The mean age of respondents was 9.91 years [SD: 1.26], and ranged from 7 to 12 years. The mean age of fathers of respondents was 40.04 years [SD: 5.40], and mothers was 33.69 years [SD: 5.20]. In addition, 48.3% (139/288) of participants were male, and 51.7% (149/288) were female. Nearly 44.8% (129/288), 49.7% (143/288), and 5.6% (16/288) of the respondents reported that their fathers were under diploma, diploma and academic education, respectively.

In addition, 26.4% (76/288), 63.2% (182/288), and 10.4% (30/288) of the respondents reported that their mothers were under diploma, diploma and academic education, respectively.

Almost 39.6% (114/288) of the participants reported history of referred to the dentist in the last year at least once. Furthermore, use of dental floss after each brushing was reported among 10.4 % (30/288) of the participants. In addition, daily tooth brushing after each meal was reported 30.6 (88/288) among participants.

Our result indicated family (22.6% of participants), dentist (18.4% of participants), and health center stuff (17.7% of participants) as the most effective factors that persuaded them to perform oral health behaviors. A Backward step-wise model was used to determine predictors of background variables on tooth brushing among participants. As can be seen in Table 1, finally on the 6th step the procedure was stopped and the best model was selected. Among the background variables, sex, and mother education were the most influential predictive factors for tooth brushing (Table 1).

Table 1: Multiple logistic regression analysis for background variables on tooth brushing


Table 2 shows the correlations and significance levels at the 0.01 and 0.05 were the criteria for the analysis. Our results showed that for the sample, behavior was significantly related to cues to action (r=0.420), and self-efficacy (r=0.530). In addition, behavior was inversely correlated with barrier (r=-0.352). However there was no significant correlation between behavior with susceptibility (r=0.051), severity (r=0.111), and benefit (r=0.016). Self-efficacy was significantly related to susceptibility (r=0.328), severity (r=0.337), benefit (r=0.232), and cues to action (r=0.327). Furthermore, self-efficacy was inversely significant correlated with barrier (r=-0.246). In addition, cues to action was significantly related to susceptibility (r=0.212). However there was no significant correlation between cues to action with severity (r=0.030), barrier (r=-0.027), and benefit (r=0.054). Benefit was significantly related to susceptibility (r=0.208), severity (r=0.445), and inversely correlated with barrier (r=-0.199). Also, severity was significantly related to susceptibility (r=0.546). Finally, there was no significant correlation between barrier with severity (r=0.032), and susceptibility (r=-0.066).

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Table 2: Correlation between HBM constructs

Logistic regression analysis and backward stepwise method was calculated for predictability of HBM variables on tooth brushing. As mentioned in statistical analyses, a step-wise model procedure was conducted and finally on the 5th step the procedure stopped and the best model was selected, among the HBM variables: Cues to action with odds ratio estimate of 1.371 [95% CI: 1.009, 1.865], and self-efficacy with odds ratio estimate of 1.291 [95% CI: 1.117, 1.492], were more influential predictors of tooth brushing (Table 3).

Table 3: Logistic regression analysis for HBM variables related to tooth brushing

DISCUSSION

The findings of the present study indicated that 30.6% and 10.4% of the participants used brush and dental floss respectively after each meal. In addition, 25% of them said that they would use sodium fluoride mouth rinse at least once a day. In this regard, in the study by Mazloomi et al 37.5% of the students used dental floss daily and 11.1% had visited dentists once each six months (7). In the study by Varenne et al the findings indicated that 58% of the rural and urban children aged 12 in Burkina Faso did not brush at all (12). In the study by Keikhaee et al 4.2% of the students used sodium fluoride mouth rinse (13). Considering the importance of the use of fluoride for the prevention of tooth decay and free distribution of sodium fluoride rinse in schools, the need for more efforts for education in this regard is felt. Overall, these findings indicate that status of the adoption of behaviors that improve oral health is not favorable in Iran and there is a necessity to pay more attention to this issue and to provide appropriate education in this regard.

The findings indicated that, among background factors, being a female and mother’s education were very important factors in predicting brushing after meal. In this regard, Mehri and Morowatisharifabad showed significant statistical difference between the means of dental and oral health behaviors based on the parents’ education (14). In addition, Kawamura et al conducted a study on Japanese students and their findings indicated that female students adopted oral health care behavior more than male students (15). These findings show the necessity of providing males with more education.

Paying attention to oral health is a school health priority and the first step in planning for dental and oral health is determining the factors that impact it. This study was conducted with the aim of determining the status of performing oral health behaviors (daily brushing after each meal, the use of dental floss, the use of fluoride mouth rinse and visiting a dentist) and the beliefs related to observing oral health using HBM. Our findings indicated that self-efficacy and cues to action were the strongest predictors. These findings are highly consistent with other studies on this subject. For example, Mehri and Morowatisharifabad pointed out in their study that the direct effect of self-efficacy on oral health behaviors had been more than that of other variables. Also, in their study employing HBM, Buglar et al explored beliefs on dental care including brushing and flossing. Their study was conducted on 92 individuals visiting dental clinics in Australia. Their findings indicated that barriers and self-efficacy significantly predicted oral health behaviors in the participants (9). In another study, Anagnostopoulos used HBM to analyze brushing behavior. Their study was conducted on 125 patients at dentist offices and their findings indicated that self-efficacy and perceived severity were strong predictors of brushing behaviors in the participants (10). The study by Karami et al also indicated that self-efficacy was the strongest predictor of performing oral health behaviors in students at elementary schools in Ahvaz (11). Self-efficacy is recognized as an important factor in adopting preventive behaviors and it is a behavioral perception that increases the probability of adhering to a work plan and health-improving behaviors (16). In this study too, the mental perception of the students in performing behaviors that improve oral health as self-efficacy was explored and the results indicated that the sense of self-efficacy has a significant role in performing oral health care behaviors.
Our findings indicated that the behaviors that improve oral health did have a significant correlation with perceived susceptibility, severity and benefits. These findings are consistent with the findings obtained by Mazloomi et al (7). In this regard, it can be said that individuals, especially children and adolescents, may perceive the seriousness of health issues but they do not probably see themselves as susceptible to the risk and have few susceptibility beliefs regarding the risks around them. In other words, they view themselves as immune to the health risks and threats (17,18). Children’s and adolescents’ encounter with their peers who are dealing with oral and dental disease problems may impact their beliefs and may encourage them to adopt behaviors related to oral health .

Our findings indicated that family was the main source of information for students regarding behaviors that promote oral health. In this regard, Karami et al too showed that parents were the students’ main source of information in oral health behaviors (11). Also, in many studies on different healthy behaviors the role of external supports and incentives has been shown to be positive in a way that reminding by acquaintances is an important determinant in adopting oral health care impacts on the behavior of children. In addition, family forms the cognitive and social dimensions in individuals and results in the improvement of favorable and reminding behaviors and key signs for creation of favorable behaviors; therefore the role of family especially that of parents should be paid attention to in interventional programs for oral health behaviors.

Limitations
The low number of samples that reduces the generalizability of the results is one limitation . Also, the collection of data through questionnaire can be accompanied by a percentage of error. In addition, the lack of exploring missing teeth and dental plaques was another limitation of the present study.

CONCLUSION

Cues to action and self-efficacy may be the most effective determinants of tooth brushing among primary school students.

Acknowledgement
It is a part of a research confirmed by Student Research Committee, Abadan University of Medical Sciences, Abadan, Iran. Hereby, the researchers appreciate the committee and all those who participated in the study.