations aware about their oral health status? A study among immigrants from Ethiopia

BackgroundEvidence from Western countries indicates that there are fundamental discrepancies between self-perceived illness of immigrants and the provision of health care, according to the Western bio-medical health service model. These need to be understood in the planning and implementation stages of public health care programs for new immigrants. The objectives of the present study were to investigate self-perceived versus clinically diagnosed dental and periodontal health status among immigrants from Ethiopia.MethodsDuring 2004–2005, dental and periodontal health status was recorded among 340 Ethiopian immigrants, utilizing the DMFT and CPI indices. Additionally, participants were interviewed using a questionnaire which included perceived dental and periodontal health status. Sensitivity and specificity levels of this perception were calculated and compared with the published scientific literature.ResultsRegarding dental caries, according to the three operational cut-off points, sensitivity ranged from 70% to 81%, and specificity ranged from 56% to 67%. Regarding periodontal status, 75% of the subjects clinically diagnosed with periodontal pockets self-perceived a "bad" health status of gums (sensitivity) and 54% of the subjects diagnosed without periodontal pockets, reported a "good" health status of gums (specificity). These indications of perception levels were higher than a previous study conducted among native born Israelis.ConclusionMinority ethnic groups should not be prejudicially regarded as less knowledgeable. This is illustrated by the unexpected high level of oral health status perception in the present population. Oral health promotion initiatives among immigrants should be based upon optimal descriptive data in order to accomplish the inherent social commitment to these diverse populations.

Factors associated with parents’ and adolescents’ perceptions of oral health and need for dental treatment

The aim of this study was to characterize the association between clinical and psychosocial factors as they related to perceptions by parents and adolescents to the adolescent's oral health status and treatment need. Additionally, the degree to which adolescent's and parent's perceptions of oral health and treatment need were related was examined. Data from the Pennsylvania oral health needs assessment for 530 parent-adolescent pairs were used to address the objectives of this study. Comparisons between clinical oral health measures, psychosocial factors, and the parent- and adolescent-reported perceptions of the adolescent's oral health status were made using descriptive and inferential statistics, including exploratory factor analysis and path analysis. Parents and adolescents exhibited only modest concordance on ratings of the adolescent's oral health status and need for dental treatment. Furthermore, parents tended to rate their adolescent's oral health status as better than did the adolescent. The results of the path analysis showed that adolescents based their ratings of oral health status more on oral symptoms, while parents rated their adolescent's oral health more on esthetic or psychosocial factors. Adolescents and parents based their perceptions of oral health status and treatment need on different underlying factors. Additionally, adolescents' perceptions of their oral health status and treatment needs did not appear to be communicated to their parents.

Self‐perceived oral health among three subgroups of Asian‐Americans in New York City: a preliminary study

Abstract – Objectives: The aim of this preliminary study was to compare the perception of oral health among subgroups of Asian‐American residents of New York City, USA. Methods: A close‐ended questionnaire was administered to 255 Chinese, 134 Indian and 84 Pakistani adults, aged 18–65 years, during 1994–95. A comprehensive dental and oral examination was also performed. The associations of demographic and oral health variables with perceived oral health were evaluated using multivariate ordinal regression models. Results: When data were analyzed in a multivariate context, only ethnicity and income were significant predictors of perceived oral health, after adjusting for DMFT. The within‐group multivariate analysis of the three ethnic subgroups’ results were as follows: Among the Chinese there were no significant predictors, only income was strongly suggestive; among the Indians, number of missing teeth and number of years in the USA were significant predictors; and within the Pakistani group, DMFT was the only significant predictor. Conclusions: Results suggest that there are ethnic differences in the perception of oral health status even after adjusting for clinical variables as well as for demographic variables in this particular group of Asian‐American residents of New York City. Predictors associated with the perception of oral health are different for each ethnic group. When designing oral health promotion activities to diverse ethnic groups, the cultural characteristics of each subgroup should be considered.