Socio-behavioral Factors Research Articles

The global burden of oral diseases and risks to oral health.

This paper outlines the burden of oral diseases worldwide and describes the influence of major sociobehavioural risk factors in oral health. Despite great improvements in the oral health of populations in several countries, global problems still persist. The burden of oral disease is particularly high for the disadvantaged and poor population groups in both developing and developed countries. Oral diseases such as dental caries, periodontal disease, tooth loss, oral mucosal lesions and oropharyngeal cancers, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS)-related oral disease and orodental trauma are major public health problems worldwide and poor oral health has a profound effect on general health and quality of life. The diversity in oral disease patterns and development trends across countries and regions reflects distinct risk profiles and the establishment of preventive oral health care programmes. The important role of sociobehavioural and environmental factors in oral health and disease has been shown in a large number of socioepidemiological surveys. In addition to poor living conditions, the major risk factors relate to unhealthy lifestyles (i.e. poor diet, nutrition and oral hygiene and use of tobacco and alcohol), and limited availability and accessibility of oral health services. Several oral diseases are linked to noncommunicable chronic diseases primarily because of common risk factors. Moreover, general diseases often have oral manifestations (e.g. diabetes or HIV/AIDS). Worldwide strengthening of public health programmes through the implementation of effective measures for the prevention of oral disease and promotion of oral health is urgently needed. The challenges of improving oral health are particularly great in developing countries.

Oral health knowledge, attitudes and behaviour of adults in China

To describe oral health behaviour, illness behaviour, oral health knowledge and attitudes among 35-44 and 65-74-year-old Chinese; to analyse the oral health behaviour profile of the two age groups in relation to province and urbanisation, and to assess the relative effect of socio-behavioural risk factors on dental caries experience. A total number of 4,398 35-44-year-olds and 4,399 65-74-year-olds were selected by multistage stratified cluster random sampling which involved 11 provinces in China. Data were collected by self-administered structured questionnaires and clinical examinations (WHO criteria). 32% of the 35-44-year-olds and 23% of the 65-74-year-olds brushed at least twice a day but only 5% used fluoridated toothpaste; 30% and 17% respectively performed 'Love-Teeth-Day' recommended methods of tooth brushing. A dental visit within the previous 12 months was reported by 25% of all participants and 6% had a dental check-up during the past two years. Nearly 15% of the subjects would visit a dentist if they experienced bleeding from gums; about 60% of the subjects paid no attention to signs of caries if there was no pain. Two thirds of the urban residents and one fifth of the rural participants had economic support for their dental treatment from a third party, either totally or partially. Significant variations in oral health practices were found according to urbanisation and province. At age 35-44 years 43% of participants had daily consumption of sweets against 28% at age 65-74 years. Dental caries experience was affected by urbanisation, gender, frequency, time spent on and method of tooth brushing. Knowledge of causes and prevention of dental diseases was low with somewhat negative attitudes to prevention observed. Systematic community-based oral health promotion should be strengthened and preventive-oriented oral health care systems are needed, including promotion of further self-care practices and the use of fluoridated toothpaste.

Sociobehavioural risk factors in dental caries – international perspectives

Diseases probably have their roots in a complex chain of environmental and behavioural events which are shaped by broader socioeconomic determinants. Most studies of sociobehavioural risk factors in dental caries have been carried out in industrialized countries, but such reports from low- and middle-income countries have been published in recent years. World Health Organization international collaborative studies and other international studies of social factors in dental caries using the same methodology provide empirical evidence of social inequality in oral health across countries and across oral health care systems. The paper highlights the challenges to dental public health practice, particularly the importance of risk assessment in estimating the potential for prevention. In future public health programmes, systematic risk factor assessment may therefore be instrumental in the planning and surveillance of oral health promotion and oral disease intervention programmes.

Correlates of cognitive impairment and depressive symptoms among older adults in Korea and Japan

Cognitive impairment and depressive symptoms impose a heavy burden on the care of the elderly in Japan and Korea, two of the fastest aging nations in Asia. The purpose of this study was to examine and compare factors associated with cognitive impairment and depressive symptoms among older persons in the two countries. In 2002, representative samples of community-dwelling people aged 65 and older were selected among residents in Anyang, Korea and Yoita, Japan. Mini-Mental State Examination and Geriatric Depression Scale were used to assess the elderly's mental status. Sociodemographics, physical function, chronic conditions, social support, and health behaviors were examined to identify significant associations. The prevalence of cognitive impairment in older adults was 17.0% in Anyang and 14.6% in Yoita. The rates for depressive symptoms were 15.2% and 19.8%, respectively. Overall, functional capacity was the universal factor significantly associated with mental conditions. Self-rated health and social support were also found to be independently associated with depressive symptoms in the study subjects. Differences in the patterns of association by community, however, were notable for other characteristics. For example, in factors associated with cognitive impairment, sociodemographic factors such as age, gender, and education were significant among Koreans, whereas socio-behavioral factors such as obesity, social support and hospitalization experience were found to be significant for older Japanese residents. Similarities in the patterns of association indicate the need for joint explorations into the role these factors play in affecting the mental health of older persons. Socioeconomic and regional differentials, however, may account for the disparity in the associations observed, suggesting the importance of developing mental health programs sensitive to the older individual's culture.

Self-assessed dental health, oral health practices, and general health behaviors in Chinese urban adolescents

The objectives of this study were: to describe perceived dental health status and oral health-related knowledge, attitudes, and behavior in Chinese urban adolescents; to assess the associations of oral health variables with socio-economic status and school performance; and to analyse the relative effect of socio-behavioral risk factors on perceived dental health, perceived need for dental care, and experience of dental symptoms. A cross-sectional survey of 2662 adolescents was conducted in eight capital cities in China; the response rate was 92%. The study population was chosen by multistage cluster sampling and covered three age groups: 11, 13, and 15 years. Data on dental and general health were collected by self-administered questionnaires. Self-assessment of dental health of Chinese adolescents was generally good, only 12% of the students answered that their teeth were “poor” or “very poor”, and 9% claimed having “poor” or “very poor” gums. Eleven percent of participants said that other students made fun of their teeth; 24% of the respondents were dissatisfied with the appearance of their teeth, and 41% claimed that they had experienced toothache or symptoms during the previous 12 months. Positive attitudes towards dental care were found in all age groups; 67% of adolescents brushed their teeth at least twice a day and 48% of the students used fluoridated toothpaste. Only 26% of the students visited a dentist during the previous 12 months. In all, 6% of the adolescents had tried cigarette smoking at least once, while 41% reported having tasted alcohol drinks. Multivariate regression analyses showed that perceived dental health status and needs were associated with gender, age, unhealthy lifestyles, poor school performance, and socio-economic status. The establishment of school-based health promotion programs in China is urgently needed, and promotion of oral health lifestyles should be integrated with other general health actions.

Perception of HIV/AIDS Risk Among Urban, Low-Income Senior-Housing Residents

Despite the rising number of cases of HIV in adults over age 50, older persons rarely are considered to be at risk for HIV/AIDS, and even though they may be involved in risky behavior, such as unprotected penetrative sex, they may not consider themselves vulnerable to becoming infected. Informed awareness of risk is essential to making positive decisions about adopting preventive measures. We examined demographic, sociobehavioral, and contextual factors that predict urban, low-income older adults' perception of HIV/AIDS risk. Logistic regression results from 398 residents aged 50-93 living in six buildings in two American cities found that males, younger participants (aged 50-61), those living in higher risk buildings, and those who worried more about contracting HIV/AIDS were more likely to perceive themselves to be at HIV/AIDS risk. Findings accounted for 32% of the variance and the prediction success rate was 72%. Results point to the importance of considering sociodemographic characteristics and environmental (contextual) factors as they influence heuristic decision making in understanding HIV/AIDS risk perception among low-income urban older adults and when designing HIV/AIDS education and intervention strategies targeting this population.

Social and behavioural determinants of body mass index among adolescent females in Croatia

For females body mass index (BMI; weight/height/2) is the strongest positive predictor of body dissatisfaction and anxiety about physique. Social factors could influence the relationship between BMI and weight-related behaviours and mechanisms depend on sociodemographic group differences. This cross-sectional study evaluated the influence of sociobehavioural factors on BMI in female adolescents in Trogir Croatia. We hypothesized that BMI in young females is associated with health behaviours and life style. During April 2001 328 females (aged 15.78 ± 1.19 years median 15.83 years range 13.31–18.10 years) who attended a comprehensive school in Trogir Croatia returned a self-report questionnaire regarding life style and health behaviours. After data collection participants were subjected to anthropometric measurements. Primary outcome measures were: body weight (kg); body height (cm); satisfaction with actual body weight (yes or no); following a diet regimen (yes or no); routinely or occasionally skipping meals (breakfast lunch and dinner; yes or no); daily milk consumption (dl); age at menarche (years); success in school compared with average school marks in Croatia (excellent very good good sufficient and insufficient); sport activity (yes or no); activity outside school (yes or no); and smoking (yes or no and number of cigarettes smoked per day). The secondary outcome measure was BMI. (excerpt)

Changing dentate status of adults, use of dental health services, and achievement of national dental health goals in Denmark by the year 2000.

This study analyzes the current profile of dentate status and use of dental health services among adults in Denmark at the turn of the millennium, assesses the impact on dentate status of sociodemographic factors and use of dental health services in adulthood and in childhood, and highlights the changes over time in dental health conditions among adults. Finally, the intention of the study was to evaluate the Danish dental health care system's level of achievement of the official goals for the year 2000 as formulated by the World Health Organization and the National Board of Health. The subjects of this study included a national representative sample of 16,690 Danish citizens aged 16 years and older (response rate=74.2%). A subsample (n=3,818) took part in a survey of dental care habits in childhood and prevalence of removable dentures; 66 percent of persons selected responded. Personal interviews were used to collect information on dentate status, use of dental health services and living conditions; data on dental care habits in childhood and prevalence of removable dentures were collected by self-administered questionnaires. In all, 8 percent of interviewed persons were edentulous, while 80 percent had 20 or more natural teeth. At age 65-74 years, 27 percent were edentulous and 40 percent had 20 teeth or more; 58 percent wore removable dentures. Dentate status and prevalence of dentures were highly related to educational background and income, particularly for older age groups. Among persons interviewed, 80 percent paid regular dental visits and visits were most frequent among persons of high education and income. At age 35-44 years 95 percent had participated in regular dental care in childhood compared to 49 percent of 65-74-year-olds. Multivariate analyses revealed that sociobehavioral factors had significant effects on dentate status. Compared to similar studies carried out in 1987 and 1994, the present survey indicates a positive trend of improved dentate status in adult Danes in general and regular use of dental health services increased considerably over time. The WHO goals for better dental health by the year 2000 were achieved for 35-44-year-olds, whereas the goal of more people with functional dentitions at age 65 years or older was not achieved. It remains a challenge to the Danish dental health system to help even out the social inequalities in dental health.

Compilation of Quantitative Overviews of Studies of Adherence

Purpose of Study. The purposes of this article are to: (1) Compile and critique quantitative reviews of studies of adherence with prescribed medications, and (2) Summarize current knowledge of adherence from the perspective of this literature.Methods. MEDLINE and other bibliographic databases were searched for quantitative reviews in which adherence with prescribed drugs was an endpoint. The reviews were classified according to type and whether they addressed either the factors associated with adherence or interventions designed to improve adherence.Findings. Three types of quantitative reviews are defined: consensus reviews, meta-analyses, and systematic reviews. There is a general agreement across review types and disease categories about the factors associated with adherence. To a first approximation, socio-demographic and disease-related factors are not associated with adherence, whereas factors related to the regimen and patient socio-behavioral factors are associated, though probably weakly. Meta-analyses and systematic reviews of interventions to improve adherence have taken disparate approaches to the pooling of primary study data. Some interventions, for example, reminder packaging, mailed reminders, and rewards, improve adherence, whereas patient information by itself typically does not. There is conflicting evidence for patient counseling, perhaps reflecting the variety of approaches or the relatively weak associations between socio-behavioral factors and adherence.Conclusions. Consensus reviews have generally been consistent in determining that features of the drug regimen and socio-behavioral factors are associated with adherence. The disparate methodological approaches of quantitative overviews of interventions to improve adherence reflect opposing ideas about combining primary data. There is, however, evidence favoring the effectiveness of some types of intervention, for example, reminders, and a consensus that patient information by itself typically is ineffective in improving adherence.

Carcinome épidermoïde sur ulcère de jambe aux Antilles

The epidemiology of carcinoma developing on a leg ulcer is poorly, although high incidence rates are reported in Africa. Retrospective study of cases reported in Guadeloupe, a tropical country with a large population from African descent and with high quality health care level. Sixteen cases, mean age 71, were diagnosed over a 10-Year period in the only referral hospital. The annual incidence was an estimated 0.4/100,000. Preceding ulcers had a long course (mean of 27 Years) and had various causes. Social distress was the rule (14/16 patients). One third of the clearly differentiated (15/16) squamous cell-type tumors exhibited metastatic extension on presentation. At Year 3, the mortality rate was of 40 p. cent. The best survival rate (6 remissions/8 cases) was associated with primary limb amputation. Malignant ulcers appeared more frequent in Guadeloupe than in the influent countries of the North, but with an instance 4-fold lower than in Africa. Like many other tropical diseases, socio-behavioral factors may play a major role.

Maternal life events and adverse pregnancy outcomes: lessons from the auvergne ectopic pregnancy registry

Objective To investigate stressful maternal life events as candidate risk factors for ectopic pregnancy. Design Population-based registry study. Setting Auvergne ectopic pregnancy registry (France). Patient(s) Women (n = 641) registered between 1997 and 2000. Intervention(s) Standard treatment of ectopic pregnancy. Main outcome measure(s) Based on the Psychiatric Epidemiology Life Events Scale, we analyzed the nonresponse bias, the confounding effects of sociobehavioral factors associated with both life events and ectopic pregnancy, and the potential buffering effects of socio-cultural variables. A multivariate model was constructed to test the association between life events and ectopic pregnancy, adjusting for identified confounders and testing interactions. Result(s) The primary hypothesis that life events might be independent risk factors for ectopic pregnancy was not confirmed in this study, which nevertheless illustrated the numerous biases and measurement problems confronting association studies of life events with adverse pregnancy outcomes. Conclusion(s) Recommendations are made for future studies on life events and adverse pregnancy outcomes to avoid most selection, information, and confounding biases. Methodological improvements are needed for measurement of life events to develop measures that more closely consider the consequences of stress and the mechanisms of buffering.

Oral health knowledge, attitudes and behaviour of children and adolescents in China

A national representative study to describe oral health behaviour, illness behaviour, oral health knowledge and attitudes among 12-year-old and 18-year-old Chinese, to analyse the oral health behaviour profile of the two age groups in relation to province and urbanisation, and to assess the relative effect of socio-behavioural risk factors on dental caries experience. The total number of 4,400 of each age group were selected and data were collected by clinical examinations (WHO criteria) and self-administered structured questionnaires. 44.4% of the respondents brushed their teeth at least twice a day but only 17% used fluoridated toothpaste. Subjects who saw a dentist during the previous 12 months or two years were 31.3% and 35.3% for 12-year-olds and 22.5% and 20.2% for 18-year-olds, respectively. Nearly one third (29%) of 12 year-olds and 40.5% of 18-year-olds would visit a dentist in case of signs of caries but only when in pain. Nearly half of the participants (47.2%) had never received any oral health care instruction. Significant variations in oral health practices were found according to province and regular dental care habits were more frequent in urban than in rural areas. The risk of dental caries was high in the case of frequent consumption of sweets and dental caries risk was low for participants with use of fluoridated toothpaste. Systematic community-oriented oral health promotion programmes are needed to target lifestyles and the needs of children, particularly for those living in rural areas. A prevention-oriented oral health care policy would seem more advantageous than the present curative approach.

The prevalence of self-reported symptoms of respiratory disease and community belief about the severity of pollution from various sources

It is postulated that health effects of air pollution may be direct and indirect through people's perception about the severity of pollution and concerns over its impact on their health. A cross sectional postal survey of some 6,559 households was conducted in the area of Ellesmere Port and Neston Borough Council. A total of 3,402 (51.9%) usable questionnaires were returned and included in the subsequent analyses. Childhood asthma was associated with central heating. Adult asthma was associated with the number of people in the house who had ever smoked and 'crowding'. General adult respiratory symptoms were associated with perception of industrial air pollution and neighbour noise in univariable but not multivariable analyses. In the multivariable model number of people in the household who had ever smoked, exposure to traffic fume pollution, crowding and living in rented accommodation. This suggests a complex relationship between actual levels of pollution (though not directly measured in this study), social deprivation, socio-behavioural factors and people's perceptions about pollution. A model of the relationship of these factors is proposed and it is argued that studies of the health impact of air pollution that concentrate only on chemical exposure will be flawed unless they are placed in the context of perception and socio-behavioural factors.

Modifiable barriers to adherence to inhaled steroids among adults with asthma: It's not just black and white

Background: Sociobehavioral factors influence adherence to inhaled corticosteroid (ICS) in adults with asthma and warrant exploration as explanations of apparent racial disparities in adherence. Objective: The purposes of this study were to identify barriers to adherence, potentially modifiable by healthcare providers, in a group of African Americans and non–African Americans and to test modifiable barriers as explanations of racial-ethnic differences in adherence. Methods: We conducted a cohort study of 85 adults (mean age, 47 ± 15 years; 61 [72%] female; 55 [65%] African American) with moderate or severe persistent asthma to determine modifiable sociobehavioral predictors of adherence. These were knowledge of the function of ICS, patient-perceived adequacy of communication with the provider, social support, attitude (perception of risks/benefits of ICS), depression, and self-efficacy. Adherence was calculated from electronic monitoring data as the mean of the number of doses recorded per 12 hours divided by the number prescribed, truncated at 100%. Past adherence, baseline severity of symptoms, and sociodemographics were treated as fixed confounders in ordinal logistic modeling. Results: Adherence was 60% ± 30%. In bivariate analyses, favorable attitude to ICS (P = .01) was associated with better adherence. Of immutable predictors, African American race-ethnicity (P = .001), lower educational achievement (P = .01), lower household income (P = .002), and more baseline symptoms (P = .003) were associated with poorer adherence. In multivariable analysis, controlling for immutable predictors, favorable attitude was associated with adherence. Favorable attitude was associated with greater adherence in African Americans and non–African Americans. Controlling for immutable factors, the race-adherence relationship was not mediated by the mutable factors, but economic factors (income and insurance) were mediators. Conclusion: Attitude is strongly related to adherence but does not mediate the effect of race-ethnicity. (J Allergy Clin Immunol 2003;111:1219-26.)

Oral pre-cancer and the associated risk factors among industrial workers in Japan's overseas enterprises in the UK.

Screening at industries has been advocated as a method of early detection for cancer. This study describes the prevalence of oral pre-cancerous lesions and other mucosal diseases following oral mucosal screening, and associated risk factors among Japanese industrial workers in the UK. Oral mucosal screening was by invitation at 51 industrial locations in the UK. A self-administered questionnaire was used to record socio-behavioural factors and frequency of daily intake of fruits and vegetables. Four hundred and eighty-four subjects attended for oral mucosal screening (mean age 39.9 +/- 8.3 years) and their mean period of residence in UK was 5.3 +/- 4.5 years. 63.4% examined were male. 31.3% of males and 26.6% of females smoked daily. The gender differences were striking compared with Japan's national rates. A higher proportion of managerial staff was regular heavy (20+ per day) smokers. The intake of more than five portions per day of vegetables and/or fruits during the weekend was significantly higher in females than in males (P = 0.022). One hundred and six subjects (22%) were detected with oral mucosal lesions, including 16 leukoplakia lesions (3.3%) and three with oral lichen planus (1%). The rate of positive detections was higher in managers (7.5%). Odds ratios were estimated by socio-behavioural variables. Among subjects positive for oral leukoplakia, managers accounted for 68.8% (OR 5.26; 95% CI, 1.24-22.29). 87.5% of subjects detected with oral leukoplakia smoked daily and had done so for the past 10 years (OR 28.40; 95% CI, 5.63-143.28). Though regular alcohol drinking was a common feature among male leukoplakia cases, heavy alcohol misuse was not encountered. None reported an intake of five or more portions of fruits or vegetables. The Japanese nationals working in managerial positions in the UK and daily regular smokers in the industries visited were found to be at a high risk of oral pre-cancer. Regular dental/oral check up and tobacco education programmes are encouraged for oral cancer/pre-cancer control in industrial settings.

Side effects and sociobehavioral factors associated with the discontinuation of hormone therapy in a Massachusetts health maintenance organization.

To identify sociobehavioral factors and side effects associated with the discontinuation of postmenopausal hormone therapy in a clinical practice setting A total of 816 women aged 45-59 who began hormone therapy between July 1993 and June 1995 in a Massachusetts health maintenance organization were followed for 2 years from the day they received a prescription for estrogen. This cohort has been previously studied for health, treatment, and demographic determinants of hormone therapy discontinuation. In March 1999, these women were mailed a questionnaire containing closed and open-ended questions. A total of 449 women (55%) completed the survey. Discrete-time hazards models were used to identify determinants of discontinuation, controlling for medical predictors of survey nonresponse. Women separated from their partners when they initiated hormone therapy (relative risk [RR] of discontinuation = 3.42; 95% confidence interval [CI] = 1.09, 10.73) and women with a body mass index greater than 29.0 (RR = 1.62; 95% CI = 1.18, 2.23) were more likely to discontinue. Women who had ever used oral contraceptives were less likely to discontinue hormone therapy (RR = 0.70; 95% CI = 0.51, 0.98). After women began using hormone therapy, those who experienced irregular bleeding (RR = 1.58; 95% CI = 1.08, 2.31), edema (RR = 2.18; 95% CI = 1.42, 3.34), or abdominal cramps and pelvic pain (RR = 2.42; 95% CI = 1.46, 4.02) while using hormones were more likely to discontinue. The effect of edema and abdominal cramps on the rate of discontinuation was greatest during the first 6 months of use. Women who adjusted their progestin schedule on their own were four times more likely than other women to discontinue hormones (RR = 4.18; 95% CI = 2.20, 7.94). The use of alternative therapies was not statistically associated with discontinuation. Women who report therapeutic benefits from hormone therapy are more likely to continue using hormones long-term. The experience of certain side effects, especially during the first few months of hormone use, strongly affects whether women continue using hormone therapy.

Oral health status and oral health behaviors in Chinese Children.

The objectives of the study were to describe the oral health status and treatment needs of the 5- to 6-year-old and 12-year-old children in Southern China; to describe the patterns of oral health behaviors, knowledge, and attitudes among the 12-year-olds; and to assess the effects of socio-behavioral factors on the 12-year-old children's dental caries experiences. The study sample was comprised of 1,587 5- to 6-year-old and 1,576 12-year-old urban and rural schoolchildren living in Guangdong Province. Three calibrated dentists clinically examined the children, and trained interviewers interviewed the 12-year-olds. Caries prevalence of the 5- to 6-year-old children was high (urban 78% vs. rural 86%); the mean dmft of the urban and rural children was 4.8 and 7.0, respectively. The caries prevalence and mean DMFT score of the 12-year-olds were 41% and 0.9 (urban) and 42% and 0.9 (rural). Only 2% of the 12-year-olds exhibited no calculus or gingival bleeding, while more than 70% had calculus. In conclusion, there is an urgent need for establishing caries-preventive activities for preschool children. The prevalence of caries among the 12-year-olds was not high, but their periodontal condition was unsatisfactory. Knowledge about gum bleeding and the use of fluoride was low. More oral health education activities should be organized, especially for the rural children.

Oral health status and oral health behaviour of urban and rural schoolchildren in Southern Thailand

To describe the level of oral disease in urban and rural schoolchildren in Southern Thailand; to analyse self-care practices and dental visiting habits of 12-year-olds, and to assess the effect of socio-behavioural factors on dental caries experience. A cross sectional study of 6- and 12-year-old children, urban and rural schools chosen at random from 19 districts of one province. Suratthani Province, Southern Thailand. A total of 1,156 children of grade 1 (6 yrs) and 1,116 children of grade 6 (12yrs). Clinical recordings of dental caries and periodontal CPI scores 0, 1 or 2 according to WHO; structured interviews of 12-year-olds (n=1,084) concerning oral health behaviour and attitudes. At age 6, 96.3% of children had caries and mean dmft was 8.1. In 12-year-olds, 70% had caries in permanent teeth and the level of DMFT was 2.4. Experience of pain during the previous 12 months was reported by 53% of 12-year-olds, 66% saw a dentist within the previous year and 24% reported that visits were due to troubles in teeth. Toothbrushing at least once a day was claimed by 88%. Significant numbers of the children reported having hidden sugar every day: soft drinks (24%), milk with sugar (34%), and tea with sugar (26%). Important predictors of high caries experience were dental visits, consumption of sweets, ethnic group (Muslim) and sex (girls) whereas lower risk was observed in children with positive oral health attitudes. Systematic health education may further improve the oral health of Thai children and the primary school provides a unique setting for such programmes.

Orthopaedic aspects of child abuse.

Increased awareness of child abuse has led to better understanding of this complex problem. However, the annual incidence of abuse is estimated at 15 to 42 cases per 1,000 children and appears to be increasing. More than 1 million children each year are the victims of substantiated abuse or neglect, and more than 1,200 children die each year as a result of abuse. The diagnosis of child abuse is seldom easy to make and requires a careful consideration of sociobehavioral factors and clinical findings. Because manifestations of physical abuse involve the entire child, a thorough history and a complete examination are essential. Fractures are the second most common presentation of physical abuse after skin lesions, and approximately one third of abused children will eventually be seen by an orthopaedic surgeon. Thus, it is essential that the orthopaedist have an understanding of the manifestations of physical abuse, to increase the likelihood of recognition and appropriate management. There is no pathognomonic fracture pattern in abuse. Rather, the age of the child, the overall injury pattern, the stated mechanism of injury, and pertinent psychosocial factors must all be considered in each case. Musculoskeletal injury patterns suggestive of nonaccidental injury include certain metaphyseal lesions in young children, multiple fractures in various stages of healing, posterior rib fractures, and long-bone fractures in children less than 2 years old. Skeletal surveys and bone scintigraphy with follow-up radiography may be of benefit in cases of suspected abuse of younger children. The differential diagnosis of abuse includes other conditions that may cause fractures, such as true accidental injury, osteogenesis imperfecta, and metabolic bone disease. Management should be multidisciplinary, with the key being recognition, because abused children have a substantial risk of repeated abuse and death.

A study of aged population and associated health risks in rural India.

This article examines the prevalence of age-related diseases in different socioeconomic and demographic groups. The study is based on a sample of 267 aged persons (> 60 years) collected through a survey entitled "Aging and Health Conditions in Rural Area-A Sample Survey, 1990" conducted in the rural areas of the Varanasi district of Uttar Pradesh, a northern province of India. Various socio-behavioral factors are found to play a significant role in determining the health conditions of aged people. Also, illiteracy and poverty are found to have their own impact on health during aging. It is also noted that due to adverse familial relationships, many stress-related disorders occur which may result in the poor health of the elderly. Demands for old age pensions were made by most of the elderly people in the sample.