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7
National Activities in
Oral Health Literacy
NATIONAL ACTIVITIES IN ORAL HEALTH LITERACY,
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
RADM William Bailey, D.D.S., M.P.H.
Centers for Disease Control and Prevention
Limited health literacy is associated with poor health and negatively
associated with the use of preventive services, management of chronic
conditions, and self-reported health, Bailey said. He added that oral
health literacy is positively associated with oral health status and quality
of life, frequency of dental visits, and knowledge and understanding of
preventive measures. In his view, health disparities can be reduced by
empowering people and giving them the capacity to obtain, process, and
understand basic information. This will then allow them to be partners in
their own health decisions. In short, Bailey stated, improvements in health
literacy will ensure a healthier population.
Clear communication is essential, said Bailey. He recounted a joke
in which a woman came into a grocery store and told the clerk that she
needed 50 gallons of milk. The clerk asked the woman why she needed 50
gallons of milk. She explained that she had been to see a dermatologist for
a skin condition and the dermatologist instructed her to take milk baths.
The clerk asked if the milk needed to be pasteurized and she replied, no,
just up to my chin. Bailey felt that this joke illustrates the complexity that
underpins communication. He suggested that this complexity is mag-
nified in the context of dental care, where there are strange noises and
79
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80 ORAL HEALTH LITERACY
smells and complex terminology is used. Dental patients may experience
a range of emotions from mild apprehension to dread.
Bailey summarized some of the actions being taken by the Depart-
ment of Health and Human Services (HHS) with regard to health literacy,
specifically those focusing on oral health literacy. He said that much has
been accomplished across HHS in this area in just the past 2 years. The
Affordable Care Act, passed in 2010, addresses oral health literacy by
incorporating health literacy into professional training, facilitating the
movement of clients into Medicaid and CHIP programs, and establishing
state-based insurance exchanges. Participating health plans and insurers
are required to use clear, consistent, and comparable health information
using a standardized template to describe plan coverage and benefits.
Bailey described how the Health Information Technology for Eco-
nomic and Clinical Health Act (HITECH) provisions of the 2009 American
Recovery and Reinvestment Act (ARRA) call for adoption of electronic
health records to provide health information that is meaningful and use-
ful to consumers.
He then discussed the Plain Writing Act of 2010 that requires federal
agencies to write documents clearly so that the public can understand
and use them. This requirement does not just apply to health. It applies
across the federal government to any information that the federal govern-
ment is providing on federal benefits or services, or how to comply with
federal regulations. Federal agencies are required by law to report on this
requirement beginning in 2012. These reports will serve as the baseline
for measuring future progress.
The HHS 2010 National Action Plan to Improve Health Literacy
involved more than 700 individuals and organizations. The seven goals
of the plan focus on
1. health information creation and dissemination,
2. health care services,
3. early childhood through university education,
4. community-based services,
5. partnership and collaboration,
6. research and evaluation, and
7. dissemination of evidence-based practice.
Bailey noted that the Affordable Care Act, the Plain Language Act,
the HITECH provisions, and the HHS National Action Plan to Improve
Health Literacy provide a unified way to address health literacy goals
and strategies. Bailey felt that these accomplishments provide a roadmap
for progress. He stated that it is remarkable that these initiatives have all
occurred within the past 2 years.
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NATIONAL ACTIVITIES IN ORAL HEALTH LITERACY 81
Bailey enumerated other milestones, for example, the development
of the Agency for Healthcare Research and Quality (AHRQ) Health Lit-
eracy Universal Precautions Toolkit. The underlying concept here is that
providers are not able to gauge the health literacy of patients so effective
communication tools should be used with all patients. This follows the
rationale for universal precautions that are used for infection control.
Bailey described the National Stakeholder Strategy for Achieving
Health Equity along with the 2011 HHS Strategic Action Plan to Reduce
Racial and Ethnic Health Disparities. The action plan address health lit-
eracy; for example, it calls for an update of the 2009 national standards
on culturally and linguistically appropriate services.
The National Institute of Dental and Craniofacial Research (NIDCR)
in 2004 hosted a workshop on oral health literacy that examined a frame-
work for studying relationships between oral health literacy and other
points of intervention; summarized available evidence; identified research
gaps; and provided a map for future work (NICDR, 2005).
Bailey described the oral health content of Healthy People 2010 and
2020. He said that the number of Healthy People communication objec-
tives doubled from 2010 to 2020. The objectives address the need to mea-
sure system level changes in the areas of health literacy, including health
care providers’ use of the teach-back method; the level of shared decision
making between patients and providers; and population-wide access to
personalized eHealth tools. The oral health objectives for 2010 included
explicit language to promote oral health and prevent oral disease. The
objectives stated that oral health literacy is necessary for all Americans.
Bailey said that the Healthy People 2020 objectives lack this explicit state-
ment, but in a background statement, there is a discussion of a person’s
ability to access oral health being associated with factors such as educa-
tion level, income, and race/ethnicity.
Bailey discussed the release in 2011 of two IOM reports. In the first
report, Advancing Oral Health in America (2011a), the IOM committee rec-
ommended that all relevant HHS agencies undertake oral health literacy
and education efforts aimed at individuals, communities, and health
care professionals. The IOM committee recommended that community-
wide public education on oral diseases and preventive interventions was
needed, especially on the infectious nature of dental caries, the effective-
ness of fluorides and sealants, the role of diet and nutrition in oral health,
and how oral diseases affect other health conditions. The second recom-
mendation of the IOM committee related to communitywide guidance on
how to access oral health care with the focus on using websites such as the
National Oral Health Clearinghouse and healthcare.gov. The third IOM
recommendation pertained to professional education on best practices in
patient-provider communication with the focus on how to communicate
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82 ORAL HEALTH LITERACY
to an increasingly diverse population about prevention of oral cancers,
periodontal disease, and dental caries.
Bailey stated that needed action steps have been clearly identified
through the accumulated wisdom from these activities and documents of
the past two years.
In terms of current HHS oral health literacy activities, Bailey said
that in 2004, seven research projects on oral health literacy were funded
through NIDCR. These projects received $15.5 million and have been
extended to 2013. The research described by Dr. Divaris at this IOM work-
shop is one of the projects funded through NIDCR. There are six other
NIDCR research initiatives that focus on oral health education:
1. Examination of oral health literacy in public health practice
2. Health literacy and oral health knowledge
3. Latinos’ health literacy, social support, and oral health knowledge
and behaviors
4. Development of an oral health literacy instrument
5. Use of videogames to promote oral health knowledge
6. Health literacy and oral health status of African refugees
One of the NIDCR research projects is designed to estimate dental
literacy among people enrolled in the Women, Infants, and Children’s
(WIC’s) Supplemental Food Program. The goal of the project is to reduce
dental health disparities by helping pregnant women and their children
to better interpret dental health information, navigate the dental health
system, understand instructions, and participate in care decisions. As part
of this project, multicenter assessments for oral health literacy are being
conducted in Atlanta, Baltimore, Los Angeles, and Washington. This proj-
ect examines the relationship between health literacy, oral health decision
making, and oral health status, and determines the extent to which four
different measures of health literacy represent unique skills.
Bailey also described research being sponsored by the Centers for Dis-
ease Control and Prevention (CDC). The San Diego Prevention Research
Center was funded to sponsor community dialogue sessions on fluorida-
tion. The project tested whether bringing community members together
and giving them both negative and positive messages about fluoridation
would allow them to enter into a dialogue and then make evidence-based
decisions. Bailey described how this process did not lead to individuals
supporting water fluoridation. He said that the study demonstrated that
it is difficult to overcome fears when it comes to fluoridation messages. If
people are uncertain, then they tend to say no to doing anything.
Bailey described educational initiatives of the Office of Minority
Health. This office is creating a cultural competency e-learning continuing
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NATIONAL ACTIVITIES IN ORAL HEALTH LITERACY 83
education program for oral health professionals. The Office on Women’s
Health is integrating oral health messages into their materials and web-
site. They are also conducting a physician survey to better understand
physician’s knowledge and behaviors related to oral health. NIDCR has
developed easy-to-read oral health education brochures. They also have
a curriculum for first and second graders (Open Wide and Trek Inside),
and are developing educational videos. The CDC has tested messages
and developed the Brush Up on Healthy Teeth campaign. The Centers for
Medicare and Medicaid Services (CMS) is collaborating with text4Baby
to include oral health messages. Bailey added that they are also going to
award a contract summer 2012 on the National Children’s Health Cover-
age Campaign.
Bailey provided a list of resources and associated website links per-
taining to HHS resources:
• Health Literacy Plans
o CDC Action Plan to Improve Health Literacy
o AHRQ Health Literacy Action Plan
• Training and Education
o Clear Communication: NIH Health Literacy Initiative (http://
www.nih.gov/clearcommunication/healthliteracy.htm)
o CDC Health Literacy Portal (http://www.cdc.gov/health
literacy)
o HRSA Training for Health Care Professionals (http://www.
hrsa.gov/publichealth/healthliteracy/index.html)
• Resources
o IHS Health Literacy Tools and Resources (http://www.ihs.
gov/healthcommunications/index.cfm?module=dsp_hc_
health_literacy)
o CMS Health Literacy Toolkit (http://www.cms.gov/
WrittenMaterialsToolkit)
Bailey concluded by stating that action steps have been identified to
advance oral health literacy. These steps are as follows:
• Assure a more competent workforce.
o Train clinicians in communication skills/cultural competency.
o Have staff complete CDC/HRSA courses in health literacy.
• Use plain language in publications and websites.
o Oral health care prevention and education, special popula-
tions, access to care, coverage.
• Assist patients with disease self-management.
• Assess and improve user friendliness of our clinics.
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84 ORAL HEALTH LITERACY
• Utilize guidance, resources, and tools.
o Action steps are outlined and resources available for health
professionals to make health information and services accu-
rate, accessible, and actionable.
• Foster and enhance collaboration (internal and external).
HEALTH LITERACY IN DENTISTRY
Kathy O’Loughlin, D.M.D., M.P.H.
American Dental Association
O’Loughlin prefaced her remarks by noting the difficulty of chang-
ing health beliefs and behaviors and the need to instigate these changes
both from the bottom up with patients and top-down with practitioners.
Dental care providers can be influenced through educational institutions
and dental care delivery systems. O’Loughlin mentioned her 12-year
involvement in oral health literacy and the challenges of the field. She said
she is optimistic and that progress has been made in oral health literacy.
For example, a definition of health literacy in dentistry (Box 7-1) and a
framework for understanding it (Figure 3-1) have been accepted by health
and dental professionals.
As the Executive Director and Chief Operating Officer of the ADA,
O’Loughlin described the twofold mission of the ADA. The ADA’s pur-
pose, as outlined in its bylaws, is to enhance the health of the public and
promote the profession of dentistry. O’Loughlin stated that this bifurcated
mission creates tension within the organization because resources have to
be divided between the needs of 157,000 member dentists who actively
seek ADA support and a silent majority of the U.S. population.
The ADA has been active in several dental oral health activities:
• Oral Health in America: A Report of the Surgeon General (2000)
• Healthy People 2010 and 2020
• National Call to Action to Promote Oral Health (NIDCR, 2003)
• Institute of Medicine reports (IOM, 2011a,b)
• NIDCR Workgroup on Functional Health Literacy
• Presentations at professional association meetings (e.g., National
Oral Health Conference, International Association for Dental
Research, American Association for Dental Research, American
Public Health Association)
• National Action Plan to Improve Health Literacy (2010)
The ADA has learned from these initiatives and is now turning to
action and evaluation of the impact of those actions, said O’Loughlin.
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NATIONAL ACTIVITIES IN ORAL HEALTH LITERACY 85
BOX 7-1
The Definition of Health Literacy in Dentisty
Health literacy in dentistry 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.”
SOURCE: Adapted from Ratzan and Parker, 2000.
She noted that health literacy is a pervasive issue that involves many
health professions. Dentists, with their oral health expertise, are essential,
but she indicated that they are insufficient to “turn the needle” on this
issue. According to O’Loughlin, change will only occur by integrating
the efforts of physicians, nurses, social workers, educators, and people in
the community who have influence, for example, promotores. Promotores
are trained lay health workers that provide basic health education in the
Hispanic/Latino community. Some promotores receive about 18 months
of oral health education and then work as Community Health Coordina-
tors. They educate, navigate, intervene, provide preventive services, and
on occasion, triage and reroute emergency cases to ensure that people in
at-risk communities receive needed oral health care.
O’Loughlin relayed an anecdote from a pediatric dentist that illus-
trates the need for oral health education and clear communication. In
the course of talking to a mother about proper tooth brushing, someone
in her practice handed the parent a little 2-minute egg timer and told
her to use it. The timer is intended to be used as an aid to help children
maintain their teeth brushing for 2 minutes. Instead, the mother took the
timer home, broke it open, and used the granules to brush her child’s
teeth.
The ADA sells millions of dollars of patient education information. It
would be very helpful, O’Loughlin said, to have those materials reviewed
and appraised in terms of its integrity and level of health literacy.
The ADA is working with the National Advisory Committee to
develop a health literacy plan. There are five areas of focus:
1. Education and training (change perceptions of oral health)
2. Advocacy (overcome barriers by replicating effective programs)
3. Research (build the science base and accelerate science transfer)
4. Dental practice (workforce diversity, capacity, and flexibility)
5. Build and maintain coalitions (increase collaborations)
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86 ORAL HEALTH LITERACY
The ADA is actively working on at least three of these five areas with
a focus on three strategic goals. The first goal is to help ADA members
succeed (as defined by the members). The second goal is to ensure that
the public has access to information so that individuals can be better
stewards of their own health. The third goal is to improve the public’s
health through collaboration. O’Loughlin described two major collabora-
tions, one a Web-based initiative (Sharecare) and the other an advertising
campaign conducted in collaboration with the Ad Council that focuses
on oral health.
Two years ago, the ADA joined forces with Sharecare, an online
resource launched by Dr. Oz and Jeff Arnold of WebMD that focuses on
diet, wellness, and nutrition. Oral health is 1 of 48 topics covered on the
site. Questions posted by the public are answered by health profession-
als. O’Loughlin said that Sharecare is accessed by 2.6 million visitors, on
average, every month; growing by 125 percent per quarter in terms of
people visiting the site; being used fairly extensively—on average visitors
to the site view 10 pages of information; and subscribed to by 1.3 million
registered users, people who provide personal information so that they
can receive emails, social media, and text messages from this site.
When a Sharecare user types in a question, the site’s search engine
finds answers to the question from multiple sources, sometimes compet-
ing sources. The site initially had only one dental expert, Bill DeVizio
from Colgate-Palmolive; however, the ADA is now actively involved
with Sharecare. ADA staff and its nine trained member spokespersons
respond to questions that come through the website. Nearly 300 ADA
active, licensed, member dentists have answered questions as individual
oral health experts on the site (i.e., they do not represent ADA when
they answer questions). ADA spokespeople and member dentists have
answered more than 3,000 dental-related questions. All dentists can now
contribute to the site. The site is monitored for accuracy and if a dentist
posts information that is questionable, the dentist is contacted to correct
the information. O’Loughlin indicated that the Sharecare initiative has
been a great success. She stated that ADA is a fairly trusted source of oral
health information and that the ADA’s reviews and policies are evidence-
based. In O’Loughlin’s view, this website is a wonderful asset for the
public. It allows individuals to ask questions and get credible, trusted
answers. The service also helps the ADA by promoting the ADA; reinforc-
ing the ADA’s role as the leading advocate for oral health; engaging the
public; and enhancing the recognition and importance of the dentist as
the authority on oral health and care.
O’Loughlin believes that the ADA collaboration with Sharecare has
helped improve public oral health literacy. When questions are answered
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NATIONAL ACTIVITIES IN ORAL HEALTH LITERACY 87
by dentists with credible oral health information, people learn more about
their oral health.
O’Loughlin described another recent collaborative effort, a National
Roundtable for Dental Collaboration, which is an annual 1-day meeting
of dental organizations. In setting the agenda for the first meeting in 2010,
representatives of the organizations were asked to prioritize their most
important issues and their proposed solutions. The meeting was focused
on developing an action plan based on this input. The number one issue
submitted by the organizations was health literacy, especially among
high-risk populations. The 16 organizations represented diverse inter-
ests including those of nine dental specialties, the Dental Trade Alliance
(the group representing large manufacturers and distributors of dental
products), Medicaid dentists, community health center dentists, public
health dentists, and state and territorial dental directors. The meeting led
to the formation of a coalition whose principle purpose was to increase
the awareness of the importance of oral health among both deliverers and
receivers of care. This collaboration led directly to the formation of a new
coalition: the Partnership for Healthy Mouths, Healthy Lives. O’Loughlin
said that the coalition has grown to include 34 oral health organizations.
The Partnership for Healthy Mouths, Healthy Lives submitted a suc-
cessful proposal to the Ad Council in 2011. The Ad Council was founded
in 1942 to sell war bonds in World War II. It has been responsible for some
high-profile public service campaigns, including the Smokey the Bear
campaign (relating to fire prevention), and the Crash Dummies campaign
(relating to auto safety). The Ad Council specializes in major, multiyear
campaigns that leverage an organization’s direct cost contribution to cre-
ate a $100 million dollar campaign that reaches millions.
The Ad Council will launch a 3-year national advertising campaign in
the summer 2012, worth $100 million.1 The goal of the campaign, called
“Two Plus Two,” is to reduce the risk of oral diseases in children through
prevention. The slogan refers to getting children, by age 2, to brush their
teeth for 2 minutes. Campaign messages will target parents and caregiv-
ers to raise awareness and change behaviors. The campaign will include
a special focus on the Hispanic community and high-risk communities.
Through its media research, the ADA found that people in the United
States are more likely to have cell phones than either computers or televi-
sions. Therefore, an ADA-sponsored consumer website, MouthHealthy.
org, will be available June 2012. The website will allow people who have
1
Information on the Ad Council children’s oral health campaign can be found at http://
www.adcouncil.org/News-Events/Press-Releases/Coalition-of-More-Than-35-Leading-
Dental-Organizations-Joins-Ad-Council-to-Launch-First-Campaign-on-Children-s-Oral-
Health (accessed October 1, 2012).
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88 ORAL HEALTH LITERACY
been alerted to oral health issues through the Ad Council campaign to
find additional information online. The website, called “Mouth Healthy
for Life,” has been designed to be consumer friendly and provide infor-
mation at different life stages, including pregnancy. The site will also
include a dental symptom checklist and information about nutrition.
O’Loughlin concluded her remarks by reiterating that the dental com-
munity alone is insufficient to solve the problem of poor oral health
literacy. She stated that the ADA has developed good relationships with
several physician groups, including the American Academy of Pediatrics,
the American College of Obstetrics and Gynecology, and the American
Academy of Family Physicians. The ADA has also reached out to rep-
resentatives of the U.S. Department of Health and Human Services: for
example, the Centers for Medicare and Medicaid Services (CMS) and the
Centers for Disease Control and Prevention (CDC). O’Loughlin, stated
that the ADA looks forward to future collaborations. She stated that coali-
tions of partners are able to bring messages related to oral health and
prevention to larger audiences.
AETNA: ACTIVITIES IN ORAL HEALTH LITERACY
Mary Lee Conicella, D.M.D., F.A.G.D.
Aetna
Conicella is the dental representative to a health literacy workgroup
at Aetna. The workgroup includes members from various departments,
including medical, pharmacy, behavioral health, and communications.
The workgroup has three subgroups to address its primary audiences:
members, health care professionals, and employees. The goals of the
workgroups are to
• research the effects of health literacy,
• increase awareness,
• provide tools and resources to address challenges, and
• promote plain language.
Aetna assists its members through the use of plain language. Plain
language is a way of writing and speaking that helps people understand
something the first time they read or hear it. By using plain language,
members can find what they need; understand what they find; and use
what they find to meet their needs. Conicella said that the use of plain
language helps Aetna’s members use services appropriately, better under-
stand health care information, and act on that information. The Aetna
employee newsletter includes a column “In Plain Language,” a how-to
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NATIONAL ACTIVITIES IN ORAL HEALTH LITERACY 89
guide to simplify speech and prose. This column helps employees find
better ways to convey information.
Conicella said it is important that employees embrace the concept
of health literacy because it is employees who weave the concepts of
health literacy and plain language into the fabric of the organization.
Two features of Aetna’s employee intranet address health literacy: (1)
Jargon Alerts; and (2) Because You Asked. Jargon Alerts is a once-a-week
feature that that focuses on a word that is used, but lacks a clear meaning.
Recent examples of words featured include noncompliant, adjudicate, and
impactful. These words are used within the industry, but may be confus-
ing to members of the public. The “Because You Asked” feature on the
intranet allows employees to submit questions and receive answers about
the use of words. A recent example of a question submitted related to the
correct use of “flush out” and “flesh out.”
Aetna encourages employees to nominate peers for the Aetna Way
Excellence Awards for their work in language simplification and health
literacy, said Conicella. In addition, she said that each month a health lit-
eracy champion is recognized for creating member materials or otherwise
promoting health literacy.
Conicella said that Aetna has had a long-standing commitment to
voluntary activities. Every February, during children’s dental health
month, dental hygienists, dentists, and other employees visit preschools,
schools, and other organizations to educate children about oral health.
The Aetna team provided education and screening at the Pittsburgh chil-
dren’s museum during that time. Oral health education was provided
jointly to parents and children.
As part of its outreach to clinicians, Aetna communicates with doctors
and other health care professionals about their role in helping patients
better understand their health and health care. These clinician awareness
activities, include the following:
• Health literacy messaging via ePocrates2
• Health literacy features in the physician newsletter
• A health literacy reference tool on the provider education website
• A cultural competency course for clinicians
• An online continuing education course for dentists
In terms of research and collaboration, Conicella described two
research studies that Aetna was involved in, one on asthma health lit-
eracy and one on migraine health literacy. Aetna has collaborated with a
2
ePocrates is a company that creates point-of-care digital products (online and for mobile
devices) for health care professionals (http://www.epocrates.com/who).
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90 ORAL HEALTH LITERACY
number of organizations, for example, the American College of Physicians
Foundation, the Institute of Medicine’s Roundtable on Health Literacy,
the America’s Health Insurance Plans (AHIP) Health Literacy Taskforce,
and the American Medical Association Foundation. The collaboration
with AHIP resulted in a continuing medical education (CME) course on
health literacy for clinicians.
Conicella described a writer certification training program at Aetna
which aims to ensure that Aetna communicators
• inform, educate, and engage members/consumers,
• follow Aetna writing guidelines,
• write in plain language,
• simplify codes for explanation of benefits statements, and
• simplify member letters.
Conicella recommended Navigating Your Health Benefits for Dummies
(Cutler and Baker, 2006), a book that breaks down the complex health
benefits system into easily digestible pieces and helps consumers navigate
their way the system.
Conicella described an oral health literacy continuing education
course that was designed with Aetna’s research partner, the Columbia
University College of Dental Medicine. The course is called Oral Health
Literacy: A Dental Practice Priority. The course became available on Aet-
na’s website in 2009. Aetna’s participating dentists are encouraged to take
the course. The course is lengthy and includes a description of the various
tools available to assess patient health literacy. For example, the following
screening tests are available online to assess patient reading levels:
• Wide Range Achievement Test-Revised (WRAT-R)
• Rapid Estimate of Adult Literacy in Medicine (REALM)
• Test of Functional Health Literacy in Adults (TOFHLA)
• Newest Vital Sign (NVS)
Newest Vital Sign interprets a patient’s ability to understand a nutritional
label from ice cream. Conicella pointed out that a dentist does not have to
use any of these formal tools and most dentists would not be comfortable
with these tools. However, she said that a dentist could add a few simple
questions to the health history form that could help them assess the health
literacy of their patients (Box 7-2).
The Aetna continuing education course provides a summary of exist-
ing dental educational materials and the readability of those resources.
The review includes patient educational brochures and pamphlets cur-
rently available from the National Institute of Dental and Craniofacial
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NATIONAL ACTIVITIES IN ORAL HEALTH LITERACY 91
BOX 7-2
Examples of Health Literacy Questions
1. How often are medical forms difficult to understand and fill out?
• Always
• Often
• Sometimes
• Occasionally
• Never
2.
How often do you have difficulty understanding written information your health
care provider (like a dentist or dental hygienist) gives you?
• Always
• Often
• Sometimes
• Occasionally
• Never
3.
How often do you have problems learning about your dental or medical condi-
tion because of difficulty understanding written information?
• Always
• Often
• Sometimes
• Occasionally
• Never
SOURCE: Chew et al., 2004. From Conicella Presentation, March 29, 2012.
Research and the National Institutes of Health. The reading level of the
materials ranges from 4th to 10th grade. When dental terms such as “gin-
givitis” and “periodontal disease” were replaced with the word “dog,”
the reading level of the brochures and pamphlets was lowered, but many
of them remained above a 7th-grade level. Conicella stated the many of
the materials in use are highly technical. Ideally, materials at the 4th- or
5th-grade reading level are needed so that the majority of people can
understand them.
Conicella said that the Plain Language Thesaurus for Health Communica-
tion (HHS, 2007) is a useful resource. She agreed with a quote from the
thesaurus that relates to patient communication: “It is more important to
be understood than to be medically precise.”
To encourage patients to feel comfortable and ask questions, Conicella
recommended adoption of the “Ask Me 3TM” method from the Partner-
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92 ORAL HEALTH LITERACY
ship for Clear Health Communication, National Patient Safety Founda-
tion. According to this method, dentists should encourage their patients
to ask (www.npsf.org/askme3)
1. What is my main problem?
2. What do I need to do?
3. Why is it important for me to do this?
Conicella described an award-winning, consumer-oriented, Aetna-
sponsored website, Simple Steps To Better Dental Health® (http://www.
simplestepsdental.com). The content on this website is primarily provided
by the Columbia University College of Dental Medicine. The content is
comprehensive, however, the reading level was set so that most members
of the public could learn from it. The website includes an interactive tool
for parents and caregivers of small children to teach them about prevent-
ing early childhood caries. Another interactive tool helps assess the risk
for caries for adults and children. The website also includes information
on oral health and diabetes.
Conicella said that Aetna also works to advance health literacy
through collaborations between dentists and physicians. For example,
Aetna sponsored three symposia in the past 4 years at the New York
Academy of Sciences that brought the dental and medical community
together. The symposia focused on the implications of oral health to the
aging population, diabetes, cardiovascular disease, and pregnancy. Aetna
has also been involved with other health conferences, mostly in affiliation
with the National Dental Association and their local chapters where there
is a good working relationship with the National Medical Association.
Three additional collaborative conferences are scheduled for 2012.
DENTAQUEST FOUNDATION ORAL HEALTH 2014 INITIATIVE
Ralph Fucillio, M.A.
DentaQuest Foundation
Fucillio described the origins of Oral Health 2014, an initiative funded
by the DentaQuest Foundation, formerly known as the Oral Health Foun-
dation. The Oral Health Foundation limited its activities to Massachusetts.
The DentaQuest Foundation expanded the mission and has a national
focus.
Fucillio recounted an experience he had while volunteering in 2009
in Wise County, Virginia, an area without good access to dental care.
Dental services offered through charitable organizations such as Remote
Area Medical Volunteer Corps and Missions of Mercy are sometimes
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offered in such areas. These volunteer-staffed programs are sponsored
by dental societies and other stakeholders and treat people who do not
otherwise have access to dental care. Fucillio arrived at the clinic site, a
county fairground at 7:00 am. There were already long lines forming for
care, with some having arrived days before to be assured of being seen. A
circus tent was set up with 90 dental stations. Fucillio observed that while
many were being served, the delivery was not the way dental care should
be delivered in the United States in a sustainable way. There were many
people in pain, with some in severe pain. Most clients were expecting
their teeth to be pulled. This experience motivated Fucillio to start think-
ing about a national movement on oral health. In March 2009, he attended
an access to oral health care summit convened by the American Dental
Association. The summit involved multiple stakeholders and addressed
the long- and short-term needs of U.S. populations that lacked access to
oral health care, especially preventive services.
In the three years since the summit, a number of stakeholders have
joined together to build a National Oral Health Alliance. A coordina-
tion and communication committee worked for 2 years to establish the
National Oral Health Alliance. A number of contentious issues, including
water fluoridation and workforce issues, had to be discussed among the
stakeholders to build new levels of trust, create opportunities for dia-
logue, ensure civic engagement across sectors, and establish a foundation
for a national plan to address oral health. The U.S. National Oral Health
Alliance was launched March 22, 2011. Mr. Fucillio recognized two of
the other founding board members in attendance, Dr. Kleinman and Dr.
Robinson.
Fucillio identified four system components that are needed for
change: funding, policy, community, and care. These four components
are interdependent (Figure 7-1). In his view, the overall system cannot
change without a change in one of these components. Funding and reim-
bursement systems may need to change to facilitate prevention-oriented,
evidence-based dental care, he said. In the policy arena, Fucillio discussed
prevention provisions of the Affordable Care Act that could help people
understand both their general and oral health. Social determinants of
health fit into community systems and greatly affect health outcomes.
Based on his review of the literature, Fucillio estimated that 10 percent of
what is spent on health actually improves health and 90 percent of what
is going on in people’s lives is what really contributes to whether they are
healthy or not. He said that the community is one of the most important
places for improvements in health to occur. Using the language of the
community is key to health literacy. Fucillio recounted an anecdote from
research on language used to describe food. In one study, people from
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94 ORAL HEALTH LITERACY
policy funding
• Oral health is a key component • Sufficient public funding to
of health policy support care and prevention
• Oral-health-supporting policies/ • Alignment of payment
regulations protected and with prevention with disease
adopted management
• Oral health surveillance systems • Active philanthropic
in place engagement in oral health
• Oral health policy consistent
at local, state,
and federal
levels
optimal
oral health
• Equal access to care
• Strong health and
community systems
• Effective public
policies
care community
• Strong, stable safety net • Oral health integrated into
• Sufficient and equitable access education and social services
to multiple points of care • Effective navigation of
• Care based on prevention and community-based prevention
disease management and care
• Oral health prevention and • Optimal oral health literacy
guidance integrated into
primary care
FIGURE 7-1 Systems change for optimal oral health.
SOURCE: Fucillio, 2012.
Figure 7-1.eps
southern states were asked if they ate poultry. They reported that they
did not. They were more familiar with the term chicken.
DentaQuest Foundation provides funding and engagement opportu-
nities at the state level that address one or more of the six priorities of the
National Oral Health Alliance:
1. Prevention and public health infrastructure
2. Medical dental collaboration
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NATIONAL ACTIVITIES IN ORAL HEALTH LITERACY 95
3. Strengthening the dental care delivery system
4. Data and surveillance
5. Financing models
6. Oral health literacy
The DentaQuest Foundation offered states $100,000 for the first year of
planning. The foundation received 69 letters of intent and 36 propos-
als. The foundation funded 20 states (Table 7-1). Four of those states
are focused on oral health literacy (Arizona, Florida, Maryland, Rhode
Island).
Fucillio discussed two colloquia held by the U.S. National Oral Health
Alliance. The first colloquium focused on medical and dental collabora-
TABLE 7-1 State Oral Health Programs Funded by the DentaQuest
Foundation
Arizona: American Indian • wenty-two tribes in the state starting regional
T
Oral Health Coalition “roundtables” as a culturally sensitive means of
bringing tribes in various regions together
• n “oral health 101” session is hosted by a dental
A
hygienist from the community in which the
roundtable is being held
• oundtables work to create consensus around
R
which aspects of the oral health plan are most
important to those tribes and how they can work
together to implement them
Florida: Healthy Mouth, • o develop culturally competent messages
T
Healthy Body Campaign regarding the importance of good oral health, to
create support for public policy solutions and to
improve access to dental care
• evelop a series of messages (messaging plan) for
D
their alliance and local coalitions: the plan was
officially adopted by their alliance
Maryland: Maryland • educing health disparities, enhancing oral health
R
Dental Action Coalition literacy among community-based groups
• ral health literacy campaign officially launched
O
with engagement by elected officials and the
Maryland Oral Health Learning Alliance (created
for Oral Health 2014 Initiative) as a support and
alignment mechanism to keep the campaign
moving forward
Rhode Island: Rite Smiles- • ncrease the knowledge and skills of families and
I
Smart Smiles: Rhode providers and improve access to dental care among
Island’s Oral Health families and children with Medicaid coverage
Literacy Improvement
Initiative
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96 ORAL HEALTH LITERACY
tion. Numerous professions came forward to describe their cooperative
initiatives. The second colloquium focused on prevention and public
health infrastructure. A third colloquium on oral health literacy was held
June 6 and 7, 2012.
Fucillio said that the many oral health literacy initiatives under way
point to progress in this relatively new field. He cited as examples of these
promising initiatives, the grant programs of Oral Health 2014, coalition
development, the National Oral Health Alliance, the Oral Health Coor-
dinating Committee at the federal level, and the current IOM workshop.
Fucillio stated that these and other initiatives will contribute to improve-
ments in oral health. However, he cautioned that change will not occur
unless literacy levels improve. He indicated that literacy interventions
must go beyond targeting individual behavior and reach communities.
Fucillio concluded his remarks by providing four key oral health
literacy messages:
1. The mouth is part of the body.
2. Oral health problems stem from an infectious process in the mouth.
3. Dental disease is preventable.
4. Oral health literacy and oral health is everybody’s business.
Fucillio encouraged members of the audience to learn more about the
Alliance’s national initiatives at the DentaQuest Foundation website
(dentaquestfoundation.org).
DISCUSSION
Roundtable member Kelly began the discussion of the presentations
by asking O’Loughlin whether the ADA had reached out to the payor
community in terms of involvement with the Ad Council dental health
campaign. Kelly suggested that receiving key messages from insurers as
well as through the media would reinforce the campaign’s information.
O’Loughlin replied that the ADA discussed the Ad Council campaign
with representatives of Delta Dental and the National Association of
Dental Plans (NADP). The plans have been preoccupied with health care
reform legislation. The ADA welcomes collaboration with health and
dental insurance plans. She pointed out that the Ad Council “owns” the
campaign, has their own website for the campaign, and is in charge of the
media launch to the public. All members of the partnering coalition are
recognized on the website.
Roundtable member Epstein provided the audience with information
about the online Unified Health Communication course offered by the
Health Resources and Services Administration (HRSA). The course has
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been updated and is now called Effective Health Care Communication
Tools for Healthcare Professionals. An hour of ethno-cultural and lesbian,
gay, bisexual, transgender (LGBT)-specific content is being added to the
course and six continuing education (CE) credits can be earned upon its
completion. Epstein anticipates the inclusion of additional oral health
content in the course so that it will be eligible for CE credits for oral health
care providers.
Roundtable member Francis asked Fucillio how social determi-
nants fit into the framework he described that included interconnections
between policy, funding, community, and care. Fuccillio replied that social
determinants operate on all four components of the framework. Social
determinants are usually thought to operate at the community level, for
example, by influencing factors affecting people’s everyday lives, such
as economics, transportation, education, and housing. However, he said,
decisions made in the areas of policy, funding, and care also greatly
affect the conditions of people’s lives, which, in turn, affects their health.
Fucillio said that a shift of focus from individual behavior to the condi-
tions in which individuals find themselves is an important part of this
framework. Francis added that a focus on social determinants is needed
because they can preclude access to care. Fucillio agreed and said that if
people do not have a place to receive care, or do not have the means to
pay for that care, they will likely not get care.
Roundtable member Schyve asked members of the panel to discuss
interventions at the level of the individual practitioner that improve com-
munication with patients. He noted that from the practitioner’s point of
view, effective interventions such as the teach back method take time.
Schyve suggested that taking this extra time with patients would likely
mean that fewer patients could be seen in the course of the day. He asked
the panel to address this practical issue.
O’Loughlin observed that insurers do not usually provide reimburse-
ment for oral health literacy interventions such as the teach back method.
There is a code for the provision of education and guidance, but payors
usually do not reimburse for this service. She indicated that fundamental
systems issues, including reimbursement, need to be addressed to help
practitioners intervene to improve the health literacy of their patients. The
first step is to teach dental providers how to intervene in effective ways.
O’Loughlin added that there is a Commission on Dental Accreditation
communication standard, but that it could be strengthened. She observed
that the dental curriculum is already very full. There is a growing recogni-
tion that medical and dental schools need to do a better job of teaching
practitioners how to communicate effectively, O’Loughlin said. She stated
that there is also a greater emphasis on interprofessional collaboration in
dental schools and medical schools.
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In terms of giving practitioners incentives to use health literacy inter-
ventions, Conicella said that dentists who have completed Aetna’s course
have not raised this issue. As a practicing dentist, she said that perhaps
demands on her time are less than those experienced by physicians. She
noted that dentists often use their hygienist and dental assistants to work
with them to further health literacy interventions.
Bailey added that informing dentists that health literacy interventions
improve outcomes is a powerful incentive. Many dentists do not realize
the impact that good communication has on oral health outcomes. He
suggested that educating oral health providers about this link would
encourage them to incorporate health literacy interventions into their
practices.
Roundtable member Patel asked Fucillio whether there is an eco-
nomic evaluation planned of the state interventions funded through the
DentaQuest grant program. She noted that it is useful to have a business
case to support public health interventions. Fucillio replied that the state
programs have been in operation for a short time (6 months) and that the
evaluation process is ongoing. The first year of the grant focuses on plan-
ning. Some of the grantees will be selected to implement their plans. The
evaluation metrics will vary according to which of the six priority areas
the grantees elect to target. One of the financial benefits of the interven-
tions observed so far is that strengthening the oral health safety net has
led to improvements in the financial results of the safety net dental clin-
ics. These benefits have occurred in states where there is a primary care
association working with the grantee to mobilize local stakeholders.
Ratzan posed a series of questions related to opportunities for sustain-
able solutions in health literacy. First he asked O’Loughlin how health
literacy education can be integrated throughout the health science under-
graduate and graduate curriculum. In addition, he noted that revisions to
the Medical College Admission Test (MCAT) might include health literacy
questions. He asked Conicella about incentives that insurers could offer
employers to encourage healthy behaviors among employees. Ratzan
noted that employers receive a large discount if they can show that their
employees are aware of measures such as blood pressure and blood sugar
levels. Incentives can be built into the plan structure. Ratzan asked Bailey
about the evaluation of the text4Baby program and how it might be tied to
the Ad Council media campaign as a resource. He noted that the program
has had some impact in terms of improving the rate of flu vaccinations.
Ratzan asked more generally, How can we come up with sustainable
solutions? He urged the government agencies and other stakeholders to
work together.
Fucillio replied that the National Oral Health Alliance was formed
to conduct business differently. In his view, the Alliance should be a
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public–private partnership. Fucillio added that there are 27 members
of the Alliance funders group who are focused solely on oral health. He
mentioned that three foundations are sponsoring an interprofessional
collaborative on oral health. Fucillio is hopeful that when norms, com-
munication patterns, and the way business is done change, systems will
change. Bailey added that one way to “span the silos” is to involve top
leadership because they have control across all of the silos. From his per-
spective Bailey suggested that stating health literacy as a priority across
an agency, in his case, the Department of Health and Human Services, is
an effective way to motivate integration. He added that agency staff may
work within silos, but that this does not preclude having a coordinated
effort across silos. Bailey suggested that having a public–private national
oral health plan serves to focus on priority areas. Individual agencies can
tie into a national strategic framework. He likened this to a zipper that
connects all of the partners even though each is working on their own
element of the plan.
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