From Volume 41, Issue 7, September 2014 | Pages 605-612
This article introduces the concept of oral health literacy and its potential impact on patient care to the dental team. Factors which influence an individual's level of functional oral health literacy are discussed, along with methods which have been developed to measure it. Finally, public health initiatives to improve oral health literacy are considered, along with measures that individual practitioners can take.
This paper aims to introduce the concepts of health literacy, oral health literacy and its importance to all dental care professionals. The medical profession has recognized the important role that health literacy can play in healthcare outcomes for over a decade. Recognition amongst the dental profession of the link between health literacy and oral health has been more recent, but is now being firmly established and acted upon.
Adequate literacy skills are vital in everyday life to allow a person to function in society. Literacy skills are needed for virtually every aspect of daily life; this includes the ability to access health information and allow an individual to remain in good health. Individuals must be able to understand, process and act upon information in order to manage disease and remain healthy. Literacy does not solely mean one's ability to read information, but also encompasses writing, numeracy, speaking and listening.1 Patients can obtain information relating to both general and oral health from a vast array of sources. This includes written and pictorial material, the internet, television, conversations with healthcare professionals and lay people. The ability to understand information fully in any of the above contexts requires a certain level of literacy. To obtain information from the internet, for example, requires many skills which we probably take for granted. One must first realize that the information is available and be able to use a computer. One must then be able to find the appropriate site, be able to read and comprehend the information and decide if it is valid and reliable. The person must be able to remember the information and use it to make a balanced decision. Someone with low literacy levels is unlikely to be able to carry out all these steps.
When treating patients, we are continuously told to use ‘jargon free’ terms and use diagrams and simple explanations to convey oral health messages and explain disease processes. We can all be guilty of assuming that our patients can understand the information we tell them. Given the importance of patient care in the prevention and management of oral diseases, it is of great importance that we ourselves comprehend the factors that can affect a patient's ability to understand and act upon the information given to him or her.
Health literacy can be 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’.2 This implies that an individual's ability to read, communicate and understand basic health information has a significant effect on his/her health. The above definition is one of functional health literacy, not just the ability to understand information, but also act upon it. It is not, therefore, simply applying general literacy to healthcare settings, but is a set of functional skills which are context specific.3 Obviously, this is an important factor influencing an individual's health. Nutbeam et al proposed three levels of health literacy as depicted in Table 1.4
| Functional health literacy | Basic skills in reading and writing so as to be able to function effectively in a health context. |
| Interactive health literacy | More advanced cognitive, literacy and social skills to participate in healthcare actively. |
| Critical health literacy | The ability to analyse and use information critically to participate in action to overcome structural barriers to health. |
Functional oral health literacy can therefore be defined as ‘The degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make decisions about their oral health’.4 From this definition, it becomes apparent that other factors can influence health literacy besides the patient. The American Dental Association stated that ‘Health literacy is a shared function of individual patient skills, the provider's ability to communicate effectively and accurately and the information demands placed on patients by the healthcare systems’.5 This statement assumes that three areas are important in shaping a person's oral health literacy:
The General Dental Council (GDC) places significant emphasis on effective communication, both during undergraduate training and amongst its registrants. The GDC document Preparing for Practice: Dental Team Learning Outcomes for Registration specifies the outcomes such students must achieve upon graduation in order for them to be eligible to be placed on the appropriate register.6 The learning outcomes are centred around four domains, one of which is communication. The learning outcomes relating to communication can be found in Table 2. This is echoed in the new Standards for the Dental Team document. The second guiding principle in this document is to communicate effectively with patients.7 The document goes further, highlighting the need to provide patients with information in a way that they can understand, in order to make decisions about their oral health.7 To be able to do this effectively, however, requires the healthcare provider to be able to assess the capacity and level of understanding, and thereby the functional health literacy, of the patient. Finally, the importance of the healthcare system, media and healthcare agencies in providing health information in a suitable manner for the patient also becomes evident.4
| Communication Domain | Learning Outcome |
|---|---|
| Patients, their representatives and the public | Communicate appropriately, effectively and sensitively at all times with and about patients, their representatives and the public and in relation to difficult circumstances, such as breaking bad news, or discussing issues such as alcohol consumption, smoking, or diet. |
| Recognize the importance of non-verbal communication, including listening skills, and barriers to effective communication. | |
| Explain and check patients' understanding of treatments, options, costs and informed consent and enable patients to make their choice. | |
| Team and the wider healthcare environment | Communicate appropriately with colleagues from dental and other healthcare professions in relation to: Oral health promotion; The wider contribution which the department/practice makes to dental and healthcare in the surrounding community. |
| Generic communication skills | Communicate appropriately, effectively and sensitively by spoken, written and electronic methods and maintain and develop these skills. |
| Recognize the use of a range of communication methods and technologies and their appropriate application in support of clinical practice. |
One would assume that low literacy levels would be directly related to socio-economic status, but this is not the case. The Partnership for Clear Health Communication found that ‘literacy skills predict an individual's health status more strongly than age, income, employment status, education level, and racial or ethnic group’.8 One might also expect literacy and a person's level of education to be very closely linked, however, this is not always true. In Canada, the International Adult Literacy Survey found that in a third of the population there was a discrepancy between the level of literacy and highest educational qualification, with the former being lower than expected.9 An immigrant may be very well educated, for example, but have poor literacy levels in his/her new country. It is well documented that minority groups tend to have literacy levels below that of the rest of the population and this may, in part, be due to lower education levels and socio-economic status, but other factors may come into play.9 The National Institute of Dental and Craniofacial Research workgroup designed an Oral Health Literacy Framework in the United States (Figure 1). They proposed that culture, society, the education and healthcare systems can all affect a person's oral health literacy. This, is turn, will directly influence an individual's oral health outcomes and costs.1
Health literacy impacts upon all aspects of patient care. It can affect a patient's ability to take medication correctly, follow instructions from a healthcare professional, understand disease-related information and learn about prevention and self management.8 Low health literacy, therefore, can result in incorrect use of medications, poor self management of chronic conditions, improper use of health services and poor health outcomes.9 Obviously, this has a direct impact not only in medicine, but also dentistry. As we well know, most oral diseases are preventable, thus if oral health literacy has such a large impact upon oral health, then we must aim to improve the oral health literacy of the population. This in turn could reduce a patient's incidence of caries and periodontal disease, acute oral infections, and result in early detection and treatment of diseases like oral cancer.
Much of the work relating to health literacy has been carried out in the United States and yielded some interesting findings in several areas of medicine. There is a body of evidence which shows that improving health literacy decreases health disparities.10 People with low health literacy are less likely to seek preventive care, comply with prescribed treatment and maintain the self-care programmes that are required in chronic disease management.4 Studies relating to chronic diseases and health literacy have supported these findings. Schillinger et al found that Type 2 diabetic patients with low health literacy scores were found to have poorer glycaemic control and increased incidence of retinopathy.8 Similarly, Kalichman found that a group of HIV patients with low health literacy were found to have lower CD4 cell counts and an increased incidence of hospitalization due to HIV-related illnesses. This group were also less likely to receive antiretroviral medication and had higher viral loads when compared to patients with higher health literacy.8 Williams et al looked at the relationship between reading ability and asthma knowledge. They discovered that 89% of patients, with a reading level equivalent or less to that expected of an 8-or 9-year-old child, had poor metered dose inhaler technique. This compared to only 48% of patients who could read at the level expected by a 14-year-old child having poor metered dose inhaler technique.8 The Institute of Medicine estimate that 90 million people in the United States have difficulty understanding and using health information. This directly translates into the problems mentioned above relating to disease management. Reardon implies that the impact of health literacy on patient health is second only to genetic factors.11 It is estimated that limited health literacy costs the United States between $100 and $200 billion dollars per year.4
Less work has been carried out in the field of oral health literacy but, interestingly, Jones et al found that 29% of patients seeking dental care in general practice in Carolina had low oral health literacy levels.12 This could mean that nearly a third (or possibly more) of our patients have difficulty understanding and acting upon the information that we give them as General Dental Practitioners, including both verbal and written material. Several studies have been carried out relating to the readability of dental educational materials. Alexander found that the reading levels of 24 patient education documents ranged from 8-to -9-year-old standard up to 28-year-old reading levels, with 41% of the material written at a level higher than that recommended for understanding by most patients.13 Alexander postulated that most patients in the US read at the level of a 12-to 15-year-old, and recommended that educational material reflect this.13
Having established the importance of oral health literacy in the dental setting, how can we assess an individual's oral health literacy?
Initially, tools were developed to measure health literacy in medicine, which were then adapted to measure oral health literacy specifically. The REALM (Rapid Estimation of Adult Literacy in Medicine) test was developed by Davis et al in 1991, which was then adapted by Lee et al and called REALD-30 (Rapid Estimation of Adult Literacy in Dentistry).14 This is essentially a word recognition test. Thirty dental words are listed in order of difficulty, encompassing word length, syllables and sound combinations. The words relate to dental anatomy, aetiology, prevention and treatment.14 The words are taken from the American Dental Association's Glossary of Common Dental Terminology in addition to terms used in dental promotional leaflets. The subject then has to read the words out loud and, for every word they pronounce correctly, they score a point.
The authors found that the scores achieved correlated to the patient's oral health-related quality of life. Interestingly though, the scores did not correspond to the subject's perceived dental health status.14 REALD-30 has limitations as it is only a limited test of reading ability through word recognition.14 The subject only recognizes and pronounces a single word, which is not in any context. Obviously, this is linked to reading ability and possibly exposure to oral health information, but the test does not assess any comprehension of the words. It is only designed to be used as a rapid screening device for word recognition and reading ability and not functional oral health literacy.14 The advantage of the test, however, is that it is quick and easy to administer, therefore can be used in clinical settings.
Following this, the authors went on to develop REALD-99. This is essentially the same test, but containing 99 words instead of 30. The extra 69 words were chosen using the same categories as in REALD-30 and were taken from the same sources.10 The authors hoped that by increasing the number of words in the test, they could assess more components of dental health and hopefully measure dental literacy with greater accuracy.10 They also created a REALD-99 for adults and one for children. A systematic review of literacy and health outcomes by DeWalt et al found that REALM correlated highly with other reading tests.15
Following the development of REALD, and realization of its limitations, another test to determine oral health literacy was developed. This was also adapted from a medical health literacy precursor called TOFHLA (Test Of Functional Health Literacy in Adults). As discussed, the main shortcoming of REALM is that it is purely a word recognition test, and does not assess a person's functional health literacy. This is what ultimately dictates a patient's ability to access and act upon health information and improve his or her health. TOFHLA aims to assess functional health literacy, and is a far more comprehensive test. It consists of a 50 item reading comprehension test, and a 17 item numerical ability test. The comprehension section requires the patient to read and fill in missing words that have been removed from passages relating to preparation for medical procedures and filling in forms. The numeracy section aims to assess the respondent's ability to understand numbers found in instructions for taking medicines, keeping appointments and measuring blood glucose.16
From this template, TOFHLiD (Test Of Functional Health Literacy in Dentistry) was created. The authors designed three comprehension passages about application of fluoride to a child's teeth, consent for treatment and Medicaid rights. The passages then had words omitted and the respondent had to choose from three similar sounding words to fill in the gaps. The numeracy section comprised 12 questions relating to 4 topics. The questions related to instructions for the use of fluoride toothpaste in children of different ages.16 After completion of both sections, the test is scored out of 100.
When this tool was tested, the authors found that people who scored highly in TOFHLiD, also scored highly in REALD. The main disadvantage of this test is that it takes longer to complete. The authors concluded that it should not be widely used in health practice, but does provide a starting point for further research.16 As research in this area is still in its infancy, hopefully a more reliable and practical method of assessing functional oral health literacy will become available in the future.
A person's oral health literacy results from a complex interaction of his/her education, ethnic background, culture and language ability. These factors interact with external forces such as healthcare organizations and policies, available patient information, healthcare professionals and their communication skills, in addition to others. Owing to the multi-dimensional nature of health literacy, no single method will be able to improve a patient's health literacy on its own, but rather multiple methods, each targeting a different aspect, should be used in conjunction with each other.
As previously mentioned, much of the research in this area has been carried out in the United States, where the importance of health literacy has been well recognized for over a decade. The American Dental Association has formulated a Health Literacy in Dentistry – Strategic Action Plan for 2010–2015. The document recognizes the critical role oral health literacy plays in determining oral health outcomes. The Strategic Action Plan aims at improving oral health literacy by targeting the three main areas highlighted in Figure 1. They hope to improve oral health literacy using a variety of methods targeted in several different areas, as highlighted in Table 3.
| Training and Education | Educate the public and policy makers about oral health, and its relationship to overall health. Educate current and future dental care professionals about health literacy and the importance of effective communication. |
| Advocacy | Try and persuade legislators and regulators about health literacy being a priority public health concern, and the need for further funding in this area. |
| Research | Build a growing body of research related to health literacy in dentistry. |
| Dental Practice | Improve communication and patient understanding in dental practice. |
| Build and Maintain Collaborations | Establish health literacy as a priority for dental and other healthcare organizations. |
Obviously, this is a very ambitious, time consuming and expensive proposal, but it does attempt to address the range of factors involved in health literacy. In the UK, the Health Foundation is a charitable organization which aims to improve the quality of healthcare in the UK. In 2006, it published a review document which related to improving health literacy. The findings of the document suggested that little research has been carried out into the prevalence of low health literacy in the UK and its effects. They concluded each different method of health education (eg written material, mass media, website) has its own limitations, but the public do want more information than they currently receive.3
Although national initiatives are crucial to improving health literacy, local strategies have also been implemented and could prove very useful. The Miami Dade College's medical centre has produced a website containing a bibliography of high quality web-based material aimed at adults with limited literacy levels. The website, entitled Oral Health Literacy: An Annotated Bibliography of Materials for People with Limited Literacy Skills, covers a range of topics including dental procedures, prevention advice and medical conditions and oral health. It is also available in four different languages, with each section stating the reading level of the material (www.mdc.edu/medical/library/dentalbib.htm).17
In the UK, although there are no national strategies at present, NHS organizations are beginning to recognize the importance of health literacy. NHS Manchester is keen to develop an ‘Oral Health Curriculum’ with local residents in order to improve the oral health literacy in a local population comprising a multitude of ethnicities and cultures.18 New dental practices opening in the area will also be expected to improve the oral health of their patients and increase their oral health literacy through patient education. NHS Manchester is keen to develop a tool to measure oral health literacy and assess the new practices’ progress.
Dental care professionals play a key role in relation to a patient's oral health literacy. First, we need to be able to acknowledge and ideally assess a patient's level of oral health literacy. Although the instruments discussed in this paper would not be practical to administer to all patients, some investigation into a patient's oral health literacy could be undertaken. How patients fill out their medical history forms may provide an insight into their background knowledge about their medications and general health. Spelling mistakes and incorrect pronunciation of words during the medical history may indicate a low level of health literacy. Asking patients about their previous disease experience and oral hygiene practices might also shed light on their knowledge of oral health and disease. Finally, a questionnaire could be administered to new patients asking them to rate how confident they feel about their knowledge of, for example, tooth decay, gum disease and how to look after their mouth. An individual with low oral health literacy may not even, for example, realize that sugar causes decay and the foods in which it is present. In such circumstances, detailed dietary information would need to be provided in order to make a patient aware of the range of foodstuffs which contain sugar, coupled with realistic advice on how to change the diet to reduce sugar intake and frequency. We then need to be able to communicate effectively and accurately with our patients and create a ‘stress free’ environment, in which patients with low health literacy are not afraid to ask questions and admit not understanding. Tailored information could be given to them using simple language, diagrams and demonstrations, possibly by suitably trained dental nurses away from the dental surgery, which patients may find to be a less intimidating environment.
In order to educate patients effectively and aim to improve their oral health literacy, current practice literature may require redesigning, using more basic language. Alexander highlighted some suggestions relating to dental educational materials.
Such recommendations include substituting larger words for shorter, simpler words, eg discomfort for pain. Other recommendations include using a ‘comic book’ approach, bright colours, simple type faces, and upper and lower case letters.13,19 Hopefully, this article has explained the concept of health literacy and its impact on health, disease management and progression. Health literacy is complex and multiple factors, both internal and external, can directly affect a person's health literacy. Low health literacy is deemed to be a huge problem in the United States, and organizations are taking steps to try and improve the health literacy of the nation. In the UK, we are less certain of the levels of oral health literacy and the effect it has on the population. Dental care professionals have a direct effect on a person's oral health literacy. It is crucial that we communicate effectively and accurately with our patients, at a level which they can understand. In order to do this, we need to have an appreciation of health literacy and its origins and ideally be able to gauge a person's level of health literacy. It is also crucial that we create an environment in which patients are not afraid to ask questions and admit a lack of understanding. Finally, we should evaluate the level of our educational material, and substitute complex words for shorter simpler ones, to make the information understandable to the maximum number of patients.
