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4
What Should One Look for in an
Oral Health Literacy Assessment?
ASSESSMENT OF ORAL HEALTH LITERACY: ONE APPROACH
Alice M. Horowitz, Ph.D.
University of Maryland School of Public Health
Dr. Horowitz discussed her experiences while performing a state-
wide assessment of oral health literacy in Maryland. A guiding thesis
for this activity is that health literacy is inextricably linked to improv-
ing oral health, especially among low-income groups. Health literacy,
as was reported in the IOM report, is the interaction between skills of
individuals and demands of the health care system. Horowitz stated that
the challenge is to address the mismatch between demands of the health
care system and the skills of those using and working in the health care
system. To overcome this challenge, Horowitz described that consumers
and patients need to
• know how to locate and navigate a health facility;
• read, understand, and complete many kinds of forms to receive
treatment and payment reimbursement;
• articulate their signs and symptoms;
• listen to providers;
• know about various types of health professionals and what ser-
vices they provide and how to access those services;
• trust the provider;
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28 ORAL HEALTH LITERACY
• know how and when to ask questions or ask for clarification when
they do not understand;
• understand their options in all procedures; and
• understand that oral health is part of total health and that individu-
als can keep their mouths healthy.
Horowitz discussed the steps of the oral health literacy assessment
undertaken in Maryland:
1. Establish local and state needs.
2. Determine public knowledge regarding caries prevention and early
detection.
3. Determine the public’s perceptions of providers’ communications
skills.
4. Determine what other public services, for example, Head Start and
the Special Supplemental Nutrition Program for Women, Infants,
and Children (WIC), know and do regarding caries prevention and
early detection.
5. Determine what health providers know and practice regarding
caries prevention and early detection.
6. Determine communication techniques of health care providers.
7. Conduct environmental scans of dental facilities.
Data collection activities conducted as part of the oral health lit-
eracy assessment included surveys and focus groups to seek informa-
tion about current oral health attitudes, behaviors, and practices. Mail
surveys of dentists, dental hygienists, physicians, and nurse practitioners
collected information on knowledge and practices related to preventing
tooth decay. In addition, the surveys included questions about the routine
use of communication techniques used by these health providers. A mail
survey of WIC programs was conducted and a Head Start survey is now
being fielded. A survey of adults, ages 18 and older and with children
ages 6 and younger in the home was conducted. To obtain qualitative
information, focus groups and one-on-one interviews were conducted
with all of these groups. Focus groups among low-income individuals
included both English and Spanish speakers.
Horowitz also said that the Agency for Healthcare Research and Qual-
ity (AHRQ) Health Literacy Universal Precautions toolkit was valuable
in conducting environmental scans of community based dental clinics in
Maryland.
Results of these efforts indicate that the general public does not
understand how to prevent tooth decay. This is especially true among
those with low incomes and those on Medicaid. Furthermore, the findings
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ORAL HEALTH LITERACY ASSESSMENT 29
indicate that the public does not know what fluoride is or what it does,
and they do not know what sealants are or what they are used for. The
appropriate use of fluorides and sealants can essentially eliminate tooth
decay. In addition, the survey results show that many children do not
drink tap water. Water can be fluoridated, but it does not benefit children
if it is not consumed. Horowitz concluded that the public does not under-
stand these important dental health messages.
There are also discouraging results from health care providers, accord-
ing to Horowitz. Many providers, including dentists and dental hygien-
ists, do not have a good understanding of how to prevent tooth decay.
Most providers surveyed do not provide dental sealants, and they do not
use the recommended communication techniques.
Clear messages about interventions and next steps have emerged
from the surveys and focus groups. The findings have also laid the
groundwork for conducting environmental scans in community-based
dental clinics. This next step, the conduct of health literacy environmental
scans in community-based dental clinics, is needed because approaching
a health facility for some can be an onerous task. The purpose of conduct-
ing environmental scans is to determine if the clinics are user-friendly and
patient-centered. These scans are currently going on in federally-qualified
health centers and county health departments in Maryland.
The environmental scans consist of phone interviews with the clinic
director to obtain information on the demographic characteristics of the
clinic attendees, and a review of the clinic websites and phone system.
Some telephone systems are very frustrating for clients, with no person
available to provide individual attention. Some of the clinic websites are
outstanding while others are “outstandingly awful,” Horowitz said. She
concluded that there are many practical things that can be done in these
areas to improve client services and to enhance access to information.
The clinic environmental scan also includes a review of signage, edu-
cational materials, and posters, for example, whether there are educational
materials that relate to the prevention of dental caries. Personal interviews
are conducted with patients to determine their perceptions of their care
and the quality of their communications with clinic providers. Dentists
and dental hygienists practicing in the clinics are surveyed regarding
their use of communication skills. Horowitz said that the response of the
federally-qualified health centers is very positive and that most directors
are motivated to improve their dental services.
Data collected from the environmental scan will inform plans to
design, implement, evaluate, and revise, when necessary, interventions
for specific groups. To illustrate the connection between health literacy
and oral health, Horowitz recounted some findings from focus groups
that included parents of young children. All of the parents were from
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30 ORAL HEALTH LITERACY
low-income groups and all were either on Medicaid or had no health
insurance. Parents were amazed to learn that they could prevent tooth
decay, even though how to prevent tooth decay has been known for
decades. The primary preventive measures include the appropriate use
of fluoride and the use of sealants. Horowitz concluded that disparities in
oral health can be greatly reduced by increasing oral health literacy and
using health promotion to give parents the tools to promote and protect
their children’s oral health.
DISCUSSION
Roundtable member Margaret Loveland began the discussion by ask-
ing Horowitz if the status of oral health literacy in the state of Maryland
is representative of the nation as a whole and whether there are states
that are doing better or worse than Maryland in terms of their oral health
literacy. Horowitz stated that while their study is conducted throughout
the state of Maryland, there are some limitations to the inferences that can
be drawn. The phone survey of adults may not have had a representative
pool of respondents. For example, a majority of respondents had a col-
lege level of education and it is likely that their educational attainment is
associated with higher levels of knowledge regarding oral health. Putting
this limitation aside, Horowitz speculated that findings from Maryland
are generalizable to the nation and these findings are consistent with
older national survey data reported in the Surgeon General’s report on
oral health.
Roundtable member Leonard Epstein asked Horowitz how culturally
and linguistically appropriate oral health care issues are factored into
a statewide assessment. Horowitz replied that the IOM health literacy
model is applied, where culture and society are integral to practice. Any
program would not be health literate if it did not also include cultural
competency.
Laurie Francis, Roundtable member, asked about the status of the
evidence base used to support knowing what interventions translate into
behavior change on the part of individuals or communities. In addition
Francis asked whether the Reach Out and Read program,1 a literacy
intervention supported by medical providers, could be adapted by the
oral and dental community as an intervention tool for literacy. Horowitz
replied that educational interventions must be multi-pronged to reach the
public, especially pregnant women during prenatal care and parents with
1
Reach Out and Read prepares America’s youngest children to succeed in school by part-
nering with doctors to prescribe books and encourage families to read together (http://
www.reachoutandread.org).
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ORAL HEALTH LITERACY ASSESSMENT 31
children age 6 and younger. With interventions targeted to these groups,
prevention can be achieved. Horowitz added that the oral and dental
health community needs to act to prevent any more tragic deaths, such
as that of Deamonte Driver. Oral health literacy concepts need to be inte-
grated into both professional school curriculum and board examinations.
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