Abstract
This study analyzed changes over time in order to identify disparities in health and oral health behaviors among adolescents from multicultural families residing in Korea. This was a cross-sectional analysis of secondary data utilizing raw data from 2011 to 2022 from the Korea Youth Risk Behavior Survey, a statistical dataset provided by the Korea Disease Control and Prevention Agency. The variables included demographic characteristics, socioeconomic characteristics, health behavior (diet, alcohol consumption, smoking), and oral health behavior (toothbrushing behavior, preventive care behavior, oral symptom experience, and school-based oral health education experience). In comparison to non-multicultural adolescents, multicultural adolescents were more likely to perceive their oral health behavior as unhealthy and less likely to engage in toothbrushing after lunch. In addition, multicultural adolescents had higher rates of soda intake and smoking experience than non-multicultural adolescents. During the period between 2011 and 2022, multicultural adolescents had less experience of dental sealants and scaling than non-multicultural adolescents. The disparities in health status and oral health behavior between the 2 groups persisted over a 12-year period. It was necessary to develop active interventions to reduce health and oral health disparities between multicultural and non-multicultural adolescents.
Susceptibility to dental caries and other oral diseases is heightened during adolescence.
In South Korea, immigrants’ healthcare access is limited by financial constraints and inadequate language skills.
Adolescents from multicultural families have relatively limited access to dental care, influenced by their parents’ circumstances.
Multicultural adolescents are more likely considered their oral behaviors unhealthy than non-multicultural adolescents.
Multicultural adolescents were less likely to brush their teeth after lunch than non-multicultural adolescents.
During 2011–2022, multicultural adolescents had lesser experience with sealants and scaling than non-multicultural adolescents.
This research provides evidence that could be used as a basis for policy development to promote the oral health of multicultural adolescents.
Introduction
A multicultural family comprises of a married immigrant or naturalized foreigner and a South Korean citizen. This definition was recently expanded to include internationally married families and families with foreign workers as members, as well. 1 Since the late 1980s, Korea’s economic development and enhanced international status have been attracting a large number of foreign workers due to the expansion of human exchanges. Concurrently, an imbalance occurred in the supply and demand of marriage, resulting in an increase in the number of immigrants from international marriages and the growth of multicultural families. The Ministry of the Interior and Safety’s statistical data on the status of foreign residents in 2022 indicated that the number of foreign residents living in South Korea was 2 258 248, which was 4.4% of the country’s total population. 2 Of this number, 175 756 were married immigrants. Furthermore, the number of children of foreign residents in 2022 was 282 077, representing a 3.1% increase in the corresponding number for 2021. 2
Conversely, foreign residents encounter several significant challenges in adapting to the sociocultural environment, including communication difficulties, discrepancies in cultural norms, and socioeconomic disparities. 3 The majority of married migrant women living in Korea experience pregnancy and childbirth after settling in the country. While raising their children, they become increasingly concerned about their own and their children’s health, causing them to voice their demands for health and welfare services. 3 However, their ability to access healthcare services is reportedly limited by financial constraints and a lack of the language skills necessary to navigate welfare and medical service systems. This has a detrimental impact on both their health and their children’s health.4,5
Researchers identified the major health problems of children and adolescents from multicultural families and found that, compared to non-multicultural youth, multicultural adolescents were 1.19 times more likely to consume alcohol, 1.14 times more likely to experience stress, and more likely to perceive their subjective health status negatively. 6 In addition, 24.6% of the adolescents from multicultural families reported experiencing symptoms of periodontal disease compared with 19.8% of adolescents from non-multicultural families, indicating poor oral care among multicultural adolescents. 7 However, less than half of the multicultural adolescents received care to prevent oral diseases, including appropriate oral health education (32.7%), fluoride application (22.5%), scaling (20.4%), and tooth groove filling (28.2%). These findings indicate the necessity of establishing policies and providing support to increase the number of preventive dental visits. 7
Since adolescence is a period of heightened susceptibility to dental caries and other oral diseases, it was imperative to strengthen oral health policies applicable to multicultural families to provide essential health services for oral disease prevention and oral health promotion among multicultural adolescents with low access to dental care.4,8 To achieve this, we need to identify problems related to preventive dental care utilization care and develop practical solutions. However, to date, only a few studies have analyzed the changes in the health and oral health behaviors of adolescents from multicultural families in Korea. To identify problems in the health and oral health behavior of youth from multicultural families in Korea, this study analyzes and reports the trends in the health and oral health behaviors of adolescents from multicultural families using 2011 to 2022 (12-year) data from the Korea Youth Risk Behavior Survey (KYRBS).
Methods
Data Sources
We downloaded raw data from the 7th (2011) to 18th (2022) KYRBS after checking the raw data use procedure. 9 KYRBS is a nationally authorized statistical survey that identifies the status of health behaviors among South Korean adolescents, provided by the Korea Disease Control and Prevention Agency (KDCA). The survey was conducted annually for students from the first grade of middle school to the third grade of high school, and the sample was selected using stratified cluster sampling to minimize errors. In the primary sampling phase, samples were selected from 400 middle schools and 400 high schools across 17 cities and provinces in Korea using a permanent random number extraction method. In the secondary sampling phase, one class was randomly chosen from each grade in the selected schools. In order to ensure the anonymity of participating students, all the students in the sampled class were asked to access the KYRBS through their school computers using their personal identification numbers. They were instructed to read the informed consent form on the website and, if they chose to participate, click the “Survey Participate” button to complete the anonymous, self-administered online survey. Survey items on “general characteristics and health equity,” which included familial information, such as parental nationality, were administered only to those students who agreed to provide the information after following an additional consent process. The study used KYRBS because it contains information on the health behaviors of both non-multicultural and multicultural adolescents.
Study Population
In this study, to identify multicultural families, the questions “Was your father or mother born in Korea?” and “In which country was your father or mother born?” were used. Adolescents from multicultural families were defined as adolescents who reported that at least 1 parent was foreign-born. Adolescents from non-multicultural families were defined as adolescents who reported that both parents were born in Korea. To identify multicultural families, this study employed parental nationality information. Consequently, students who participated in the KYRBS but did not agree to provide household member information were excluded from subsequent analyses.
Variable Selection
To analyze the yearly trends in the health and oral health behaviors of multicultural adolescents, we divided the data into general characteristics, health perceptions, health behaviors, and oral health behaviors. General characteristics included gender, grade level, father’s education, mother’s education, academic performance, and economic status. Health Perceptions included subjective health and oral health perception. Further, health behaviors included fruit, milk, and soda intake, alcohol drinking and smoking. Oral health behaviors included brushing teeth after lunch, dental sealant experience in the past 12 months, fluoride application experience in the past 12 months, scaling experience in the past 12 months, oral symptom experience, school-based oral health education experience in the past 12 months, and the frequency of teeth brushing per day.
The variables included in the KYRBS were subject to annual adjustments through discussions between the KDCA and experts. For example, the subjective oral health perception was surveyed every 3 years from 2016 onward. However, soda intake was not surveyed from 2022 onward. The frequency of teeth brushing was first surveyed in 2013, while scaling experience was not surveyed in 2018, 2020, and 2021. For the purposes of this study, we only analyzed data from the years in which the surveys were conducted.
Data Analysis
The data was downloaded on May 15, 2023, and after data cleaning, statistical analysis was conducted from June to August 2023. This study was a cross-sectional analysis of secondary data. A complex sample chi-square test was conducted to determine the status and trends of health and oral health behavioral factors by multicultural family status and year. Statistical analyses were performed using SPSS ver. 28.0 (SPSS Inc., Chicago, IL). Data are presented in terms of the weighted number and percentage(%). Statistical significance was set at P < .05.
This study followed the STROBE guidelines for cross-sectional studies to ensure clarity and transparency in reporting.
Results
General Characteristics of Study Subjects by Year
An examination of the general characteristics of the study population by year revealed that the percentage of adolescents from multicultural families increased from 0.6% in 2011 to 3.0% in 2022. For 2011 to 2022, multicultural adolescents reported lower academic performance than non-multicultural adolescents and both multicultural and non-multicultural adolescents reported low economic status (Table 1).
General Characteristics of Study Participants by Year (Unit: N(wt%)).
The analysis was performed using a Chi-square test.
Trends in Health Perceptions Among Adolescents From Multicultural Families
Multicultural adolescents were more likely to report being unhealthy compared to non-multicultural adolescents, and the number of multicultural adolescents who perceived themselves to be unhealthy increased from 2016 to 2022. Subjective oral health perceptions revealed that multicultural adolescents perceived their oral health to be worse than that of non-multicultural adolescents, and this gap did not decrease over a 12-year period (Supplemental Figure 1).
Trends in Health Behaviors Among Adolescents From Multicultural Families
Table 2 depicts health behavioral trends among adolescents from multicultural families. The prevalence of fruit intake at least once a day increased from 16.7% in 2011 to 22.0% in 2016 but decreased to 15.4% in 2022. The prevalence of soda intake 3 or more times per week was higher among multicultural compared to non-multicultural adolescents. Adolescents from non-multicultural families were more likely than those from multicultural families to have consumed alcohol, and multicultural adolescents were more likely to have smoked than non-multicultural adolescents (Supplemental Figure 2).
Trends in Health Behaviors Among Adolescents from Multicultural and Non-multicultural Families by Year (Unit: N(wt%)).
The analysis was performed using a Chi-square test.
Trends in Oral Health Behaviors and Oral Symptom Experience Among Multicultural Adolescents
A review of teeth brushing after lunch in school revealed higher rates of brushing for non-multicultural than multicultural adolescents; however, both groups have been experiencing a decline in this behavior since 2020. The rate of brushing teeth twice a day or more among multicultural adolescents was lower compared to non-multicultural adolescents and it decreased after 2020.
Multicultural adolescents’ dental sealant experience decreased from 37.8% in 2011 to 25.5% in 2022 and fluoride application experience increased from 15.6% in 2011 to 19.2% in 2013. In addition, the experience of scaling among adolescents from multicultural families decreased from 29.1% in 2011 to 24.0% in 2022. Among oral symptom experiences, multicultural adolescents were more likely to experience sore or bleeding gums than non-multicultural adolescents (Table 3, Supplemental Figure 3).
Trends in Oral Health Behaviors and Oral Symptom Experience Among Adolescents from Multicultural and Non-multicultural Families by Year (Unit: N(wt%)).
The analysis was performed using a Chi-square test.
Discussion
Having passed the 2 million foreign immigrant mark recently, South Korea is witnessing an increase in the number of multicultural families and a gradual rise in the number of multicultural children. However, it has been reported that multicultural families in Korea, including both foreign parents and their children, remain relatively vulnerable to socioeconomic discrimination and suffer from various health problems since language barriers prevent them from accessing healthcare facilities.4,10 To achieve health equity and ensure that the future burden of disease remains low in Korea, health policies must prioritize the health management of multicultural families. Therefore, this study conducted a trend analysis using 2011 to 2022 KYRBS data to identify the health and oral health statuses of adolescents in multicultural families.
The number of multicultural adolescents in South Korea increased from 2011 to 2022. Further, these adolescents are more likely to have lower levels of parental education and economic status than non-multicultural adolescents. These findings are consistent with the results of earlier studies on the nationwide status of multicultural families. 11 Since low socioeconomic levels can affect health behaviors12,13 and cause health problems by reducing people’s access to healthcare, 14 effort must be expended to identify the health and oral health needs of socioeconomically disadvantaged multicultural families and facilitate their access to necessary health services.
The results of the health behaviors of multicultural adolescents revealed that they were less likely to consume fruit at least once a day than non-multicultural adolescents and more likely to engage in health-risk behaviors such as soda intake and smoking. However, non-multicultural adolescents were more likely to experience alcohol consumption than multicultural adolescents. This finding was consistent with the result of Ahn et al 15 that examined the health behaviors of adolescents from multicultural families in Korea. Ahn et al 15 explained that adolescents from multicultural families were likely to face difficulties in forming peer relationships due to their appearance and language, increasing the risk of engaging in addictive behaviors such as smoking, which could be done alone. Conversely, they noted that alcohol consumption was relatively more social, often occurring in groups, thereby potentially limiting the experiences of alcohol drinking among adolescents from multicultural families. Hence, future research should examine the characteristics of adolescents’ health-risk behaviors and their peer relationships to identify the factors that influence health behaviors and find methods to improve these behaviors.
The results of this study on multicultural and non-multicultural adolescents’ oral health perceptions and oral health behaviors revealed that compared to the youth from non-multicultural families, adolescents from multicultural families were more likely to perceive their oral health to be unhealthy and less likely to engage in teeth brushing after lunch. In particular, since 2019, the rate of teeth brushing after lunch in school showed a 9.7% decrease, and subjective oral health perceptions became increasingly negative. There was a reduction in twice-daily brushing behavior after 2019, as well. These findings supported previous research indicating that multicultural adolescents have been experiencing negative health behavioral changes since the occurrence of coronavirus disease 2019 (COVID-19).16,17 The closure of schools to facilitate social distancing during the COVID-19 pandemic period reportedly reduced the healthy behaviors practiced in schools, and the loss of access to school-based healthcare facilities caused a variety of health problems. 18 Golberstein et al 19 argued that the social distancing measures implemented by the government significantly affected public health and widened health disparities by reducing the healthcare access of adolescents who were ethnic minorities or had a low socioeconomic status. In particular, adolescents were reported to follow better health behaviors when they had the social support of teachers who live with them and interventions to improve such behaviors actively leverage the school system. 20 Therefore, school-based healthcare programs should be designed to help multicultural adolescents regain their healthcare routines at school and practice good health and oral health behaviors in the post-pandemic period.
A review of multicultural adolescents’ dental service utilization found that preventive dental care, involving dental sealant and scaling, was less common among multicultural compared to non-multicultural adolescents from 2011 to 2022 and that oral symptoms of caries and periodontal disease were more common among multicultural adolescents. Further, Crespo 21 and Ng 22 found that multicultural parents reported limited use of dental services for their children resulting from the parents’ distrust of healthcare providers caused by language and cultural barriers, parents’ negative dental experiences in their country of origin, low demand for preventive care, and the children’s limited use of dental services. Further, compared to those from non-multicultural families, adolescents from multicultural families experienced relatively more oral symptoms because they visited the dentist only when they had symptoms. With that in mind, further research was required to clarify the association between children’s dental care utilization and oral health symptoms in multicultural families. In addition, oral health education and management programs targeting adolescents in multicultural families and their parents should change parental perceptions and increase these families’ access to dental care and preventive oral health services.
Over the past 12 years, multicultural adolescents had been found to have higher rates of health and oral health risk behaviors than non-multicultural adolescents. In addition, multicultural adolescents had lower rates of experience in oral disease prevention practices, confirming that adolescents from multicultural family were vulnerable to health and oral health management. The practice of health-risk behaviors during adolescence could lead to health inequalities in adulthood, as well as financial burdens associated with treatment costs. 23 Given that adolescents often had limited control over their health behaviors, these behaviors could be significantly influenced by the health behaviors of parents or guardians, socioeconomic status, peer groups, teachers, and others in their immediate environment. 23 Therefore, it was essential to address these factors to mitigate future health inequalities and financial burdens for adolescents from multicultural families. Policymakers and health and oral health professionals might develop and implement targeted health promotion strategies aimed at reducing health disparities between multicultural and non-multicultural adolescents, ensuring that all adolescents in Korea lead healthy live and adopt positive oral health practices.
This study was significant in that it identified the changes in the health and oral health statuses of Korean adolescents from multicultural families over a 12-year period using nationwide statistical data and provided evidence that could be used as a basis for policy development to promote the oral health of multicultural adolescents. This study had 3 limitations. First, as it was a cross-sectional analysis of secondary data, causal relationships between variables could not be determined. Second, the reliance on self-reported data might have introduced response bias, especially regarding sensitive topics like health and oral health behaviors. Third, the weighted N numbers in this study differed between 2011 and 2022. The weighted N reported by year was related to the phenomenon of the declining adolescent population in Korea. The adolescent population, which accounted for about 37% of the total population in Korea, fell to 15% in 2023. Similarly, the adolescent population, which exceeded 10 million in 2010, steadily decreased to 7 million by 2020. 24 However, since the Korea Youth Risk Behavior Survey was a national statistical data set that could represent all adolescents in Korea, efforts were made to enhance the reliability of the data through a stratified sampling process and the application of weights by year. Therefore, in this study, the analysis was conducted in accordance with the guidance on complex sample analysis methods and weighting applications provided in the Korea Youth Risk Behavior Survey Utilization Guidelines to ensure that the relevant content was accurately reflected. In the future, further studies are required to identify the causes of health and oral health problems among multicultural adolescents and examine practical measures to solve such problems.
Conclusion
This study identified a clear disparity in the health and oral health behaviors of multicultural adolescents in South Korea when compared to their non-multicultural counterparts over the past 12 years. These adolescents encountered considerable obstacles related to their low socioeconomic status and language barriers, which impede their access to healthcare services. Furthermore, the advent of the COVID-19 pandemic had served to exacerbate these disparities, resulting in increased engagement in health-risk behaviors and a negative perception of oral health, along with reduced utilization of preventive dental care. It was therefore imperative that policymakers and health and oral health professionals developed and implemented targeted health promotion strategies for multicultural families. The strategies might seek to enhance healthcare access, improve health literacy and foster supportive environments within schools. Ultimately, the resolution of these imbalances would facilitate the adoption of healthier lifestyles and achieve equitable health outcomes for all adolescents in Korea.
Supplemental Material
sj-docx-1-inq-10.1177_00469580241302199 – Supplemental material for Disparities in Health and Oral Health Behaviors Among Adolescents from Multicultural Families in South Korea
Supplemental material, sj-docx-1-inq-10.1177_00469580241302199 for Disparities in Health and Oral Health Behaviors Among Adolescents from Multicultural Families in South Korea by Seon-Hui Kwak and Deuk-Sang Ma in INQUIRY: The Journal of Health Care Organization, Provision, and Financing
Footnotes
Author Contributions
Conceptualization: SH Kwak, DS MA; Formal analysis: SH Kwak, DS MA; Methodology: SH Kwak, DS MA; Supervision: DS MA; original draft: SH Kwak; and Writing - review & editing: DS Ma.
Data Availability Statement
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical Considerations
Not applicable. This study used raw data from the Korea Youth Risk Behavior Survey (Nationally Approved Statistics No. 117058) provided by the Korea Disease Control and Prevention Agency. The data from the Korea Youth Risk Behavior Survey are publicly available secondary data and were not reviewed by an Institutional Review Board (IRB).
Consent to Participate
Not applicable. The Korean Disease Control and Prevention Agency obtained informed consent from adolescents prior to data collection. The researcher did not directly obtain consent because he conducted secondary analyses using the informed consent data.
Supplemental Material
Supplemental material for this article is available online.
References
Supplementary Material
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