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170]

Original Research

Oral Health Knowledge, Attitude, and Practices among Yemeni

School Students
Badr Abdullah Al-Tayar1, Azlina Ahmad2, Mohd Zulkarnain Sinor1, Masitah Hayati Harun3
1
Dental Public Health Unit, School of Dental Sciences, Universiti Sains Malaysia, 2Oral Biology Unit, School of Dental Sciences, Universiti Sains Malaysia,
3
Oral Medicine and Oral Pathology Unit, School of Dental Sciences, Universiti Sains Malaysia, Health Campus, 16150 Kubang Kerian, Kelantan, Malaysia

Abstract
Aim: Oral health is fundamental to general health and well‑being. However, the sources of oral health information among Yemenis are
limited. This study aimed to evaluate the oral health knowledge, attitude, and practices among secondary school students in Dawan Valley,
Yemen. Materials and Methods: A descriptive cross‑sectional survey was conducted among 392 secondary school students. Students were
interviewed using structured questionnaires in Arabic. The structured questionnaires included inquiries on oral health knowledge, attitude, and
practices. Chi‑square test was used to assess significant differences in oral health knowledge, attitude, and practices with respect to gender.
Results: The study population comprised 392 participants of 15–22 years’ age group. Approximately 87% of students reported brushing
their teeth daily. Girls showed better oral hygiene practices compared with boys in terms of daily brushing habit, brushing intervals, and
toothbrush replacement (P = 0.001, 0.001, and 0.002, respectively). Statistically significant difference (in favor of females) was observed
related to knowledge on the impact of dental diseases on the general health, toothbrushing preventing dental decay, sugar consumption
possibly leading to dental decay, bleeding during brushing possibly indicating gum diseases, and effects of smoking and khat chewing on
oral health (P = 0.009, 0.020, 0.001, 0.001, 0.002, and 0.023, respectively). Conclusion: The majority of students possess an adequate level
of knowledge and practices on oral health, with female students showing predominance. However, regular visits to the dentist remain low
among the study participants.

Keywords: Attitude, knowledge, oral health, practice, secondary school students

Introduction chewing and smokeless tobacco. Such habits are showed to

One significant aspect of ensuring the quality of life is good
oral health. Good oral hygiene practices allow people to eat,
talk, and socialize normally and confidently.[1] Oral infections,
such as dental caries and periodontal problems, are burdens to
the state of global oral health. In societies with low economic
status, treatment of dental diseases, including traditional
restorative treatments, probably surpasses the available
resources allotted to the health‑care programs of the entire
country.[2,3] Oral health knowledge is considered as an essential
prerequisite for health‑related behavior,[4] and studies have
demonstrated an association between increased knowledge
and improved oral health.[5,6]
The prevalence of oral diseases, such as dental caries and
gingivitis, is extremely high among school students in
Yemen.[7,8] Moreover, a society such as the Yemeni society has
developed numerous traditional deleterious habits, such as khat
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be a risk factor for cancer of the head and neck, precancerous
lesions of oral mucosa, and periodontal diseases.[9‑14]
Knowledge on the oral health effects of these habits can
motivate school students to quit and consequently help in
the prevention of numerous oral diseases at an early age.
The level of oral health knowledge, attitude, and practices
among secondary school students is extremely low and
worth investigating. Therefore, this study was conducted
to evaluate the level of oral health knowledge, attitude,
and practices among secondary school students in Dawan
Valley, Yemen.
Address for correspondence: Dr. Masitah Hayati Harun,
School of Dental Sciences, Universiti Sains Malaysia, Health Campus,
16150 Kubang Kerian, Kelantan, Malaysia.
E‑mail: masitahh@usm.my
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
is given and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

DOI: How to cite this article: Al-Tayar BA, Ahmad A, Sinor MZ, Harun MH. Oral
10.4103/jioh.jioh_176_18 health knowledge, attitude, and practices among Yemeni school students. J
Int Oral Health 2019;11:15-20.

© 2019 Journal of International Oral Health | Published by Wolters Kluwer - Medknow 15

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Al‑Tayar, et al.: Oral health knowledge, attitude, and practices among students
Materials and Methods
A descriptive cross‑sectional survey was conducted from
March 2016 to June 2016 among 392  secondary school
students aged between 15 and 21 years from two selected
schools in Dawan Valley. The sample size was estimated
with the PS software as described by Dupont and Plummer[15]
comparing two proportions with the following parameters:
P0  =  0.13  (proportion of secondary school students who
do not use toothbrush reported by the previous study),[16]
P1 = 0.246 (expected proportion of secondary school students
who use toothbrush based on expert opinion), alpha (α) =
level of significance at 0.05, (1‑β) = power of study at 0.8, and
M = 1 (ratio of secondary school students who use toothbrush
to those who do not use toothbrush). The sample size for this
study was 177 per group, but another 11% was added for the
nonrespondents (177+ [177 × 0.11] = 196 × 2) = 392. In this
case, the required minimum sample size was 392. Convenience
sampling technique was used, and all students who were
willing to participate from the selected secondary schools of
1–3 levels were included.
Before the study, approval was obtained from the Office of
Education in Dawan Valley under the Ministry of Education
in Yemen  (Reference number: Dawan Office/Seef/13116).
Written consent was also obtained from the school principals
and each of the participants after selection and before
enrolment into the study.
The students were interviewed using structured questionnaires
in Arabic. The structured questionnaires were adopted
and modified from previous studies. [17‑19] The designed
questionnaire consists of three parts: part 1, comprising six
questions to assess the participants’ practice of oral hygiene,
including daily toothbrush, flossing, mouth rinse with water
after eating, miswak use, brushing intervals, and toothbrush
replacement; part  2, comprising two questions to assess
the participants’ attitude toward oral health, including the
frequency of dental visits and reasons behind not visiting the
dentist; and part 3, comprising seven questions to assess the
participants’ oral health knowledge, including items on the
impact of dental diseases on general health, effects of brushing
on dental decay, effect of sugars on dental decay, gingival
bleeding during brushing and the effects of smoking, khat
chewing, and shammah on oral health.
The Statistical Package for the Social Sciences (SPSS, IBM,
and Chicago, IL, USA version 22.0) was used for data entry
and analysis. Descriptive analysis was presented as frequency
with percentage for categorical variables. The Chi‑square
test was used to assess the significant differences in oral
health knowledge, attitude, and practices between males
and females.
Results
A total of 392 participants, comprising 195 (49.7%) male
and 197 (50.3%) female students, were enrolled in this study.
16 Journal of International Oral Health  ¦  Volume 11  ¦  Issue 1  ¦  January-February 2019
The mean age of the students was 17.68  years  (standard
deviation  =  1.27). The toothbrushing practice of
participants (daily toothbrushing, time spent for brushing,
brushing intervals, and timing for toothbrush replacement)
is shown in Table 1. A majority of the participants (87.0%)
clean their teeth using a toothbrush. Significantly more females
reported daily brushing (P = 0.001) compared to males. Almost
51% of the participants brush their teeth twice daily. There
was a significant association between brushing intervals and
gender (P = 0.001), whereby females performed toothbrushing
twice a day more often than males.
A majority of the students replaced their toothbrushes when
bristle were frayed (61.7%). There was a significant association
between gender and toothbrush replacement (P  =  0.002).
Almost half  (46.2%) of the participants spent 1  min for
brushing their teeth. However, the association between gender
and the time allocated for brushing was not statistically
significant (P = 0.144).
Table 2 presents other forms of oral hygiene aids practiced
by the students according to gender. A  significantly higher
percentage of male students (55.4%) used miswak to clean
their teeth compared to female students (31%) (P = 0.001).
Only 15.3% of participants practice dental flossing, while more
than half (69%) rinse their mouth after meals. A comparison
between male and female students showed no statistically
significant difference (P > 0.05).
Attitude toward oral health according to gender is summarized
in Table  3. About 56.1% of the participants reported
that toothache was the main cause for dental visit. No
significant difference was observed in the frequency of
dental visits between genders (P  =  0.630). High cost of
dental treatments was the main consideration among the
participants that prevented them from visiting the dentist.
The reasons behind not visiting the dentist were significantly
different (P = 0.002) [Table 3].
Table 4 illustrates the participants’ knowledge of oral health
according to gender. Most students were aware that dental
diseases impact the general health (88.8%), toothbrushing
prevents dental decay (94.9%), consumption of sugars can
lead to dental decay (92.3%), and bleeding during brushing
may indicate gum disease  (66.6%). Female students had
significantly better knowledge of dental diseases compared
to male students (P < 0.05). Knowledge towards deleterious
habits on oral health according to gender is represented in
Table 5. Similarly, statistically significant difference was found
(in favor of females) regarding knowledge on the effect of
smoking and khat chewing on oral health (P < 0.05).
Discussion
Oral health care should be an important component of routine
health care for students. Good oral health practice can be
accomplished mainly through self‑induced habits, such as
maintenance of dental hygiene, quitting deleterious habits, and
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Al‑Tayar, et al.: Oral health knowledge, attitude, and practices among students

Table 1: Toothbrushing practice according to gender (n=392)

Variable Gender, n (%) X2 statistics (df) P*
Total Male Female
Practices
Daily toothbrushing
Yes 341 (87.0) 150 (76.9) 191 (97.0) 34.74 (1) 0.001
No 51 (13.0) 45 (23.1) 6 (3.0)
Time spent for brushing (min)
<1 51 (13.0) 31 (15.9) 20 (10.2) 5.407 (3) 0.144
1 181 (46.2) 92 (47.2) 89 (45.2)
2 97 (24.7) 40 (20.5) 57 (28.9)
>2 63 (16.1) 32 (16.4) 31 (15.7)
Brushing intervals
Morning 131 (33.4) 92 (47.2) 39 (19.8) 39.184 (2) 0.001
Before bed 62 (15.8) 33 (16.9) 29 (14.7)
Morning and before bed 199 (50.8) 70 (35.9) 129 (65.5)
Replacing toothbrush
Every months 78 (19.9) 54 (27.7) 24 (12.2) 14.798 (3) 0.002
Every 3 months 45 (11.5) 20 (10.3) 25 (12.7)
Every 6 months 27 (6.9) 12 (6.2) 15 (7.6)
When bristles are frayed 242 (61.7) 109 (55.9) 133 (67.5)
*Chi‑Square test was applied

Table 2: Other forms of oral hygiene practice according to gender (n=392)

Variable Gender, n (%) X2 statistics P*
(df)
Total Male Female
Practices
Flossing
Yes 60 (15.3) 36 (18.5) 24 (12.2) 2.980 (1) 0.084
No 332 (84.7) 159 (81.5) 173 (87.8)
Mouth rinsing after taking meals
Yes 272 (69.4) 141 (72.3) 131 (66.50) 1.566 (2) 0.457
No 24 (6.1) 11 (5.6) 13 (6.6)
Sometimes 96 (24.5) 43 (22.1) 53 (26.9)
Miswak use
Yes 169 (43.1) 108 (55.4) 61 (31.0) 23.828 (1) 0.001
No 223 (56.9) 87 (44.6) 136 (69.0)
*Chi‑Square test was applied

the aid of available dental services. Oral diseases should be
avoided before they occur, and the prevention can be achieved
through simple oral hygiene practices, such as daily brushing
and flossing.[7,8]
The findings from this study showed that toothpaste
is commonly used for toothbrushing among the study
population and is in agreement with those in the similar Arab
population.[17-20] The present study also showed that majority of
the students brush their teeth in the morning and before bed, and
fraying of toothbrush bristles was reported as the most common
explanation for tooth brush replacement. These results were in
accordance with those of Gopikrishna et al.[21] However, the
females appeared to be statistically more conscious of oral
hygiene in terms of daily toothbrushing, brushing intervals,
and toothbrush replacement. This finding is consistent with
those of other studies conducted in school children and dental
students.[22‑24]
Numerous populations in Arab countries still use miswak,[25‑27]
which is a tooth‑cleaning twig made from the Salvadora
persica tree (also known as arak in Arabic). Miswak is a
traditional alternative to the modern toothbrush and offers
stronger mechanical and chemical cleaning of oral tissues
compared with a standard toothbrush.[28] In the present study,
miswak was used by 169 (43.1%) of the study participants,
with significantly more males using miswak compared to
females. This finding was similar to that of Al‑Shammari
et  al. and Bahannan et  al.  (2018).[29,30] The present study
reported that only 15.3% of the study participants used dental
floss, indicating that the importance of dental floss use is still
underestimated among study participants. However, the present

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Al‑Tayar, et al.: Oral health knowledge, attitude, and practices among students

Table 3: Attitude toward oral health according to gender (n=392)

Variable Gender, n (%) X2 statistics (df) P*
Total Male Female
Attitude
Frequency of dental visits
Regularly 18 (4.6) 9 (4.6) 9 (4.6) 1.730 (3) 0.630
Occasionally 49 (12.5) 28 (14.4) 21 (10.7)
When there is toothache 220 (56.1) 104 (53.3) 116 (58.9)
Never 105 (26.8) 54 (27.7) 51 (25.9)
Reason behind not visiting the dentist
Afraid of instruments 64 (16.3) 22 (16.3) 42 (21.3) 12.358 (2) 0.002
No clinic nearby 50 (12.8) 19 (9.7) 31 (15.7)
High cost 278 (70.9) 154 (79.0) 124 (62.9)
*Chi‑Square test was applied

Table 4: Knowledge of oral health according to gender (n=392)

Variable Gender, n (%) X2 statistics (df) P*
Total Female Male
Knowledge
Dental diseases impact the general health
Yes 348 (88.8) 180 (91.4) 168 (86.2) 9.495 (2) 0.009
No 33 (8.4) 9 (4.6) 24 (12.3)
Don’t know 11 (2.8) 8 (4.1) 3 (1.5)
Brushing the teeth prevent dental decay
Yes 372 (94.9) 192 (97.5) 180 (92.3) 5.377 (1) 0.020
No 20 (5.1) 5 (2.5) 15 (7.7)
Having sugars can lead to dental caries
Yes 362 (92.3) 193 (98.0) 169 (86.7) 24.153 (2) 0.001
No 28 (7.1) 2 (1.0) 26 (13.3)
Don’t know 2 (0.5) 2 (1.0) 0 (0.0)
Bleeding during brushing may indicate the presence of gum diseases
Yes 261 (66.6) 160 (81.2) 101 (51.8) 62.862 (2) 0.001
No 120 (30.6) 26 (13.2) 94 (48.2)
Don’t know 11 (5.6) 11 (5.6) 0 (0.0)
*Chi‑Square test was applied

value was higher than the reported value in a study conducted
in Saudi Arabia by Al‑Sadhan (5.1%)[31] and the study by
Al Subait et al.,[16] which reported that the study participants
did not frequently use dental floss.
Our results were in agreement with those described in
previous studies, which documented that toothache was the
main driving factor for participants to visit the dentist.[32‑35]
However, no statistically significant difference in the
frequency of dental visits was observed between girls
and boys. Meanwhile, when the participants were asked
regarding forgoing dental visits, almost 71% of participants
cited the high cost of the treatment as the reason. This finding
was identical to the results published by Ahmad et al.[36] A
report by the World Bank confirmed that Yemen is the most
populous country in the Arabian Peninsula and that half of
the total population live below the poverty line.[37] These
data may explain why high cost of dental treatment hinders
dental visits.
In general, this study showed that the majority of students
possess adequate level of knowledge on oral health. These
findings were in agreement with the results obtained
by Carneiro et  al.[38] but superior to those of a study by
Farsi et al.[39] Girls are more knowledgeable on the impact of
dental diseases on general health, toothbrushing preventing
dental decay, and consumption of sugars possibly leading
to dental caries and bleeding during brushing possibly
indicating gum diseases, as supported by the study of Al Subait
et  al.,[16] who reported that girls are more aware of gum
bleeding and the influence of oral health on general health. In
addition, girls are more conscious of the effects of smoking
and khat chewing on oral health. In addition to the harms of
tobacco and khat chewing, tobacco use and khat chewing
among women in a conservative community are considered
shameful and result in social stigma, and our study area is one
such community. This finding may explain why females are
more conscious of these habits compared to males.

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Al‑Tayar, et al.: Oral health knowledge, attitude, and practices among students

Table 5: Knowledge on the effects of deleterious habits toward oral health according to gender (n=392)
Variable Gender, n (%) X2 statistics (df) P*
Total Female Male
Knowledge
Smoking affects oral health
Yes 352 (89.8) 179 (90.9) 173 (88.7) 12.205 (2) 0.002
No 23 (5.9) 5 (2.5) 18 (9.2)
Don’t know 17 (4.3) 13 (6.6) 4 (2.1)
Khat chewing affects oral health
Yes 368 (93.9) 190 (96.4) 178 (91.3) 7.524 (2) 0.023
No 10 (2.6) 5 (2.5) 5 (2.6)
Don’t know 14 (3.6) 2 (1.0) 12 (6.2)
Shammah use affects oral health
Yes 353 (90.1) 178 (90.4) 175 (89.7) 0.249 (2) 0.883
No 24 (6.1) 11 (5.6) 13 (6.7)
Don’t know 15 (3.8) 8 (4.1) 7 (3.6)
*Chi‑Square test was applied

The current study has strengths and limitations. In terms of
strengths, females were almost equal to male participants in
this study. This makes the comparison between males and
females more reliable with respect to oral health knowledge,
attitude, and practices categories. In addition, this is one of
few studies that have explored the differences in oral health
knowledge, attitude, and practices with respect to gender
among secondary school students in Yemen. With regard to
the limitations, this study was carried out in only two schools
using nonprobability sampling method with a small sample size.
However, the findings of this study would provide local baseline
data on the oral health knowledge, attitude, and practices among
Yemeni school students. Moreover, better understanding of the
importance of oral hygiene practices may help to reduce the
burden of oral diseases. The results could be utilized in planning
programs on school students’ awareness of smoking, shammah,
and khat‑related oral problems. Future research should also
consider the following: an increased sample size that includes
students from different areas of Yemen and prevalence and
factors associated with smoking, shammah, and khat chewing
among Yemeni school students as well as common oral diseases
such as dental caries and periodontal diseases.
Conclusion
Secondary school students reported a high level of oral health
knowledge and practices, with female students showing
predominance. However, their attitude towards regular
dental visits was relatively poor. Increased awareness of oral
health‑related knowledge, practices, and attitude of school
students can facilitate the prevention of oral diseases.
Acknowledgments
The authors acknowledge the staff of the Office of Education
in Dawan Valley, Yemen, who helped to make this study a
reality. We would like to thank all staff and participant students
from the selected schools, Eng. Abdulrahman Ahmed Omer
Al‑Madfa and Miss. Fosyah Omar Al‑Tayar for all their
support and assistance in the progress toward the completion
of this study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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