Assessing the oral health literacy: A review

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. The current review is based on some of the extensive literature in health literacy, much of it focused on the intersection of low literacy and the understanding of basic health care information. Health literacy is a non-pharmacological method of managing and preventing diseases. There are three distinct levels in oral health literacy, i.e. functional, interactive and critical. 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 ageing parents and interpret insurance and Medicare rules, regulations and benefi ts. There are several factors which impact on low health literacy level in the community. Poor health literacy is considered as a contributor of poor oral health status in an individual, poor heath outcome in a community and health inequalities. 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.


INTRODUCTION
There are many reasons why preventable diseases remain so common and why people often do not adopt practices that have been scientifi cally shown to be effective in maintaining health.These range from social, [1] environmental, [2] biological, behavioral, [3] community, cultural, fi nancial and political factors, [3,4] lack of access to oral health care services, complicated oral health care systems, lack of oral health information material [5] and low oral health literacy. [6]nce; the modern health care system makes complex demands on the health consumers' side, this lead them to face several challenges to seek health care and its information.As a result, the health consumers with low health literacy are left unable to reap the benefits of available information.
Health literacy is increasingly described as the currency for improving the quality of health and health care. [7]It's the basic reading and numerical skills that allow a person to function in the health care environment.There are various defi nitions of health literacy in literature.The widely accepted defi nition 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". [7]The American Medical Association (AMA) more specifi cally defi nes functional health literacy as "the ability to read and comprehend prescription bottles, appointment slips and the other essential health related materials required to successfully function as a patient". [8]e process of acquiring oral health information, appraising its concepts and applying oral health prevention and treatment plans appropriately requires new skill development called oral health literacy (OHL). [6]Oral health literacy is an interplay between culture and society, the health system, education system, language and oral health outcomes [5,9] indicating that it may be a new determinant of oral health and should be considered more intensively in oral health research.The signifi cance of oral health literacy and its role in oral health promotion was highlighted in the Surgeon General's report on oral health.In January (NIDCR) convened a working group on Literacy and Its Relationship with Oral Health, the group adapted the health literacy defi nition proposed by Healthy People 2010 to the context of oral health as "The degree to which individuals have the capacity to obtain, process and understand basic oral health information and services needed to make appropriate health decisions". [10]Furthermore, according to the report, 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 tend to use materials that were readily available but diffi cult to understand, this made 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. [10]are 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 fi nancial and health-related burdens placed on care providers and patients; and defining how to achieve oral health literacy on an individual and community basis.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 primarily defi nes on oral health literacy, emphasizes its importance and integral relationship with health literacy, impacts of low oral health literacy, different tools used to assess the literacy level in dentistry and suggests few tips for dental professionals to improve the literacy level among the general population seeking the dental care.

MATERIALS AND METHODS
The current review is based on some of the extensive literature in health literacy, much of it focused on the intersection of low literacy and the understanding of basic health care information.Articles with other documents for this review were selected by searching MEDLINE and related databases, such as Web of Science, ERIC, Psych INFO, LISA, CINAHL, Indus Medicus and BIOSIS; by consulting existing bibliographies; by using both forward and backward reference chaining techniques and by tracking recent activities in oral health literacy.References that were primarily anecdotal or that were only peripherally related to the topic were excluded.

Importance and key features of health literacy
A two-year-old was diagnosed with an inner ear infection and was prescribed an antibiotic.Her mother understood that her daughter should take the prescribed medication twice a day.After carefully studying the label on the bottle and deciding that it didn't tell how to take the medicine, she fi lled a teaspoon and poured the antibiotic into her daughter's painful ear. [11]The example refl ects how patients with low health literacy are vulnerable to misunderstandings and misinterpretations which may result in devastating results at times.
Health literacy is an excellent antidote to these confusions in health care.Health literacy is a non-pharmacological method of managing and preventing diseases. [12]Basic health knowledge is needed in order to have a healthy life.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 benefi ts. [12]Overwhelming developments in information technology and rapid advances in medical scientifi c knowledge demand that the public get an everincreasing understanding of diseases for good decision-making and for self-management of diseases.Naidu (2008) indicates health literacy as the "cornerstone of many other life skills". [13] 1974, the term health literacy was fi rst used in a discussion of health education as a policy issue affecting the health system. [14]Some key features of low health literacy include, Low health literacy will interfere with the ability to process and understand information about health; [9] Low health literacy is associated with a range of poor health outcomes; [14] and data from many developed countries show a relationship between low health literacy levels and improper use of available health services. [14]he WHO commission on the social determinants of health, identifi ed health literacy as having a central role in determining inequalities in health in both rich and poor countries. [4]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. [8]

Dimensions of oral health literacy
According to Kickbusch, Maag, and Kris (2008) there are fi ve important key dimensions for oral health literacy.Those are: [15] 1. Oral health care system knowledge and utilization; 2. Basic oral health knowledge; 3. Market and consumer behavior; 4. Oral health competencies at the workplace and 5. Political participation.

Oral health literacy levels
There are three distinct levels in oral health literacy, which are the functional, interactive and critical. [16,17] Functional: basic skills in reading and writing necessary for effective functioning in a health context; 2. Interactive: more advanced cognitive literacy and social skills that enable active participation in health care; and 3.The oral health literacy is a distinct concept, rather than a derivative concept from literacy and numeracy skills.The oral Health literacy is considered to be obtained and processed in the following way; [18] [Figure 1].

According to the fi gure:
-A person with general literacy, ability to understand health information; and ability to access health information is expected to have high level of health knowledge.-Basic health knowledge will possibly increase the interest in receiving health information.At the same time, interest in getting health information is expected to increase the health literacy.-Health knowledge will help an individual to participate in shared-decision making in health care.By participating in shared-decision making, the existing level of health knowledge is expected to be increased with the help of health care providers.-Thereby, a person with high level of health literacy will have healthy behaviors and attitudes and also they will self-manage diseases and participate well in shared-decision making.

Health literacy statistics worldwide
The overall average oral health literacy level among the population appears to be low.The level of health literacy among Australian adults is comparatively higher than Canada, United States of America and New Zealand adults. [19][Table 1] Results from the National Assessment of Adult Literacy (NAAL) reported that on average health literacy levels were lower among particular ethnic minorities (Black, Hispanic, American Indian/ Alaska Native, and multiracial adults), men, older adults, those in poverty, those who received publically funded insurance, those with lower levels of education and those who failed to fi nish high school. [17,20]Furthermore; the report stated that most of the adults with higher levels of health literacy received their health information from the internet compared to those with lower levels, who relied primarily on "magazines and newspapers."Moreover, those with the lowest levels, were the least likely to use the internet and received the majority of their health information by radio or television rather than print media. [20]

Impact and outcomes of low oral health literacy
A committee formed by the Institution of Medicine in the U.S. to understand health literacy and its impact on health outcomes have developed a health literacy framework [Figure 2].This framework identifi es three major areas that may play important roles in shaping individuals health literacy: culture and society, the health system and the education system.Interventions should be directed towards these three areas to improve health literacy. [16]ere are several factors which impact on low health literacy level in the community.[26] Other factors that can be added to this list are depression due to misunderstanding of one's disease conditions; increased use of specialty care; increased need for health care work force; and poor response in health care research and surveys. [27]or health literacy is considered as a contributor of poor oral health status in an individual, poor heath outcome in a community   and health inequalities.The overall major consequence is the cost as the patients with relatively low health literacy use more health care resources than those with higher literacy abilities. [28]Health care costs due to low health literacy in the USA are estimated at $US 73 billion and at 77.5 billion pounds in the European Union. [29]Another study estimated the cost for an individual due to lack of health literacy as US$143-7,798. [30]me of the reasons for increased health care costs due to a lack of health literacy in the community are: -People with a low level of health literacy are less likely to seek treatment from primary care providers which leads into hospital admission and to specialist consultations. [31]Due to an inadequate awareness about diseases, patients with a low level of health literacy will seek treatment in the fi nal stage of the diseases such as cancer and diabetes.This might increase the treatment cost due to more complicated and expensive intervention requirements at the stage of the diseases. [31]They are less likely to use preventive services such as vaccination and screening. [29]They are more likely to use emergency services. [31]alth literacy can also impact oral health.Adults with inadequate oral health literacy have poorer oral health knowledge, tend to have fewer dental visits, and are more likely to report poor or fair oral health. [32]Oral health literacy varies between racial groups; those from ethnic minorities tend to have inadequate literacy levels that may impact their oral health. [33,34]Children of parents with low literacy have poor reported oral health [35,36] and are less likely to have sealants on their permanent teeth. [37]Miller and colleagues [35] examined the association between caregiver's literacy and preschool children's oral health.This study evaluated clinical oral health status and oral health behavior of children, caregiver's oral health knowledge and children's oral health as perceived by their caregiver.There was a signifi cant association between caregiver's oral health literacy and children's oral health as determined by both clinical examination and caregiver's perception.Oral health knowledge and behavior was not found to be affected by literacy, however; another study concluded that low levels of oral health literacy were associated with poor knowledge and behavior among low-income mothers. [36]This variation between the two studies could be the result of the different characteristics of their study populations, especially the level of education.

Tools for assessing the oral health literacy
The fi rst two measures of health literacy developed focus on an individual's ability to read and on word recognition.The Rapid Estimate of Adult Literacy in Medicine (REALM) test was developed by Davis et al. in 1991; this tool assesses word recognition and pronunciation skills. [38]The second instrument, Test of Functional Health Literacy in Adults (TOFHLA), was developed in 1995 and it measures reading comprehension and numeracy skills. [39]Other instruments use screening questions to assess a patient's ability to read and write the necessary information in a medical setting; an example of such a scale is the health literacy scale developed by Chew et al. [40] which is a short questionnaire used to identify patients with inadequate health literacy.These instruments have been validated and are used widely in the medical literature; however, they are limited to measuring individuals" ability to read and write while health literacy itself goes beyond that. [41] measure oral health literacy, researchers developed modified versions of the REALM: Rapid Estimate of Adult Literacy in Dentistry (REALD). [42,43]There are two versions of this tool (REALD-30 and REALD-99) depending on the number of words used in the instrument.
Atchison et al. [44] created a new instrument based also on REALM; this new instrument (REALM-D) combines both medical and dental terms into a single 84-item scale to screen for oral health literacy and was found to be a valid and reliable measure when tested on a diverse sample of dental clinics patients in the USA.Other instruments used in the dental literature are based on the TOFHLA; [45] for example, the Test of Functional Health Literacy in Dentistry (TOFHLiD) assesses comprehension and numeracy skills for dental patients.These instruments have the same limitations as their original versions: they focus only on word recognition and numeracy skills.More recently, another instrument was developed by Sabbahi et al. [46] to determine the oral health literacy of adults: Oral Health Literacy Instrument (OHLI).
In addition to comprehension and numeracy skills, OHLI also measures oral health knowledge in an attempt to capture another dimension of health literacy.With the increasing interest in health literacy in the last 25 years, it has become clear that health literacy is a multi-dimensional concept, which further complicates the development of a single scale to measure all dimensions of health literacy.Frisch et al. [47] suggest that other domains of literacy should be incorporated into health literacy to develop an extensive scale inclusive of different dimensions such as functional, critical, attitude, awareness and procedural knowledge.To date, such an instrument does not exist but the research is ongoing.

Guidelines for dental healthcare professionals to improve oral health literacy
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."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. [24,32,48]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 infl uence how dental health care information is processed. [49,50]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. [51]Plain language embodies clear communication and offers healthcare professionals an opportunity to make patientcentered 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. [51]e 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 health care providers: [47,48,52] -

CONCLUSION
From the reviewed literature on oral health related literacy the following conclusion can be drawn: -The process of acquiring oral health information, appraising its concepts, and applying oral health prevention and treatment plans appropriately requires new skill development called oral health literacy (OHL).-Oral health literacy is an interplay between culture and society, the health system, education system, language and oral health outcomes indicating that it may be a new determinant of oral health and should be considered more intensively in oral health research.-There are several factors which impact on low health literacy level in the community.Those are difficulty in navigating the health care system; increased risk of hospitalization and emergency care use; lower use of preventive services; diffi culty in understanding and completing documents and consent form; inability to read directions for prescriptions; use of more expensive services; misuse of medications; misunderstanding of self-care instructions and practice of less preventive health care. - 2004, National Institute of Dental and Craniofacial Research International Journal of Medicine and Public Health | Oct-Dec 2013 | Vol 3 | Issue 4 Critical: the ability to critically analyze and use information to participate in actions that overcome structural barriers to health."International Journal of Medicine and Public Health | Oct-Dec 2013 | Vol 3 | Issue 4

Figure 1 : 2 :
Figure 1: Flow chart that describes the process in health literacy Figure 2: Health Literacy Framework

(
Source: Health Literacy Statistics, 2010) International Journal of Medicine and Public Health | Oct-Dec 2013 | Vol 3 | Issue 4 International Journal of Medicine and Public Health | Oct-Dec 2013 | Vol 3 | Issue 4

Table 1 : Health literacy statistics Country Percentage of poor health literacy (Adult: 16-65 years)
Literacy tools such as Rapid Estimate of Adult Literacy in Dentistry (REALD) i.e.REALD-30 and REALD-99; Test of Functional Health Literacy in Dentistry (TOFHLiD); and Oral Health Literacy Instrument (OHLI) can be used to assess the degree of oral health literacy.-To enhance the likelihood of positive oral care outcomes, dentistry should develop a greater knowledge of how to interact with patients who have low oral health literacy and are at risk.