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Effect of the number of risk factors on betel quid chewing in adolescents living in rural Taiwan
Public Health 123 (2009) 66–68
Contents lists available at ScienceDirect
Public Health journal homepage: www.elsevierhealth.com/journals/pubh
Short Communication
Effect of the number of risk factors on betel quid chewing in adolescents living in rural Taiwan C-F. Yen a, b, M-S. Yang c, *, Y-C. Su c, M-H. Wang c, C-M. Lan d a
Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 807, Taiwan Department of Psychiatry, Kaohsiung Medical University Hospital, 100 Tzyou 1st Road, Kaohsiung 807, Taiwan c School of Nursing, College of Nursing, Kaohsiung Medical University, 100 Shih Chuan 1st Road, Kaohsiung 807, Taiwan d Graduate Institute of Guidance and Counselling, National Kaohsiung Normal University, 116 Heping 1st Road, Lingya District, Kaohsiung, Taiwan b
a r t i c l e i n f o Article history: Received 17 May 2007 Received in revised form 1 April 2008 Accepted 16 July 2008 Available online 16 December 2008
Betel quid chewing has been found to increase the risk of oral cancer.1 In Taiwan, a higher prevalence of betel quid chewing was found in adolescents living in rural areas compared with urbanized areas.2 As rural areas may have fewer resources for preventing and intervening in the complications of long-term betel quid chewing, prevention and control of betel quid chewing for adolescents living in rural areas are important. Several risk factors of betel quid chewing in Taiwanese adolescents have been determined in previous studies, including male gender,2 indigenous,3 disruptive family,4 older age2 and smoking.2,3 It has been suggested that an effective health education programme should be implemented for adolescents with the risk factors for betel quid chewing.5 However, no studies have examined the effect of the number of risk factors on betel quid chewing in adolescents living in rural areas. If it is found that adolescents who have more risk factors are more likely to chew betel quid, they should be the focus of intervention programmes to prevent betel quid chewing. The aim of this study was to examine the risk factors of betel quid chewing and the effect of the number of risk factors on betel quid chewing in adolescents living in rural Taiwan. It is hypothesized that adolescents with more individual and family factors related to betel quid chewing have a higher risk of chewing betel quid. The current investigation is based on data from the Project for Health of Adolescents in Rural Taiwan, a research programme studying the mental and physical health status of adolescents living in the rural areas of southern Taiwan. In this study, 38 villages from two counties were defined as rural areas. Forty-three junior high
* Corresponding author. Tel.: þ886 7 321 0479; fax: þ886 7 321 8364. E-mail address: [email protected] (M.-S. Yang).
schools in these areas were stratified into mountain regions (n ¼ 11) and plains areas (n ¼ 32), where the majority of students were indigenous and non-indigenous, respectively. As the schools in the plains areas have more students than the schools in the mountain regions, six schools from the mountain regions and three schools from the plains areas were selected at random in order to obtain approximately equal numbers of indigenous and nonindigenous adolescents. In total, 2079 adolescents from the nine junior high schools were recruited into this study in 2003. A research assistant explained the study purpose, procedure and the expectations of them as subjects, and told the students that participation was voluntary and all information disclosed would be confidential; written informed consent was obtained from the students beforehand, and the participants were invited to complete the research questionnaires anonymously. This study received ethical approval from the Human Research Ethics Committee of Kaohsiung Medical University. All participants were asked whether they had ever chewed betel quid or smoked cigarettes. The five-item Chinese version of the Family APGAR Index (APGAR) was used to evaluate the level of family support perceived by the adolescents; a family with a total APGAR score 6 is considered to be low functioning.6 In addition, the four-point, 20-item, self-rated Zung Depression Scale (ZDS) was used to assess adolescents’ depression in the preceding month.7 Subjects with a total ZDS score 50 were considered to be depressed. Adolescents’ sociodemographic factors, including gender, age, ethnicity and rank of academic performance in their class, were also ascertained. Those whose rank of academic performance was in the bottom one-third of their class were classified as having poor academic performance. The frequency of family conflict (0 ¼ never, 1 ¼ seldom, 2 ¼ frequently, 3 ¼ always) was also ascertained from the adolescents’ point of view. In this study, the subjects who answered ‘frequently’ or ‘always’ were considered to ‘perceive frequent family conflict’. The adolescents were asked to anonymously self-complete all questionnaires based on the explanations of the research assistants and under their direction in the classrooms. Data were analysed using Statistical Package for the Social Sciences Version 10.0. The associations between the experience of betel quid chewing and individual, family and school factors and the experience of smoking
0033-3506/$ – see front matter Ó 2008 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2008.07.008
C.-F. Yen et al. / Public Health 123 (2009) 66–68
cigarettes were examined using a multiple logistic regression model. A P-value of 0.05 was used for all statistical tests. Effects of the number of risk factors on betel quid chewing were examined using odds ratios (OR) and 95% confidence intervals (CI). Of the enlisted students (n ¼ 2079), 15 (0.7%) refused to participate in this study and 399 (19.2%) had incomplete items in the returned questionnaires. Thus, the results of questionnaires from 1665 adolescent students (response rate ¼ 80.1%) were analysed further. No difference in gender or age was found between nonresponders and responders. Of the participants, 819 (49.2%) were males, 747 (44.9%) were indigenous, 212 (12.7%) were depressed on the ZDS, 408 (24.5%) had poor academic performance, 463 (27.8%) perceived frequent family conflict, and 1118 (67.1%) reported low family function on the APGAR. Their mean age was 14.4 years (standard deviation ¼ 1.0 years). Two hundred and seventy-eight adolescents (16.7%) had ever chewed betel quid and 450 (27.0%) had ever smoked cigarettes. The results of the logistic regression analysis indicated that adolescents who were indigenous (OR ¼ 6.428, 95% CI 4.592– 8.998), had smoked cigarettes (OR ¼ 5.543, 95% CI 4.091–7.511), had poor academic performance (OR ¼ 1.636, 95% CI 1.191–2.249), perceived frequent family conflict (OR ¼ 1.560, 95% CI 1.138–2.138) and were male (OR ¼ 1.546, 95% CI 1.138–2.101) were more likely to have chewed betel quid (-2 Log likelihood ¼ 1133.082, df ¼ 8, P < 0.001). Depression on the ZDS (OR ¼ 1.260, 95% CI 0.826–1.921), family function on the APGAR (OR ¼ 1.227, 95% CI 0.873–1.724) and age (OR ¼ 1.025, 95% CI 0.878–1.196) were not associated with betel quid chewing in this logistic regression model. Effects of the number of risk factors identified in the logistic regression model on betel quid chewing are shown in Table 1. The results indicated that the risk of adolescents with one risk factor for having chewed betel quid was 7.192. The risk increased as the number of risk factors increased. Adolescents who had all five risk factors had the highest risk for having chewed betel quid (OR ¼ 373.500). The present study found that indigenous adolescents were more likely to have experienced betel quid chewing. In Taiwan, betel quid chewing is much more prevalent among the indigenous population than the non-indigenous population.8 Meanwhile, adolescents whose parents are betel quid chewers are more likely to chew betel quid themselves.5 Indigenous adolescents may have more opportunities to be in contact with betel quid chewers, consider it to be acceptable behaviour, and then attempt betel quid chewing themselves. Cigarette smoking has been found to be associated with betel quid chewing in adolescents2,3 and the general population.8–10 Concurrent betel nut chewing and smoking has a synergistic effect on the development of cancer of the oral cavity, nasopharynx, lung and liver.1,10 Thus, betel quid chewing should not be considered as an isolated issue, but should be viewed conjointly with cigarette smoking. In this study, adolescents who perceived frequent family conflict were more likely to have ever chewed betel quid. Betel quid chewing may be one of the risky behaviours that adolescents may
Table 1 Effect of the number of risk factors on betel quid chewing.
0 1 2 3 4 5
Ever chewed betel quid n (%)
Never chewed betel quid n (%)
OR
95% CI
2 29 83 82 67 15
249 502 380 204 51 5
–
–
7.192 27.193 50.044 163.559 373.500
1.702–30.384 6.629–111.559 12.159–205.978 38.816–689.185 66.840–2087.123
(0.7) (10.4) (29.9) (29.5) (24.1) (5.4)
(17.9) (36.1) (27.3) (14.7) (3.7) (0.4)
OR, odds ratio; CI, confidence interval.
67
develop in their adverse family environments. More male adolescents than females had ever chewed betel quid, which is in agreement with the results of previous studies.2 The disfiguring effects of betel quid chewing, including red staining of lips and teeth and foul-smelling breath, may account for this difference.8 This study found that the risk of betel quid chewing increased with the number of risk factors. The results support the notion that adolescents who have several risk factors for betel quid chewing should be the major focus of prevention programmes. In this study, multiple family, school and individual factors were found to be related to chewing betel quid among Taiwanese adolescents. The factors identified in this study may be helpful when designing and implementing preventive intervention programmes. Early monitoring of the possibility of involvement with chewing betel quid should be commenced for adolescents who are male, indigenous or who perceive high family conflict. As poor academic achievement is also a correlate of betel quid chewing in adolescents, strategies to prevent betel quid chewing should be implemented on school campuses as early as possible, and in such a way that will capture the adolescents’ attention and persuade them to avoid chewing betel quid. Meanwhile, incorporating betel quid control into tobacco control may provide a new paradigm to attenuate the explosive increase in betel quid use.10 Some potential limitations of this study should be considered. The cross-sectional nature of the investigation limited the authors’ ability to draw conclusions about the causal relationship between betel quid chewing and some risk factors, such as smoking cigarettes. Some factors that may be associated with betel quid chewing were not investigated in this study, such as betel quid chewing by parents and peers,5 and adolescents’ expectations regarding betel quid chewing.9 The numbers in some cells of Table 1 are small, which may result in wide CIs. Meanwhile, adolescents were asked if they had ever chewed betel quid, but were not asked about regular or pathological use of betel quid. Adolescents who try chewing betel quid once due to curiosity may be different from regular users. Further studies are needed to examine the correlates in adolescents regarding different levels of betel quid usage.
Ethical approval Human Research Ethics Committee of Kaohsiung Medical University. Funding None declared. Competing interests None declared. References 1. Ko YC, Huang YL, Lee CH, Chen MJ, Lin LM, Tsai CC. Betel quid chewing, cigarette smoking and alcohol consumption related to oral cancer in Taiwan. J Oral Pathol Med 1995;24:450–3. 2. Wang SC, Tsai CC, Huang ST, Hong YJ. Betel nut chewing and related factors in adolescent students in Taiwan. Public Health 2003;117:339–45. 3. Tsai YF, Wong TK, Chen SC. Prevalence and related risk factors of areca quid chewing among junior high students in eastern Taiwan. Public Health 2002;116:190–4. 4. Wang SC, Tsai CC, Huang ST, Hong YJ. Betel nut chewing: the prevalence and the intergenerational effect of parental behavior on adolescent students. J Adolesc Health 2004;34:244–9. 5. Ho CS, Gee MJ. The parental influence of betel-chewing behavior among junior high school students in Taiwan. Subst Abus 2002;23:183–9. 6. Chau TT, Hsiao TM, Huang CT, Liu HW. A preliminary study of family Apgar index in the Chinese. Kaohsiung J Med Sci 1991;7:27–31.
68
C.-F. Yen et al. / Public Health 123 (2009) 66–68
7. Zung WW, Richards CB, Short MJ. Self-rating depression scale in an outpatient clinic. Further validation of the SDS. Arch Gen Psychiatry 1965;13: 508–15. 8. Ko YC, Chiang TA, Chang SJ, Hsieh SF. Prevalence of betel quid chewing habit in Taiwan and related sociodemographic factors. J Oral Pathol Med 1992;21:261–4.
9. Chen JW, Shaw JH. A study on betel quid chewing behavior among Kaohsiung residents aged 15 years and above. J Oral Pathol Med 1996;25:140–3. 10. Wen CP, Tsai SP, Cheng TY, Chen CJ, Levy DT, Yang HJ, et al. Uncovering the relation between betel quid chewing and cigarette smoking in Taiwan. Tob Control 2005;14(Suppl. 1):i16–22.
Contents lists available at ScienceDirect
Public Health journal homepage: www.elsevierhealth.com/journals/pubh
Short Communication
Effect of the number of risk factors on betel quid chewing in adolescents living in rural Taiwan C-F. Yen a, b, M-S. Yang c, *, Y-C. Su c, M-H. Wang c, C-M. Lan d a
Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 807, Taiwan Department of Psychiatry, Kaohsiung Medical University Hospital, 100 Tzyou 1st Road, Kaohsiung 807, Taiwan c School of Nursing, College of Nursing, Kaohsiung Medical University, 100 Shih Chuan 1st Road, Kaohsiung 807, Taiwan d Graduate Institute of Guidance and Counselling, National Kaohsiung Normal University, 116 Heping 1st Road, Lingya District, Kaohsiung, Taiwan b
a r t i c l e i n f o Article history: Received 17 May 2007 Received in revised form 1 April 2008 Accepted 16 July 2008 Available online 16 December 2008
Betel quid chewing has been found to increase the risk of oral cancer.1 In Taiwan, a higher prevalence of betel quid chewing was found in adolescents living in rural areas compared with urbanized areas.2 As rural areas may have fewer resources for preventing and intervening in the complications of long-term betel quid chewing, prevention and control of betel quid chewing for adolescents living in rural areas are important. Several risk factors of betel quid chewing in Taiwanese adolescents have been determined in previous studies, including male gender,2 indigenous,3 disruptive family,4 older age2 and smoking.2,3 It has been suggested that an effective health education programme should be implemented for adolescents with the risk factors for betel quid chewing.5 However, no studies have examined the effect of the number of risk factors on betel quid chewing in adolescents living in rural areas. If it is found that adolescents who have more risk factors are more likely to chew betel quid, they should be the focus of intervention programmes to prevent betel quid chewing. The aim of this study was to examine the risk factors of betel quid chewing and the effect of the number of risk factors on betel quid chewing in adolescents living in rural Taiwan. It is hypothesized that adolescents with more individual and family factors related to betel quid chewing have a higher risk of chewing betel quid. The current investigation is based on data from the Project for Health of Adolescents in Rural Taiwan, a research programme studying the mental and physical health status of adolescents living in the rural areas of southern Taiwan. In this study, 38 villages from two counties were defined as rural areas. Forty-three junior high
* Corresponding author. Tel.: þ886 7 321 0479; fax: þ886 7 321 8364. E-mail address: [email protected] (M.-S. Yang).
schools in these areas were stratified into mountain regions (n ¼ 11) and plains areas (n ¼ 32), where the majority of students were indigenous and non-indigenous, respectively. As the schools in the plains areas have more students than the schools in the mountain regions, six schools from the mountain regions and three schools from the plains areas were selected at random in order to obtain approximately equal numbers of indigenous and nonindigenous adolescents. In total, 2079 adolescents from the nine junior high schools were recruited into this study in 2003. A research assistant explained the study purpose, procedure and the expectations of them as subjects, and told the students that participation was voluntary and all information disclosed would be confidential; written informed consent was obtained from the students beforehand, and the participants were invited to complete the research questionnaires anonymously. This study received ethical approval from the Human Research Ethics Committee of Kaohsiung Medical University. All participants were asked whether they had ever chewed betel quid or smoked cigarettes. The five-item Chinese version of the Family APGAR Index (APGAR) was used to evaluate the level of family support perceived by the adolescents; a family with a total APGAR score 6 is considered to be low functioning.6 In addition, the four-point, 20-item, self-rated Zung Depression Scale (ZDS) was used to assess adolescents’ depression in the preceding month.7 Subjects with a total ZDS score 50 were considered to be depressed. Adolescents’ sociodemographic factors, including gender, age, ethnicity and rank of academic performance in their class, were also ascertained. Those whose rank of academic performance was in the bottom one-third of their class were classified as having poor academic performance. The frequency of family conflict (0 ¼ never, 1 ¼ seldom, 2 ¼ frequently, 3 ¼ always) was also ascertained from the adolescents’ point of view. In this study, the subjects who answered ‘frequently’ or ‘always’ were considered to ‘perceive frequent family conflict’. The adolescents were asked to anonymously self-complete all questionnaires based on the explanations of the research assistants and under their direction in the classrooms. Data were analysed using Statistical Package for the Social Sciences Version 10.0. The associations between the experience of betel quid chewing and individual, family and school factors and the experience of smoking
0033-3506/$ – see front matter Ó 2008 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2008.07.008
C.-F. Yen et al. / Public Health 123 (2009) 66–68
cigarettes were examined using a multiple logistic regression model. A P-value of 0.05 was used for all statistical tests. Effects of the number of risk factors on betel quid chewing were examined using odds ratios (OR) and 95% confidence intervals (CI). Of the enlisted students (n ¼ 2079), 15 (0.7%) refused to participate in this study and 399 (19.2%) had incomplete items in the returned questionnaires. Thus, the results of questionnaires from 1665 adolescent students (response rate ¼ 80.1%) were analysed further. No difference in gender or age was found between nonresponders and responders. Of the participants, 819 (49.2%) were males, 747 (44.9%) were indigenous, 212 (12.7%) were depressed on the ZDS, 408 (24.5%) had poor academic performance, 463 (27.8%) perceived frequent family conflict, and 1118 (67.1%) reported low family function on the APGAR. Their mean age was 14.4 years (standard deviation ¼ 1.0 years). Two hundred and seventy-eight adolescents (16.7%) had ever chewed betel quid and 450 (27.0%) had ever smoked cigarettes. The results of the logistic regression analysis indicated that adolescents who were indigenous (OR ¼ 6.428, 95% CI 4.592– 8.998), had smoked cigarettes (OR ¼ 5.543, 95% CI 4.091–7.511), had poor academic performance (OR ¼ 1.636, 95% CI 1.191–2.249), perceived frequent family conflict (OR ¼ 1.560, 95% CI 1.138–2.138) and were male (OR ¼ 1.546, 95% CI 1.138–2.101) were more likely to have chewed betel quid (-2 Log likelihood ¼ 1133.082, df ¼ 8, P < 0.001). Depression on the ZDS (OR ¼ 1.260, 95% CI 0.826–1.921), family function on the APGAR (OR ¼ 1.227, 95% CI 0.873–1.724) and age (OR ¼ 1.025, 95% CI 0.878–1.196) were not associated with betel quid chewing in this logistic regression model. Effects of the number of risk factors identified in the logistic regression model on betel quid chewing are shown in Table 1. The results indicated that the risk of adolescents with one risk factor for having chewed betel quid was 7.192. The risk increased as the number of risk factors increased. Adolescents who had all five risk factors had the highest risk for having chewed betel quid (OR ¼ 373.500). The present study found that indigenous adolescents were more likely to have experienced betel quid chewing. In Taiwan, betel quid chewing is much more prevalent among the indigenous population than the non-indigenous population.8 Meanwhile, adolescents whose parents are betel quid chewers are more likely to chew betel quid themselves.5 Indigenous adolescents may have more opportunities to be in contact with betel quid chewers, consider it to be acceptable behaviour, and then attempt betel quid chewing themselves. Cigarette smoking has been found to be associated with betel quid chewing in adolescents2,3 and the general population.8–10 Concurrent betel nut chewing and smoking has a synergistic effect on the development of cancer of the oral cavity, nasopharynx, lung and liver.1,10 Thus, betel quid chewing should not be considered as an isolated issue, but should be viewed conjointly with cigarette smoking. In this study, adolescents who perceived frequent family conflict were more likely to have ever chewed betel quid. Betel quid chewing may be one of the risky behaviours that adolescents may
Table 1 Effect of the number of risk factors on betel quid chewing.
0 1 2 3 4 5
Ever chewed betel quid n (%)
Never chewed betel quid n (%)
OR
95% CI
2 29 83 82 67 15
249 502 380 204 51 5
–
–
7.192 27.193 50.044 163.559 373.500
1.702–30.384 6.629–111.559 12.159–205.978 38.816–689.185 66.840–2087.123
(0.7) (10.4) (29.9) (29.5) (24.1) (5.4)
(17.9) (36.1) (27.3) (14.7) (3.7) (0.4)
OR, odds ratio; CI, confidence interval.
67
develop in their adverse family environments. More male adolescents than females had ever chewed betel quid, which is in agreement with the results of previous studies.2 The disfiguring effects of betel quid chewing, including red staining of lips and teeth and foul-smelling breath, may account for this difference.8 This study found that the risk of betel quid chewing increased with the number of risk factors. The results support the notion that adolescents who have several risk factors for betel quid chewing should be the major focus of prevention programmes. In this study, multiple family, school and individual factors were found to be related to chewing betel quid among Taiwanese adolescents. The factors identified in this study may be helpful when designing and implementing preventive intervention programmes. Early monitoring of the possibility of involvement with chewing betel quid should be commenced for adolescents who are male, indigenous or who perceive high family conflict. As poor academic achievement is also a correlate of betel quid chewing in adolescents, strategies to prevent betel quid chewing should be implemented on school campuses as early as possible, and in such a way that will capture the adolescents’ attention and persuade them to avoid chewing betel quid. Meanwhile, incorporating betel quid control into tobacco control may provide a new paradigm to attenuate the explosive increase in betel quid use.10 Some potential limitations of this study should be considered. The cross-sectional nature of the investigation limited the authors’ ability to draw conclusions about the causal relationship between betel quid chewing and some risk factors, such as smoking cigarettes. Some factors that may be associated with betel quid chewing were not investigated in this study, such as betel quid chewing by parents and peers,5 and adolescents’ expectations regarding betel quid chewing.9 The numbers in some cells of Table 1 are small, which may result in wide CIs. Meanwhile, adolescents were asked if they had ever chewed betel quid, but were not asked about regular or pathological use of betel quid. Adolescents who try chewing betel quid once due to curiosity may be different from regular users. Further studies are needed to examine the correlates in adolescents regarding different levels of betel quid usage.
Ethical approval Human Research Ethics Committee of Kaohsiung Medical University. Funding None declared. Competing interests None declared. References 1. Ko YC, Huang YL, Lee CH, Chen MJ, Lin LM, Tsai CC. Betel quid chewing, cigarette smoking and alcohol consumption related to oral cancer in Taiwan. J Oral Pathol Med 1995;24:450–3. 2. Wang SC, Tsai CC, Huang ST, Hong YJ. Betel nut chewing and related factors in adolescent students in Taiwan. Public Health 2003;117:339–45. 3. Tsai YF, Wong TK, Chen SC. Prevalence and related risk factors of areca quid chewing among junior high students in eastern Taiwan. Public Health 2002;116:190–4. 4. Wang SC, Tsai CC, Huang ST, Hong YJ. Betel nut chewing: the prevalence and the intergenerational effect of parental behavior on adolescent students. J Adolesc Health 2004;34:244–9. 5. Ho CS, Gee MJ. The parental influence of betel-chewing behavior among junior high school students in Taiwan. Subst Abus 2002;23:183–9. 6. Chau TT, Hsiao TM, Huang CT, Liu HW. A preliminary study of family Apgar index in the Chinese. Kaohsiung J Med Sci 1991;7:27–31.
68
C.-F. Yen et al. / Public Health 123 (2009) 66–68
7. Zung WW, Richards CB, Short MJ. Self-rating depression scale in an outpatient clinic. Further validation of the SDS. Arch Gen Psychiatry 1965;13: 508–15. 8. Ko YC, Chiang TA, Chang SJ, Hsieh SF. Prevalence of betel quid chewing habit in Taiwan and related sociodemographic factors. J Oral Pathol Med 1992;21:261–4.
9. Chen JW, Shaw JH. A study on betel quid chewing behavior among Kaohsiung residents aged 15 years and above. J Oral Pathol Med 1996;25:140–3. 10. Wen CP, Tsai SP, Cheng TY, Chen CJ, Levy DT, Yang HJ, et al. Uncovering the relation between betel quid chewing and cigarette smoking in Taiwan. Tob Control 2005;14(Suppl. 1):i16–22.