Oral health literacy among adult patients seeking dental care

Brazilian immigrants' oral health literacy and participation in oral health care in Canada

BACKGROUND

Inadequate functional health literacy is a common problem in immigrant populations. The aim of this study was to investigate the association between oral (dental) health literacy (OHL) and participation in oral health care among Brazilian immigrants in Toronto, Ontario, Canada.

METHODS

The study used a cross-sectional design and a convenience sample of 101 Brazilian immigrants selected through the snowball sampling technique. Data were analyzed using descriptive statistics and logistic regression modeling.

RESULTS

Most of the sample had adequate OHL (83.1 %). Inadequate/marginal OHL was associated with not visiting a dentist in the preceding year (OR = 3.61; p = 0.04), not having a dentist as the primary source of dental information (OR = 5.55; p < 0.01), and not participating in shared dental treatment decision making (OR = 1.06; p = 0.05; OHL as a continuous variable) in multivariate logistic regressions controlling for covariates. A low average annual family income was associated with two indicators of poor participation in oral health care (i.e., not having visited a dentist in the previous year, and not having a dentist as regular source of dental information).

CONCLUSION

Limited OHL was linked to lower participation in the oral health care system and with barriers to using dental services among a sample of Brazilian immigrants. More effective knowledge transfer will be required to help specific groups of immigrants to better navigate the Canadian dental care system.

Association of parental health literacy with oral health of Navajo Nation preschoolers

Health literacy is 'the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions'. Although numerous studies show a link between health literacy and clinical outcomes, little research has examined the association of health literacy with oral health. No large-scale studies have assessed these relationships among American Indians, a population at risk for limited health literacy and oral health problems. This analysis was conducted as part of a clinical trial aimed at reducing dental decay among preschoolers in the Navajo Nation Head Start program. Using baseline data for 1016 parent-child dyads, we examined the association of parental health literacy with parents' oral health knowledge, attitudes, and behavior, as well as indicators of parental and pediatric oral health. More limited health literacy was associated with lower levels of oral health knowledge, more negative oral health attitudes, and lower levels of adherence to recommended oral health behavior. Parents with more limited health literacy also had significantly worse oral health status (OHS) and reported their children to have significantly worse oral health-related quality of life. These results highlight the importance of oral health promotion interventions that are sensitive to the needs of participants with limited health literacy.

Validity and Reliability of the Brazilian Version of the Rapid Estimate of Adult Literacy in Dentistry--BREALD-30

Objective

The aim of the present study was to translate, perform the cross-cultural adaptation of the Rapid Estimate of Adult Literacy in Dentistry to Brazilian-Portuguese language and test the reliability and validity of this version.

Methods

After translation and cross-cultural adaptation, interviews were conducted with 258 parents/caregivers of children in treatment at the pediatric dentistry clinics and health units in Curitiba, Brazil. To test the instrument's validity, the scores of Brazilian Rapid Estimate of Adult Literacy in Dentistry (BREALD-30) were compared based on occupation, monthly household income, educational attainment, general literacy, use of dental services and three dental outcomes.

Results

The BREALD-30 demonstrated good internal reliability. Cronbach’s alpha ranged from 0.88 to 0.89 when words were deleted individually. The analysis of test-retest reliability revealed excellent reproducibility (intraclass correlation coefficient = 0.983 and Kappa coefficient ranging from moderate to nearly perfect). In the bivariate analysis, BREALD-30 scores were significantly correlated with the level of general literacy (r_s = 0.593) and income (r_s = 0.327) and significantly associated with occupation, educational attainment, use of dental services, self-rated oral health and the respondent’s perception regarding his/her child's oral health. However, only the association between the BREALD-30 score and the respondent’s perception regarding his/her child's oral health remained significant in the multivariate analysis.

Conclusion

The BREALD-30 demonstrated satisfactory psychometric properties and is therefore applicable to adults in Brazil.

Perspectives of Maryland adults regarding caries prevention

OBJECTIVES

We obtained in-depth information from low-income parents and caregivers of young children about their knowledge and understanding of and practices related to the prevention and control of dental caries (tooth decay).

METHODS

In 2010, we conducted 4 focus groups in Maryland communities with low-income, English-speaking parents and caregivers who had at least 1 child aged 6 years or younger or who were pregnant. We developed a focus group guide based on findings of a previous statewide random telephone survey of adults with young children.

RESULTS

Most participants had limited understanding of and extensive misinformation about how to prevent dental caries. They were confused about the use of juice and its impact on their child's teeth and had limited understanding of the use of fluorides to prevent caries. Most did not drink tap water and did not give it to their children; rather, they used bottled water.

CONCLUSIONS

These results and those of the statewide telephone survey strongly suggest the need for educational interventions designed for those with limited levels of education.

Social media in adolescent health literacy education: a pilot study

Background

While health literacy has gained notice on a global stage, the initial focus on seeking associations with medical conditions may have overlooked its impact across generations. Adolescent health literacy, specifically in dentistry, is an underexplored area despite the significance of this formative stage on an individual’s approach to healthy lifestyles and behaviors.

Objective

The aim is to conduct a pilot study to evaluate the efficacy of three major social media outlets - Twitter, Facebook, and YouTube - in supporting adolescents’ oral health literacy (OHL) education.

Methods

A random sample of 22 adolescents (aged 14-16 years) from an English-medium international school in Hong Kong provided informed consent. Sociodemographic information, including English language background, social media usage, and dental experience were collected via a questionnaire. A pre- and post-test of OHL (REALD-30) was administered by two trained, calibrated examiners. Following pre-test, participants were randomly assigned to one of three social media outlets: Twitter, Facebook, or YouTube. Participants received alerts posted daily for 5 consecutive days requiring online accessing of modified and original OHL education materials. One-way ANOVA ( analysis of variance) was used to compare the mean difference between the pre- and the post-test results among the three social media.

Results

No associations were found between the social media allocated and participants’ sociodemographics, including English language background, social media usage, and dental experience. Of the three social media, significant differences in literacy assessment scores were evident for participants who received oral health education messages via Facebook (P=.02) and YouTube (P=.005).

Conclusions

Based on the results of the pilot study, Facebook and YouTube may be more efficient media outlets for OHL promotion and education among adolescent school children when compared to Twitter. Further analyses with a larger study group is warranted.

Measuring oral health literacy: a scoping review of existing tools

BACKGROUND

This article presents findings from a scoping review of tools used to measure oral health literacy. Internationally, interest in oral health literacy is driven by oral health disparities, particularly for disadvantaged groups, with conditions such as dental caries and periodontal disease contributing substantially to the global burden of disease. The increasing focus on measuring oral health literacy aligns with reasons for measuring broader health literacy, that is, by assessing oral health literacy, decisions can be made about instigating interventions at policy and practice level to improve individual and population level oral health. There are numerous tools available that measure oral health literacy using a range of indicators.

METHODS

A scoping review was designed to map the existing tools designed to measure oral health literacy (OHL). Key search terms were developed and mapped. Selected databases were used that identified 32 relevant studies reporting a range of OHL tools.

RESULTS

We identified 32 articles that reported a range of oral health literacy tools. Many of the studies used the Rapid Estimate of Adult Literacy in Dentistry (REALD) and/or the Test of Functional Health Literacy in Dentistry (ToFHLiD) that were developed from earlier tools designed to measure broader health literacy. These tools have been widely criticised for providing only an approximate measure of OHL based mainly on word recognition. A number of newer tools have included new measures of oral health literacy including numeracy and oral health conceptual knowledge however tools that measure important indicators of oral health literacy such as service navigation are rare.

CONCLUSIONS

Findings from this scoping exercise confirm our findings from preliminary scans that the majority of tools are heavily biased towards word recognition, numeracy and reading skills, rather than what this means in terms of health behaviours and service utilisation. More recent developments have attempted to incorporate other aspects considered important, including decision making and service navigation. The incorporation of these aspects into newer tools will provide oral health researchers and policy makers with further evidence of the importance of oral health literacy when designing interventions to improve oral health.

Evaluation of a Russian version of the oral health literacy instrument (OHLI)

Background

Oral health literacy has become a popular research area in the last decade; however, to date no health literacy instruments in the Russian language exist. The objectives of this study were to develop a Russian version of the Oral Health Literacy Instrument (OHLI) and to examine its reliability and validity.

Methods

A convenience sample of patients who visited the dental division of the district hospital in Belarus was used in the study. The OHLI, created originally in English, was modified to adapt it to characteristics of routine dental services in Belarus and then translated into Russian, followed by back-translation. Participants completed a self-administered socio-demographic questionnaire, an oral health knowledge test and the Russian version of the OHLI (R-OHLI). Bivariate and multivariate statistical analyses, including multiple regression modeling, were performed to examine reliability and validity of the R-OHLI.

Results

Participants were 281 adult patients aged from 18 to 60 years, with a mean age of 33.1 ± 12.2; 64.1% of them were women. Cronbach’s alpha values for the two sections (reading comprehension and numeracy) and the total R-OHLI were 0.853, 0.815 and 0.895, respectively. The mean total R-OHLI score was 77.2 ± 14.5; the mean reading comprehension and numeracy scores were 39.5 ± 7.5 and 37.8 ± 8.8, respectively. The R-OHLI was significantly correlated to the oral health knowledge test. Pearson’s correlation coefficients between the oral health knowledge test and the reading comprehension, numeracy and total R-OHLI were 0.401, 0.258, and 0.363, respectively (p < 0.001). Women, participants with a university degree, and those who visited a dentist at least once a year had significantly (p < 0.05) higher mean scores for each section (reading comprehension, numeracy) and for total R-OHLI compared to their counterparts.

Conclusions

The R-OHLI showed good internal consistency and test-retest reliability. It was significantly associated with the oral health knowledge test, socio-demographic and behavioral factors. Therefore, the R-OHLI was proved to be a reliable and valid oral health literacy instrument for Russian-speaking people.

A pilot study to assess oral health literacy by comparing a word recognition and comprehension tool

Background

Oral health literacy is important to oral health outcomes. Very little has been established on comparing word recognition to comprehension in oral health literacy especially in older adults. Our goal was to compare methods to measure oral health literacy in older adults by using the Rapid Estimate of Literacy in Dentistry (REALD-30) tool including word recognition and comprehension and by assessing comprehension of a brochure about dry mouth.

Methods

75 males and 75 females were recruited from the University of Connecticut Dental practice. Participants were English speakers and at least 50 years of age. They were asked to read the REALD-30 words out loud (word recognition) and then define them (comprehension). Each correctly-pronounced and defined word was scored 1 for total REALD-30 word recognition and REALD-30 comprehension scores of 0–30. Participants then read the National Institute of Dental and Craniofacial Research brochure “Dry Mouth” and answered three questions defining dry mouth, causes and treatment. Participants also completed a survey on dental behavior.

Results

Participants scored higher on REALD-30 word recognition with a mean of 22.98 (SD = 5.1) compared to REALD-30 comprehension with a mean of 16.1 (SD = 4.3). The mean score on the brochure comprehension was 5.1 of a possible total of 7 (SD = 1.6). Pearson correlations demonstrated significant associations among the three measures. Multivariate regression showed that females and those with higher education had significantly higher scores on REALD-30 word-recognition, and dry mouth brochure questions. Being white was significantly related to higher REALD-30 recognition and comprehension scores but not to the scores on the brochure.

Conclusions

This pilot study demonstrates the feasibility of using the REALD-30 and a brochure to assess literacy in a University setting among older adults. Participants had higher scores on the word recognition than on comprehension agreeing with other studies that recognition does not imply understanding.

The Relation Between Caregivers' Multiliterate Reading Habits and Their Children's Oral Health Status

BACKGROUND

Caregivers' oral health literacy (OHL) assessment results have been found to be related to their children's oral health status. A further aspect of this relationship may be the role of caregivers' reading habits.

OBJECTIVE

Our goal was to describe the relationship between caregivers' multimodal (digital and print) and multilingual (English and Chinese) reading habits, their OHL, and their child's oral health status in Hong Kong.

METHODS

A random sample of 301 child-caregiver dyads was recruited from kindergartens in Hong Kong. Data included sociodemographic information and caregivers' self-reported digital print and reading habits across two languages (Chinese and English). Caregivers' OHL levels were assessed by two locally developed and validated oral health literacy assessment tasks: Hong Kong Rapid Estimate of Adult Literacy in Dentistry-30 (HKREALD-30) and the Hong Kong Oral Health Literacy Assessment Task for Pediatric Dentistry (HKOHLAT-P). Children's oral health status was assessed using two measures: dental caries experience (number of decayed, missing, and filled teeth) and oral hygiene status (Visible Plaque Index).

RESULTS

Bivariate variations revealed significant differences in mean OHL scores between caregivers with different reading habits (P<.01). Correlations revealed significant associations between caregivers' practices of reading multimodal (print/digital) and multilingual (English/Chinese) texts, their literacy levels, and their children's oral health status (P<.01). Adjusting for sociodemographics and all other reading habits in the regression analysis, the caregivers' habit of reading digital and print texts was significantly retained in the final model. Regression analysis revealed significant associations between caregivers' reading habits (digital Chinese) and their OHL word recognition scores: OR 5.00, 95% CI 1.10-3.65, P=.027. Significant associations were also evident for their OHL comprehension scores (digital Chinese: OR 2.30, 95% CI 1.30-4.20, P=.004; print Chinese: OR 2.50, 95% CI 1.40-4.30, P=.001). However, no significant associations were found between caregivers' reading habits and child's oral health status (P>.05).

CONCLUSIONS

Caregivers' habits of reading print and digital Chinese texts are significantly associated with their OHL scores. Their reading habits, however, do not affect their children's oral health status.

Oral health literacy among clients visiting a rural dental college in North India-a cross-sectional study

Background

Limited health literacy among adults is one of the many barriers to better oral health outcomes. It is not uncommon to find people who consider understanding oral health information a challenge. Therefore, the present study assessed oral health literacy among clients visiting Gian Sagar Dental College and Hospital, Rajpura.

Materials and Methods

A cross-sectional study was conducted on 450participants who visited the Out Patient Department (OPD) of Gian Sagar Dental College and Hospital for a period of two months (Nov–Dec, 2013). A questionnaire was given to each of the participants. Oral health literacy was graded on a 12-point Likert scale based on the total score. Oral Health Literacy of the participants was assessed as low, medium and high on the basis of responses. Statistical analysis was done using SPSS-15 statistical package. ANOVA and Student t-test were used to do comparisons between groups.

Results

Low oral health literacy scores were reported in 60.2% (271) participants. More than 60% of the study participants had knowledge about dental terms such as ‘dental caries,’ and ‘oral cancer.’ Only 22% of the graduates had a high literacy score. Mean oral health literacy score according to educational qualification was statistically significant (p<0.05), whereas there was no significant difference in terms of age and gender (p>0.05).

Conclusion

The majority of the participants had low literacy scores. There is a need to address these problems especially among rural population by health care providers and the government.

Health literacy environmental scans of community-based dental clinics in Maryland

OBJECTIVES

We conducted health literacy environmental scans in 26 Maryland community-based dental clinics to identify institutional characteristics and provider practices that affect dental services access and dental caries education.

METHODS

In 2011-2012 we assessed user friendliness of the clinics including accessibility, signage, facility navigation, educational materials, and patient forms. We interviewed patients and surveyed dental providers about their knowledge and use of communication techniques.

RESULTS

Of 32 clinics, 26 participated. Implementation of the health literacy environmental scan tools was acceptable to the dental directors and provided clinic directors with information to enhance care and outreach. We found considerable variation among clinic facilities, operations, and content of educational materials. There was less variation in types of insurance accepted, no-show rates, methods of communicating with patients, and electronic health records use. Providers who had taken a communication skills course were more likely than those who had not to use recommended communication techniques.

CONCLUSIONS

Our findings provide insight into the use of health literacy environmental scan tools to identify clinic and provider characteristics and practices that can be used to make dental environments more user friendly and health literate.

The relationship between caregiver functional oral health literacy and child oral health status

OBJECTIVE

To describe the relationship between caregivers' oral health literacy (OHL) and the oral health status of their children in an Asian population.

METHODS

A random sample of 301 child/caregiver dyads was recruited from kindergartens in Hong Kong. Two locally-developed and validated OHL assessment tasks were administered to caregivers with Hong Kong Rapid Estimate of Adult Literacy in Dentistry-30 (HKREALD-30) assessing word recognition and Hong Kong Oral Health Literacy Assessment Task for Paediatric Dentistry (HKOHLAT-P) assessing comprehension. Their children's oral health status was assessed [dental caries experience - decayed, missing, filled teeth index - (dmft) and oral hygiene status - Visible Plaque Index (VPI)].

RESULTS

Caregivers' literacy was associated with children's oral health status. The HKOHLAT-P had a stronger association with children's oral health than HKREALD-30. HKOHLAT-P and HKREALD-30 remained associated with dmft in the adjusted negative binomial regression models (accounting for socio-demographics), Incidence Rate Ratio (IRR) 0.97, p=0.02, and 0.96, p=0.03, respectively. In the adjusted model, HKOHLAT-P was associated with VPI (IRR 0.90, p<0.05), but no association between HKREALD-30 and VPI was evident.

CONCLUSION

The main conclusion of this study was that caregiver oral health literacy was associated with their child's oral health status. A comprehension instrument had a more robust association with children's oral status than a word recognition instrument.

PRACTICE IMPLICATIONS

This study has implications for general public health education for designing community-level interventions.

The association between oral health literacy and failed appointments in adults attending a university-based general dental clinic

OBJECTIVES

The purpose of this study is to determine the association between personal characteristics, a person's oral health literacy, and failing to show for dental appointments at a university dental clinic.

METHODS

A secondary data analysis was conducted on data collected from 200 adults at a university dental clinic between January 2005 and December 2006. In the original study, an oral health literacy instrument, the Rapid Estimate of Adult Literacy in Medicine and Dentistry (REALM-D), was administered, sociodemographic and health information seeking behavior was gathered, and electronic records were reviewed.

RESULTS

Descriptive and bivariate analyses and a classification and regression tree (CART) analysis were conducted. Seeking health information through fewer sources vs. multiple sources was the strongest predictor of failing to show. The subjects' oral health literacy, as measured by the REALM-D List 3 score, was the next most significant variable. Classification and regression tree analyses also selected gender, chief complaint, age, and payment type as predictor variables.

CONCLUSIONS

Multiple factors contribute to failing to show for dental appointments. However, individuals who use fewer sources of oral health information, a subset of health literacy skills, are more likely to fail to show for dental appointments.

Examining the accuracy of caregivers' assessments of young children's oral health status

BACKGROUND

Caregivers' perceptions of their young children's oral health status (OHS) are a strong determinant of whether the children visit a dentist. Our aims were to quantify the correlation between caregivers' assessments and their children's clinically determined restorative treatment needs, while investigating factors related to this association.

METHODS

One hundred eight caregivers assessed their children's OHS by answering a question on the self-reported National Health and Nutrition Examination Survey III instrument. Children underwent clinical oral examinations at one of two study sites of the Carolina Oral Health Literacy Project: a dental school-based clinic and a community-based health clinic. Examiners recorded the children's clinical treatment needs by using a modification of the caries severity index. The authors quantified concordance between the two measures with use of the Spearman rank correlation (ρ) and Kendall τ rank correlation, whereas they assessed differences in sociodemographic factors and oral health literacy (OHL) levels by using a homogeneity χ(2) test (P < .2 criterion).

RESULTS

The concordance between caregivers' assessments and clinically determined OHS was lower for younger children (< 2 years, ρ = 0.29 versus = 2 years, ρ = 0.63 [homogeneity P = .03]), a pattern that was evident in the community clinic but not in the university clinic. Caregivers' age, education and OHL did not influence the accuracy of self-reports.

CONCLUSIONS

For children younger than 2 years, caregivers' assessments correlated poorly with clinical needs, which routinely were underestimated. Practice Implications. These findings underscore the importance of preventive dental visits at a young age and the early establishment of a dental home.

Parents' dental anxiety and oral health literacy: effects on parents' and children's oral health-related experiences

OBJECTIVE

To explore a) the relationship between parents'/guardians' dental anxiety and oral health literacy and b) those between these variables and background and oral health-related characteristics.

METHODS

Survey data were collected from 187 parents/guardians (81% female; average age 37 years). Dental anxiety was measured with the Dental Anxiety Scale - Revised (DAS-R) and oral health literacy with the Rapid Estimate of Adult Literacy in Dentistry (REALD-30). Children's dental charts were reviewed to collect information about their dental treatment.

RESULTS

DAS-R and REALD-30 scores were correlated (r = -0.22; P = 0.003). A multivariate regression model with DAS-R score as the dependent variable showed that the DAS-R score has a significant multivariate association with REALD-30, oral health, income, and presence of fillings.

CONCLUSIONS

Dental anxiety and oral health literacy are related. However, DAS score has a significant multivariate association with the four variables REALD-30 score, oral health, income, and presence of fillings. These findings show that among socioeconomically disadvantaged patients, the contributors to poor oral health are interrelated and multidetermined and include poor oral health literacy and dental anxiety. The public health message is that in order to improve the overall oral health of socioeconomically disadvantaged patients, public health stakeholders need to consider how to communicate with these patients effectively and how to reduce dental anxiety. Gaining a better understanding of how to communicate with parents a) at an appropriate literacy level and b) in a way that it reduces dental anxiety is therefore crucial.

Health literacy among Indian adults seeking dental care

BACKGROUND

Poor literacy can impede one's ability not only to seek out needed health information but also to process, understand and use it to make appropriate health care decisions. The objective of the study was to assess the health literacy among adult patients seeking oral health care at in a private dental hospital in Bangalore, Karnataka, India.

MATERIALS AND METHODS

A cross sectional questionnaire survey was carried out on 500 subjects. The questionnaire designed by Chew and colleagues (2004) was modified and used as the survey instrument. To be eligible to participate in the study, the participants had to be aged above 18 years and able to read or write English/Kannada (local language). Analysis of variance (ANOVA) and Student's t-test (two tailed, independent) was used to find the significance of study parameters at 95% confidence interval.

RESULTS

About 60.4% of the subjects had low health literacy level, 29.4% average and only 10.2% had high health literacy levels. Age and educational qualification had a suggestive significant difference with the mean health literacy scores while gender did not have any significant difference. Subjects who had completed post-graduation (57.8%) too had low health literacy levels.

CONCLUSION

A large number of patients have low levels of health literacy that may interfere with their ability to process and understand basic health information.

What Maryland adults with young children know and do about preventing dental caries

OBJECTIVES

We sought to determine Maryland adults' knowledge, understanding, opinions, and practices with respect to prevention and early detection of dental caries.

METHODS

We conducted a statewide random-digit-dialing, computer-assisted telephone survey in 2010 among 770 adults who had a child aged 6 years or younger living in their home. A traditional random-digit sample and a targeted low-income sample were included. Analyses included frequencies, percentages, the χ(2) test, and multivariate logistic regression.

RESULTS

Respondents' overall level of knowledge about preventing dental caries was low. Those with higher levels of education were more likely to have correct information regarding prevention and early detection of dental caries. Nearly all respondents (97.9%) reported that they were aware of fluoride, but only 57.8% knew its purpose. More than one third (35.1%) of the respondents were not aware of dental sealants. Those with lower levels of education were significantly less likely to drink tap water, as were their children, and significantly less likely to have had a dental appointment in the preceding past 12 months.

CONCLUSIONS

Our results demonstrate the need to increase oral health literacy regarding caries prevention and early detection.

New oral health literacy instrument for public health: development and pilot testing

AIM

The aim of the present study was to develop a functional oral health literacy (OHL) instrument for adults, including new measures of literacy skills (OHL Adults Questionnaire: OHL-AQ).

METHODS

An item pool was provided, and an expert panel evaluated the items by assessing the content validity index and content validity ratio. The reliability analysis, including internal consistency and reproducibility, were examined using Cronbach's alpha coefficient and intraclass correlation coefficient (ICC). In addition a known-groups comparison was performed to assess how well the questionnaire discriminates between individuals who differ in education and brushing behavior.

RESULTS

A total of 97 participants were studied. The mean age of the participants was 36.3 (standard deviation [SD] = 12.8) years; 34% had more than 12 years' formal education. Overall, 39.2% of interviewees had inadequate, 16.5% had marginal, and 44.3% had adequate OHL. The internal consistency, as measured by Cronbach's alpha, was found to be 0.72, and the ICC was 0.84. Participants who brushed more frequently had significantly higher OHL scores (P = 0.03). The association between OHL scores and years of education was also significant (P < 0.001).

CONCLUSION

The OHL-AQ is a valid and reliable measure of functional OHL, with additional sections for evaluating listening and decision-making skills.

Determinants of oral health: does oral health literacy matter?

Objective. To evaluate oral health literacy, independent of other oral health determinants, as a risk indicator for self-reported oral health. Methods. A cross-sectional population-based survey conducted in Tehran, Iran. Multiple logistic regression analysis served to estimate the predictive effect of oral health literacy on self-reported oral health status (good versus poor) controlling for socioeconomic and demographic factors and tooth-brushing behavior. Results. In all, among 1031 participants (mean age 36.3 (SD 12.9); 51% female), women reported brushing their teeth more frequently (P < 0.001) and scored higher for oral health literacy (mean 10.9 versus 10.2, P < 0.001). In the adjusted model, high age (OR = 1.01, 95% CI 1.003–1.034), low education (OR = 1.88, 95% CI 1.23–2.87), small living area in square meters per person (OR = 1.85, 95% CI 1.003–3.423), poor tooth brushing behavior (OR = 3.35, 95% CI 2.02–5.57), and low oral health literacy scores (OR = 1.58, 95% CI 1.02–2.45) were significant risk indicators for poor self-reported oral health. Conclusions. Low oral health literacy level, independent of education and other socioeconomic determinants, was a predictor for poor self-reported oral health and should be considered a vital determinant of oral health in countries with developing health care systems.

Investigating the impact of a community-based geriatric dentistry rotation on oral health literacy and oral hygiene of older adults

OBJECTIVE

This study investigated the impact of a community-based geriatric dentistry rotation on older adults' oral health literacy and oral hygiene.

MATERIALS AND METHODS

A pre-post study design was used to assess the impact of the educational intervention. The study sample consisted of 67 older adults, who resided in independent or assisted living apartments (age: M = 84, SD = 7.3). Over the course of the programme, participants received patient education pertaining to oral health and oral hygiene. Oral health literacy was assessed using the Rapid Estimation of Adult Literacy in Dentistry (REALD-30) test at baseline and on the final visit. Oral hygiene was measured on four visits using the O'Leary, Drake and Naylor Plaque Control Record (PI).

RESULTS

REALD-30 scores significantly increased, and PI scores significantly decreased for all subjects following participation in the programme (p < 0.001, and p < 0.01, respectively). Hierarchical multiple regression demonstrated that neither study subjects' individual characteristics nor their health literacy significantly predicted the change in oral hygiene.

CONCLUSION

This study demonstrated that a community-based geriatric dentistry rotation involving multiple interactions with dental students can in the short term significantly and positively impact older adults' oral health literacy and oral hygiene status.

A brief 20-item dental/medical health literacy screen (REALMD-20)

OBJECTIVES

Few health literacy instruments are available to clinicians to help understand the implications of patient difficulty understanding health information. Those that do exist are lengthy and would not be conducive to use in a busy clinical setting. Long-term dental and medical outcomes may improve if health care providers can identify individuals with low health literacy levels who may benefit from tailored communication, yet few instruments are available for clinical use. The purpose of this study is to introduce a brief 20-item screener for limited dental/medical health literacy among adult dental patients.

METHODS

Two-hundred adult patients seeking treatment at a dental clinic in a large medical complex completed a health literacy screening instrument and survey. Steps in the development of the 20-item instrument are described. Comparison of the 20-item dental/medical instrument with other health literacy measures are calculated using mean health literacy scores, tests of reliability and readability, and correlation coefficients.

RESULTS

Scores on the brief 20-item measure varied significantly by race, education level, language use, needing help with medical/health materials forms. Those with lower dental/medical health literacy, as measured by the REALMD-20 were less likely to receive regular follow-up care than those with higher literacy.

CONCLUSIONS

The REALMD-20 is a quick screening instrument that can be used by clinicians to detect limited dental/medical health literacy among adult patients seeking treatment in dental/medical clinic settings.

The impact of oral health literacy on periodontal health status

OBJECTIVE

The objective of this study was to describe oral health literacy (OHL) among periodontal patients and to examine its association with periodontal health status.

METHODS

This cross-sectional study included new and referred patients presenting to the University of North Carolina Graduate Periodontology Clinic. Sociodemographic and dental history information were collected. OHL was measured using a dental word recognition instrument, Rapid Estimate of Adult Literacy-30 (REALD-30). Clinical periodontal examinations were completed.

RESULTS

One hundred and twenty-eight participants enrolled and 121 completed all study examinations and instruments. Despite a high level of education among participants in our study, low levels of OHL were found in one-third (33 percent) of the study population. Thirty-one percent had moderate OHL (score of 22-25), 37 percent had high OHL (score ≥ 26). The mean REALD-30 score was 23. Fifty-three percent of participants had severe periodontitis, 29 percent had moderate periodontitis, and 18 percent had mild or no periodontitis. Bivariate analysis showed a significant association between OHL and periodontal status (P < 0.05). The effect of OHL on periodontal health status remained statistically significant (P < 0.002) even after controlling for smoking, race, and dental insurance.

CONCLUSION

Lower OHL was associated with more severe periodontal disease among new and referred patients presenting to the University of North Carolina Graduate Periodontology Clinics.

Opinions of Maryland adults regarding communication practices of dentists and staff

Communication practices of dental care providers are especially important to provider-patient and provider-caregiver communication because most patients report that they obtain oral health information from their dentist. The purpose of this study was to determine the perceptions of English-speaking Maryland adults who had a child 6 years and younger in the home about the communication practices of their dentists and staff. Five questions from the Consumer Assessment of Healthcare Providers and Systems survey were included in a random digit dial telephone survey administered in March and April 2010. A total of 803 surveys were completed with adults 18-65 years of age who had a child in their home 6 years of age and younger. Land and cell phones were used. The analysis included frequencies, percentages, chi-square tests, and multivariate logistic regression. The response rate was 24%. Overall, those with higher levels of education and women were more likely to respond favorably about the communication practices of their dentist and staff. Respondents whose child was insured with Medicaid/State Children's Health Insurance Program (SCHIP) were less likely to respond favorably. Medicaid/SCHIP recipients are the individuals with the greatest dental disease and in need of preventive information and regimens for themselves and for their children. Spending time with patients and providing them with accurate information in a manner that patients feel respected and listened to contributes to the patient's ability to understand and act upon this information. Thus, these communication practices are pivotal to increasing oral health literacy and decreasing dental disparities.

Oral health literacy: a pathway to reducing oral health disparities in Maryland

Oral health literacy is a relatively new but critical concept in our efforts to decrease disparities and increase oral health for all Marylanders. Oral health literacy is important because low health literacy contributes to disease which results in increased costs for all of us. Those with low health literacy are usually at highest risk for oral diseases and problems. These individuals include the poor, those with low levels of education, minorities, and the elderly. Prompted by the untimely demise of Deamonte Driver, Maryland has taken the lead in developing a statewide approach to improving oral health literacy with the ultimate objective of reducing disparities.

'English leaflets are not meant for me': a qualitative approach to explore oral health literacy in Chinese mothers in Southwestern Sydney, Australia

OBJECTIVES

The aim of this study was to record the views of Chinese mothers living in southwestern Sydney on the value of commonly used dental health education materials that gave behavioural advice on looking after the oral health of young children.

METHODS

This qualitative study was nested within a large cohort study in south-western Sydney. Chinese-speaking mothers (n = 27) with young children were approached for a face-to-face, semi-structured interview at their home. Two dental leaflets in English that gave behavioural advice on monitoring young children's oral health were sent to each mother prior to interview. On the day of the interview, mothers were also given translated versions of the leaflets for comparison. Interviews were recorded and subsequently transcribed verbatim. Transcripts were analysed by thematic coding.

RESULTS

Mothers reported that the leaflets were not tailored to match the different levels of English literacy within the Chinese community, and participants favoured health information material written in their first language with the use of illustrations. However, translations had to take account of the Chinese culture, as some of the advice in the leaflets presented did not reflect Chinese family values. Mothers also felt that the information should be more specific to provide a better understanding of the rationale for changing or implementing a different behaviour.

CONCLUSIONS

Dental health information literature for Chinese people should not be translated directly from those intended for an English-speaking audience, but should reflect Chinese culture-specific advice such as examples of the type and amount of foods to be given during early years of life. Supportive illustrations were also preferred.

Assessment of health literacy and numeracy among Spanish-Speaking parents of young children: validation of the Spanish Parental Health Literacy Activities Test (PHLAT Spanish)

OBJECTIVE

To assess the health literacy and numeracy skills of Spanish-speaking parents of young children and to validate a new Spanish language health literacy assessment for parents, the Spanish Parental Health Literacy Activities Test (PHLAT Spanish).

METHODS

Cross-sectional study of Spanish-speaking caregivers of young children (<30 months) enrolled at primary care clinics in 4 academic medical centers. Caregivers were administered the 10-item PHLAT in addition to validated tests of health literacy (S-TOFHLA) and numeracy (WRAT-3 Arithmetic). Psychometric analysis was used to examine item characteristics of the PHLAT-10 Spanish, to assess its correlation with sociodemographics and performance on literacy/numeracy assessments, and to generate a shorter 8-item scale (PHLAT-8).

RESULTS

Of 176 caregivers, 77% had adequate health literacy (S-TOFHLA), whereas only 0.6% had 9th grade or greater numeracy skills. Mean PHLAT-10 score was 41.6% (SD 21.1). Fewer than one-half (45.5%) were able to read a liquid antibiotic prescription label and demonstrate how much medication to administer within an oral syringe. Less than one-third (31.8%) were able to interpret a food label to determine whether it met WIC (Special supplemental nutrition program for Women, Infants, and Children) guidelines. Greater PHLAT-10 score was associated with greater years of education (r = 0.49), S-TOFHLA (r = 0.53), and WRAT-3 (r = 0.55) scores (P < .001). Internal reliability was good (Kuder-Richardson coefficient of reliability; KR-20 = 0.61). An 8-item scale was highly correlated with the full 10-item scale (r = 0.97, P < .001), with comparable internal reliability (KR-20 = 0.64).

CONCLUSIONS

Many Spanish-speaking parents have difficulty performing health-related literacy and numeracy tasks. The Spanish PHLAT demonstrates good psychometric characteristics and may be useful for identifying parents who would benefit from receiving low-literacy child health information.

The relationship of oral health literacy with oral health-related quality of life in a multi-racial sample of low-income female caregivers

Background

To investigate the association between oral health literacy (OHL) and oral health-related quality of life (OHRQoL) and explore the racial differences therein among a low-income community-based group of female WIC participants.

Methods

Participants (N = 1,405) enrolled in the Carolina Oral Health Literacy (COHL) study completed the short form of the Oral Health Impact Profile Index (OHIP-14, a measure of OHRQoL) and REALD-30 (a word recognition literacy test). Socio-demographic and self-reported dental attendance data were collected via structured interviews. Severity (cumulative OHIP-14 score) and extent of impact (number of items reported fairly/very often) scores were calculated as measures of OHRQoL. OHL was assessed by the cumulative REALD-30 score. The association of OHL with OHRQoL was examined using descriptive and visual methods, and was quantified using Spearman's rho and zero-inflated negative binomial modeling.

Results

The study group included a substantial number of African Americans (AA = 41%) and American Indians (AI = 20%). The sample majority had a high school education or less and a mean age of 26.6 years. One-third of the participants reported at least one oral health impact. The OHIP-14 mean severity and extent scores were 10.6 [95% confidence limits (CL) = 10.0, 11.2] and 1.35 (95% CL = 1.21, 1.50), respectively. OHL scores were distributed normally with mean (standard deviation, SD) REALD-30 of 15.8 (5.3). OHL was weakly associated with OHRQoL: prevalence rho = -0.14 (95% CL = -0.20, -0.08); extent rho = -0.14 (95% CL = -0.19, -0.09); severity rho = -0.10 (95% CL = -0.16, -0.05). "Low" OHL (defined as < 13 REALD-30 score) was associated with worse OHRQoL, with increases in the prevalence of OHIP-14 impacts ranging from 11% for severity to 34% for extent. The inverse association of OHL with OHIP-14 impacts persisted in multivariate analysis: Problem Rate Ratio (PRR) = 0.91 (95% CL = 0.86, 0.98) for one SD change in OHL. Stratification by race revealed effect-measure modification: Whites--PRR = 1.01 (95% CL = 0.91, 1.11); AA--PRR = 0.86 (95% CL = 0.77, 0.96).

Conclusions

Although the inverse association between OHL and OHRQoL across the entire sample was weak, subjects in the "low" OHL group reported significantly more OHRQoL impacts versus those with higher literacy. Our findings indicate that the association between OHL and OHRQoL may be modified by race.

Screening for oral health literacy in an urban dental clinic

OBJECTIVE

Studies show that the average person fails to understand and use health care related materials to their full potential. The goal of this study was to evaluate a health literacy instrument based on the Rapid Estimate of Adult Literacy in Medicine (REALM) that incorporates dental and medical terms into one 84-item Rapid Estimate of Adult Literacy in Medicine and Dentistry (REALM-D) measure and determine its association with patient characteristics of a culturally diverse dental clinic population.

METHODS

An 84-item dental/medical health literacy word list and a 48-item health beliefs and attitudes survey was provided to a sample of 200 adult patients seeking treatment for the first time at an oral diagnosis clinic located in a large urban medical center in Los Angeles, California.

RESULTS

Of the total sample, 154 participants read all of list 1 correctly, 141 read list 2 correctly, and only 38 read list 3 correctly. Nonwhite participants had significantly lower REALM-D scores at each level of difficulty as well as the total scale score compared to white participants. Participants who reported English as not their main language had significantly lower REALM-D scores. REALM-D scores also varied significantly by level of education among participants where as level of education increased, oral health literacy increased. At a bivariate level, race, education, and English as a main language remain predictive of health literacy in a regression model. An interaction between education and English as a main language was significant.

CONCLUSIONS

The REALM-D is an effective instrument for use by medical and dental clinicians in detecting differences among people of different backgrounds and for whom English was not their primary language.

Oral health literacy levels among a low-income WIC population

OBJECTIVES

To determine oral health literacy (OHL) levels and explore potential racial differences in a low-income population.

METHODS

This was a cross-sectional study of caregiver/child dyads that completed a structured 30-minute in-person interview conducted by two trained interviewers in seven counties in North Carolina. Sociodemographic, OHL, and dental health-related data were collected. OHL was measured with a dental word recognition test [Rapid Estimate of Adult Literacy in Dentistry (REALD-30)]. Descriptive, bivariate, and multivariate methods were used to examine the distribution of OHL and explore racial differences.

RESULTS

Of 1658 eligible subjects, 1405 (85 percent) participated and completed the interviews. The analytic sample (N=1280) had mean age 26.5 (standard deviation = 6.9) years with 60 percent having a high school degree or less. OHL varied between racial groups as follows: Whites--mean score = 17.4 (SE = 0.2); African-American (AA)--mean score = 15.3 [standard error (SE) = 0.2]; American Indian (AI)--mean score = 13.7 (SE = 0.3). Multiple linear regression revealed that after controlling for education, county of residence, age, and Hispanic ethnicity, Whites had 2.0 points (95 percent CI = 1.4, 2.6) higher adjusted REALD-30 score versus AA and AI.

CONCLUSIONS

Differences in OHL levels between racial groups persisted after adjusting for education and sociodemographic characteristics.

Measuring conceptual health knowledge in the context of oral health literacy: preliminary results

OBJECTIVES

Health literacy encompasses several abilities including word recognition, reading comprehension, communication skills, and conceptual knowledge. To date, conceptual knowledge has not been included in oral health literacy research. This study assesses the validity and reliability of a new instrument and describes conceptual oral health knowledge among a sample of low-income adults.

METHODS

One hundred Baltimore adults were administered the Rapid Estimate of Adult Literacy in Medicine (REALM), Short Test of Functional Health Literacy in Adults (Short-TOFHLA), and a new survey of conceptual oral health knowledge. Respondents were also asked about sociodemographics, dental health, and utilization.

RESULTS

Psychometric analysis was used to identify a subset of oral health knowledge questions from the new survey instrument. The resulting Comprehensive Measure of Oral Health Knowledge (CMOHK) was categorized into three levels of knowledge (poor, fair, good). Nearly one-third of Baltimore adults exhibited the lowest level. CMOHK scores were significantly associated with age, education level, and word recognition (REALM). CMOHK scores were not associated with reading comprehension (Short-TOFHLA) or dental care visits. Instrument reliability was good (Cronbach alpha = 0.74).

CONCLUSIONS

This preliminary study yielded a new measure of oral health conceptual knowledge, available for use in future oral health literacy studies. The author presents a conceptual framework of oral health literacy that separates health literacy into four unique components and places decision-making at the center. Future studies are needed to determine whether this framework is supported by empirical data and leads to improvements in oral health and reductions in health disparities.

Oral health literacy among female caregivers: impact on oral health outcomes in early childhood

The aim of this study was to investigate the association of female caregivers' oral health literacy with their knowledge, behaviors, and the reported oral health status of their young children. Data on caregivers' literacy, knowledge, behaviors, and children's oral health status were used from structured interviews with 1158 caregiver/child dyads from a low-income population. Literacy was measured with REALD-30. Caregivers' and children's median ages were 25 yrs (range = 17-65) and 15 mos (range = 1-59), respectively. The mean literacy score was 15.8 (SD = 5.3; range = 1-30). Adjusted for age, education, and number of children, low literacy scores (< 13 REALD-30) were associated with decreased knowledge (OR = 1.86; 95% CI = 1.41, 2.45) and poorer reported oral health status (OR = 1.44; 95% CI = 1.02, 2.05). Lower caregiver literacy was associated with deleterious oral health behaviors, including nighttime bottle use and no daily brushing/cleaning. Caregiver oral health literacy has a multidimensional impact on reported oral health outcomes in infants and young children.

Short Assessment of Health Literacy-Spanish and English: a comparable test of health literacy for Spanish and English speakers

OBJECTIVE

The intent of the study was to develop and validate a comparable health literacy test for Spanish-speaking and English-speaking populations.

STUDY DESIGN

The design of the instrument, named the Short Assessment of Health Literacy-Spanish and English (SAHL-S&E), combined a word recognition test, as appearing in the Rapid Estimate of Adult Literacy in Medicine (REALM), and a comprehension test using multiple-choice questions designed by an expert panel. We used the item response theory (IRT) in developing and validating the instrument.

DATA COLLECTION

Validation of SAHL-S&E involved testing and comparing the instrument with other health literacy instruments in a sample of 201 Spanish-speaking and 202 English-speaking subjects recruited from the Ambulatory Care Center at the University of North Carolina Healthcare System.

PRINCIPAL FINDINGS

Based on IRT analysis, 18 items were retained in the comparable test. The Spanish version of the test, SAHL-S, was highly correlated with other Spanish health literacy instruments, Short Assessment of Health Literacy for Spanish-Speaking Adults (r=0.88, p<.05) and the Spanish Test of Functional Health Literacy in Adults (TOFHLA) (r=0.62, p<.05). The English version, SAHL-E, had high correlations with REALM (r=0.94, p<.05) and the English TOFHLA (r=0.68, p<.05). Significant correlations were found between SAHL-S&E and years of schooling in both Spanish- and English-speaking samples (r=0.15 and 0.39, respectively). SAHL-S&E displayed satisfactory reliability of 0.80 and 0.89 in the Spanish- and English-speaking samples, respectively. IRT analysis indicated that the SAHL-S&E score was highly reliable for individuals with a low level of health literacy.

CONCLUSIONS

The new instrument, SAHL-S&E, has good reliability and validity. It is particularly useful for identifying individuals with low health literacy and could be used to screen for low health literacy among Spanish and English speakers.

A survey of oral health education provided by certified diabetes educators

The purpose of this study was to investigate certified diabetes educators' (CDEs) perceptions of the adequacy of their diabetes education curricula in providing oral health information. A questionnaire was mailed to all CDEs with a mailing address in South Carolina (SC), United States (US). Of the 130 respondents, between 50%-60% indicated that they adequately addressed frequent dental visits, daily brushing and flossing, and importance of good oral hygiene. Almost all (93.8%) reported that their curricula did not include an oral health module; the two predominant reasons were: not having enough time (61.0%), and not knowing enough about oral health and its relationship to diabetes (37.0%). Respondents who expressed that they did not know enough about oral health and its relationship to diabetes were less likely to provide adequate 'oral-health-related information' (p=0.008), especially information about the effect of periodontal disease on diabetes (p=0.016). This study indicates that SC CDEs do not routinely provide comprehensive oral health education to people with diabetes primarily due to lack of time and knowledge related to oral health. To better serve their patients, CDEs should integrate oral health education in the diabetes education curriculum.

Development and evaluation of an oral health literacy instrument for adults

OBJECTIVES

To develop and validate an instrument to measure the functional oral health literacy of adults.

METHODS

For the generation of items different dental patient educational materials and text types were selected that had reading levels similar to materials used for the Test of Functional Health Literacy in Adults (TOFHLA) which was the model for our Oral Health Literacy Instrument (OHLI). The OHLI contains reading comprehension and numeracy sections. The reading comprehension section is a 38-item test with words omitted from one passage on dental caries and another on periodontal disease. The numeracy section has 19 items to test comprehension of directions for taking common prescriptions associated with dental treatment, postextraction instructions and dental appointments. We also developed a 17-item oral health knowledge test. The OHLI, the TOFHLA, the oral health knowledge test and a brief questionnaire were administered to a convenience sample of 100 patients. Internal reliability of OHLI was assessed with Cronbach's alpha. Test-retest reliability was examined by intra-class correlation coefficient (ICC). Concurrent validity was tested by comparing OHLI scores across categories of education level and frequency of dental visits. Construct validity was assessed by correlating OHLI scores with TOFHLA scores and with the oral health knowledge scores using Spearman's rho (rho) and multiple linear regression.

RESULTS

Participants averaged 39 years (SD = 12.4); 73% were female; 64% had college/university education; 40% visited a dentist every 3-6 months. Total OHLI and TOFHLA weighted mean scores were 87.2 and 91.7, respectively (possible range 0-100). The Cronbach's alpha values were high (>0.7) for OHLI and its components. The ICC values indicated good agreement between the test and retest results for OHLI and the oral health knowledge test. Patients visiting a dentist every 3-6 months had significantly higher levels of oral health literacy than those visiting only when they felt pain. The association between OHLI and education level was not significant. OHLI scores were significantly correlated with the scores on the TOFHLA (rho = 0.613) and the test of oral health knowledge (rho = 0.573). These associations remained significant in multiple regression models.

CONCLUSION

Initial testing of OHLI suggested that it is a valid and reliable instrument to evaluate oral health literacy among adults, although additional work is needed to investigate the instrument's predictive validity and sensitivity to change using oral health outcomes with population groups known to be at high risk of low functional oral health literacy.

Health literacy in an adult dental research population: a pilot study

OBJECTIVE

The purpose of this investigation was to gather data concerning the level of health literacy in adults who frequently volunteer for our clinical research programs.

METHODS

A convenience sample of 99 adults was recruited from our database of subjects taking part in an ongoing series of investigations. Health literacy was measured using the Short Test of Functional Health Literacy in Adults (S-TOFHLA). Additional demographic and socioeconomic data were collected by means of a questionnaire.

RESULTS

The results indicated that 13 percent of the cohort of subjects scored in the "inadequate" or "marginal" categories as described by the criteria of the S-TOFHLA. Inadequate or marginal health literacy was associated with race, gender, and age. Unfortunately, the sample size was too small to determine the interaction of these variables.

CONCLUSIONS

Dental faculty conducting clinical research investigations should be cognizant of the fact that a portion of adults, especially older adults, may have difficulty reading written instructions, informational letters of consent, prescriptions, and other documents. Researchers should make every effort to ensure that information provided in text form is provided in a manner that is easily understandable to the reader. Technical terminology and jargon should be avoided or if used, it should be explained in plain, simple language. If a potential subject is having difficulty, the investigator is obligated to take the additional time to educate the potential subject using alternative methods.

Oral health literacy: the new imperative to better oral health

Effective communication with patients is the cornerstone of quality dental care and oral health outcomes. Oral health literacy skills are critical to empowering individuals' ability to improve their oral health. A large part of the American public has low health literacy skills. Low health literacy contributes to disease and is costly. Being able to understand health information and how to obtain services is critical to oral health management. The communication skills of the dental team are pivotal to increasing oral health literacy skills of Americans.