Oral health literacy: An approach to end oral health disparities

Amandeep Chopra; NC Rao; Nidhi Gupta; Shelja Vashisth

doi:10.4103/0976-433X.116834

| Users Online: 568

REVIEW ARTICLE

Year : 2013 | Volume : 4 | Issue : 1 | Page : 16-20

Oral health literacy: An approach to end oral health disparities

Amandeep Chopra, NC Rao, Nidhi Gupta, Shelja Vashisth
Department of Public Health Dentistry, Swami Devi Dyal Hospital and Dental College, Golpura, Barwala, Haryana, India

Date of Web Publication

22-Aug-2013

Correspondence Address:
Amandeep Chopra
Department of Public Health Dentistry, Swami Devi Dyal Hospital and Dental College, Golpura, Barwala, District Panchkula, Haryana
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/0976-433X.116834

Abstract

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. Studies have revealed that literacy skills are strong predictor of individual's health status than age, income, employment status, education level, and racial or ethnic group. Dentist and dental staff are in unique position to help patients with low oral or general health literacy, thus empowering them to play active role in their oral healthcare. This review article introduces some of the key concepts and practical aspects of oral health literacy.

Keywords: Communication, literacy assessment, oral health literacy

How to cite this article:
Chopra A, Rao N C, Gupta N, Vashisth S. Oral health literacy: An approach to end oral health disparities. SRM J Res Dent Sci 2013;4:16-20

How to cite this URL:
Chopra A, Rao N C, Gupta N, Vashisth S. Oral health literacy: An approach to end oral health disparities. SRM J Res Dent Sci [serial online] 2013 [cited 2023 Jun 3];4:16-20. Available from: https://www.srmjrds.in/text.asp?2013/4/1/16/116834

Introduction

Oral health is an integral part of overall health and well-being. ^[1] It represents far more than a healthy mouth, a pleasing smile, and freedom from pain and infection. It also contributes positively to self esteem and personal success. ^[2] US Surgeon General has referred to dental and oral diseases as a "silent epidemic" affecting our most vulnerable citizens (which includes populations with lower incomes and less education, the uninsured and underinsured, the elderly, and racial and ethnic minorities). Oral diseases are common because people often do not adopt practices that have been scientifically shown to be effective in maintaining oral health. Other contributing factors includes limited access to care, limited funds, or low health literacy. ^[1],[2],[3] Studies have revealed that literacy skills are strong predictor of individual's health status than age, income, employment status, education level, and racial or ethnic group. ^[4] This review focuses on oral health literacy, which is considered to be important determinant of health.

Health literacy is defined as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions." ^[5] This includes people's ability to read, understand, and act on articles and magazines about oral health and general health prevention, decipher dosage charts, understand appointment slip, doctor's directions, and complete medical, dental or insurance forms. ^[2],[6] Individuals with limited health literacy are likely to encounter difficulties navigating the dental healthcare system and managing their oral health. ^[7],[8]

The literacy barrier to oral health has been largely invisible until recently because it was seldom recognized and poorly understood and many healthcare providers could not address the literacy needs of their patients. ^[2] Oral health literacy, as defined by Healthy People 2010, 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." ^[6],[9],[10] Study conducted by American Dental Hygienists' Association (ADHA) and Institute of Medicine (IOM) committees on oral health, which comprised of dental hygienists, dentists, nurses, physicians, epidemiologists, and health promotion experts revealed that patient's literacy is a factor to be evaluated to determine a patient's level of general or oral health risk. ^[11] Dentist and dental staff are in unique position to help patients with low oral or general health literacy, thus empowering them to active role in their oral healthcare. Research is going on to study the effect of low oral health literacy in different clinical settings and on different clinical outcomes (including prescription, treatment, and recovery) and developing instruments to aid in identification of those who struggle with literacy and how to achieve oral health literacy on individual and community bases.

Effect of Health Literacy on Treatment Outcomes

Basic literacy is fundamental to the success of each patient provider interaction - every prescription, every treatment, and every recovery. ^[12] The poor literacy can impede one's ability not only to seek out needed health information but also helps to process, understand, and use it to make appropriate healthcare decisions. ^[13] Limited health literacy has been associated with a range of adverse health outcomes which include the following:

Decreased use of preventive health services: Patients with limited health literacy do not understand instructions or importance of prevention and/or know the signs and symptoms of disease that should motivate people to action. These includes decreased use of preventive health services such as immunizations and cancer screenings. ^[12],[13]
Poorer disease-specific outcomes for certain chronic conditions - Patients who have insufficient health literacy levels have less knowledge about their chronic medical conditions and are less able to manage the conditions. ^[14]
Increased risk of hospitalization and mortality^[15] - Patients with low health literacy levels are more prone to make medication errors due to misinterpretations of drug label instructions or a lack of knowledge of dosing methods or measurements. ^[16],[17]
Impact on child health outcomes - Children with parents or caregivers who have low health literacy scores are more likely to be hospitalized, engage in more risky health behaviors, and have less desirable health outcomes both in dental and medical situations. ^[6],[18]

Signs of Limited Health Literacy

Various signs that can be looked in patient with limited health literacy include the following:

Little or no interest in written documentation, such as pamphlets or health history forms. The patient will often express frustration or impatience when encouraged to use printed materials. ^[6]
Take long time filling out forms and return them incompletely or incorrectly completed.
Patients may ask to take paperwork home to complete.
Patients may say that they forgot their glasses at home. ^[12],[19]
Poor readers may show signs of nervousness, confusion, frustration, or even indifference and withdraw from situations where their reading difficulties may be noticed. This includes holding paper very close to eyes, eyes wandering over the page rather than focusing on one area, and looking at the pills inside the bottle rather than reading the label when describing purpose of purpose of medication. ^[20],[21]
Patients may always bring a friend or family member to appointments to complete paperwork. ^[6]

Health Literacy Assessment Tools

Observing a patient with low reading ability for various signs allows the dentist to offer the assistance a patient needs without causing any shame or discomfort. Various health literacy tools can be important in assessing patient literacy but cannot be used ideally in practice as these may cause discomfort, alienation, and shame to the patient. ^[22] There has been no medical or dental test available that comprehensively measure a person's reading fluency, vocabulary, ability with numbers, oral and written communication skills, and his or her capacity to meet the demands placed on these abilities by the healthcare system. ^[23] However, valid and reliable instruments are available to measure key aspects of these literacy skills.

The health literacy assessment tools most commonly used in medical practice includes the following:

REALM (Rapid Estimate of Adult Literacy in Medicine) (1991) - Word recognition test. ^[23]
REALM (1993) - Shortened version of REALM. ^[24]
Test of Functional Health Literacy in Adults (1995) - Reading comprehension and numerical ability. ^[25]
NVS (Newest Vital Sign) (2005) - Literacy and numeracy skills. ^[26]

The concept of health literacy is new in dental practice and the important tools that have been developed to assess health literacy [Table 1].

Table 1: Important tools to access oral health literacy

Click here to view

These assessment tools can be safely administered in research settings in which the patients are informed of the purpose of the study and give consent, but are not currently recommended as regular screening techniques. ^[22]

Barriers in Health Literacy

The most vulnerable population to oral health literacy challenges are children, elderly (>65 years), minority, immigrant, low income, and people with chronic mental and/or physical health conditions. ^[2]

"The biggest barrier is realizing it is not just about reading and writing about health. It is a social issue. We must assume that everyone has some limited health literacy. An estimated 88% of adults- almost all of us-do not have the health literacy skills to proficiently interact with the healthcare system."-

Andrew Pleasant (Director of Health Literacy and Communication at the Canyon Ranch Institute). ^[31]

The various barriers include the following:

Overestimation of patients' literacy levels by health professionals that cause failure to recognize patients at risk of low literacy. This presents a barrier to effective communication and can be detrimental to a positive treatment outcome. This includes the use of medical and technical communications in public communications and the inclusion of statistics or terms that patient find confusing to explain risk. ^[31]
Stress and illness are other contributing factors that hamper the patient's ability to read, understand, or remember a health provider's advice. ^[21]
Aging can contribute to limited health literacy. This can be attributed to loss of visual, auditory, or mental acuity in the aged population which in turn limits patient's health literacy levels. ^[20]
Language barrier can also limit patient health literacy levels. Patient finds it easier to communicate in native language. The communication process will be hindered if that language is not the language of healthcare provider. ^[6]
Cultural difference such as showing deference and politeness to those who are perceived as authority figures, such as healthcare providers can act as a barrier. There is limited targeting of information and interventions to diverse cultural preferences and practices. ^[31],[32]

Improving Oral Health Literacy

Role of Communication: Many factors can affect a person's ability to read, comprehend, and use information. Communication is one of the important parameter that can help in improving literacy. Achieving clear communication with patients involves the following:
1. The amount of information initially given to dental patients and public should be limited to what the patient needs to know as opposed to what is good to know. This includes limiting the number of messages delivered at one time, which in turn will reduce the informational burden and make the communication more effective. ^[33]
2. Use simplified language with patients with low health literacy by trying to define technical terms and instructions in lay language, e.g., cavities as opposed to caries or gum disease as opposed to periodontal disease. ^[6],[34]
3. The Teach-Back Technique can be a useful tool to ensure that a patient understands the instructions from a healthcare provider. The patient is asked to explain to dentist a procedure or concept he/she has just tried to explain to them. ^[7]
4. Consider culture and language: Culture influences how people communicate, understand, and respond to health information. So, it is necessary to encourage and develop educational opportunities for increased cultural competence. ^[35]
5. Maintain a "shame-free" environment; this includes patients should be offered assistance and staff should never try to single out patients they believe have low health literacy skills. ^[36]
Receive health literacy training: Dentist should receive training, which should include how to collect assessment data, when and how to use interpreters, and how to engage in cross-cultural and clear communication. ^[35]
Educate all team members within the organization to recognize and respond appropriately to patients with literacy and language needs.
Use supplemental interventions where appropriate, like models, pictures, and short videos to explain treatment and preventive procedures. ^[1],[12]

Conclusion

Oral health literacy is a new subject, which is fundamental for success of patient-provider interaction to achieve successful clinical outcome. It enhances the patients' role in their own healthcare. As a health professional, dentists have a responsibility to ensure that health information and service provided are easily understandable, accessible, and people are able to comprehend and apply these recommendations.

The relationship between oral health literacy and oral health disparities is only beginning to be explored. There is need for further research to understand the scope of oral health literacy, its implication in different clinical setting, and various cultural and language challenges patients face and developing remedies to address them.

References

1.	National Institute of Dental and Craniofacial Research, National Institute of Health, U.S. Public Health Service, Department of Health and Human Services. The invisible barrier: Literacy and its relationship with oral health. A report of a workgroup sponsored by the National Institute of Dental and Craniofacial Research, National Institute of Health, U.S. Public Health Service, Department of Health and Human Services. J Public Health Dent 2005;65:174-82.
2.	Reardon GT. Low oral health literacy: An elusive dream or dentistry′s target for advocacy? Compendium 2010;31:184-9.
3.	Kirsch I, Jungeblut A, Jenkins L, Kolstad A. Adult literacy in America. Washington, DC: US Department of Education, 1993. Available from: http://nces.ed.gov/pubs93/93275.pdf [Last accessed on 2012 Oct 06].
4.	Health literacy: Report of the Council on Scientific Affairs. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association. JAMA 1999;281:552-7. [PUBMED]
5.	Ratzan SC, Parker RM. Introduction. In: Selden CR, Zorn M, Ratzan SC, Parker RM, editors. National Library of Medicine Current Bibliographies in Medicine: Health Literacy. Bethesda: National Institutes of Health; 2000. p. 5-8.
6.	Schiavo JH. Oral health literacy in the dental office: The unrecognized patient risk factor. J Dent Hyg 2011;85:248-55. [PUBMED]
7.	Horowitz AM, Kleinman DV. Oral health literacy: The new imperative to better oral health. Dent Clin North Am 2008;52:333-44. [PUBMED]
8.	Macek MD, Haynes D, Wells W, Bauer-Leffler S, Cotton PA, Parker RM. Measuring conceptual health knowledge in the context of oral health literacy: Preliminary results. J Public Health Dent 2010;70:197-204.
9.	U.S. Department of Health and Human Services. Healthy People 2010. Washington, DC: U.S. Department of Health and Human Services, January; 2000. Available from: www.health.gov/healthypeople/ [Last accessed on 2012 Oct 06].
10.	U.S. Department of Health and Human Services. Oral health in America: A Report of the Surgeon General. U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000. Available from: http://profiles.nlm.nih.gov/ps/access/NNBBJV.pdf [Last accessed on 2012 Oct 06].
11.	Standards of Clinical Dental Hygiene Practice. American Dental Hygienists′ Association. 2008. Available from: http://www.adha.org/downloads/adha_standards08.pdf [Last accessed on 2012 Oct 06].
12.	Barrow SL. Health literacy: Why is it important? Access 2012;26 (1):20-2.
13.	Jones M, Lee JY, Rozier RG. Oral health literacy among adult patients seeking dental care. J Am Dent Assoc 2007;138:1199-208. [PUBMED]
14.	Gazmararian JA, Williams MV, Peel J, Baker DW. Health literacy and knowledge of chronic disease. Patient Educ Couns 2003;51:267-75. [PUBMED]
15.	Hironaka LK, Paasche-Orlow MK. The implications of health literacy on patient-provider communication. Arch Dis Child 2008;93:428-32. [PUBMED]
16.	Wolf MS, Davis TC, Shrank W, Rapp DN, Bass PF, Connor UM, et al. To err is human: patient misinterpretations of prescription drug label instructions. Patient Educ Couns 2007;67:293-300. [PUBMED]
17.	Yin HS, Mendelsohn AL, Wolf MS, Parker RM, Fierman A, van Schaick L, et al. Parents′ medication administration errors: Role of dosing instruments and health literacy. Arch Pediatr Adolesc Med 2010;164:181-6. [PUBMED]
18.	DeWalt DA, Hink A. Health literacy and child health outcomes: A systematic review of the literature. Pediatrics 2009;124:S265-74. [PUBMED]
19.	Hasnain-Wynia R, Baker DW. Obtaining data on patient race, ethnicity, and primary language in health care organizations: Current challenges and proposed solutions. Health Serv Res 2006;41:1501-18. [PUBMED]
20.	Baker DW, Parker RM, Williams MV, Pitkin K, Parikh NS, Coates W, et al. The health care experience of patients with low literacy. Arch Fam Med 1996;5:329-34. [PUBMED]
21.	Cornett S. Assessing and addressing health literacy. Online Journal of Issues in Nursing. 2009. Available from: http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/No3Sept09/Assessing-Health-Literacy-.html [Last accessed on 2012 Oct 06].
22.	Paasche-Orlow MK, Wolf MS. Evidence does not support clinical screening of literacy. J Gen Intern Med 2008;23:100-2. [PUBMED]
23.	Baker DW. The meaning and the measure of health literacy. J Gen Intern Med 2006;21:878-83. [PUBMED]
24.	Davis TC, Crouch MA, Long SW, Jackson RH, Bates P, George RB, et al. Rapid assessment of literacy levels of adult primary care patients. Fam Med 1991;23:433-5. [PUBMED]
25.	Davis TC, Long SW, Jackson RH, Mayeaux EJ, George RB, Murphy PW, et al. Rapid estimate of adult literacy in medicine: A shortened screening instrument. Fam Med 1993;25:391-5. [PUBMED]
26.	Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults: A new instrument for measuring patients′ literacy skills. J Gen Intern Med 1995;10:537-41. [PUBMED]
27.	Sabbahi DA, Lawrence HP, Limeback H, Rootman I. Development and evaluation of an oral health literacy instrument for adults. Community Dent Oral Epidemiol 2009;37:451-62. [PUBMED]
28.	Gong DA, Lee JY, Rozier RG, Pahel BT, Richman JA, Vann WF Jr. Development and testing of the test of functional health literacy in dentistry (TOFHLiD). J Public Health Dent 2007;67:105-12. [PUBMED]
29.	Richman JA, Lee JY, Rozier RG, Gong DA, Pahel BT, Vann WF Jr. Evaluation of a word recognition instrument to test health literacy in dentistry: The REALD-99. J Public Health Dent 2007;67:99-104. [PUBMED]
30.	Lee JY, Rozier RG, Lee SY, Bender D, Ruiz RE. Development of a word recognition instrument to test health literacy in dentistry: The REALD-30--a brief communication. J Public Health Dent 2007;67:94-8. [PUBMED]
31.	Marketing and Communication Strategy Branch in the Division of Health Communication and Marketing, National Center for Health Marketing, Centers for Disease Control and Prevention (CDC). What we know about health literacy. Available from: http://www.cdc.gov/healthmarketing/resources.htm [Last accessed on 2012 Oct 06].
32.	Singleton K, Krause EM. Understanding cultural and linguistic barriers to health literacy. Ky Nurse 2010;58:6-9.
33.	Ong LM, de Haes JC, Hoos AM, Lammes FB. Doctor-patient communication: A review of the literature. Soc Sci Med 1995;40:903-18. [PUBMED]
34.	Words to Watch. Pfizer. Available from: http://www.pfizerhealthliteracy.com/media/WordsToWatch.aspx [Last accessed on 2012 Oct 06].
35.	Andrulis DP, Brach C. Integrating literacy, culture, and language to improve health care quality for diverse populations. Am J Health Behav 2007;31:S122-33. [PUBMED]
36.	Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. Shame and health literacy: The unspoken connection. Patient Educ Couns 1996;27:33-9. [PUBMED]

Tables

[Table 1]

This article has been cited by
1	The relationship between oral health literacy and oral health among nursing students in Chengalpattu district, India: A correlational study
	K Indrapriyadharshini, S Vishnuprasad, J Mahesh
	Journal of Nursing and Midwifery Sciences. 2022; 9(3): 224
	[Pubmed] \| [DOI]

2	Contextual and individual factors associated with oral health literacy in adolescents: A multi-level approach
	Érick Tássio Barbosa Neves,Ramon Targino Firmino,Edja Maria Melo de Brito Costa,Saul Martins Paiva,Fernanda Morais Ferreira,Ana Flávia Granville-Garcia
	Brazilian Dental Journal. 2021; 32(2): 1
	[Pubmed] \| [DOI]