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

Oral health literacy and its association with oral health-related quality of life amongst pregnant women: a cross-sectional study

PURPOSE

This study aimed to evaluate the association of oral health literacy (OHL) and oral health-related quality of life (OHRQoL) of pregnant women.

METHODS

This cross-sectional study evaluated a representative sample of pregnant women assisted in public health services in southern Brazil. Demographic, socioeconomic, psychosocial and behavioural data were collected through structured questionnaires. The Oral Health Impact Profile (OHIP-14) questionnaire was used to evaluate the OHRQoL. The Brazilian Rapid Estimate of Adult Literacy in Dentistry (BREALD-30) was used to measure OHL. Dental caries and gingival bleeding were evaluated by clinical examinations. Adjusted multilevel Poisson regression models with a hierarchical approach were used to assess the associations. The results are presented as rate ratio (RR) and 95% confidence interval (95% CI).

RESULTS

A total of 520 pregnant women were evaluated. Pregnant women with lower levels of OHL presented overall OHIP-14 scores 14% higher (RR 1.14; 95% CI 1.07-1.22) than their counterparts. High household income and high education level were related to low overall OHIP-14 scores. Furthermore, less dental attendance, low social support, untreated dental caries and gingival bleeding were also associated with high overall OHIP-14 scores.

CONCLUSION

Our findings reinforce that health literacy levels influence patient-reported outcomes. Pregnant women with lower OHL were more likely to present poorer OHRQoL.

eHEALS as a predictive factor of digital health information seeking behavior among Brazilian undergraduate students

This study aimed to perform the cross-cultural adaptation and validation of the eHealth Literacy Scale (eHEALS) for Brazilian Portuguese. The cross-cultural adaptation was conducted through conceptual equivalence, verbatim translation, semantic, item and operational equivalence, and back-translation. Subsequently, 521 undergraduate students answered the adapted version of the eHEALS, the General Perceived Self-Efficacy Scale (GSES), the Oral Health Impact Profile-14 (OHIP-14) and sociodemographic and health-related questions. Statistical analysis was performed to determine the dimensionality, internal consistency, stability and concurrent/convergent/discriminant/predictive validities of the eHEALS (p < 0.05). The adequacy of sample size was confirmed by a non-identity correlation matrix (Bartlett's test of sphericity, p < 0.001), without influence of multicollinearity (determinant = 0.026). The confirmatory factor analysis identified four factors in agreement to the constructs namely as online searching self-efficacy, awareness of available sources, information usage ability, and critical analysis of useful information. The eHEALS displayed an excellent internal consistency (Cronbach's alpha = 0.88), a good stability (ICC = 0.71, 95% CI: 0.49-0.84), and it was significantly correlated with GSES (concurrent validity). Higher eHEALS scores were identified among (i) white and (ii) younger students, (iii) from health sciences courses, (iv) with more years of graduation, (v) who their fathers were working in specialized functions (discriminant validity), and (vi) among those who were frequently interested in digital health information (convergent validity). The students with higher eHealth literacy levels were more likely to seek health information in the last 24 h (predictive validity). In conclusion, the eHEALS demonstrated adequate psychometric properties to be applied for the Brazilian population.

The influence of different dimensions of oral health literacy on parental attitudes and comprehension of an information leaflet about permanent tooth avulsion

BACKGROUND/AIM

Permanent tooth avulsion requires proper management at the time of the accident and parental oral health literacy (OHL) may influence decision-making with regards to dental trauma. The aim of this study was to investigate the influence of OHL on: (1) self-rated comprehension of an information leaflet (IL), (2) self-rated capacity to execute the tasks proposed on the IL, and (3) attitudes regarding the avulsion of a permanent tooth in children.

MATERIAL AND METHODS

A longitudinal study was conducted involving the reading of an IL by 466 parents/caregivers. Evaluations were performed prior to the IL (Phase I), immediately after the application of the IL (Phase II) and 60 days after the application of the IL (Phase III). Self-rated comprehension and capacity to execute the proposed tasks were analyzed in Phase II. Attitude was evaluated in all three phases. Functional OHL was measured using the BREALD-30 and interactive OHL was measured using HeLD-14.

RESULTS

Correlations were found between self-rated comprehension and both the OHL/BREALD-30 score (rs = 0.179; p = .012) and OHL/HeLD-14 score (r = 0.258; p < .001). Correlations were also found between the self-rated capacity to execute the proposed tasks and both the OHL/BREALD-30 score (rs = 0.133; p = .047) and the OHL/HeLD-14 score (rs = 0.225; p < .001). Higher BREALD-30 and HeLD-14 scores were associated with a better performance regarding parental attitudes toward permanent tooth avulsion comparing Phases I and II and Phases II and III (p < .05).

CONCLUSIONS

Higher levels of OHL were associated with better parental self-rated comprehension of the IL and the capacity to execute the tasks proposed therein as well as more adequate attitudes regarding the avulsion of a permanent tooth.

Is oral health literacy associated with conceptions of care and behavior related to the prevention of COVID-19?

The aim of the present study was to investigate the impact of oral health literacy (OHL) on conceptions of care and behaviors related to COVID-19. The sample came from two preliminary cross-sectional studies that determined the level of OHL of parents/guardians of six-to-12-year-old children in two major Brazilian cities (Curitiba and Belo Horizonte). Functional OHL was measured using the Brazilian version of the Rapid Estimate of Adult Literacy in Dentistry (BREALD-30) and the Health Literacy Dental Scale (HeLD-14) for the evaluation of interactive OHL. Participants were recruited through e-mail, social media, and telephone contact. The questionnaire on conceptions of care and behaviors related to COVID-19 was created based on the guidelines of the World Health Organization. Two hundred nineteen individuals participated in the study. There was no significant difference in socioeconomic and demographic variables and in the medians of BREALD and HeLD-14 between the two cities (P>0.05). Higher levels of functional OHL were associated with an appropriate conception that individual care affects collective care (P=0.038), but with an inappropriate conception of seeking medical assistance in cases of mild symptoms (P=0.030). Higher levels of interactive OHL were related to social distancing behavior in the city of Curitiba (P=0.049) and in the overall sample (P=0.040). It is concluded that functional OHL was associated with two of the investigated conceptions about COVID-19, while interactive OHL was associated with social distancing behavior. These data may suggest that different dimensions of the OHL can have an impact on different aspects of coping with the pandemic.

Psychometric properties of an oral health literacy scale for people living with diabetes

This study evaluated the construct validity of the instrument Oral Health Literacy among diabetics. A probabilistic random sample of 239 diabetics from an infinite population answered the 10 items of the questionnaire. The structural validity was assessed by confirmatory factor analysis and goodness of fit, chi-square per degrees of freedom ratio (X2/df), comparative fit index (CFI), goodness-of-fit index (GFI), and root-mean-square error of approximation (RMSEA). Internal consistency was estimated by the average variance extracted (AVE) and composite reliability (CR). The scores were dichotomized with the upper limit of the 95% confidence interval as the cutoff point. The three-dimensional model presented good quality parameters (X2 /df = 2.459; CFI = 0.988; TLI = 0.981) and poor RMSEA (0.078). Internal consistency was adequate; AVE for the Access, Understand/appraise, and Apply subscales were 0.831, 0.981, and 0.954 and the CR for these subscales were 0.893, 0.962, and 0.822, respectively. Inadequate literacy ranged from 41.8 to 48.1%. The three-dimensional model identified (access, understand/appraise, and apply) showed structural validity, good internal consistency, and understandability.

Criterion validity of 14-item Health Literacy Scale (HLS-14) questionnaire in Brazilian adults and older people

The objective of this study was to evaluate the criterion validity of the 14-item Health Literacy Scale (HLS-14) in Brazilian adults and older adults. The cross-sectional study performed in an oral health (OH) prospective cohort was conducted in 2017 in Piracicaba, Brazil. The HLS-14 questionnaire was applied to evaluate Health Literacy (HL) by dimensions: Functional literacy (FunL), Communicative literacy (ComL) and Critical literacy (CriL). An evaluation protocol (EP) was proposed to evaluate the criterion validity of HLS-14 considering HL dimensions (FunL: reading of the drug information leaflets; ComL: reading of the medical prescription and CriL: identification of OH conditions). HL (total) was dichotomized by the median in high (≥35 point) or low (&lt;35 point) HL. Kendall’s rank correlation coefficient (p &lt; 0.05) and chi-squared test (p &lt; 0.05) were applied. There was agreement between EP and HLS-14 for FunL (p &lt; 0.01). There was association between high HL, measured through the HLS-14 questionnaire, assessing the reading of the drug information leaflets (p &lt; 0.01) and the need for help to read them (p &lt; 0.01). EP showed association between high HL and being able to read the drug information leaflet (p &lt; 0.01), not needing help to read (p &lt; 0.01), having found in the prescription all the information to take the medicine (p &lt; 0.01) and knowing two or more health and OH information in the educational material (p &lt; 0.01). The HSL-14 questionnaire showed criterion validity to measure FunL, and for some items of ComL and CriL evaluation. HL evaluation in a practical and multidimensional way could have an effect on the communication between health professional and patient, motivation and health outcomes.

Relationship between oral health literacy of caregivers and the oral health-related quality of life of children: a cross-sectional study

Background

Oral health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate oral health decisions. However, scientific evidence about the oral health literacy of caregivers and the children’s oral health-related quality of life. The purpose of this study was to verify the relationship between the level of oral health literacy of caregivers and the children's oral health-related quality of life (OHRQOL).

Methods

This study was conducted with children aged 2 to 4 in Diadema, São Paulo, Brazil. Six hundred thirty children were examined to assess the prevalence of dental caries (dmft index). Parents were interviewed to obtain sociodemographic status, oral conditions, and oral health literacy (OHL). The variable outcome was the children's OHRQOL as assessed by the Early Childhood Oral Health Impact Scale (ECOHIS). We fitted zero-inflated negative binomial regression (ZINB) models to evaluate associations between the study outcome and covariates in terms of PR (Prevalence Ratios), RR (Rate Ratios), and their respective Confidence Intervals (95% CI).

Results

Children's OHRQOL was not associated with OHL. Dental caries had a negative impact on the children's quality of life (p < 0.05). A reduced impact on OHRQOL is also associated with having siblings (PR = 0.70, 95% CI 0.52–0.95). A higher age of the mother reduced OHRQOL impacts (PR = 0.72, 95% CI 0.52–0.98).

Conclusions

The factors associated with children's OHRQOL were the number of siblings, the mothers' age, and dental caries. This study observed no association between parental OHL and children's OHRQOL.

Validation of the Brazilian Oral Health Literacy-Adults Questionnaire

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Validity and reliability of the Portuguese version of the rapid estimate of adult literacy in dentistry: REALD-29 PT

BACKGROUND

Health literacy is a main factor in health for its improvement, allowing the individuals to have a greater capacity to engage and participate in collective health promotion actions. The evaluation of functional health literacy is essential to determine the ability that each individual has to understand basic health information. The present study aimed to perform the translation and cross-cultural adaptation of the Rapid Estimate of Adult Literacy in Dentistry-30 to the Portuguese language and test the reliability and validity of this version.

METHODS

After translation and cultural adaptation, the instrument was applied to a group of individuals that participate in the program Atividade Senior, developed by the municipality of Viseu, Portugal. The final sample was composed by 206 participants that accepted responding to the translated version of the instrument. Statistical validation was accomplished to complete the process and obtain the final instrument. One question was removed for the creation of the final instrument with 29 questions, therefore being named Rapid Estimate of Adult Literacy in Dentistry-29 PT.

RESULTS

The Rapid Estimate of Adult Literacy in Dentistry-29 PT presented good internal reliability. Cronbach's alpha ranged from 0.89 to 0.90 when words were deleted individually. The analysis of test-retest reliability revealed excellent reproducibility. We can verify that the Rapid Estimate of Adult Literacy in Dentistry-29 PT scale for assessment of oral health literacy among older adults presents an acceptable internal consistency, with a global Cronbach´s alpha of 0.894.

CONCLUSIONS

The new scale can be applied to assess oral health literacy among older Portuguese adults, presenting an acceptable internal consistency and is validated to assess oral health literacy and is crucial in epidemiological studies.

Development and validation of a short form of the BOHLAT-P

The authors developed and validated a short form of the Brazilian Oral Health Literacy Assessment Task for Paediatric Dentistry (BOHLAT-P). Data included responses from 200 parents of preschoolers to sociodemographic and oral health service access questions on the BOHLAT-P, the Brazilian Rapid Estimate of Adult Literacy in Dentistry (BREALD-30), and the Brazilian Early Childhood Oral Health Impact Scale (B-ECOHIS). Data on the preschoolers' dental caries experience (ICDAS-II) were also included. An item response theory-based approach was employed to develop the short form, while confirmatory factor analysis evaluated the instrument dimensionality. The validity and reliability of the short form were tested by statistical analysis using BREALD-30, B-ECOHIS, and sociodemographic and dental caries experience data. The short form (BOHLAT-P-30) comprises 30 items, is unidimensional, and presents better model fit estimates (TLI = 0.94; CFI = 0.94; RMSEA = 0.05) than those of the BOHLAT-P. Moreover, BOHLAT-P-30 demonstrated excellent reliability (Cronbach's alpha = 0.91; intraclass correlation coefficient [ICC] = 0.95). BOHLAT-P-30 scores were positively correlated with BREALD-30 scores (r = 0.71), with the number of years of schooling (r = 0.60), and with the number of hours spent reading (r = 0.33). BOHLAT-P-30 scores were negatively correlated with B-ECOHIS scores (r = -0.21), and with the number of teeth with cavitated caries (r = -0.18). After controlling for confounding factors, BOHLAT-P-30 scores were not found to be associated with caries presence, or with the number of teeth with cavitated caries. The BOHLAT-P-30 had properties similar to those of the BOHLAT-P, and proved to be a valid measure to assess the OHL of Brazilian parents.

Attention-deficit Disorder, Family Factors, and Oral Health Literacy

Introduction

Relationships amongst attention-deficit/hyperactivity disorder (ADHD), family factors, and oral health literacy (OHL) in adolescents are unclear. The objective of this research was to investigate whether family environment and signs of ADHD are associated with OHL at the onset of adolescence.

Methods

A cross-sectional study was performed with 448 twelve-year-old adolescents enrolled in schools in Cajazeiras, Brazil. Adolescents responded to an instrument measuring OHL (Brazilian version of the Rapid Estimate of Adult Literacy in Dentistry [BREALD-30]) and a validated questionnaire addressing family cohesion and adaptability (Family Adaptability and Cohesion Scales [FACES III]). Parents and teachers answered subscales of the Swanson, Nolan, and Pelham Questionnaire (SNAP-IV) and a socioeconomic questionnaire. Adjusted Poisson regression analysis was employed for the data analysis (P < .05).

Results

Greater OHL was found in adolescents with higher family cohesion scores (rate ratio [RR], 1.02; 95% confidence interval [CI], 1.01–1.03), those whose mothers had more than 8 years of schooling (RR, 1.07; 95% CI, 1.03–1.12), and those whose families earned more than the Brazilian minimum salary (RR, 1.08; 95% CI, 1.03–1.12). Higher family adaptability scores (RR, 0.99; 95% CI, 0.98–0.99) and more signs of ADHD (teachers’ reports) (RR, 0.95; 95% CI, 0.91–0.99) were associated with lower OHL.

Conclusions

OHL in adolescents was influenced by family adaptability and cohesion, signs of ADHD, maternal schooling, and family income.

Attention-deficit/hyperactivity disorder and oral health literacy exert an influence on the occurrence of dental caries in early adolescence

Little is known regarding the influence of psychosocial factors on dental caries at early adolescence. The study aimed to investigate associations between family environment, attention-deficit/hyperactivity disorder (ADHD) and oral health literacy (OHL) with dental caries experience in early adolescence. A cross-sectional study was conducted with a representative sample of 448 12-year-old adolescents at public and private schools in North-eastern Brazil. Parents/guardians and teachers answered the Brazilian version of the inattention and hyperactivity/impulsivity subscales (SNAP- IV) for the evaluation of ADHD and a sociodemographic questionnaire. An OHL instrument (BREALD-30) and the Family Adaptability and Cohesion Scales (FACES III) were administered to the adolescents. Caries experience (DMFT) was the dependent variable. Data analysis involved Poisson regression with robust variance (α = 5%). Adolescents with more symptoms of ADHD (teachers' reports) (RR: 1.73; 95% CI: 1.31-2.28), those with lower OHL (RR: 1.59; 95% CI: 1.01-2.51), those with a lower family income (RR: 1.38; 95% CI: 1.03-1.83), and those from families with a greater number of residents in the home (RR: 1.18; 95% CI: 1.06-1.31) had greater caries experience. Family adaptability and cohesion were not associated with caries experience. Dental caries experience in early adolescence was influenced by symptoms of ADHD, OHL, and sociodemographic factors.

Cross-cultural adaptation and validation of Malay version of Rapid Estimate of Adult Literacy in Dentistry (MREALD-30) among Orang Asli population in Malaysia

BACKGROUND

The aim of this study was to adapt, translate and validate the Rapid Estimate of Adult Literacy in Dentistry (MREALD-30) instrument for the Orang Asli population in Malaysia.

METHODS

After translation and cross-cultural adaptation, interviews were conducted with 326 participants of the Temuan tribe from village Kampung Tering in Johol, Negeri Sembilan, Malaysia. The instrument's validity was assessed using the scores of MREALD-30, which were compared based on occupation, monthly household income, educational attainment, general literacy, use of dental services, and three dental outcomes. A questionnaire containing socio-behavioral information and validated Malay Oral Health Impact Profile (M-OHIP-14) was also administered. The reliability of the MREALD-30 was assessed by re-administering it to 30 subjects after two weeks. Its correlations evaluated convergent and discriminative validity of MREALD-30 with the level of education and dental visiting habits, monthly household income, respectively. Predictive validity was assessed with M-OHIP-14, while construct validity was evaluated by exploratory factor analysis using the Rasch model.

RESULTS

The internal consistency of the MREALD-30 measured by Cronbach's alpha was 0.89. The test-retest reliability was excellent (ICC 0.95, k = 0.85). MREALD-30 exhibited good construct validity. Rasch analysis showed two factors, and infit mean-square statistics for MREALD-30 were all within the desired range of 0.50-2.0. The discriminant validity and predictive validity were statistically significant (p < 0.05).

CONCLUSIONS

MREALD-30 showed very strong reliability, good construct, discriminant, and predictive validity, but poor convergent validity. Overall, it showed good psychometric properties and can be used in these community settings.

A Systematic Review of Cross-Cultural Adaptation and Psychometric Properties of Oral Health Literacy Tools

The aims of this systematic review were to critically appraise the quality of the cross-cultural adaptation and the psychometric properties of the translated versions of oral health literacy assessment tools. CINAHL (EBSCO), Medline (EBSCO), EMBASE (Ovid), and ProQuest Dissertation and Thesis were searched systematically. Studies focusing on cross-cultural adaptation and psychometric properties of oral health literacy tools were included. The methodological quality of included studies was assessed according to the COSMIN Risk of Bias checklist. Sixteen oral health literacy instruments in 11 different languages were included in this systematic review. However, only seven instruments met the criteria for an accurate cross-cultural adaptation process, while the remaining tools failed to meet at least one criterion for suitable quality of cross-cultural adaptation process. None of the studies evaluated all the aspects of psychometric properties. Most of the studies reported internal consistency, reliability, structural validity, and construct validity. Despite adequate ratings for some reported psychometric properties, the methodological quality of studies on translated versions of oral health literacy tools was mostly doubtful to inadequate. Researchers and clinicians should follow standard guidelines for cross-cultural adaptation and assess all aspects of psychometric properties for using oral health literacy tools in cross-cultural settings.

Family cohesion and attention deficit exert an influence on visits to the dentist in early adolescence

OBJECTIVES

To determine whether family environment, signs of attention deficit/hyperactivity disorder (ADHD) and oral health literacy (OHL) are associated with visits to the dentist in adolescents.

METHODS

A school-based cross-sectional study was conducted with a representative sample of 448 12-year-old adolescents enrolled at schools in the city of Cajazeiras, Brazil. The adolescents answered a validated questionnaire addressing family cohesion and adaptability (FACES III), an OHL measure (Brazilian Rapid Estimate of Adult Literacy in Dentistry [BREALD-30]) and a questionnaire addressing the history of visits to the dentist and previous toothache experience. The parents answered a questionnaire addressing sociodemographic characteristics. Parents and teachers answered the inattention and hyperactivity/impulsivity subscales of the Swanson, Nolan & Pelham (SNAP-IV) questionnaire for the detection of signs of ADHD. Multiple Poisson regression with robust variance was used for data analysis (α = 5%).

RESULTS

The prevalence of having visited a dentist some time in life was higher among adolescents with enmeshed (PR = 1.08; 95% CI: 1.01-1.15) and connected (PR = 1.06; 95% CI: 1.01-1.13) families and those with attention deficit according to parents' reports (PR = 1.09; 95% CI: 1.04-1.14). A family income higher than the Brazilian minimum wage (PR = 1.06; 95% CI: 1.01-1.12) and toothache in the previous six months (PR = 1.05; 95% CI: 1.01-1.11) were also associated with the outcome.

CONCLUSION

Family cohesion and attention deficit according to parental reports influenced visits to the dentist among adolescents. In contrast, OHL was not associated with the outcome.

Association of Oral Health Literacy and School Factors with Untreated Dental Caries among 12-Year-Olds: A Multilevel Approach

Dental caries are a global health problem that affects all age groups and must be considered a public health priority due to its significant financial costs and impact on the quality of life. This study evaluated the association between oral health literacy (OHL), school factors, and untreated dental caries in 12-year-old Brazilian adolescents using a multilevel approach. A population-based cross-sectional study was carried out with 740 adolescents randomly selected from private and public schools in Campina Grande, Brazil. Two dentists were trained and calibrated to diagnose dental caries using the Nyvad index and OHL using the Brazilian Rapid Estimate of Literacy in Dentistry (BREALD-30). The caregivers of the adolescents reported demographic data (sex, skin color, and socioeconomic status). Data of school factors such as the type of school and the school grade retention rate were classified through a 2-step hierarchical cluster analysis to obtain the school environment. A robust multilevel log-linear negative binomial regression for complex samples was performed (p < 0.05). In the analysis, adjusted by individual determinants, nonwhite skin color (RR = 2.20; 95% CI 1.56-3.12), a low socioeconomic status (RR = 1.60; 95% CI 1.09-2.34), a low OHL score (RR = 0.94; 95% CI 0.91-0.98), and low satisfaction with the last dental appointment (RR = 2.25; 95% CI 1.67-3.04) were associated with untreated dental caries. The following factors remained associated with untreated dental caries in the final model: students from an unfavorable learning environment (RR = 2.20; 95% CI 1.27-3.80), nonwhite skin color (RR = 1.92; 95% CI 1.27-2.91), a low socioeconomic status (RR = 1.82; 95% CI 1.12-2.94), a low OHL score (RR = 0.95; 95% CI 0.91-0.98), and low satisfaction with the last dental appointment (RR = 2.07; 95% CI 1.47-2.91). Untreated dental caries in early adolescence were impacted by the school environment, the socioeconomic status, OHL, and the adolescent's satisfaction with the last dental appointment.

The reliability and validity of the Romanian rapid estimate of adult literacy in dentistry (RREALD-30)

OBJECTIVES

This study aimed to translate and adapt the Rapid Estimate of Adult Literacy in Dentistry (RREALD-30) instrument for Romanian urban adults and to test its reliability and validity for oral health literacy studies.

MATERIAL AND METHODS

The study examined urban adult patients (n = 224) who attended the dental school clinic at the Faculty of Dental Medicine, Bucharest. We collected data through face-to-face interviews utilising the REALD-30 instrument. The interviews enquired about the Oral Health Impact Profile (OHIP-14), background characteristics, oral health-related knowledge, visits to dentists and self-rated oral health status. We applied principal component analysis for factor structure and Item Response Theory models to discriminate ability. A structural equation model (SEM) evaluated whether knowledge, perceived oral health, and visits to the dentist mediate the effect of RREALD on OHIP-14.

RESULTS

Of the 224 participants, 113 (50.4%) were males. The internal consistency of the RREALD-30 measured by Cronbach's alpha was 0.88. The test-retest reliability was excellent (Spearman's correlation coefficient 0.98, ICC 0.90). RREALD-30 exhibited good concurrent and predictive validity. SEM demonstrated that RREALD mediated the effect of visits to dentist on OHIP-14.

CONCLUSION

The RREALD-30 proved satisfactory psychometric properties and may serve to evaluate dental health literacy among Romanian adults.

Systematic review of the tools of oral and dental health literacy: assessment of conceptual dimensions and psychometric properties

BACKGROUND

This article aims to provide a description of conceptual dimensions and psychometric properties of the tools of oral and dental health literacy.

METHODS

Two authors in this study conducted electronic searches in the Medline (via PubMed), and Embase databases to find relevant articles from 1990 to present day. Evaluation of the tools was carried out in two parts; general evaluation of the tools using skills introduced by Sørensen et al., and qualitative assessment of psychometric properties using COSMIN checklist.

RESULTS

After reviewing 1839 articles on oral and dental health literacy and evaluating 33 full text articles for eligibility, 21 articles entered the study. The sample size varied from 20 to 1405 subjects and the items of each tool ranged from 11 to 99 items. Of the 21 tools examined, 16 tools were evaluated for word recognition. For the studies examined, the evaluation of COSMIN scores was often fair or good. Of the 21 tools examined, 9 tools at least in one dimension were in the category of "poor", 19 tools were in the category of "fair", 20 tools were in the category of "good", and 4 tools were in the category of "excellent" in at least one dimension.

CONCLUSION

The findings of this study showed that some aspects of oral and dental health literacy are being ignored in the existing tools. Therefore, the authors of present study emphasize on the necessity to design and develop a comprehensive tool and take into account two characteristics of simplicity and briefness for international use.

Socioeconomic status and family functioning influence oral health literacy among adolescents

OBJECTIVE

Evaluate socio-demographic, family and behavioral factors associated with oral health literacy (OHL) in adolescents.

METHODS

Cross-sectional study conducted with adolescents aged 15 to 19 years in Campina Grande, Brazil. Parents/guardians answered a questionnaire addressing socio-demographic data. The adolescents answered validated instruments on family cohesion and adaptability (family adaptability and cohesion evaluation scale), drug use (alcohol, smoking and substance involvement screening test), type of dental service used for last appointment and OHL (Brazilian version of the Rapid Estimate of Oral Health Literacy in Dentistry). Two dentists were trained to evaluate OHL (K = 0.87-0.88). Descriptive analysis was performed, followed by Poisson regression analysis (α = 5%). A directed acyclic graph was used to select independent variables in the study.

RESULTS

The following variables remained associated with better OHL: high mother's schooling level (RR = 1.07; 95%CI: 1.03-1.12), high income (RR = 1.04; 95%CI: 1.01-1.09), white ethnicity/skin color (RR = 1.05; 95%CI: 1.01-1.10), married parents (RR = 1.04; 95%CI: 1.01-1.09), "enmeshed" family cohesion (RR = 1.21; 95%CI: 1.12-1.30), "structured" (RR = 1.06; 95%CI: 1.01-1.12) or "rigid" (RR = 1.11; 95%CI: 1.04-1.19) family adaptability, having more than five residents in the home (RR = 1.07; 95%CI: 1.01-1.14) and having used a private dental service during the last appointment (RR = 1.08; 95%CI: 1.03-1.13).

CONCLUSION

Family functioning and socio-demographic factors influence the level of oral health literacy among adolescents.

Validation for Brazilian Portuguese language of the Hong Kong Oral Health Literacy Assessment Task for Paediatric Dentistry (BOHLAT-P)

BACKGROUND

Oral health literacy (OHL) is associated with oral health outcomes.

AIM

To validate the Brazilian Portuguese version of the Hong Kong OHL Assessment Task for Paediatric Dentistry (HKOHLAT-P).

DESIGN

We performed cross-cultural adaptation of the HKOHLAT-P. A sample of 200 pre-schoolers and caregivers from Campina Grande, Brazil completed the Brazilian HKOHLAT-P (BOHLAT-P), sociodemographic questionnaire, the Brazilian Early Childhood Oral Health Impact Scale (B-ECOHIS), and the Brazilian Rapid Estimate of Adult Literacy in Dentistry (BREALD-30). Child dental caries was assessed. Instrument reliability was measured by internal consistency (Cronbach's alpha) and test-retest (ICC). Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) evaluated dimensionality. Regression models tested associations between BOHLAT-P and exploratory variables (P < .05).

RESULTS

BOHLAT-P demonstrated excellent reliability (Cronbach's alpha = 0.92; ICC = 0.95). BOHLAT-P and BREALD-30 scores (r = .71), number of schooling years (r = .60), and reading hours (r = .34) were positively correlated. BOHLAT-P and B-ECOHIS scores (r = -.22), and BOHLAT-P scores and number of cavitated teeth (r = -.15) were negatively correlated. After controlling for confounding variables, BOHLAT-P scores were not associated with caries or number of teeth with cavitated caries.

CONCLUSION

BOHLAT-P is a valid and reliable instrument to assess the OHL of Brazilian parents.

Development of a Greek Oral health literacy measurement instrument: GROHL

Background

Oral health literacy is an important construct for both clinical and public health outcomes research. The need to quantify and test OHL has led to the development of measurement instruments and has generated a substantial body of recent literature. A commonly used OHL instrument is REALD-30, a word recognition scale that has been adapted for use in several languages. The objective of this study was the development and testing of the Greek language oral health literacy measurement instrument (GROHL).

Methods

Data from 282 adult patients of two private dental clinics in Athens, Greece were collected via in-person interviews. Forty-four words were initially considered and tested for inclusion. Item response theory analysis (IRT) and 2-parameter logistic models assessing difficulty and discriminatory ability were used to identify an optimal scale composition. Internal consistency was examined using Cronbach’s alpha and test-retest reliability was measured using intraclass correlation coefficient (ICC) in a subset of 20 participants over a two-week period. Convergent validity was tested against functional health literacy screening (HLS) items, dental knowledge (DK), oral health behaviors (OHBs), oral health-related quality of life (OHRQoL; OHIP-14 index), as well as self-reported oral and general health status.

Results

From an initial item pool of 44 items that were carried forward to IRT, 12 were excluded due to no or little variance, 10 were excluded due to low item-test correlation, and 2 due to insignificant contribution to the scale, i.e., difficulty parameter estimate with p > 0.05. The twenty remaining items composed the final index which showed favorable internal consistency (alpha = 0.80) and test-retest reliability (ICC = 0.95). The summary score distribution did not depart from normality (p = 0.32; mean = 11.5; median = 12; range = 1–20). GROHL scores were positively correlated with favorable oral hygiene behaviors and dental attendance, as well as HLS, DK and education level.

Conclusion

The GROHL demonstrated good psychometric properties and can be used for outcomes research in clinical and public health settings.

Protocol of the TOHLA instrument: A Test of Oral Health Literacy in Adults

BACKGROUND

A proper measurement instrument is selected based on the suggested use of the instrument, the target concept of measurement, and features of measurement (e.g. internal consistency, reproducibility, content and construct validity, responsiveness, and interpretability). Concerning the design and features of measurement, there are not any adequately specific standards for instrumentation to measure oral health literacy (OHL). The present study proposes a protocol that attempts to fill this gap by introducing the psychometrics of a standard questionnaire which measures OHL.

MATERIALS AND METHODS

The present research employs a methodological design and is carried out in Tehran, with data collected through interviews that are held face to face. The data collection procedure involves a review of the related literature, cognitive interviews, fuzzy Delphi Method, and focal groups with participants with OHL work experience for item generation. The target participants of this research are the Iranian adult population and experts working professionally in different health domains. For qualitative data analysis, the content analysis strategy and in the instrument Psychometrics COSMIN checklist will use.

CONCLUSIONS

Achievement of the present research will be used to evaluate the capability of the Iranian adult population in searching, processing, and deciding on healthcare services. This instrument will focus on evaluating both clinical and nonclinical settings. The present research can vastly improve our knowledge of the state of OHL in the Iranian adult population.

Validation of the Health Literacy in Dentistry scale in Brazilian adults

OBJECTIVES

To perform cross-cultural adaptation and validation of the Health Literacy Dental scale (HeLD) in Brazilian adults.

METHODS

The HeLD instrument was translated and cross-culturally adapted to the Brazilian Portuguese language to create longer (HeLD-29) and shorter (HeLD-14) versions. The reliability and validity of these versions were assessed in a sample of 603 adults living near six primary care units in the city of Piracicaba, São Paulo, Brazil.

RESULTS

Both versions of HeLD demonstrated high internal reliability, acceptable convergent validity and discriminant validity. However, the confirmatory factor analysis showed that only HeLD-14 demonstrated satisfactory goodness of fit. There were associations between HeLD-14 scores and social demographic characteristics, general and oral health and oral health-related behaviours. Higher scores were observed for the total HeLD-14 and/or individual components of HeLD-14 among women, ethnic white subjects, those with high educational attainment, those with higher income, those reporting toothbrushing twice or more daily, regular dental attenders, those who usually attended for dental care for a check-up, those with excellent or very good self-ratings of general health, those with excellent or very good self-ratings of oral health, and those without tooth extraction and oral health impact.

CONCLUSION

The Brazilian version of HeLD-14 was demonstrated to be a reliable and valid instrument for measuring broad aspects of oral health literacy in the adult Brazilian population.

Adolescents with worse levels of oral health literacy have more cavitated carious lesions

The aim of the present study was to investigate whether the ability to recognize and read oral health terms is associated with the number of teeth with cavitated carious lesions in adolescents. A population-based cross-sectional study was conducted involving a sample of 746 adolescents representative of students aged 15 to 19 years at the public and private school systems in a city in northeast Brazil. Two examiners who had undergone a training and calibration exercise (inter-examiner and intra-examiner Kappa coefficient: 0.87 to 0.93) performed the diagnosis of caries using the Nyvad Index and evaluated the level of OHL (BREALD-30) of the adolescents. The participants answered questions regarding their history of visits to the dentist and the parents/caregivers answered a questionnaire addressing socioeconomic characteristics. A directed acyclic graph was created to direct the selection of covariables for adjustments in the Poisson multiple regression analysis to test the association between dental caries and OHL (α = 5%). Cavitated carious lesions (codes 3 to 6 on the Nyvad index) were found in 41.6% of the adolescents. Only 29.4% had a high level of OHL (BREALD-30 scores between 23 and 30); 42.3% of the families belonged to the A-B social class and 93% of the adolescents had been to the dentist at least once in their lifetimes. In the multivariate analysis, adolescents with inadequate (PR: 1.69; 95% CI: 1.18–2.41; p = 0.004) and marginal (PR; 1.42; 95% CI: 1.01–1.99; p = 0.042) OHL and those in the lower social classes (C-D-E) (PR: 1.85; 95% CI: 1.39–2.47; p<0.001) had more teeth with cavitated carious lesions. In conclusion, adolescents aged 15 to 19 years with poorer levels of OHL had a larger number of teeth with cavitated carious lesions, independently of their socioeconomic status and history of visiting a dentist.

Psychometric properties of BREALD-30 for assessing adolescents' oral health literacy

OBJECTIVE

To evaluate the psychometric properties of the Brazilian Portuguese version of the Rapid Estimate of Adult Literacy in Dentistry (BREALD-30) administered to adolescents.

METHODS

The study included 750 adolescents: 375 aged 12 years and 375 aged 15–19 years, attending public and private schools in Campina Grande, state of Paraíba, Brazil, in 2017. Reliability was measured based on internal consistency and test-retest reliability. Convergent validity was measured based on correlations between BREALD-30 and Functional Literacy Indicator scores. Divergent validity was measured by comparing BREALD-30 scores with sociodemographic variables. For predictive validity, the association between BREALD-30 scores and the presence of cavitated carious lesions was tested using a multiple logistic regression model. All statistical tests were performed with a significance level of 5%.

RESULTS

BREALD-30 showed good internal consistency for the 12 year olds and 15 to19 year olds (Cronbach’s alpha = 0.871 and 0.834, respectively) and good test-retest reliability [intraclass correlation coefficient (ICC) = 0.898 and 0.974; kappa = 0.804 and 0.808, respectively]. Moreover, item-total correlation was satisfactory for all items. BREALD-30 had convergent validity with the Functional Literacy Indicator for 12 year olds (rs = 0.558, p < 0.001) and for 15 to 19 year olds (rs = 0.652, p < 0.001). Participants with higher oral health literacy levels who attended private schools (p < 0.001), belonged to economic classes A and B2 (p < 0.001), and who had parents with higher education levels (p < 0.001) were included, indicating the divergent validity of the BREALD-30. Participants with lower BREALD-30 scores were more likely to have cavitated carious lesions [12 year olds: odds ratio (OR) = 2.37; 95% confidence interval (95%CI): 1.48–3.80; 15 to 19 year olds: OR = 1.96; 95%CI 1.24–3.11].

CONCLUSIONS

BREALD-30 shows satisfactory psychometric properties for use on Brazilian adolescents and can be applied as a fast, simple, and reliable measure of oral health literacy.

Caregiver’s oral health literacy is associated with prevalence of untreated dental caries in preschool children

Abstract The aim of this study was to evaluate the relationship between oral health literacy (OHL) among caregivers and untreated dental caries among preschoolers. A cross-sectional study was conducted involving 415 preschool children and their caregivers from Curitiba, Brazil. The children were examined for dental caries and dental plaque. The caregivers’ OHL was evaluated using an instrument translated and validated for Brazilian Portuguese: the Brazilian Rapid Estimate of Adult Literacy in Dentistry-30. The prevalence of children with untreated caries was 42.9% (95%CI: 38.1-47.7%). A low degree of OHL was found among 15.7% (95%CI: 12.2-19.2) of caregivers. The multivariable Poisson regression analysis indicated a higher prevalence of untreated caries among children whose caregivers had a low OHL (PR = 1.35; 95% CI: 1.01-1.79), those with visible plaque (PR = 1.28; 95% CI: 1.01-1.62) and those who never or only occasionally had their teeth brushed by their caregivers (PR = 1.48; 95% CI: 1.16-1.91) in comparison to those without these conditions. In conclusion, a higher prevalence of untreated dental caries was found among preschool children whose caregivers had a low degree of OHL.

Evaluation of the psychometric properties of the Brazilian version of the Oral Health Literacy Assessment in Spanish and development of a shortened form of the instrument

OBJECTIVE

The objective of this study was to investigate the psychometric properties of the Oral Health Literacy Assessment in Spanish (OHLA-S) for the Brazilian-Portuguese language using robust analysis and with the results disclose possibilities to develop a shorter and more valid instrument.

METHODS

OHLA-S is an oral health literacy instrument comprising a word recognition section and a comprehension section. It consists of 24 dental words. It was translated into the Brazilian-Portuguese language (OHLA-B) and its psychometric properties were evaluated in a random sample of 250 adults aged 20-59 years. To assess the dimensionality and factor structure were tested by means of Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA). Reliability was assessed using two indicators: Cronbach's alpha and McDonald's Omega.

RESULTS

EFA and CFA demonstrated that the OHLA-B with 24 items did not present an adequate adjustment of the model, compromising its validity. In addition, reliability values at 0.50 for Cronbach's alpha and 0.67 for McDonald's omega were below the minimum acceptable rate of 0.70. As no support was found for the original structure, we decided to proceed with the withdrawal of individual items and successive reanalysis of the model until the indicators were adjusted in a shorter instrument. A new structure with 15 items produced an instrument with two dimensions and a better goodness of fit than the original instrument. The Alpha and Omega reliability index values increased to 0.83 and 0.80, respectively, and all scores were better in the OLHA-B with 15 items than in the instrument with 24 items.

CONCLUSION

OLHA-B with the original structure composed by 24 items did not show acceptable construct validity. The shorter version with 15 items showed more promising results for assessing oral health literacy levels in the Brazilian population.

The Brazilian validation of a health literacy instrument: the newest vital sign

OBJECTIVE

This study aimed to perform the cross-cultural adaptation and validation of the NVS for Brazilian Portuguese.

MATERIAL AND METHODS

Two hundred and fifty adults responded to the adapted version of the NVS, the Brazilian version of the Rapid Estimate of Adult Literacy in Dentistry (BREALD-30), ten questions of the National Functional Literacy Index (NFLI), and a questionnaire about demographic and oral health-related aspects. Statistical analysis determined the internal consistency, stability, difficulty of items, and convergent/discriminant/predictive validities of the NVS. p < .05 was considered significant.

RESULTS

The NVS displayed a good internal consistency (Cronbach's alpha = 0.79) and a fair stability (ICC = 0.57; 0.39-0.70 95% CI). Seventy-two percent of participants answered the easier question (#5) correctly, whereas only 28.4% were successful in responding the most difficult question (#1). The convergent validity of the NVS was demonstrated by its significant correlation with the BREALD-30 (Rs = 0.601, p < .001) and NFLI (Rs = 0.544, p < .001). The observation of higher NVS scores among health professionals, white and more educated people confirmed the discriminant validity of the instrument. Moreover, health literacy was a significant predictor of self-reported oral health and reason for dental utilization.

CONCLUSION

The NVS demonstrated adequate psychometric properties to be applied in Brazilian oral health epidemiological surveys.

Oral health knowledge levels of Hispanics in Iowa

BACKGROUND

Hispanics disproportionately experience preventable oral health conditions in the United States. This study aimed to determine the oral health knowledge (OHK) of Hispanic adults in Iowa to identify potential gaps in knowledge.

METHODS

This cross-sectional study included a convenience sample of self-identifying Hispanic adults. Data pertaining to oral health literacy and demographic, cultural, and dental characteristics were collected. OHK was assessed with the Conceptual Measure of Oral Health Knowledge, and it was categorized as low or high. Bivariate analyses and multiple logistic regression models were conducted to identify the variables related to OHK (P < .05). Institutional review board approval was obtained.

RESULTS

Three hundred thirty-eight participants completed the questionnaire, 68% of participants completed the questionnaire in Spanish, and 51% of all participants had low OHK. Participants were less likely to correctly answer questions pertaining to children's oral health, periodontal disease, and oral cancer. Low OHK was associated with having less than 12th grade education, lack of dental insurance, and preference for a Spanish-speaking oral health care provider.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

OHK appears to be low in this population. Increasing OHK may help decrease oral health disparities and improve oral health outcomes. Furthermore, it is important that oral health care providers have an understanding of barriers that can impede patients' understanding of the health care system. Specifically, minority populations, such as Hispanics, may have a harder time because of certain cultural differences that exist among this ethnic group.

Impact of oral health literacy on self-reported missing data in epidemiological research

OBJECTIVES

To investigate whether oral health literacy (OHL) impacts missing data obtained through self-reporting in oral health epidemiological research.

METHODS

A cross-sectional study was conducted with parents (n = 344) of 4- to 5-year-old children randomly selected from public schools within the city of Curitiba, Brazil. Parental OHL was measured using the Brazilian version of the Rapid Estimate of Adult Literacy in Dentistry (BREALD-30). Parents answered a set of questionnaires comprising 88 items concerning sociodemographic and economic data, children's access to dental services, oral hygiene behaviour, diet and mealtime behaviour. The total number of unanswered items (TUI) and the number of unanswered items in each type of question (open-ended, dichotomous, multiple choice with up to 4 options and with 5-9 options) for each participant was compared across different levels of OHL (chi-squared, Mann-Whitney, Kruskal-Wallis and Spearman's correlation test). Multiple Poisson regression was used to estimate rate ratios (RR) of TUI between OHL scores and their respective 95% confidence interval (95% CI).

RESULTS

Approximately one-third of studied parents (37%) exhibited low OHL (BREALD-30 ≤ 21). The prevalence of missing data in at least one item was 85.5%. Low OHL was associated with failing to respond open-ended items (P = 0.003) and multiple-choice items with up to 4 (P = 0.003) and between 5 and 9 options (P = 0.030). There was a negative correlation between OHL scores and TUI (r = -0.195; P < 0.001), as well as with the number of unanswered items in all types of questions (P < 0.01), except dichotomous questions. Parents with lower OHL were more likely to show higher values of TUI (RR 0.95: 0.93-0.98), when adjusted by income and education.

CONCLUSIONS

Participants with lower OHL were significantly more likely to fail to complete research questionnaires. The impact of OHL on missing data was greater with more complex types of items.

How to Select a Questionnaire with a Good Methodological Quality?

Abstract In the last decades, several instruments have been used to evaluate the impact of oral health problems on the oral health-related quality of life (OHRQoL) of individuals. However, some instruments lack thorough methodological validation or present conceptual differences that hinder comparisons with instruments. Thus, it can be difficult to clinicians and researchers to select a questionnaire that accurately reflect what are really meaningful to individuals. This short communication aimed to discuss the importance of use an appropriate checklist to select an instrument with a good methodological quality. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist was developed to provide tools for evidence-based instrument selection. The COSMIN checklist comprises ten boxes that evaluate whether a study meets the standard for good methodological quality and two additional boxes to meet studies that use the Item Response Theory method and general requirements for results generalization, resulting in four steps to be followed. In this way, it is required at least some expertise in psychometrics or clinimetrics to a wide-ranging use of this checklist. The COSMIN applications include its use to ensure the standardization of cross-cultural adaptations and safer comparisons between measurement studies and evaluation of methodological quality of systematic reviews of measurement properties. Also, it can be used by students when training about measurement properties and by editors and reviewers when revising manuscripts on this topic. The popularization of COSMIN checklist is therefore necessary to improve the selection and evaluation of health measurement instruments.

The Brazilian version of the 20-item rapid estimate of adult literacy in medicine and dentistry

Background

The misunderstanding of specific vocabulary may hamper the patient-health provider communication. The 20-item Rapid Estimate Adult Literacy in Medicine and Dentistry (REALMD-20) was constructed to screen patients by their ability in reading medical/dental terminologies in a simple and rapid way. This study aimed to perform the cross-cultural adaptation and validation of this instrument for its application in Brazilian dental patients.

Methods

The cross-cultural adaptation was performed through conceptual equivalence, verbatim translation, semantic, item and operational equivalence, and back-translation. After that, 200 participants responded the adapted version of the REALMD-20, the Brazilian version of the Rapid Estimate of Adult Literacy in Dentistry (BREALD-30), ten questions of the Brazilian National Functional Literacy Index (BNFLI), and a questionnaire with socio-demographic and oral health-related questions. Statistical analysis was conducted to assess the reliability and validity of the REALMD-20 (P < 0.05).

Results

The sample was composed predominantly by women (55.5%) and white/brown (76%) individuals, with an average age of 39.02 years old (±15.28). The average REALMD-20 score was 17.48 (±2.59, range 8–20). It displayed a good internal consistency (Cronbach’s alpha = 0.789) and test-retest reliability (ICC = 0.73; 95% CI [0.66 − 0.79]). In the exploratory factor analysis, six factors were extracted according to Kaiser’s criterion. The factor I (eigenvalue = 4.53) comprised four terms— “Jaundice”, “Amalgam”, “Periodontitis” and “Abscess”—accounted for 25.18% of total variance, while the factor II (eigenvalue = 1.88) comprised other four terms—“Gingivitis”, “Instruction”, “Osteoporosis” and “Constipation”—accounted for 10.46% of total variance. The first four factors accounted for 52.1% of total variance. The REALMD-20 was positively correlated with the BREALD-30 (Rs = 0.73, P < 0.001) and BNFLI (Rs = 0.60, P < 0.001). The scores were significantly higher among health professionals, more educated people, and individuals who reported good/excellent oral health conditions, and who sought preventive dental services. Distinctly, REALMD-20 scores were similar between both participants who visited a dentist <1 year ago and ≥1 year. Also, REALMD-20 was a significant predictor of self-reported oral health status in a multivariate logistic regression model, considering socio-demographic and oral health-related confounding variables.

Conclusion

The Brazilian version of the REALMD-20 demonstrated adequate psychometric properties for screening dental patients in relation to their recognition of health specific terms. This instrument can contribute to identify individuals with important dental/medical vocabulary limitations in order to improve the health education and outcomes in a person-centered care model.

Reliability and validity of the Turkish version of the Rapid Estimate of Adult Literacy in Dentistry (TREALD-30)

OBJECTIVE

To culturally adapt the Turkish version of Rapid Estimate of Adult Literacy in Dentistry (TREALD-30) for Turkish-speaking adult dental patients and to evaluate its psychometric properties.

MATERIAL AND METHODS

After translation and cross-cultural adaptation, TREALD-30 was tested in a sample of 127 adult patients who attended a dental school clinic in Istanbul. Data were collected through clinical examinations and self-completed questionnaires, including TREALD-30, the Oral Health Impact Profile (OHIP), the Rapid Estimate of Adult Literacy in Medicine (REALM), two health literacy screening questions, and socio-behavioral characteristics. Psychometric properties were examined using Classical Test Theory (CTT) and Rasch analysis.

RESULTS

Internal consistency (Cronbach's Alpha = 0.91) and test-retest reliability (Intraclass correlation coefficient = 0.99) were satisfactory for TREALD-30. It exhibited good convergent and predictive validity. Monthly family income, years of education, dental flossing, health literacy, and health literacy skills were found as stronger predictors of patients'oral health literacy (OHL). Confirmatory factor analysis (CFA) confirmed a two-factor model. The Rasch model explained 37.9% of the total variance in this dataset. In addition, TREALD-30 had eleven misfitting items, which indicated evidence of multidimensionality. The reliability indeces provided in Rasch analysis (person separation reliability = 0.91 and expected-a-posteriori/plausible reliability = 0.94) indicated that TREALD-30 had acceptable reliability.

CONCLUSION

TREALD-30 showed satisfactory psychometric properties. It may be used to identify patients with low OHL. Socio-demographic factors, oral health behaviors and health literacy skills should be taken into account when planning future studies to assess the OHL in both clinical and community settings.