Study design and sample size
The current study utilized a cross-sectional survey with multistage random sampling to assess and understand the health-related behavior of youth using FBs in Jazan, Saudi Arabia.According to the Saudi Ministry of Education, in 2017–2018 there were approximately 12,930 first-year students in Jazan University [16] and about 106,005 students in the region’s middle and secondary schools [17]. The sample size for the current study was calculated using an online sample size calculator (Qualtrics https://www.qualtrics.com) with a confidence level of 95% and a margin error of 5% to represent the target population. Three hundred eighty-three participants (with equal numbers of both males and females) in the region’s middle and secondary schools, as well as -first-year university schools, were included in this study. To cover any unexpected problems during the study period, an additional 20% of the original 383 participants were added to the sample. Thus, 460 participants were randomly selected, which is sufficient to address the objectives of the study.
In the first stage, four cities were selected. In the second stage, the university students were selected from Jazan city and six randomly selected middle and high schools were selected from the other three areas of the data collection. In the third stage, an admission list was obtained. Only Saudi Arabian students were included to maintain the homogeneity of the study population.
Data collection process
A self-administrated questionnaire was conducted between October 2018 and March 2019. A list of all students and schools was obtained from the Ministry of Education and General Department of Education in Jazan region. Students from six schools (three male-only and three female-only schools) and first-year students in Jazan University were randomly selected from Jazan, Sabya, Abu Arish and Alardah cities, which is the largest cities in the region and where a large proportion of the region population resides. The inclusion criteria were that all individuals: were Saudi students aged 13 years or older, studying in middle or high school or first-year university students, and had guardian approval to participate in the study.
The questionnaire, a cover letter, and a consent form were distributed to all study participants. Students were instructed by the Principle investigator to complete or have their guardians complete the questionnaires and return them to the school administration office in 1 week. Parent of school children were asked to help if their children had diffeculty in understanding the questions. The questionnaires were collected from the students 1 week later.
Since the university students were all adults, they were asked to read the consent form and decide whether to participate or not prior to completion of the surveys. The students who agreed to participate were told how to fill in the questionnaire. The students completed the questionnaires under supervision, and the questionnaires were collected immediately after completion.
Data collection commenced after the ethics approval had been obtained from the Institutional Review Board (REC40/1-046) at the College of Dentistry of Jazan University. This was followed by requesting and receiving permission from the regional Department of Education to approach the middle and high schools. Informed consent was also taken from all potential subjects and parents of school children for participation in the current study.
Study instrument
The HBM was used as a theoretical framework to guide the development of the questionnaire. The questionnaire was developed in English and modified from a previously validated and published questionnaire [18, 19]. The English version of the modified questionnaire was translated into the Arabic language and a back-translation method was performed to reconcile any meaningful differences between the two languages. A pre-test was conducted among 30 students (10 students from each education level) to assess the validity and reliability of the questionnaire (Cronbach α = 0.75). This questionnaire was reviewed by two dental public health professors at Jazan University to provide suggestions on clarity and accuracy. The final version of the self-administered questionnaire recorded information on demographics and the HBM constructs.
Study variables and measures
The first part of the questionnaire included general questions about each individual’s age, gender, nationality, education level, marital status, place of residence, and family’s monthly income, as well as specific questions about FBs, such as their previous knowledge of FBs and whether they have used FBs or intend to use them. The second part included 27 items to examine the constructs of the HBM (8 questions about susceptibility and severity; 14 questions about benefits and barriers; and 5 questions about self-efficacy and cues to action) in order to gather data on the uptake of fashion orthodontics by the youth in the sample. The HBM constructs were measured using five-point semantic differential scales (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree).
For the susceptibility and severity constructs of HBM, the respondents were asked about their beliefs regarding the behavior of using fashion braces. Perceived susceptibility to having disease was assessed by using items, e.g. “It is likely that I will get tooth decay if I use fashion braces,” “it is likely that I will get gum diseases if I use fashion braces,” and “it is likely that tooth discoloration follows if I use fashion braces.” Perceived risk of the severity of using fashion braces was assessed by items, e.g., “I would experience multiple oral ulcers if I use fashion braces,” “I would experience root resorption if I use fashion braces.” Respondents were asked about their beliefs regarding the benefits and barriers of using fashion braces. The maximum score for the susceptibility and risk severity scale was 20, which was classified into three categories: low (0–12.0 points), fair (12.1–16.0 points), and high (16.1–20.0 points).
Perceived benefits were assessed by items such as “I belief that I will not get any oral problems if I visit a qualified dentist before I use FBs.” Perceived barriers were assessed using items such as “How likely are you to get FBs if you would get negative comments from your family?” The maximum score for the perceived benefits scale was 45 scores which were classified into 3 categories: low (0–27.0 points), fair (27.1–36.0 points), and high (36.1–45 points). In addition, the maximum score for the barriers scale was 40 scores that were classified into 3 categories: low (0–24.0 points), fair (24.1–32.0 points) and high (32.1–40 points).
Self-efficacy was assessed using items such as “I feel confident that I can use FB.” Also, cues to action were assessed using three items, such as “I know where to get FBs if I need them.” The maximum score for the self-efficacy scale was 15 points, were classified into 3 categories: low (0–9.0 points), fair (9.1–12.0 points), and high (12.1–15 points). In addition, the maximum score for the cues to action scale was 10 points, which were classified into 3 categories: low (0–6.0 points), fair (6.1–8.0 points), and high (8.1–10 points). Each of the subscales was assessed separately, and the total score was calculated. All subscales with higher scores indicate stronger feelings about the construct of using fashion braces which means they are more likely to use fashion braces, except for the points assigned for barriers, which are negatively associated with the probability of using FBs.
Data analysis
The pre-coded questionnaire was entered into IBM SPSS Statistics V25.0 to analyze the data. The scores for the HBM components were computed. Missing values and normality distribution were checked prior to analysis. Descriptive statistics (percentages, means, and number, as appropriate) were utilized to provide an overview of each variable. Chi Square test was carried out to establish factors associated with using, the intention to use, and previous knowledge of fashion braces. Logistic regression analysis was utilized to determine the factors associated with the use of fashion braces. Odds ratios and 95% confidence intervals were calculated. The significance level was set at 0.05.