Low Oral Health Literacy: An Elusive Dream or Dentistry’s Target for Advocacy?

Gayle Tieszen Reardon, DDS, MA

During the past decade, the medical community has been discussing health literacy and the impact of patient–physician communication on healthcare outcomes. In this same period, leaders in the dental profession have recognized that while dentistry’s focus on oral health education and its promotion—rather than oral health literacy—were laudable, these efforts were less than optimum in reaching at-risk populations.

Oral health is a fundamental and foundational part of an individual’s health and well-being, representing far more than simply a healthy mouth, a pleasing smile, and freedom from pain and infection. It contributes positively to self esteem and personal success. Unfortunately, regular dental care contributing to an optimally healthy mouth is enjoyed by fewer than half of Americans due to personal choice, limited access to care, limited funds, or low oral health literacy.

According to The Invisible Barrier: Literacy and Its Relationship with Oral Health, the literacy barrier to oral health has been largely invisible until recently because it was seldom recognized and poorly understood and many health care providers could not address the literacy needs of their patients. As a result, they presented information without ensuring that their communication was clear and successful. They also tended to use readily available materials that were difficult to understand and left patients reluctant to admit that they did not comprehend the information presented. Many patients also were found to be uncomfortable asking questions or requesting more information.¹

Aware of the need to change the tide, dentistry has made improvements in terms of determining the scope of low oral health literacy and who is affected by it; understanding the financial and health-related burdens placed on care providers and patients; and defining how to achieve oral health literacy on an individual and community basis. Recent reports estimate that the cost of low health literacy of the American public is between $106 billion and $238 billion annually.² This represents as much as 17% of all personal healthcare expenditures. Achieving more than a minimal level of improvement in oral health literacy has required dental professionals to change from the comfortable, individual patient-centered educational and promotional approach to the multifactorial method of individual, cultural, and community factors that affect oral health literacy, risk communication, and improved outcomes.

This article defines oral health literacy and emphasizes its importance and integral relationship with health literacy. Secondly, it describes what has been learned about the demographic characteristics of patient populations that contribute to the gap between knowledge and practice in dentistry. Finally, this article addresses how professionals’ awareness of at-risk population identifiers are improving health and oral health literacy within their sphere of influence by initiating methodologies focused on both decreasing maldistribution and enhancing communication. Clear communication directly contributes to successful healthcare outcomes and patient safety.

Defining Oral Health Literacy and its Significance

According to the American Dental Association, oral health literacy is defined as the degree to which individuals have the capacity to obtain, process, and understand the basic health information and services needed to make appropriate decisions about their oral health. Health literacy is a shared function of individual patient skills, the provider’s ability to communicate effectively and accurately, and the informational demands placed on patients by healthcare systems.³

The 2003 National Assessment of Adult Literacy evaluated the English facility of adults in the United States. This survey revealed that 44% of Americans are able to handle a moderately dense level of text. Another 43% of Americans fall into either a basic level of literacy (29%) or below basic level of literacy (14%). This study demonstrates the vast difference between a complex, difficult-to-navigate healthcare system and a public whose proficiency for understanding health-related information is statistically low. The health literacy scale and health literacy tasks were guided by the definition of health literacy used by the Institute of Medicine (IOM) and Healthy People 2010, which states that 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 health decisions.”⁴

Health literacy is important for all adults, who must be able to read articles and magazines about oral and general health prevention, interpret instructions on prescription bottles and over-the-counter medications, manage the healthcare needs of their children and aging parents, and interpret insurance and Medicare rules, regulations, and benefits. These activities require an ability to read and understand printed materials. Unfortunately, a limited ability to understand medical and dental advice, whether written or spoken, is a problem for patients of all ages, ethnicities, cultures, and educational and income levels. In fact, inadequate levels of health literacy can be seen in well-educated individuals, regardless of income levels.⁵

According to the American Medical Association, poor health literacy is a stronger predictor of an individual’s health than age, income, employment status, educational level, or race. The IOM states that 90 million people in the United States have difficulty understanding and using health information and, as a result, patients often do not take their medications properly, miss follow-up appointments, and do not understand otherwise simple instructions that accompany medications (eg, take on an empty stomach).⁶ This statement infers that the impact of health literacy is second only to genetics in the determination of care outcomes for patients.

The publication of Oral Health in America: A Report of the Surgeon General in 2000 was pivotal in the history of oral health in this country because it alerted healthcare professionals to the full meaning of oral health and the fundamental relationship between oral health and general well-being.⁷ This landmark report also brought attention to the burden associated with oral diseases and disorders, oral health inequalities, how oral health is improved and maintained, and the challenges facing the United States for preventing oral diseases and enhancing the oral health of its diverse population. Today, it is acknowledged that among those challenges is the need to address the problem of low oral health literacy among a diverse population.

Low Oral Health Literacy in a Heterogeneous Population

Healthy People 2010 identifies six population categories as vulnerable for low health literacy (Table 1). It is reasonable to conclude that the same populations are vulnerable to oral health literacy challenges. The report also describes the reasons for limited general literacy skills, including a lack of educational opportunities (ie, people with a high school education or lower), learning disabilities, and cognitive declines as found in older adults. Wong and colleagues reported that, in the United States, people without a high school education lost 9.2 more possible life years per person than individuals who completed high school or more.⁸ Also contributing to limited health literacy skills is the “use it or lose it” phenomenon. Reading abilities are typically three to five grade levels below the last year of school completed. Therefore, people with a high school diploma typically read at a seventh or eighth grade level.

To further understand the populations at risk for low oral health literacy, it is important to note that the United States is currently experiencing a rapid change in demographics. As the French philosopher Auguste Comte stated: “Demography is destiny.” The US Census Bureau estimates that by the year 2030, more than 20% of Americans will be 65 years or older.^9,10 By the year 2045, the number will reach 80 million.¹⁰

Of equal or more significance is growth in the proportion of Americans from racial or ethnic minority backgrounds. The US Census statistics estimate that 30% of Americans represent minority groups. By the year 2010, this number is expected to increase to 35%, and by 2025, the number will approach 40% of the US population.⁹ This means that these groups will become the majority.

As health disparities are well recognized in minority populations as disproportionately contributing to the burden of disease and disability, the social, political, and economic pressures on the dental profession to meet the health challenges of an increasingly diverse society will escalate. Recent research by Garcia et al⁹ suggests that the solutions to meeting these challenges of increased diversity lie in the profession’s willingness to improve its cultural competence and its ethnic diversity, which will, in turn, decrease maldistribution.

Clear communication and successful oral care outcomes
Today, 9 years after Oral Health in America was introduced, oral health is recognized as “central to physical and psychosocial well-being.”^11,12 Numerous researchers in the dental profession recently have undertaken efforts to study how best to communicate with and improve oral health outcomes among low oral health literacy populations.^9,11-14 To enhance the likelihood of positive oral care outcomes, dentistry is developing a greater knowledge of how to interact with patients who have low oral health literacy and are “at risk.”

For example, one research group administered a version of the Rapid Estimate of Adult Literacy in Denstistry-30, a word cognition test.¹² About 29% of 101 participants scored below 22 on a 33-point test, indicating a low literacy level.¹² Another study, the first of its kind, found the skills required to perform health literacy tasks to be different than those required for general literacy tasks. Additionally, the survey disclosed that 30 million adults have a basic level of health literacy skill while another 47 million can perform only the simplest of everyday tasks. Therefore, nearly 80 million adults may directly experience the consequences of low oral health literacy, including unintentional noncompliance, medical error, and poor outcomes.

According to Jones et al, from the perspective of dental care, knowledge about dentistry is separate from an individual’s ability to use and understand oral health information. These researchers determined that the effects of low literacy on dental knowledge are significant and potentially negate the effectiveness of well-intended preventive services due to a lack of understanding. Jones et al have concluded that improvements in the population classified as having low literacy through patient counseling could change the probability of low dental knowledge and poor-to-fair oral health status by 61% and 46%, respectively.

Other recent research has shown that the population with low functional literacy has less ability to understand and care for chronic conditions, fewer self-management skills, lower use of preventive services, and increased use of urgent care services. In addition, they experience more communication difficulties and have less satisfying medical visits, particularly regarding the interpersonal and informational aspects of care.¹⁴ Roter et al have concluded that due to the rigor and demands of medical dialogue and decision-making, patients with low health literacy (or those who are less well educated) are not likely to participate actively in these processes.

Furthermore, the work of Garcia et al has shown that ethnically diverse patients have expressed an overwhelmingly strong preference for ethnically and culturally matched providers.⁹ Patient communication styles can powerfully influence the dentist’s behavior, beliefs, and impressions.¹⁵ Actively involved, culturally matched patients will more successfully engage the providers because they are exhibiting a sincere desire to better understand their health. In turn, providers have a more complete understanding of patients and their needs and desires.

As the research suggests, there is more to oral health literacy than reading and understanding oral health information. Oral heath literacy encompasses the educational, so-cial, and cultural factors that influence the expectations and preferences of the individual and the extent to which those providing dental care services can meet these expectations and preferences. Organized dentistry has come to acknowledge that it is incumbent on dentists and auxiliaries to understand the beliefs, values, cultural mores, and traditions of their patients in order to influence how dental health care information is processed.¹⁶

To this end, the communication skills of the dentist and dental team contribute to a patient’s health literacy, which, in turn, contributes to a patient’s health outcomes.² A key part of clear communication and improving low oral health literacy is the use of plain language. This term refers to communications that engage and are accessible to their intended audiences.¹⁷ Plain language embodies clear communication and offers healthcare professionals an opportunity to make patient-centered clear communication the accepted standard through which necessary policy and resource support can be garnered for broad and sustained diffusion. Using plain language facilitates accessible health communication to become the norm, rather than the exception, in medicine and dentistry.

Equally important to the communication skills of the professionals with whom patients and potential patients interact regarding oral health are the abilities of the media and marketplace to provide health information in a manner responsive to the public’s needs. Therefore, oral healthcare leaders have come to recognize the importance of understanding, creating, and maintaining environments of quality and safety for patients. This environment begins with the increased awareness throughout the organization of the impact of health and oral health literacy, as well as English proficiency and cultural competency, on patient safety. This requires an understanding of the people they serve in terms of ethnic and language diversities, as well as the general literacy level and demographics of the community.

The dental profession is indeed changing the tide and now recognizes that several solutions can be implemented to ensure effective communication becomes a national organizational priority to improve oral healthcare. It is recommended that its leaders and providers:

• Recognize and respond to the changing demographics of dentistry with strong consideration and admission of qualified minority students into dental schools.
• Encourage and develop educational opportunities for increased cultural competence.
• Educate all team members within the organization to recognize and respond appropriately to patients with literacy and language needs.
• Create patient-centered environments that stress the use of clear communication in all interactions with patients, from the first encounter at the reception desk to the last words prior to the patient’s departure.
• Revise all informed consent and educational materials from “professional language” to “plain language” format to foster increased and generalized understanding among all patient populations.
• Develop plans to accommodate patients with special literacy and language needs.
• Use well-trained dental interpreters for patients with low English proficiency or hearing impairments.
• Create an organizational environment of safety and quality that values patient-centered communications as an integral component of the delivery of patient-centered care.
• Reduce the informational burden and more effectively communicate with dental patients and the public.

Conclusion

The dental profession is aware of the communication gap between the abilities of ordinary citizens to comprehend typical oral healthcare information and is working diligently to narrow this gap. Dentistry recognizes the challenge presented by America’s changing demographics and oral health literacy. While much work is ahead, there is a professional framework of awareness and proactivity that will guide the process.

Numerous studies have revealed that the skills required to comprehend and use oral healthcare-related information far exceed the abilities of the average patient seeking care. Intentional–behavioral and cultural learning by dentists and their teams enables caregivers to create an environment designed to increase the likelihood that people with the greatest oral health burden will have access to the health information and services they need.

Committed partnerships between providers and patients create relationships that lead to improved quality and reduced costs of oral healthcare. Outcomes cannot be optimum without simultaneous improvements in health and oral health literacy, cultural competence, and communication. Improvement in individual oral health literacy requires system-wide targeted interventions and advocacy as well as educational and cultural competency.

References

1. National Institute of Dental and Craniofacial Research, National Institutes 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 Institutes of Health, U.S. Public Health Service, Department of Health and Human Services. J Public Health Dent. 2005;65(3): 174-182.

2. Horowitz AM, Kleinman DV. Oral health literacy: the new imperative to better oral health. Dent Clin North Am. 2008:52(2):333-344.

3. American Dental Association. What is oral health literacy? Community Brief. 2007;4(9): 1-2.

4. Kutner M, Greenberg E, Jin Y, et al. The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy. U.S. Department of Education. Institute of Education Sciences National Center for Education Statistics; 2006.

5. American Dental Association. Communication between health care providers and patients: addressing the challenges of limited oral health literacy. A-Z topics: Science in the News; 2007. Accessed November 11, 2009.

6. Williams MV, Parker RM, Baker DW, et al. Inadequate functional health literacy among patients at two public hospitals. JAMA. 1995;274(21):1677-1682.

7. United States Public Health Service, Office of the Surgeon General, National Institute of Dental and Craniofacial Research. Oral health in America: a report of the Surgeon General: executive summary. Rockville, MD: National Institute of Dental and Craniofacial Research; 2000.

8. Wong MD, Shapiro MF, Boscardin WJ, et al. Contribution of major diseases to disparities in mortality. N Engl J Med. 2002;347(20): 1585-1592.

9. Garcia RI, Cadoret CA, Henshaw M. Multicultural issues in oral health. Dent Clin North Am. 2008;52(2): 319-332.

10. U.S. Census Bureau. The 2008 statistical abstract, National Data Book. https://www.census.gov/compendia/statab/past_years.html. Accessed July 20, 2009.

11. Quandt SA, Chen H, Bell RA, et al. Disparities in oral health status between older adults in a multiethnic rural community: the rural nutrition and oral health study. J Am Geriatr Soc. 2009; 57(8):1369-1375.

12. Jones M, Lee JY, Rozier RG. Oral health literacy among adult patients seeking dental care. J Am Dent Assoc. 2007;138(9): 1199-1208.

13. Kutner ME, Greenberg D, Jin Y, et al. The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy. Washington, DC: National Center for Education Statistics, US Department of Education; 2006.

14. Roter DL, Erby L, Larson S, et al. Oral literacy demand of prenatal genetic counseling dialogue: predictors of learning. Patient Educ Couns. 2009;75(3):392-397.

15. Street RL Jr, Gordon H, Haidet P. Physicians’ communication and perceptions of patients: is it how they look, how they talk, or is it just the doctor? Soc Sci Med. 2007;65(3):586-598.

16.“What Did the Doctor Say?:” Improving Health Literacy to Protect Patient Safety. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2007.

17. Stableford S, Mettger W. Plain language: a strategic response to the health literacy challenge. J Public Health Policy. 2007;28(1):71-93.

About the Author

Gayle Tieszen Reardon, DDS, MA
Private Practice
Sioux Falls, South Dakota