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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; 27
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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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