By Dushanka V. Kleinman, DDS, MScD, Alice M. Horowitz, PhD
Have you, or members of your staff, ever been asked to clarify a question on your health history form? Has a patient, or their family member, ever called you to clarify your instructions on self-care after a surgical procedure? Has a patient ever asked to take a health history form or educational materials home to read because ‘they don’t have their glasses with them’? If your answer is yes, read on.
What is health literacy and is it a problem in the United States?
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.1-3 The key concepts inherent in this definition are: obtain, process, understand, and act. The 2004 Institute of Medicine report, Health Literacy: A Prescription to End Confusion, estimated that 90 million American adults - nearly half of all adults - have difficulty in understanding and acting on health information.2 The report critically looked at the state of knowledge in health literacy and recommended actions that would lead to a health literate society. Surgeon General Richard Carmona embraced health literacy as one of his top priorities and noted that “Health literacy can save lives, save money, and improve health and well-being of millions of Americans...health literacy is the currency of success for everything I am doing as Surgeon General.”
A recent release of the National Assessment of Adult Literacy (NAAL) survey that included the first health literacy survey conducted in the United States revealed disappointing results.4 The majority of adults - 53 percent - had Intermediate health literacy. Only 12 percent had Proficient health literacy. Of the remaining 36 percent, 22 percent had Basic and 14 percent had Below Basic. Adults 65 and older had lower health literacy as did those who did not complete high school. Further, black, Hispanic, and American Indian/Alaska Native adults had lower health literacy than white and Asian/Pacific islanders. The assessment measured literacy and health literacy through completed tasks. The tasks were developed based on the definition of health literacy used by Healthy People 2010 and the Institute of Medicine and included clinical, prevention, and navigation of the health care system. There were no dental-related tasks, rather they included a range of activities adults face in their daily activities related to health such as buying over the counter medications and understanding health insurance forms. All of these activities are dependent upon the ability to read and understand written and printed materials.
Health literacy is dependent upon both individual and systemic factors. Communication skills of both the patient and the provider are major factors. Primary intervention points to enhance health literacy and make a difference in health outcomes and costs have been identified and include the educational system, culture and society and the healthcare system. It is in the latter area that clinical practitioners have an opportunity to increase oral health literacy.
What about oral health literacy?
Health literacy is a relatively new concept especially in connection with oral health, although clearly promoting and maintaining oral health requires a close partnership among individual, professional and community services. 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.3 Again, the focus here is on functional oral health literacy. A call for a focus and study of oral health literacy is included in the Healthy People 2010 Objectives,3 the Surgeon General’s report on oral health,5 and A National Call to Action to Promote Oral Health.6 While there has been a modest amount of research regarding health literacy and medicine, especially concerning chronic diseases or conditions, to date little research has been conducted on the impact of health literacy on oral health.7
How does health literacy and oral health literacy affect me and my patients?
Health literacy is critical because it affects people’s ability to understand dental and medical concepts, share personal and health information with dentists and physicians participate in their health care by following through on self-care practices, and navigating the complex healthcare system. The latter includes everything from locating needed services to understanding and completing forms.
The changing demographics of our patient populations, the increase in chronic diseases and emerging infections and the abilities of our dental health team and practice protocols all play a role in health literacy. The IOM report highlights that health literacy emerges when “expectations, preferences, and skills of individuals seeking health information meet the expectations, preferences, and skills of those providing information and services.”2 The issues surrounding the older patient is one example. In this group we are seeing individuals with complex disorders and co-morbidities. The multiple treatments, dietary requirements and their interactions increase the intricacy of what is expected of both patients and providers. We also expect the patient to navigate the health care system between dental, medical and social services as well as handle related reimbursement forms. Patient’s concerns with emerging and re-emerging infections and their ready access to the internet for personal health information are another example. Patients of all ages will continue to rely on you and your office staff members for answers to their questions about how these emerging infections affect their general and oral health, and what they should be doing for themselves and their families.
What can I do?
You already have started by reading this article and you now know that health literacy is a recognized problem that your practice can begin to address. Here are a few suggestions for your team’s consideration:
Ensure that you and your staff have current science-based information:
This will ensure that you are not only providing correct information but also can detect inaccuracies in educational materials to be provided to your patients. To access materials from the National Institute of Dental and Craniofacial Research, the Centers for Disease Control and Prevention and Health Resources and Services Administration as well as general health information from the Department of Health and Human Services websites are provided for you.
Review the reading and clarity level of your office educational and pre- and post-appointment material:
The NAAL health literacy survey provides us with valuable information, but we must remember that the results are based on only one aspect of health literacy - one’s ability to read. It is critical that the educational materials used in our offices are written at a level that all patients can understand. Keep information simple and straightforward. Most patient educational materials and office forms are written for individuals with some college education. Educational materials from the agencies of the Department of Health and Human Services follow plain language recommendations and are a good source.
Be clear in your communication with patients and go beyond verbal exchanges:
Ensure that you and your staff are trained in effective communication. We need to ensure that when we talk with our patients that we use terms they can understand. For example for many people it is much better to talk about gum disease rather than periodontal disease. Use open-ended questions to assess patient understanding: What questions do you have? Not, do you have any questions? Having the patient repeat your instructions has been shown to be effective in conveying an accurate message.
Communication includes more than verbal exchanges. When providing instructions to patients to brush or floss their teeth the desired method should be demonstrated on a model and the patient should demonstrate the method in his or her mouth prior to leaving and at future visits. This practice is especially important for patients with gingivitis or periodontal disease and when instructing a mother on how to clean her infant’s mouth.
Listen to your patients
While we need to talk with our patients so that they understand us, we also need to listen to them when they ask questions or respond to our recommendations. Take time to recognize signs of a patient’s inability to read. For example, some patients when handed printed material claim that they will take it home to read because they have forgotten their glasses. Others may bring a friend or family member with them to read materials. Hiding the fact they cannot read is not uncommon and is likely more prevalent than we realize.
Help is on the way
Recently the American Dental Association affirmed that “limited oral health literacy is a potential barrier to effective prevention, diagnosis and treatment of oral disease: (Res. 14H-2006) and authorized the formation of the National Oral Health Literacy Advisory Committee (Res. 17H-2006). Stay tuned for related activities.
References
- Ratzen SC, Parker RM. 2000. Introduction. Selden CR, Zorn M, Ratzan SC, Parter RM, Editors. In: National Library of Medicine Current Bibliographies in Medicine: Health Literacy. Vol. NLM Pub. No. CBM 2000-1. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services.
- Nielsen-Bohlman L, Panzer AM, Kindig DA. Editors. Health Literacy A Prescription to End Confusion. Committee on Health Literacy, Institute of Medicine, National Academies Press Washington, DC. 2004.
- U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed., Vol. II: Oral Health. Washington, DC: US Government Printing Office, 2000.
- Kutner M, Greenberg E, Jin Ying. The health literacy of America’s adults. National center for Education statistics. US Department of Education. NCES 2006-483.
- U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.
- U.S. Department of Health and Human Services. A National Call to Action to Promote Oral Health. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention and the National Institutes of Health, National Institute of Dental and Craniofacial Research. NIH Publication No. 03-5303, May 2003.
- The invisible barrier: Literacy and its relationship with oral health. J Public Health Dent. 2005;65: 174-182.
Web sites for Resources
DHHS Health Communication Information
• www.health.gov/communications
CDC Oral Health Resources
• www.cdc.gov/OralHealth
HRSA supported National Maternal and Child Oral Health Resource Center
• www.mchoralhealth.org
NIDCR Oral Health Information Clearinghouse
• www.nidcr.nih.gov/HealthInformation/Special CareResources
Dental, Oral and Craniofacial Data Resource Center
• drc.nidcr.nih.gov
