INTRODUCTION

Adolescent health behaviors are shaped not only by individual choices but also by public policies and environmental contexts [1,2]. The coronavirus disease 2019 (COVID-19) pandemic led to substantial policy changes that directly influenced these behaviors. The Korea Disease Control and Prevention Agency (KDCA) established nationwide quarantine guidelines and enforced them in public facilities, including schools. These included restrictions such as “limited use of water dispensers and toothbrushing in schools” and “prohibition of overlapping movement in shared spaces such as restrooms and shower facilities.” As the pandemic eased, the KDCA revised its guidelines, prohibiting “excessive quarantine measures” and thereby relaxing some regulations.

Schools function as shared community spaces for adolescents, and uniformly applied quarantine measures may unintentionally restrict routine health behaviors, leading to adverse effects [3]. Oral health is closely linked to systemic health and correlates with quality of life indices such as the EuroQol-5

Dimension [4]. Zaborskis et al. [5] reported that oral health behaviors in adolescence serve not only as hygiene indicators but also as predictors of adult health, emphasizing the importance of developing proper habits early in life. Before COVID-19, toothbrushing after lunch was a widely promoted daily health behavior as part of national public health initiatives [6]. During the pandemic, however, this behavior became subject to personal discretion under quarantine restrictions. Thus, toothbrushing after lunch was selected as a representative indicator to assess adolescents’ compliance and recovery rates.

The aim of this study is to examine changes in adolescent health behaviors following policy transitions and to evaluate group-specific compliance and recovery rates. The compliance rate is defined as the extent to which students adhered to quarantine policies, while the recovery rate reflects the resumption of positive pre-pandemic health behaviors.

In this context, compliance signifies adherence to policies or regulations [7], particularly important when public safety is prioritized and often serving as a determinant of policy effectiveness [8].

Resilience, as described by Southwick et al. [9], refers to psychological adaptation and internal growth after trauma. In contrast, this study focuses on external behavioral responses to policy and environmental changes. For this reason, we introduce the term “recovery rate” to describe the resumption of health behaviors before the restriction period, such as toothbrushing frequency, after the relaxation of regulations. This concept differs from “habit resumption” or “behavioral rebound,” as it emphasizes externally driven, policy-related behavioral adjustments.

The recovery rate can therefore serve as a useful metric for evaluating the impact and appropriateness of public health policies. Furthermore, it may offer critical insights for designing effective policies and avoiding excessive restrictions during future health crises. Rimehaug highlighted that environmental shifts can strongly influence adolescent behaviors, demonstrating the link between policy interventions and behavioral changes [10]. While most prior studies of adolescent health have concentrated on behavioral change or short-term outcomes during the restriction period, the present study adds significance by addressing the recovery rate after the restriction period.

METHODS

Data Source

Data from the 14th (2018) to the 20th (2024) survey were analyzed. Each year, approximately 800 schools (400 middle schools and 400 high schools) participated, with about 55 000 to 65 000 students responding annually. The final analysis included 354 943 respondents across all survey years. For analysis, the data were categorized into 3 policy periods: pre-restriction (2018–2019), restriction (2020–2022), and recovery (2023–2024). The classification was based on the policy timeline: in March 2020, the KDCA announced the implementation of strict social distancing. In this study, the compliance rate was assessed by comparing the Before and Pandemic periods, while the recovery rate was assessed by comparing the Pandemic and After periods. Additionally, the Ministry of Education, Central Disease Control Headquarters, and the Composition and Operation of Central Accident Control Headquarters jointly issued the Guidelines for the Prevention and Control of COVID-19 in Kindergarten, Primary, Secondary, and Special Education Schools. These guidelines included specific restrictions related to toothbrushing facilities, such as prohibiting simultaneous use of multiple faucets, limiting toothbrushing in waiting areas, and staggering brushing times [11]. Because these measures could directly affect adolescent oral health behaviors, the restriction period was defined as 2020–2022. In August 2023, COVID-19 was downgraded from a class 2 to a class 4 infectious disease, which led to an easing of control measures [12]. Accordingly, 2023 was designated as the beginning of the recovery period.

Study Variables

Toothbrushing behavior was assessed with the question: “During the past 7 days, how often did you brush your teeth after lunch at school?” Responses of “always,” “usually,” and “sometimes” were categorized as practicing toothbrushing, while “never” was categorized as not practicing.

Academic performance was evaluated by the question: “In the past 12 months, how was your academic performance?” Responses of “high,” “mid-high,” and “average” were grouped as high academic performance, while “mid-low” and “low” were classified as low academic performance. School level was classified as “middle school” or “high school” (including general and specialized high schools). School type was categorized into “coeducational” and “single-sex” schools (boys’ and girls’ schools).

Drinking status was based on the question: “During the past 30 days, on how many days did you have at least 1 drink of alcohol?” Respondents who answered “0 days” were defined as non-drinkers, while others were classified as drinkers. Smoking status was assessed by whether respondents had smoked at least 1 cigarette of any type on 1 or more days during the past 30 days. Those who had were defined as smokers; those who had not were defined as non-smokers.

Hand hygiene was measured with the question: “During the past 7 days, how often did you wash your hands with soap before meals at school?” Respondents who answered “always” or “usually” were classified as practicing handwashing, while all others were classified as not practicing. Oral health status was assessed using self-reported symptoms within the past year, with responses recorded as “yes” or “no.”

Statistical Analysis

To assess differences in adolescents’ oral health behaviors across COVID-19 policy phases, the data were grouped into 3 policy periods. The Cochran–Mantel–Haenszel test was applied to estimate the common odds ratio, and the Breslow–Day test was used to examine homogeneity across groups.

Subsequently, multivariable logistic regression was conducted to evaluate the effect of each variable on oral health behavior while controlling for confounders. Interaction terms were included to assess differences in oral health behaviors across groups defined by general characteristics.

All analyses were performed using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA). Because this study was based on cross-sectional rather than time-series data, group-level interaction analyses were conducted to compensate for this limitation.

Ethics Statement

The Korea Youth Risk Behavior Survey was conducted in accordance with the Bioethics and Safety Act and was approved as government statistics (No. 117058). Ethical review was not required for this study as it utilized publicly available data that did not contain any personally identifiable information.

RESULTS

Compliance Rate

General characteristics of the study participants

The general characteristics of the study participants are summarized in Table 1. “Yes” and “No” in the tables indicate the presence or absence of toothbrushing after lunch at school.

Among male students, the proportion who reported practicing toothbrushing decreased from 54.6% before the restriction period to 38.3% during the restriction period. Among female students, this proportion declined from 71.3% to 48.7%. The difference in compliance rates between sexes was statistically significant (p<0.001).

Students with high academic performance showed a decline in compliance rate from 63.5% to 43.7%, while those with low performance exhibited a decrease from 61.1% to 42.5%, a difference that was statistically significant (p=0.002). Compliance rate among high school students decreased from 71.0% to 55.6%, and among middle school students from 54.5% to 32.6% (p<0.001). Students attending coeducational schools reported a decrease from 63.2% to 42.4%, while those in single-sex schools showed a decline from 67.3% to 45.2%, both statistically significant (p<0.001).

The proportion of non-drinkers decreased from 62.1% to 42.5%, while that of drinkers decreased from 66.4% to 50.3% (p<0.001). The proportion of non-smokers declined from 62.8% to 42.7%, and that of smokers decreased from 62.3% to 49.4% (p<0.001). Students who reported practicing handwashing decreased from 67.9% to 48.1%, while those not practicing handwashing decreased from 58.5% to 37.3% (p=0.015). Regarding oral health, students without toothache reported a compliance rate decrease from 62.4% to 43.3%, while those with toothache exhibited a decrease from 63.9% to 43.7% (p=0.008). Students without gum bleeding showed a decrease from 62.4% to 43.2%, while those with gum bleeding demonstrated a decline from 64.1% to 43.9% (p=0.026).

The compliance rate of toothbrushing

Figure 1 presents the results of multivariable logistic regression analysis, adjusting for potential confounders. This analysis compared toothbrushing compliance before and during the restriction period. While Table 1 indicated statistically significant differences across all variables, Figure 1 shows that, after adjustment, all variables except academic performance remained statistically significant.

Recovery Rate

General characteristics of the study participants

Among male students, the proportion who reported practicing toothbrushing increased from 38.3% during the restriction period to 39.8% in the after the restriction period. For female students, the proportion rose from 48.7% to 57.9%, a statistically significant improvement (p<0.001). High school students reported an increase from 55.6% to 61.5%, while middle school students exhibited an increase from 32.6% to 37.2% (p=0.007). Students in coeducational schools improved from 42.4% to 49.0%, and those in single-sex schools increased from 45.2% to 47.9% (p<0.001).

The proportion of non-drinkers changed from 42.5% to 48.0%, and that of drinkers from 50.3% to 54.2% (p=0.009). Similarly, the proportion of non-smokers changed from 42.7% to 48.2%, while that of smokers changed from 49.4% to 52.9% (p=0.002). The proportion of students who practiced handwashing changed from 48.1% to 54.0%, and that of those who did not practice handwashing changed from 37.3% to 44.0% (p=0.004). In contrast, no statistically significant differences were observed in relation to academic performance and oral health status, as shown in Table 2.

The recovery rate of toothbrushing

Figure 2 presents the results of multivariable logistic regression analysis, evaluating recovery rate differences in toothbrushing during and after the restriction period, adjusting for confounding variables. Although Table 2 showed no statistically significant differences for academic performance and oral health status, the adjusted analysis in Figure 2 revealed statistically significant differences across all variables, including sex, academic performance, school level, school type, drinking and smoking status, hand hygiene, and oral health status. In addition, logistic regression analyses examining the association between compliance and recovery are presented in Table 3, which further support the results shown in Figures 1 and 2.

DISCUSSION

During COVID-19, the government implemented uniform public health measures without adequately considering the unique characteristics of adolescents. Although preventive policies were necessary at the time, the prohibition of communal toothbrushing in schools may have negatively influenced adolescents’ oral health behaviors. From this perspective, the restriction on communal toothbrushing is regarded in this study as inappropriate. Accordingly, we analyzed its impact on both compliance rate and recovery rate among adolescents.

Analysis of compliance rate revealed a statistically significant decrease in toothbrushing during the restriction period across all variables. By sex, compliance among male students declined from 54.6% to 38.3% (−16.3 percentage point [%p]), while compliance among female students dropped from 71.3% to 48.7% (−22.6%p), indicating higher compliance among females (p<0.001). This finding is consistent with Galasso et al. [13], who reported that females tend to demonstrate higher compliance with policies, and with Rodríguez-Ruiz et al. [14], who found that female students adopted a more proactive attitude toward quarantine rules.

Students with high academic performance showed a decrease in compliance from 63.5% to 43.7% (−19.8%p), while those with low performance decreased from 61.1% to 42.5% (−18.6%p). This suggests that students with stronger academic achievement may have responded more sensitively to policy changes, demonstrating higher compliance. This result aligns with Devi and Dhull [15], who observed that students with greater obedience tend to achieve higher academically. However, academic performance was not statistically significant in multivariate analysis after adjusting for confounders, indicating the need for further investigation. By school level, high school students decreased from 71.0% to 55.6% (−15.4%p), while middle school students decreased from 54.5% to 32.6% (−21.9%p), suggesting that compliance was higher among middle schoolers. These findings correspond with Cho, who reported greater behavioral control among middle school students [16]. Students in coeducational schools declined from 63.2% to 42.4% (−20.8%p), while those in single-sex schools decreased from 67.3% to 45.2% (−22.1%p), indicating higher compliance in single-sex schools (p<0.001). This result aligns with Clark [17], who found that female students, particularly those in girls’ schools, exhibit stronger compliance with rules and greater self-control.

Non-drinkers showed a decrease in compliance from 62.1% to 42.5% (−19.6%p), while that of drinkers decreased from 66.4% to 50.3% (−16.1%p). The compliance rate of non-smokers declined from 62.8% to 42.7% (−20.1%p), while that of smokers decreased from 62.3% to 49.4% (−12.9%p). The higher compliance among non-drinkers and non-smokers is consistent with the general theory of self-control by Gottfredson and Hirschi [18], which associates drinking and smoking with lower self-control and reduced compliance. Students who reported practicing handwashing exhibited declines in the compliance rate from 67.9% to 48.1% (−19.8%p), while those who did not practice handwashing showed a decrease from 58.5% to 37.3% (−21.2%p), suggesting that students with lower hygiene awareness demonstrated greater compliance. Regarding oral health, students without toothache had a compliance rate that decreased from 62.4% to 43.3% (−19.1%p), while those with toothache exhibited a decrease from 63.9% to 43.7% (−20.2%p). Similarly, students without gum bleeding reported a decline from 62.4% to 43.2% (−19.2%p), while those with gum bleeding showed a decrease from 64.1% to 43.9% (−20.2%p), indicating that students with poorer oral health status demonstrated higher compliance.

Analysis of behavioral recovery showed that toothbrushing increased significantly during the policy recovery period across all variables except academic performance and oral health status. Male students exhibited an increase from 38.3% to 39.8% (+1.5%p), while female students showed an increase from 48.7% to 57.9% (+9.2%p), suggesting higher recovery among females. High school students reported an increase from 55.6% to 61.5% (+5.9%p), while the compliance rate in middle school students rose from 32.6% to 37.2% (+4.6%p), indicating greater recovery among high school students. Students in coeducational schools exhibited an increase from 42.4% (n=46 413) to 49.0% (n=35 996) (+6.6%p), while those in single-sex schools showed an increase from 45.2% (n=23 636) to 47.9% (n=16 315) (+2.7%p) (p<0.001), reflecting differences by school type.

The prevalence of toothbrushing among non-drinkers increased from 42.5% to 48.0% (+5.5%p), while among drinkers, it rose from 50.3% to 54.2% (+3.9%p). Non-smokers exhibited an increase from 42.7% to 48.2% (+5.5%p), while smokers showed an increase from 49.4% to 52.9% (+3.5%p). These results suggest that individuals with greater self-control more readily resumed desirable health behaviors. Students who practiced handwashing increased from 48.1% to 54.0% (+5.9%p), while those who did not practice handwashing increased from 37.3% to 44.0% (+6.7%p), indicating faster recovery among students with weaker hygiene practices.

Overall, while toothbrushing behaviors showed improvement following the pandemic, they had not yet returned to pre-policy levels.

Overall, while toothbrushing behaviors showed improvement following the pandemic, they had not yet returned to pre-policy levels. A noteworthy finding was the contrasting patterns observed between school level and school type in relation to compliance and recovery. Specifically, middle schoolers exhibited higher compliance, whereas high schoolers demonstrated greater recovery. This discrepancy may be explained by developmental characteristics: brain regions sensitive to emotions and rewards mature earlier in adolescence, while cognitive systems associated with future planning and self-regulation develop later [19]. Thus, middle schoolers, being more responsive to external rules and directives, may have demonstrated higher compliance with policies but lacked the autonomy to facilitate recovery of health behaviors. Conversely, high schoolers, who tend to interpret behaviors more independently, showed lower compliance during the restriction period but demonstrated faster recovery once policies were lifted.

Similarly, with respect to school type, students in single-sex schools demonstrated higher compliance rates, while those in coeducational schools showed higher recovery rates. Previous studies on policy compliance reported that female students in single-sex schools exhibited greater open-mindedness and tolerance of diverse beliefs compared to those in coeducational schools [20]. They also demonstrated lower reluctance to take risks and perceived their schools as placing greater emphasis on discipline and control [21,22]. Taken together, these findings suggest that students in single-sex schools may be more flexible in adopting new policies and possess a stronger awareness of social norms, thereby exhibiting higher compliance rates.

By contrast, students in coeducational schools demonstrated higher recovery rates, suggesting that the social environment in such schools may promote a return to positive behaviors. Research indicates that individuals become more self-conscious when interacting with the opposite sex [23]. Accordingly, students in coeducational schools may have been more motivated to engage in positive behaviors, such as toothbrushing, in order to shape a favorable image, thereby accelerating recovery of such health behaviors. This implies that external stimuli—particularly the presence of the opposite sex—can serve as social motivators that facilitate recovery of desirable behaviors. However, in this study, single-sex schools were analyzed without distinguishing between boys’ and girls’ schools. Consequently, the higher compliance rates observed among female students may have been offset by the lower compliance rates of male students, potentially distorting the overall results for single-sex schools. Therefore, caution is needed when interpreting these findings. Moreover, because female students generally exhibit higher compliance and recovery rates than male students, not accounting for sex differences may exaggerate or obscure group-level effects. Nevertheless, some studies have suggested that male students show minimal variation in risk aversion depending on school type [21]. Since risk aversion is associated with the acceptance of sudden policy changes, this partially addresses the limitation that sex differences may not have been fully considered when interpreting compliance and recovery in single-sex schools.

This study also distinguished between hand hygiene and oral health status when analyzing compliance and recovery. For compliance, students with lower hygiene levels were more likely to demonstrate higher compliance. However, in terms of recovery, a significant difference was observed only in relation to hand hygiene, while oral health status did not show statistically significant results. The finding that students with lower hygiene status exhibited higher compliance and recovery may be attributable to the cross-sectional design of this study, which involved different cohorts across survey years rather than a longitudinal follow-up of the same individuals. Future studies using time-series data are needed to clarify these findings.

To further assess whether the policy had differential effects on hygiene behaviors, changes in toothbrushing rates after lunch were compared with changes in handwashing rates over the same period. While toothbrushing rates declined significantly during the restriction period, handwashing rates increased across all categories. The toothbrushing rate consistently decreased by 15.4%p to 22.6%p, whereas changes in handwashing varied more widely, with decreases from 2.7%p to 30.1%p. This suggests that the 2 behaviors were influenced differently by policy. Handwashing, measured both at school and at home, was affected by multiple environments, whereas toothbrushing was confined to school settings and directly restricted by school-based quarantine measures. These results indicate that the effects of public health policies may differ depending on context.

Given that this study relied on group-level interactions rather than longitudinal analysis of individuals, certain limitations should be acknowledged. Nonetheless, by considering both compliance and recovery rates, the study provides a novel framework for evaluating the sustainability and reversibility of policy. Variations in these rates across groups highlight the need for policies that account for behavioral recovery and are tailored to the responsiveness of specific populations.

Importantly, the finding that groups with lower hygiene practices exhibited higher compliance and recovery challenges conventional expectations and requires further investigation. Typically, individuals with higher hygiene standards are presumed to be more responsive to health interventions. However, in this study, students reporting poor hand hygiene and weaker oral health behaviors demonstrated higher compliance and recovery. This pattern may suggest a greater reliance on external directives or social norms, rather than intrinsic motivation, in shaping health-related behaviors.

Finally, given the cross-sectional nature of the data, causal relationships cannot be inferred. The observed patterns may reflect group-level behavioral trends rather than individual-level change. Self-reported survey data may also be subject to response bias, while contextual factors such as school facilities and access to hygiene resources at the time of survey administration may have influenced results. To clarify these mechanisms, future research should employ longitudinal designs and incorporate control for environmental variables.

This study analyzed changes in toothbrushing behaviors among adolescents in response to COVID-19 policy interventions, using data from the Korea Youth Risk Behavior Survey (2018–2024). Specifically, it examined compliance and recovery rates in relation to oral hygiene practices. During the restriction period, toothbrushing rates significantly declined overall. Higher compliance rates were observed among female students, middle schoolers, students attending single-sex schools, non-smokers, non-drinkers, and those with poorer oral health status. After the restriction period, most groups exhibited significant improvements in toothbrushing, indicating behavioral recovery; however, rates did not return to those before the pandemic. Recovery was more pronounced among female students, high schoolers, students in coeducational schools, non-drinkers, and non-smokers.

These findings empirically demonstrate the influence of policy on adolescent health behaviors. They underscore the need to consider both compliance and recovery when designing future public health interventions for adolescents. Even during the pandemic, it is essential to ensure the safe operation of school toothbrushing areas or to establish guidelines in advance that reflect the developmental characteristics of adolescents. Furthermore, health policies should be designed to account for differences by sex and school type, ensuring that interventions are both effective and equitable.

Notes

Conflict of Interest

The authors have no conflicts of interest associated with the material presented in this paper.

Funding

None.

Acknowledgements

None.

Author Contributions

Conceptualization: Choi S, Kim Y, Kim JM, Kim J, Jeon J, Song JS, Kwak Y, Jung SH, Kim NJ. Data curation: Choi S, Kim Y, Kim JM, Kim J, Jeon J, Song JS, Kim NJ. Formal analysis: Choi S, Kim Y, Kim JM, Kim J, Jeon J, Song JS, Kwak Y, Jung SH, Kim NJ. Funding acquisition: None. Methodology: Song JS, Kwak Y, Jung SH, Kim NJ. Writing - original draft: Choi S, Kim Y, Kim JM, Kim J, Jeon J. Writing - review & editing: Choi S, Song JS, Kwak Y, Jung SH, Kim NJ.

Figure. 1.

Compliance rate for toothbrushing before and during the COVID-19 pandemic according to general characteristics. Comparison by (A) sex, (B) academic performance, (C) school level, (D) school type, (E) drinking status, (F) smoking status, (G) handwashing practice, (H) presence of toothache, and (I) presence of gum bleeding. *p<0.05 after adjustment for other confounding variables (sex, academic performance, school level, school type, drinking, smoking, handwashing, toothache, gum bleeding). COVID-19, coronavirus disease 2019.

Figure. 2.

Recovery rate for toothbrushing during and after the COVID-19 pandemic according to general characteristics. Comparison by (A) sex, (B) academic performance, (C) school level, (D) school type, (E) drinking status, (F) smoking status, (G) handwashing practice, (H) presence of toothache, and (I) presence of gum bleeding. *p<0.05 after adjustment for other confounding variables (sex, academic performance, school level, school type, drinking, smoking, handwashing, toothache, gum bleeding). COVID-19, coronavirus disease 2019.

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References

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