title: School-level contextual factors associated with betel quid chewing among schoolchildren in Taiwan.
abstract: OBJECTIVE
  Previous to this research, no literature had explored the clustering of betel quid chewing at the school-level and the contextual factors contributing to this behavior among elementary schoolchildren. This study therefore examines this in clusters stratified according to school geography and the rate of aboriginal students in each school. Individual-level characteristics are controlled in the study.
  
  
  METHODS
  The data used derive from student and parent surveys of the School Smoking Survey Project from a sampling of third and fourth grade children from 13 elementary schools in Tao-Yuan County, Taiwan (n = 1585). The individual- and school-level characteristics regarding betel quid chewing were estimated using multi-level logistic regression analysis.
  
  
  RESULTS
  Compared to their counterparts, students attending schools with higher percentages of aboriginal students (OR = 3.60, 95% CI: 1.31-9.95), or those schools located in a mountainous region (OR = 2.82, 95% CI: 1.19-6.70), were found to have a greater risk of chewing behavior. Other observed characteristics having a significant relationship to student chewing behavior were drinking alcohol and smoking cigarettes.
  
  
  CONCLUSIONS
  The new findings from this study suggest that the specific school attended is an important point of intervention. Therefore, effective policies and preventive programs should be strongly considered for implementation in schools that are putting students at the greatest risk for betel quid chewing behavior. Our study also confirmed the relationship between betel quid chewing, cigarette smoking, and alcohol drinking, suggesting that multifaceted intervention strategies need to be considered in regard to such behaviors among elementary schoolchildren.
authors.affiliation: College of Dental Medicine, Faculty of Dental Hygiene, Kaohsiung Medical University, Kaohsiung, Taiwan.
authors.forename: Hsiao-Ling
authors.initials: HL
authors.lastname: Huang
authors.forename: Chien-Hung
authors.initials: CH
authors.lastname: Lee
authors.forename: Yea-Yin
authors.initials: YY
authors.lastname: Yen
authors.forename: Ted
authors.initials: T
authors.lastname: Chen
authors.forename: Fu-Li
authors.initials: FL
authors.lastname: Chen
authors.forename: Pei-Shan
authors.initials: PS
authors.lastname: Ho
authors.forename: Tai-Cheng
authors.initials: TC
authors.lastname: Lai
authors.forename: Wen-Ling
authors.initials: WL
authors.lastname: Tsai
authors.forename: Chih-Cheng
authors.initials: CC
authors.lastname: Hsu
mesh_terms: D000428:Alcohol Drinking / Q000453:epidemiology; D001114:Areca; D002648:Child; D004522:Educational Status; D005190:Family; D005260:Female; D015438:Health Behavior; D006801:Humans; D007182:Income; D008297:Male; D010290:Parents / Q000193:education; D010379:Peer Group; D044382:Population Groups / Q000706:statistics & numerical data; D012111:Residence Characteristics; D012307:Risk Factors; D012309:Risk-Taking; D012423:Rural Health / Q000706:statistics & numerical data; D012574:Schools; D012907:Smoking / Q000453:epidemiology; D012931:Social Environment; D012959:Socioeconomic Factors; D013334:Students; D013624:Taiwan / Q000453:epidemiology; D014504:Urban Health / Q000706:statistics & numerical data