Social Science & Medicine 70 (2010) 1780e1788

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Social Science & Medicine

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Socio-economic status and oral health-related behaviours in Korean adolescentsq

Se-Hwan Jung a, *, Georgios Tsakos b, Aubrey Sheiham b, Jae-In Ryu c, Richard G. Watt b
a
Department of Preventive and Public Health Dentistry, College of Dentistry, Gangneung-Wonju National University, 120 Gangneung Daehangno, Gangneung-si, Republic of Korea
b
Department of Epidemiology and Public Health, University College London, London, United Kingdom
c
Department of Dental Hygiene, Shingu University, Seongnam-si, Republic of Korea

a r t i c l e i n f o a b s t r a c t

Article history: The principle objective of this study was to assess the association between socio-economic status (SES)
Available online 12 March 2010 and oral health-related behaviours in Korean adolescents aged 13e18, using the Family Affluence Scale
(FAS). The secondary objective was to assess the influences of other factors (pocket money, school type,
Keywords: family structure and psychological factors) on this association. Cross-sectional data were from the
Korea national 2007 Korean Youth Risk Behavior Web-based Survey. Oral health-related behaviours included
Adolescents
health-enhancing behaviours (frequency of toothbrushing and dental visits) and health-compromising
Family affluence scale
behaviours (smoking and frequency of intake of soft drinks and confections). Logistic regression models
Oral health-related behaviours
Pocket money
were used to analyse the data. To assess the influence of other factors, additional models adjusting for
Socio-economic status (SES) sex, school grade and each of the other factors were compared to the initial model, which adjusted for
sex and school grade only.
We found that family affluence had a linear association with health-enhancing behaviours and
a roughly U-shaped association with health-compromising behaviours. After adjusting for a number of
variables, the linear association with health-enhancing behaviours persisted. The U-shaped association
with health-compromising behaviours remained but was partly attenuated and flattened. In addition, we
found a marked influence of school type and family structure and pocket money on the association
between FAS and oral health-compromising behaviours. The findings indicate that the health-enhancing
behaviours of adolescents were strongly associated with family affluence, but the health-compromising
behaviours were more strongly linked to factors other than family affluence. However, it is difficult to
determine which factors contribute most in relation to family affluence because of other confounding
factors, such as the education system, peer group, youth culture, part-time work and advertising.
Therefore, further studies are needed to assess factors that interact with family SES to better understand
the association between the SES and the oral health-compromising behaviours of adolescents.
Ó 2010 Elsevier Ltd. All rights reserved.

Introduction abovementioned health behaviours also play an important role in

Socio-economic inequalities in health have been partly attrib-
uted to social differences in health-related behaviours (Dowler,
2001; Lynch, Kaplan, & Salonen, 1997; Marmot & Wilkinson,
2006). Modifiable health-related behaviours, such as poor diet
and eating habits, smoking and physical inactivity, are generally
established during adolescence (Ferreira, Twisk, van Mechelen,
Kemper, & Stehouwer, 2005; Kohl & Hobbs, 1998). The
q This work was supported by the Korea Research Foundation Grant (KRF-2009-
013-E00037). The authors thank the Korea Centers for Disease Control and
Prevention for making available the data from the 2007 KYRBWS. The authors
thank Dr. Kawachi, Dr Subramanian and the anonymous reviewers for their
analytical comments.
* Corresponding author. Tel.: þ82 33 640 2751.
E-mail addresses: feeljsh@gwnu.ac.kr, feeljsh@hotmail.com (S.-H. Jung).
oral health and may contribute to inequalities in adolescent oral
health together with toothbrushing and dental visits (Burt et al.,
2006; Ojima, Hanioka, Tanaka, & Aoyama, 2007; Petersen, Jiang,
Peng, Tai, & Bian, 2008; Sanders, Spencer, & Slade, 2006).
Although numerous studies have examined the impact of socio-
economic inequalities on the health-related behaviours of adults,
very few have focused on the relationship between socio-economic
status (SES) and oral health-related behaviours in adolescents. This
may be related to problems measuring SES in adolescents (Currie
et al., 2008; Torsheim et al., 2004; West & Sweeting, 2004). In
adults, SES is usually measured by income, education or occupation
(Bartley, 2004), but family SES is generally used as the proxy for
adolescents. However, data on family SES can be difficult to collect
from adolescents because they either may not know or may not be
willing to reveal such information. One composite indicator of
material conditions in the family, the Family Affluence Scale (FAS),

0277-9536/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2010.02.022
 S.-H. Jung et al. / Social Science & Medicine 70 (2010) 1780e1788
is a brief and easily comprehensible measure that can be used as
a measure of family SES for adolescents (Currie et al., 2008).
However, the evidence on the relationship between FAS and
health-related behaviours in adolescents is inconsistent, and often
contradictory (Richter & Leppin, 2007; Richter, Leppin, & Gabhainn,
2006; Vereecken, Inchley, Subramanian, Hublet, & Maes, 2005).
While diet and physical activity have usually shown consistent
patterns in the expected direction, little consistency has been found
for the relationship between FAS and drinking behaviour or daily
smoking in adolescents (Currie et al., 2008). Therefore, there is
a need to critically and comprehensively assess the relationship
between health-related behaviours in adolescents and FAS, used as
a proxy for SES.
During adolescence, the relative influence of the family and
home background decreases, and that of other external factors,
such as the school, peer group and own culture, increases. As
adolescents try to develop independent lifestyles and habits, these
lifestyle changes can impact both their health behaviours and
health (Piko & Fitzpatrick, 2001; West, 1997), which results in
conflicting evidence on the relationship between family SES and
health-related behaviours in adolescents.
The amount of pocket money adolescents have as disposable
income may influence the relationship between family SES and
health-related behaviours in adolescents, and can be considered as
another external influence on their health behaviours. How
adolescents spend their pocket money is not directly under
parental control, and adolescents can buy health-compromising
goods, including soft or alcoholic drinks, cigarettes and drugs. The
amount of pocket money adolescents have has a strong relationship
with current smoking (Rudatsikira, Muula, & Siziya, 2009; West,
Sweeting, & Young, 2007). Adolescents who have more pocket
money may be more independent of their parents, which could
lead to decreasing parental control. A further complicating factor is
the source of pocket money. While it is usually received from
parents and guardians, some adolescents, particularly those with
lower SES, also earn money from part-time employment (Darling,
Reeder, McGee, & Williams, 2006).
Some demographic and psychological factors are associated
with health-related behaviours in adolescents. For example,
secondary school type has a strong relationship with smoking
(Richter & Leppin, 2007), and adolescents who do not live with both
parents have more health-compromising behaviours (Challier,
Chau, Predine, Choquet, & Legras, 2000; Griesbach, Amos, &
Currie, 2003; Simantov, Schoen, & Klein, 2000).
Psychological factors are associated with health-related behav-
iours in adolescents, including smoking, dietary behaviours, alcohol
use and physical activity (Milligan et al., 1997; Simantov et al., 2000;
Tyas & Pederson, 1998). To better understand the exact role of family
SES in determining health-related behaviours in adolescents, more
evidence is needed regarding other factors such as pocket money,
school type, family structure and psychological factors.
Therefore, the objective of this study was to assess the associ-
ation between socio-economic status and oral health-related
behaviours in Korean adolescents, using FAS as a measure of SES.
The secondary objective was to assess the influences of other
factors including pocket money, school type, family structure and
psychological factors on the association between oral health-
related behaviours and SES.
Materials and methods
Study population
The cross-sectional data for this study were from the national
2007 Korean Youth Risk Behavior Web-based Survey (KYRBWS)
1781
(Korea Centers for Disease Control and Prevention, 2009a). The
2007 KYRBWS was conducted on a national sample of middle and
high school students (13e18-year-olds) by the Korea Centers for
Disease Control and Prevention (KCDC). The education system in
South Korea has three levels: elementary (7e12-year-olds), middle
(13e15-year-olds), and high (16e18-year-olds). In 2007, 94% of
13e18-year-old adolescents in South Korea were middle and high
school students (Korea Ministry of Education Science & Technology,
Korean Education Development Institute, 2009). Ethics approval
was provided by the KCDC.
The 2007 KYRBWS used a stratified, clustered, multistage prob-
ability sampling design on a sample representative of all middle and
high school students in South Korea, according to geographic areas,
sex and school type. Schools were the primary sampling units, and
one class per each grade was chosen from each selected school. A
total of 74,698 students from 800 schools were included in an online
self-reported survey. The response rate was 94.8%. The subjects
responded electronically to the questionnaire during one teaching
session in a computer room of the sampled school. All schools in
South Korea have a room connected to the Internet for regular
computer lessons, and all students have learned how to use
computers and the Internet. The whole session was managed by
a trained support teacher, who gave the students an information
leaflet that explained the purpose of the survey and explained the
instructions for filling in the form. The students then filled in a self-
reported questionnaire form without any personal identification
and submitted it via the Internet. The students were then rewarded
with a gift. The reliability and validity of KYRBWS has been shown to
be good (Korea Centers for Disease Control and Prevention, 2009b).
Oral health behavioural variables
Oral health-related behaviours and general health-related
behaviours linked to oral health were selected for analysis. Oral
health-related behaviours included frequency of toothbrushing and
dental visits (Maes, Vereecken, Vanobbergen, & Honkala, 2006;
Petersen et al., 2008; Sanders et al., 2006). General health-related
behaviours linked to oral health consisted of smoking (Ojima et al.,
2007) and frequency of intake of soft drinks and confectioneries
(Burt et al., 2006; Petersen et al., 2008). Oral health-related
behaviours can be either health-enhancing or health-compro-
mising. Each of the five behaviours was dichotomised. Frequency of
toothbrushing was categorised into (1) less than twice daily and (2)
twice daily and more. Frequency of dental visits was categorised
into (1) less than once a year and (2) once a year and more. Smoking
was categorised into (1) non-smoker and (2) current smoker,
determined as an individual who had currently smoked a cigarette
at least once in the last month. The frequency of intake of soft
drinks and confectioneries was categorised into (1) less than once
a day and (2) once a day and more.
Socio-economic variable
The Family Affluence Scale (FAS) was used as an indicator of SES
(Currie et al., 2008). This scale consists of 4 items: i) does your
family own cars? (0, 1, 2 or more), ii) do you have your own
bedroom? (no, yes), iii) how many times did you travel on vacation
with your family during the past year? (0, 1, 2, 3 or more), and iv)
how many computers does your family own? (0, 1, 2, 3 or more).
The composite FAS score was calculated by summing the responses
to these four items, and it ranged from 0 (lowest affluence) to 9
(highest affluence).
1782 S.-H. Jung et al. / Social Science & Medicine 70 (2010) 1780e1788
Variables influencing associations
Variables influencing the association between oral health-
related behaviours and SES were school type, family structure,
pocket money, perceived stress and perceived happiness. In Korea,
middle school education is compulsory, and there are two types of
high schools: general high schools leading to university education,
and vocational high schools that qualify adolescents for various
manual jobs after graduation.
Family structure was measured by a single item question in
relation to whether the adolescent lived with their parents. There
were four response options: both parents, only father, only mother
and no parents. This variable was categorised into two groups: (1)
both parents and (2) not both parents.
Pocket money per week was measured in Korean Won (KRW)
and was categorised into six grades: 0e10,000 KRW,
10,000e20,000 KRW, 20,000e30,000 KRW, 30,000e40,000 KRW,
40,000e60,000 KRW, 60,000 KRW or more.
Perceived stress and perceived happiness were selected as
psychological variables. The participants were asked to rate their
stress or happiness on a 5-point Likert scale. To avoid small-sized
groups, these variables were categorised into four groups. Perceived
stress was categorised into (1) very much, (2) much, (3) a little and
(4) little or never. Perceived happiness was categorised into (1) very
happy, (2) a little happy, (3) fair and (4) a little or very unhappy.
Covariates
Covariates included in the analysis were sex and school grade
(age). School grade in Korean adolescents is almost consistent with
age. Students attending the 1st grade in middle school are 13 years
old, and age increases by one year per grade; those in the 3rd grade
in high school are 18 years old.
Data analyses
Sample weights were used to adjust for sampling complexity.
Weighted data were obtained using a complex sample plan and
analysed using the complex samples analysis in SPSS version 15 for
Windows. The prevalence of oral health-related behaviours within
variables influencing associations or covariates were assessed and
presented as percentages with 95% confidence intervals [SENTENCE
UNCLEAR]. The association between each oral health-related
behaviour and FAS were presented in bar charts. Logistic regression
models were used to assess socio-economic inequalities in oral
health-related behaviours. The final model was adjusted for sex,
school grade, school type, family structure, perceived stress,
perceived happiness and pocket money. To assess the influence of
other factors such as pocket money, school type, family structure
and psychological factors, the logistic models adjusting for each of
these factors in addition to sex and school grade were compared to
the initial model, which was adjusted for sex and school grade only.
Results are presented as odds ratios with 95% confidence intervals.
Results
Table 1 shows the prevalence of adolescents in the best group of
health-enhancing behaviours and the worst group of health-
compromising behaviours by variables influencing associations or
covariates. With the exception of eating confectionaries, oral
health-related behaviours were better in girls than in boys. The
same was the case for students attending general rather than
vocational high schools. With the exception of the 1st grade of high
school, the prevalence of visiting a dental clinic within a year
decreased with school grade, and the prevalence of current
smoking increased with school grade. Other behaviours did not
change with school grade level. Oral health-related behaviours
were clearly worse in adolescents that did not live with both
parents compared to those that did. Increased pocket money was
associated with a substantially higher prevalence of oral health-
compromising behaviours, while pocket money did not markedly
change the prevalence of oral health-enhancing behaviours.
Adolescents with more stress and lower levels of perceived
happiness had poorer behaviours.
The association between oral health-related behaviours and FAS
is presented in Fig. 1. While the prevalence of oral health-enhancing
behaviours, such as brushing teeth and visiting a dental clinic,
increased linearly with FAS scores, the prevalence of oral health-
compromising behaviours, such as current smoking, drinking soft
drinks and eating confectionaries, showed a nonlinear, roughly U-
shaped pattern with FAS scores.
Table 2 shows the results of the logistic regression models for the
socio-economic inequalities in oral health-enhancing behaviours,
using FAS as a measure of SES. There was a linear association
between FAS and oral health-enhancing behaviours (brushing teeth
and visiting a dental clinic) that persisted after adjusting for sex and
school grade (Model 1). The association was attenuated only slightly
after adjusting for the two psychological variables (Model 2) or
pocket money (Model 4), but the odds ratios of low FAS categories
increased considerably after adjusting for school type and family
structure (Model 3). After adjusting for all variables influencing
associations and covariates (Model 5), the association was attenu-
ated slightly further, but it still showed a consistent pattern in the
expected direction. However, the linear pattern for visiting a dental
clinic was interrupted by adolescents with the lowest FAS score (0)
because they visited dental clinics more frequently than those with
a score of 1 or 2.
Table 3 shows the results of the logistic regression models for
the impact of socio-economic inequalities on oral health-compro-
mising behaviours, using FAS as a measure of SES. The roughly U-
shaped pattern between FAS and oral health-compromising
behaviours (eating confectionaries, current smoking and drinking
soft drinks) persisted after adjusting for sex and school grade
(Model 1). The association changed only slightly after adjusting for
the two psychological variables (Model 2). The odds ratios
decreased markedly in the low FAS categories after adjusting for
school type and family structure (Model 3). However, adjusting for
pocket money (Model 4) increased the odds ratios in all FAS cate-
gories and resulted in a more flattened pattern, with the exception
of the lowest FAS score (0), for which the odds ratio was consid-
erably higher than those of the other FAS categories. After adjusting
for all variables influencing associations and covariates (Model 5),
the U-shaped association with health-compromising behaviours
remained but was partly attenuated and flattened.
Looking at the odds ratios for the higher FAS categories, there
were hardly any marked differences except for drinking soft
drinks, where the odds ratio of the highest FAS group (9) was
always considerably higher than that of the adjacent groups. The
association changed only slightly even in the fully adjusted models
(Tables 2 and 3).
Discussion
Despite the relative consistency of socio-economic differences
in health behaviours in adults, the relationship is less clear and
even heterogeneous among adolescents (Richter & Leppin, 2007;
Tuinstra, Groothoff, Heuvel, & Post, 1998; Van Lenthe et al., 2001;
Vereecken et al., 2005). In this study, we found a considerable
association between FAS, as an indicator of family SES, and oral
health-related behaviours in a large national sample of Korean
 S.-H. Jung et al. / Social Science & Medicine 70 (2010) 1780e1788 1783

Table 1
Distribution of oral health-related behaviours of Korean adolescents by sex, school grade (age), school type, family structure, pocket money per week, perceived stress and
perceived happiness.

Variables Unweighted Oral health-related behaviours

number
% (95%CI) % (95%CI) % (95%CI) % (95%CI) % (95%CI) eating
(% Weighted)
brushing teeth visiting a current drinking soft confectionaries
twice daily dental clinic smoking - drinks once a once a day
and more once a year 1e2 days day and more and more
and more per month
and more
Total 74,698 (100.0) 93.5 (93.1e93.9) 61.1 (59.3e62.8) 13.3 (12.0e14.8) 9.2 (8.7e9.7) 17.6 (17.0e18.2)

Sex
Boy 39,466 (53.1) 92.1 (91.6e92.5) 56.7 (54.8e58.6) 17.4 (15.6e19.3) 11.5 (10.8e12.1) 15.8 (15.2e16.4)
Girl 35,232 (46.9) 95.1 (94.6e95.5) 66.0 (64.2e67.7) 8.8 (7.7e10.0) 6.6 (6.1e7.1) 19.6 (18.7e20.6)

Grade (age)
1st middle school (13 years old) 13,035 (17.4) 93.7 (93.1e94.3) 72.0 (69.9e74.1) 5.9 (5.3e6.5) 8.6 (7.9e9.4) 16.3 (15.0e17.7)
2nd middle school (14 years old) 12,849 (17.6) 92.9 (92.4e93.4) 62.5 (58.9e65.9) 9.1 (8.3e9.9) 8.8 (8.2e9.4) 17.3 (16.1e18.6)
3rd middle school (15 years old) 12,936 (17.9) 94.0 (93.5e94.5) 57.3 (52.7e61.8) 12.1 (11.3e13.0) 9.3 (8.7e10.0) 17.4 (16.1e18.7)
1st high school (16 years old) 12,809 (17.1) 92.9 (91.9e93.8) 65.4 (62.6e68.1) 16.3 (14.1e18.8) 9.2 (8.2e10.5) 18.5 (17.4e19.7)
2nd high school (17 years old) 11,596 (15.1) 93.6 (92.6e94.5) 56.2 (54.2e58.2) 18.6 (16.3e21.1) 9.3 (8.2e10.5) 18.2 (16.8e19.7)
3rd high school (18 years old) 11,473 (14.9) 93.8 (92.8e94.7) 51.1 (48.8e53.4) 19.8 (16.9e23.0) 9.9 (8.8e11.2) 18.0 (17.1e19.0)

School type
Middle school 38,820 (52.8) 93.5 (93.2e93.9) 63.9 (60.7e66.9) 9.1 (8.5e9.6) 8.9 (8.5e9.3) 17.0 (15.9e18.2)
General high school 25,051 (34.5) 94.8 (94.1e95.3) 59.9 (57.4e62.3) 13.1 (12.0e14.3) 7.5 (6.8e8.2) 18.3 (17.3e19.3)
Vocational high School 10,827 (12.7) 89.8 (88.9e90.6) 52.5 (50.0e55.0) 31.9 (30.1e33.9) 14.8 (13.7e16.0) 18.3 (16.8e19.9)

Family structure
Lives with both parents 60,974 (82.8) 94.2 (93.8e94.6) 62.2 (60.3e64.0) 11.6 (10.5e12.9) 8.3 (7.8e8.7) 17.2 (16.5e17.9)
Does not live with both parents 13,724 (17.2) 90.0 (89.3e90.7) 55.6 (53.9e57.3) 21.5 (19.7e23.5) 13.5 (12.7e14.2) 19.5 (18.7e20.4)

Pocket money per week

0e10,000 KRW 25,170 (32.8) 92.2 (91.8e92.6) 60.0 (57.5e62.4) 7.0 (6.3e7.8) 6.5 (6.0e7.0) 14.0 (13.2e14.7)
10,000e20,000 KRW 17,515 (23.0) 94.0 (93.5e94.5) 60.3 (58.3e62.2) 11.6 (10.5e12.7) 8.6 (8.1e9.2) 17.7 (16.9e18.6)
20,000e30,000 KRW 11,382 (15.3) 94.0 (93.2e94.6) 62.3 (60.1e64.4) 14.3 (12.6e16.2) 9.4 (8.6e10.3) 18.2 (17.3e19.1)
30,000e40,000 KRW 7928 (10.9) 94.1 (93.4e94.8) 63.3 (61.4e65.0) 16.2 (14.5e18.0) 9.7 (8.8e10.7) 19.9 (18.9e21.0)
40,000e60,000 KRW 7223 (10.1) 94.7 (93.9e95.5) 60.9 (58.6e63.0) 19.4 (17.2e21.8) 11.6 (10.4e13.1) 21.2 (20.0e22.5)
60,000 KRW or more 5480 (7.9) 93.7 (92.8e94.5) 62.7 (60.7e64.8) 31.2 (28.3e34.3) 17.6 (16.1e19.1) 23.2 (21.8e24.7)

Perceived stress
Very much 10,257 (13.5) 92.2 (91.4e92.9) 58.4 (56.3e60.5) 19.5 (17.8e21.3) 12.5 (11.7e13.4) 22.4 (21.2e23.7)
Much 24,580 (32.9) 93.0 (92.4e93.6) 61.5 (59.5e63.5) 14.4 (12.9e16.0) 9.3 (8.7e10.0) 18.7 (17.9e19.4)
A little 29,355 (39.5) 94.0 (93.4e94.5) 61.5 (59.8e63.2) 11.5 (10.2e12.9) 8.0 (7.5e8.5) 15.8 (15.1e16.5)
Little or never 10,506 (14.0) 94.5 (93.9e95.1) 61.3 (59.0e63.4) 10.1 (8.8e11.6) 8.8 (8.1e9.6) 15.5 (14.5e16.4)

Perceived happiness
Very happy 11,519 (15.7) 95.6 (95.0e96.1) 64.6 (62.7e66.4) 10.7 (9.4e12.3) 9.2 (8.5e10.1) 16.6 (15.5e17.7)
A little happy 26,397 (35.6) 94.3 (93.8e94.7) 62.7 (61.0e64.4) 11.4 (10.1e12.7) 8.2 (7.7e8.7) 16.9 (16.2e17.6)
Fair 25,669 (34.0) 92.8 (92.3e93.3) 59.2 (57.2e61.3) 14.3 (12.9e15.9) 9.5 (8.9e10.1) 17.5 (16.7e18.3)
A little or very unhappy 11,113 (14.7) 90.8 (90.0e91.6) 57.5 (55.3e59.7) 18.6 (17.0e20.3) 10.8 (10.1e11.5) 20.6 (19.6e21.6)

adolescents. First, a linear association existed between FAS and oral
health-enhancing behaviours including brushing teeth and visiting
a dental clinic. These behaviours were more frequent among
adolescents from more affluent families, confirming previous
studies (Maes et al., 2006; Petersen et al., 2008). Although the
influence of the family on health-related behaviours diminished as
other external factors increased during adolescence (Piko &
Fitzpatrick, 2001; West, 1997), family affluence was strongly asso-
ciated with the health-enhancing behaviours of adolescents. Even
after adjusting for a number of variables, FAS, as a measure of family
SES, remained as a determinant of oral health-enhancing behav-
iours. This result indicates the importance of family affluence on
these behaviours. Exceptionally, adolescents in the lowest FAS
group visited dental clinics more frequently than those in the
adjacent two higher groups. However, the poorest groups in Korea
have free essential dental care, which is not provided for other
groups. Similar results were shown in a study on mothers with
Medicaid in Ohio (Kuthy, Odom, Salsberry, Nickel, & Polivka, 1998).
Second, we found a roughly U-shaped association with FAS for
oral health-compromising behaviours, such as current smoking,
drinking soft drinks and eating confectionaries, that contradicted
the results of previous studies (Griesbach et al., 2003; Inchley, Todd,
Bryce, & Currie, 2001; Richter et al., 2006; Vereecken et al., 2005).
These behaviours occurred more frequently among adolescents
from both very deprived and affluent families. This pattern was
highlighted because the whole range of FAS scores (0e9), rather
than arbitrarily chosen groups, was used in the analysis. Although
the association was partly attenuated and flattened after adjusting
for school type and family structure or pocket money, the associ-
ation still remained in all models. This finding suggests that health-
compromising behaviours in adolescents are not strongly
controlled by parents and are more strongly linked to other
external factors than to familial socio-economic background. As
adolescents have increasing opportunities to select and purchase
their own soft drinks, confectionaries and cigarettes outside the
home, they can be more independent of their parents for these
behaviours. Various external factors have been shown to relate to
these adolescent behaviours, including their own socio-cultural
factors such as education system, peer group, youth culture, part-
time work and advertising (Inchley et al., 2001; King, Siegel,
Celebucki, & Connolly, 1998; Powell, Szczypka, Chaloupka, &
Braunschweig, 2007; Richter & Leppin, 2007; West, 1997; West
et al., 2007). However, while all of these factors play an impor-
tant role in the oral health-compromising behaviours of
1784 S.-H. Jung et al. / Social Science & Medicine 70 (2010) 1780e1788

a % brushing teeth twice daily and more b % visiting dental clinic once a year and more
100 80
% %
95 70

90 60

85 50

80 40
0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
FAS FAS

c % current smoker d % drinking soft drinks once daily and more

30 25
% %
25 20

20 15

15 10

10 5
0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
FAS FAS

f % eating confectionary once daily and more

30
%
25

20

15

10
0 1 2 3 4 5 6 7 8 9
FAS

Fig. 1. The association between each of the oral health-related behaviours and each FAS group.

adolescents, it is difficult to determine which may be the most
influential in relation to family background.
Third, we found a marked influence of school type and family
structure and of pocket money on socio-economic differences in
oral health-related behaviours, unlike the two psychological vari-
ables. With the exception of eating confectionaries, oral health-
related behaviours were better in students attending general rather
than vocational high schools, and were clearly worse in adolescents
not living with both parents compared to those who did. These
findings are similar to those reported in other studies (Challier
et al., 2000; Griesbach et al., 2003; Richter & Leppin, 2007;
Simantov et al., 2000). After adjusting for school type and family
structure, the odds ratios of the low FAS categories increased
considerably for health-enhancing behaviours and decreased
markedly for health-compromising behaviours. This finding
suggests that school type and family structure are risk factors and
may be useful markers for factors influencing socio-economic
differences in low FAS groups of health-related behaviours.
The prevalence of oral health-compromising behaviours increased
considerably as the amount of pocket money increased, as reported in
previous studies (Darling et al., 2006; Griesbach et al., 2003;
Rudatsikira et al., 2009; West et al., 2007). These patterns of
consumption in adolescents may be largely influenced by social
environments and by incorrect information, uncontrolled commer-
cial advertising in mass media and the presence of multiple vending
machines in schools (Darling et al., 2006; Powell et al., 2007).
Adjusting the model for pocket money markedly increased the odds
ratios for oral health-compromising behaviours in all FAS categories
and resulted in a more flattened pattern for all but the lowest FAS
group (0), although the previous U-shaped pattern remained. This
finding suggests that the amount of pocket money has a strong
influence on the association between oral health-compromising
behaviours in adolescents and FAS across all FAS groups.
Adolescents with more stress and lower levels of perceived
happiness had poorer health behaviours, and this has also been
demonstrated in other studies (Milligan et al., 1997; Simantov et al.,
2000; Tyas & Pederson, 1998). However, two psychological vari-
ables had only a small impact on the association between FAS and
oral health-related behaviours in adolescents. This finding shows
that although psychological factors are associated with health
behaviours, socio-economic differences have greater influence on
the health behaviours of Korean adolescents.
Fourth, the odds ratio of the lowest FAS group (0) was remark-
ably higher than adjacent groups for oral health-compromising
behaviours and was largely influenced by school type, family
structure and pocket money. This finding suggests that the
adolescents with the lowest FAS score are more strongly linked to
other external factors than they are to familial socio-economic
background. Further research needs to explore possible explana-
tions for this finding.
Table 2
Odds ratios for the association between oral health-enhancing behaviours and the Family Affluence Scale (FAS) (n ¼ 74,698).

S.-H. Jung et al. / Social Science & Medicine 70 (2010) 1780e1788

Oral health- Models FAS scores (unweighted number)
enhancing
0 1 2 (7885) 3 4 5 6 7 8 9 (979)
behaviours
(496) (2793) (13,772) (14,766) (13,537) (11,082) (6464) (2924)
Brushing teeth e Model 1 0.32*** (0.21e0.50) 0.34*** (0.25e0.46) 0.41*** (0.31e0.54) 0.53*** (0.41e0.69) 0.73* (0.57e0.94) 0.75* (0.58e0.98) 0.95NS (0.73e1.24) 1.31NS (0.96e1.78) 1.02NS (0.73e1.43) 1.00
OR (95%CI)a Model 2 0.34*** (0.22e0.52) 0.36*** (0.27e0.49) 0.43*** (0.32e0.57) 0.55*** (0.42e0.72) 0.75* (0.58e0.97) 0.76* (0.58e1.00) 0.95NS (0.73e1.25) 1.30NS (0.95e1.78) 1.00NS (0.71e1.41) 1.00
Model 3 0.40*** (0.26e0.63) 0.41*** (0.30e0.56) 0.45*** (0.34e0.60) 0.55*** (0.42e0.71) 0.73* (0.56e0.94) 0.74* (0.57e0.97) 0.93NS (0.71e1.22) 1.27NS (0.93e1.74) 0.99NS (0.70e1.39) 1.00
Model 4 0.35*** (0.22e0.53) 0.36*** (0.27e0.48) 0.42*** (0.32e0.56) 0.54*** (0.42e0.71) 0.74* (0.58e0.96) 0.76* (0.59e0.99) 0.96NS (0.74e1.24) 1.31NS (0.96e1.79) 1.02NS (0.73e1.42) 1.00
Model 5 0.46** (0.29e0.70) 0.46*** (0.34e0.63) 0.50*** (0.37e0.67) 0.60*** (0.46e0.78) 0.78NS (0.60e1.01) 0.77NS (0.59e1.01) 0.95NS (0.72e1.25) 1.28NS (0.93e1.77) 0.98NS (0.69e1.38) 1.00

Visiting a dental Model 1 0.42*** (0.31e0.55) 0.35*** (0.27e0.45) 0.37*** (0.29e0.47) 0.45*** (0.36e0.57) 0.53*** (0.42e0.66) 0.65*** (0.51e0.82) 0.70** (0.55e0.90) 0.80NS (0.63e1.03) 0.91NS (0.72e1.15) 1.00
clinic e OR Model 2 0.42*** (0.32e0.57) 0.36*** (0.27e0.47) 0.37*** (0.29e0.48) 0.46*** (0.36e0.57) 0.53*** (0.42e0.67) 0.65*** (0.51e0.82) 0.70** (0.55e0.89) 0.79NS (0.62e1.02) 0.90NS (0.71e1.13) 1.00
(95%CI)b Model 3 0.45*** (0.34e0.59) 0.37*** (0.28e0.48) 0.38*** (0.30e0.48) 0.46*** (0.37e0.57) 0.53*** (0.42e0.66) 0.65*** (0.51e0.81) 0.70** (0.55e0.89) 0.80NS (0.63e1.02) 0.90NS (0.72e1.13) 1.00
Model 4 0.44*** (0.33e0.59) 0.37*** (0.29e0.48) 0.39*** (0.31e0.50) 0.48*** (0.38e0.60) 0.56*** (0.44e0.70) 0.68** (0.54e0.85) 0.73* (0.57e0.93) 0.83NS (0.65e1.06) 0.93NS (0.74e1.17) 1.00
Model 5 0.49*** (0.37e0.64) 0.40*** (0.31e0.52) 0.41*** (0.32e0.52) 0.49*** (0.39e0.61) 0.56*** (0.45e0.70) 0.68** (0.54e0.85) 0.73** (0.57e0.92) 0.82NS (0.65e1.05) 0.92NS (0.74e1.15) 1.00
***
p < 0.001; **p < 0.01, *p < 0.05, NS p > 0.05.
Model 1: adjusting for FAS, sex and school grade.
Model 2: adjusting for FAS, sex, school grade, perceived stress and perceived happiness.
Model 3: adjusting for FAS, sex, school grade, school type and family structure.
Model 4: adjusting for FAS, sex, school grade and pocket money per week.
Model 5: adjusting for FAS, sex, school grade, school type, family structure, perceived stress, perceived happiness and pocket money per week.
a
Odds ratio for brushing teeth twice daily and more.
b
Odds ratio for visiting a dental clinic once a year and more.

1785
 1786
Table 3
Odds ratios for the association between oral health-compromising behaviours and the Family Affluence Scale (FAS) (n ¼ 74,698).

Oral health- Models FAS scores (unweighted number)

compromising
0 1 2 3 4 5 6 7 8 9
behaviours

S.-H. Jung et al. / Social Science & Medicine 70 (2010) 1780e1788

(496) (2793) (7885) (13,772) (14,766) (13,537) (11,082) (6464) (2924) (979)
Current smoking e Model 1 1.37* (1.01e1.88) 0.74* (0.59e0.94) 0.66*** (0.54e0.81) 0.58*** (0.47e0.72) 0.57*** (0.45e0.72) 0.65*** (0.52e0.81) 0.68** (0.54e0.85) 0.70*** (0.58e0.85) 0.84 NS
(0.65e1.08) 1.00
OR (95% CI)a Model 2 1.27 NS (0.93e1.74) 0.71** (0.56e0.91) 0.64*** (0.52e0.79) 0.58*** (0.46e0.72) 0.57*** (0.45e0.73) 0.67** (0.53e0.84) 0.71** (0.56e0.89) 0.74** (0.61e0.90) 0.88 NS
(0.68e1.14) 1.00
Model 3 0.89 NS (0.64e1.25) 0.49*** (0.38e0.63) 0.51*** (0.40e0.64) 0.52*** (0.42e0.66) 0.55*** (0.43e0.71) 0.65** (0.51e0.83) 0.70** (0.55e0.89) 0.74** (0.61e0.90) 0.89 NS
(0.68e1.16) 1.00
Model 4 2.33*** (1.65e3.29) 1.24 NS (0.99e1.55) 1.09 NS (0.88e1.34) 0.91 NS (0.74e1.13) 0.84 NS (0.67e1.07) 0.92 NS (0.74e1.15) 0.93 NS (0.75e1.17) 0.94 NS (0.78e1.14) 1.04 NS
(0.80e1.34) 1.00
Model 5 1.50* (1.04e2.17) 0.82 NS (0.63e1.06) 0.83 NS (0.65e1.06) 0.80 NS (0.63e1.02) 0.82 NS (0.62e1.07) 0.95 NS (0.73e1.23) 0.99 NS (0.77e1.28) 1.02 NS (0.82e1.26) 1.13 NS
(0.85e1.52) 1.00
* ** *** *** *** *** *** *** ***
Drinking soft Model 1 1.38 (1.01e1.89) 0.65 (0.50e0.84) 0.62 (0.50e0.77) 0.49 (0.40e0.62) 0.52 (0.42e0.64) 0.51 (0.41e0.63) 0.57 (0.46e0.70) 0.58 (0.47e0.72) 0.64 (0.50e0.81) 1.00
drink e OR Model 2 1.32 NS (0.97e1.79) 0.66** (0.50e0.86) 0.63*** (0.51e0.79) 0.51*** (0.41e0.64) 0.54*** (0.43e0.66) 0.53*** (0.43e0.67) 0.60*** (0.48e0.74) 0.61*** (0.49e0.76) 0.66** (0.52e0.84) 1.00
(95% CI)b Model 3 1.03 NS (0.74e1.43) 0.50*** (0.38e0.66) 0.53*** (0.42e0.66) 0.47*** (0.37e0.59) 0.51*** (0.41e0.64) 0.51*** (0.41e0.64) 0.58*** (0.46e0.73) 0.60*** (0.48e0.75) 0.66** (0.51e0.85) 1.00
Model 4 1.97*** (1.43e2.71) 0.93 NS (0.72e1.21) 0.88 NS (0.71e1.10) 0.68** (0.54e0.85) 0.69** (0.56e0.85) 0.66*** (0.53e0.82) 0.72** (0.58e0.89) 0.72** (0.58e0.89) 0.74* (0.58e0.95) 1.00
Model 5 1.45* (1.05e2.01) 0.74* (0.57e0.97) 0.77* (0.61e0.97) 0.65*** (0.52e0.82) 0.69** (0.56e0.86) 0.68** (0.54e0.86) 0.76* (0.60e0.95) 0.76* (0.61e0.95) 0.78NS (0.61e1.01) 1.00

Eating Model 1 1.25 NS (0.94e1.66) 0.72* (0.54e0.95) 0.70** (0.55e0.90) 0.64*** (0.50e0.82) 0.69** (0.54e0.87) 0.73** (0.57e0.92) 0.78* (0.62e0.98) 0.80 NS
(0.62e1.02) 0.81 NS
(0.63e1.05) 1.00
confectionaries e Model 2 1.20 NS (0.90e1.59) 0.72* (0.54e0.95) 0.70** (0.55e0.90) 0.64** (0.50e0.83) 0.70** (0.54e0.89) 0.74* (0.58e0.95) 0.80 NS (0.64e1.00) 0.82 NS
(0.63e1.05) 0.83 NS
(0.64e1.07) 1.00
OR (95% CI)c
Model 3 1.15 NS (0.86e1.53) 0.68** (0.51e0.90) 0.68** (0.53e0.87) 0.63*** (0.49e0.81) 0.69** (0.54e0.87) 0.73* (0.58e0.93) 0.79* (0.63e0.99) 0.81 NS
(0.63e1.04) 0.82 NS
(0.63e1.06) 1.00
Model 4 1.52** (1.14e2.02) 0.87 NS (0.67e1.14) 0.84 NS (0.66e1.06) 0.75* (0.59e0.95) 0.79* (0.63e1.00) 0.82 NS (0.65e1.04) 0.87 NS (0.70e1.08) 0.88 NS
(0.69e1.12) 0.87 NS
(0.68e1.13) 1.00
Model 5 1.38* (1.04e1.83) 0.83NS (0.63e1.09) 0.82NS (0.64e1.04) 0.74* (0.58e0.95) 0.79NS (0.63e1.01) 0.84NS (0.66e1.06) 0.89 NS (0.71e1.11) 0.90 NS
(0.70e1.16) 0.89 NS
(0.69e1.15) 1.00
*** ** * NS
p < 0.001; p < 0.01, p < 0.05, p > 0.05.
Model 1: adjusting for FAS, sex and school grade.
Model 2: adjusting for FAS, sex, school grade, perceived stress and perceived happiness.
Model 3: adjusting for FAS, sex, school grade, school type and family structure.
Model 4: adjusting for FAS, sex, school grade and pocket money per week.
Model 5: adjusting for FAS, sex, school grade, school type, family structure, perceived stress, perceived happiness and pocket money per week.
a
Odds ratio for being a current smoker.
b
Odds ratio for drinking soft drink once daily and more.
c
Odds ratio for eating confectionaries once daily and more.
 S.-H. Jung et al. / Social Science & Medicine 70 (2010) 1780e1788
Fifth, socio-economic differences in oral health-related behav-
iours between the high FAS groups were relatively small and were
further reduced after adjusting for pocket money. This finding
suggests that adolescents within the high FAS categories behaved
more similarly in relation to oral health-related behaviours than
those in the low or middle FAS groups. That may be because other
factors more strongly influence those behaviours in the high FAS
groups and tend to make them more similar. However, there was no
evidence to support this notion in previous studies.
Lastly, there were sex and school grade differences in some of
the oral health-related behaviours in Korean adolescents that were
similar to those reported in other countries (Alamian & Paradis,
2009; Petersen et al., 2008; Richter et al., 2006; Simantov et al.,
2000; Vereecken et al., 2005). This finding suggests that it is
necessary to adjust for sex and school grade to assess the associa-
tion between oral health-related behaviours and SES.
Most oral health-related behaviours in Korean adolescents were
found to be better than those in adolescents from other countries,
including Europe and the USA; the frequency of dental visits was an
exception (Griesbach et al., 2003; Inchley et al., 2001; Rudatsikira
et al., 2009; Vereecken et al., 2005). This study used a very large
sample (74,698), had a very high response rate, and benefited from
not having missing data. This may have been due to systematic
efforts, as it was supported by national organisations, and the
technical advantages of online survey methods, as the software
forces respondents to complete all questions (Korea Centers for
Disease Control and Prevention, 2009a). However, there were
some limitations to our study. First, FAS as a measure of SES does
not represent the complete characteristics of family SES. In this
study, FAS was used effectively as a supplementary indicator of
family SES in Korean adolescents. Unlike traditional SES indicators,
such as parental occupation, education, or income, which are more
vulnerable to inaccurate reporting and missing data, FAS was easy
to answer and there were no missing data (Torsheim et al., 2004).
However, from a methodological point of view, it is important to
recognise that different SES indicators may give different and/or
complementary information, that no indicator is superior to any
other, and that research conclusions regarding the role of SES could
vary depending upon the SES measure used (Bartley, 2004; Shavers,
2007). FAS represents a measure of material deprivation, which has
been defined as the lack of goods and conveniences. FAS as an SES
indicator in adolescents mainly reflects the material deprivation
and financial resources of the parents. In European adolescents, the
consumption of fruit and soft drinks differed by FAS or the occu-
pation of the head of household (Vereecken et al., 2005). Therefore,
traditional indicators, such as parental education level and occu-
pation, may also be needed to better understand the role of family
SES in oral health-related behaviours in adolescents.
Second, this study did not include a great enough number of
other external variables that could influence the results, although
their own socio-cultural factors play an important role in health
behaviours of adolescents. That may be a reason why we did not
find any influence on the unusual pattern between FAS and oral
health-compromising behaviours in adolescents. Third, we tried to
clarify the role of psychological variables in socio-economic
differences in oral health-related behaviours of adolescents.
However, due to a limitation in the measurement of psychological
variables, we failed to establish the role of this parameter. As
psychological factors are important in explaining the socio-
economic differences in health and health behaviours (Marmot &
Wilkinson, 2006), more research is needed to better understand
this area. Lastly, the choice of the cut-off point for each oral health-
related behaviour may have influenced our findings.
This study demonstrated that there were socio-economic
differences in oral health-enhancing behaviours (brushing teeth
1787
and dental visits) in the expected direction, but there were roughly
U-shape patterns in oral health-compromising behaviours
(smoking and intake of soft drinks and confectioneries). As such,
oral health-compromising behaviours were more frequent among
adolescents from both very deprived and affluent families. In
addition, we found a marked influence of school type and family
structure and pocket money on the association between FAS and
oral health-compromising behaviours. The findings indicate that
the health-enhancing behaviours of adolescents were strongly
associated with family affluence and that the health-compromising
behaviours were more strongly linked to factors other than family
affluence. However, it is difficult to determine which factor
contributes the most in relation to family affluence because of
confounding factors such as education system, peer group, youth
culture, part-time work and advertising. Therefore, further studies
are needed to assess factors acting with family SES to better
understand the association between the SES and the oral health-
compromising behaviours of adolescents.
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