Organizational Health Literacy in Oral Health: A Multilevel Perspective

Lindsay Rosenfeld, ScD, ScM, is a social epidemiologist with research, practice and policy interests focused on the social and structural determinants of health and child equity. She is an instructor at the Harvard T.H. Chan School of Public Health, Department of Social and Behavioral Sciences and a scientist and lecturer with the Institute for Child, Youth and Family Policy at the Brandeis University, Heller School for Social Policy & Management. Conflict of Interest Disclosure: None reported.

Kathryn A. Atchison, DDS, MPH, is a professor in the division of public health and community dentistry at the University of California, Los Angeles, School of Dentistry and is jointly appointed in the UCLA Jonathan and Karin Fielding School of Public Health, department of health policy management. Conflict of Interest Disclosure: None reported.

Nicole Holland, DDS, MS, is an assistant professor and the director of health communication, education and promotion in the Tufts University School of Dental Medicine’s Department of Public Health and Community Service. Her research interests include the intersection of health literacy, language access and oral health as well as the impact of oral health messaging in the media. Conflict of Interest Disclosure: None reported.

Kelly Cantor, MPH, CHES, is the manager of community-based programs at the American Dental Association. Conflict of Interest Disclosure: None reported.

Lindsey A. Robinson, DDS, is a board-certified pediatric dentist and has maintained a dental practice in Grass Valley, Calif., since 1996. She has served on the National Academies of Sciences, Engineering and Medicine Roundtable on Health Literacy as an oral health representative since 2013. Conflict of Interest Disclosure: None reported.

ABSTRACT

Healthy People 2030 has been released and includes new health literacy definitions that more fully reflect it as a multidimensional concept connected to the social and structural determinants of health.

Keywords: Oral health literacy, Healthy People 2030, general health, organizational health literacy, oral health, health equity

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The importance of health literacy in oral and general health is wellestablished. [1] Two previous issues of the Journal of the California Dental Association (April 2012, August 2020) were dedicated to the idea that health literacy is vital to positive oral health outcomes. [2] The recent release of Healthy People 2030 includes new health literacy definitions that more fully reflect the connection to the social and structural determinants of health. [3] Personal health literacy is defined as: “The degree to which individuals have the ability to find, understand and use information and services to inform health-related decisions and actions for themselves and others.” Organizational health literacy is defined as: “The degree to which organizations equitably enable individuals to find, understand and use information and services to inform health-related decisions and actions for themselves and others.” A 2021 article by Brach and Harris describes how Healthy People 2030 features health literacy as part of its framework, emphasizing the responsibility of organizations at any level to focus on the systems, processes, operations and interactions that make information and services easy to find, understand and use. [4]

This commentary was invited to highlight on-the-ground organizational health literacy best practice in oral health in order to galvanize the field toward more robust adoption of such practices in efforts to meet the 15 oral health objectives in Healthy People 2030. For example, OH-02: Reduce the proportion of children and adolescents with active and currently untreated tooth decay in their primary or permanent teeth, and OH-11: Increase the proportion of persons served by community systems with optimally fluoridated water systems. As such, the newest Healthy People health literacy definitions are vital primers for the focus of this commentary and the featured examples, which highlight systems change to drive optimal, equitable oral health opportunities and outcomes through a health literacy lens. To choose the examples described, the authors discussed the best practices they had seen themselves or heard about from colleagues or via conferences, presentations, articles, listservs and beyond. This is the first known attempt to convey such organizational health literacy practice across levels in oral health, with the aim of galvanizing next research and action steps.

Briefly, health literacy is an interaction, comprised of literacy skills (e.g., skills of people and professionals related to reading, writing, talking, listening and numeracy), texts (e.g., informational brochures, patient-provider discussions, signage, websites), tasks (e.g., from completing a health history form to registering for an appointment) and context (e.g., emotive and physical issues, practice norms, structural facilitators and barriers), involving patients, professionals, organizations and systems. [5] Descriptions of the relationship between health literacy and individual or population skills are most common thus far, suggesting that more-developed personal literacy skills are related to more positive general health and oral health outcomes. [1,6–8]

An increasing evidence base also demonstrates the importance of organizational health literacy, the role of an organization in equitably enabling people to find, understand and use health information and services. This encompasses organizational policies, institutional practices, navigation, provider/patient communication and interaction, culture and language, communication (print materials, forms, websites, patient portals) and the patient/ family population, staff and others who may participate in the environment. [9] For example, a 2014 American Journal of Public Health article focused on dental organizational health literacy found that implementation of a health literacy environmental scan was acceptable to dental directors and provided clinic directors information on how to enhance care and outreach to make dental environments more user-friendly and health literate. [10]

An organizational health literacy approach allows for organizations and oral health practices to assess, adapt and design an environment that can improve general and oral health. [9–12] Though organizational health literacy assessments originally focused on patientfacing entities (e.g., dental clinics, dental practices), [9,11,13–16] organizational-level assessments are also used by oral health organizations to improve their own organizational health literacy, which extends to their staff and constituents. We present examples of organizations that have used an organizational health literacy lens to improve health at various levels (e.g., individual/ family, community, state, regional/ multistate and national) (FIGURE).

The National Academies of Sciences, Engineering and Medicine (NASEM) is an independent, nonprofit organization that was established to provide evidencebased information to decision-makers in the public and private health sectors. [17] Under the NASEM umbrella, the Roundtable on Health Literacy (Roundtable) has led efforts to explore the discipline since 2004, shortly after the release of the seminal publication “Health Literacy: A Prescription to End Confusion.” [7] In the ensuing years, health literacy has become a priority for national action. It was initially fueled by evidence reporting that people with limited literacy skills had worse health outcomes, in general. [6] And even those with average literacy skills had difficulty understanding basic printed health information, according to the 2003 National Assessment of Adult Literacy. [18] Simultaneously, the concept of health literacy evolved. Initially the emphasis was on the measurement of individual literacy skills and interventions focused on patients with underdeveloped literacy skills. Later, a shared responsibility model was highlighted, acknowledging the demand placed on patients by the complexities of the health care system (e.g., complicated informational materials, confusing health history forms, technical jargon in discussions, myriad dental benefits programs, insurance limitations, policy restrictions). Consistent with other researchers in the field, Roundtable members recognized that systems level changes were necessary to reduce the mismatch between systems demands and population skills — that is, an organizational health literacy focus. [19,20]

In 2012, the Roundtable convened a workshop aimed to catalyze discussion to develop a set of national objectives for health literacy. These were aimed at health systems to support the incorporation of health literacy principles and practices into organizational strategic goals, infrastructure, priority initiatives, workforce development, policies and communication strategies. The workshop resulted in a 2012 paper by Roundtable members and associated colleagues: Ten Attributes of Health Literate Health Care Organizations 11 (TABLE 1). The attributes consolidated current science and practice to propose ways that health care entities could implement strategies using the attributes within an organization, including dental practices, federally qualified health centers (FQHCs), dental schools, oral health payers or accrediting bodies.

Since the release of the 10 Attributes, an increasing number of health systems have used them and other organizational health literacy assessments to guide organizational health literacy goals. [9,13,16,21] In 2017, the transformational experiences of three pioneering organizations were chronicled by Dr. Cindy Brach, senior health policy researcher at the Agency for Healthcare Research and Quality and a former Roundtable member. [22] Although the three health care systems took different approaches, common characteristics catalyzed change within their organizations. Importantly, they all had dedicated internal champions or outside consultants with expertise, leadership buy-in, alignment with organizational mission and vision, readiness to change and belief in sufficient return on investment.

Oral health organizations have a critical role in driving health literacy systems change. National, state and community oral health organizations have a unique role to play in leading the way to fully incorporate health literacy across levels for optimal oral health outcomes. Countless researchers, health professionals and national and international organizations use this multilevel perspective (the social ecological model) to explore how various levels influence health outcomes, beyond individual or family behavior alone. [23–25] The FIGURE shows many organizations across multiple levels of influence that impact individual, family, and population oral health outcomes. Creating equitable access to optimal oral health opportunities and outcomes requires a health equity perspective. Taking on such a viewpoint requires attention to various issues including the social and structural determinants of health, structural racism, impacts across the life course, disability, family engagement, health literacy and more.

Here, we focus on the role of health literacy and specifically organizational health literacy in reaching oral health and health equity goals. [26,27] Organizations across national (e.g., American Dental Association, NIDCR/NIH and Centers for Disease Control and Prevention), regional/multistate (e.g., Atrium Health, HealthPartners and Kaiser), state (e.g., California Dental Association and other state associations and state departments of public health, state dental accreditation, state dental schools) and community levels (e.g., dental practices, FQHCs, local dental associations/ societies, dental schools and school-based clinics) have a crucial role to play in creating health literate organizations.

Oral health organizations across levels must incorporate health literacy principles routinely and systematically to equitably meet Healthy People 2030 oral health objectives. We present best practice work across national, state and community levels to describe best practice and highlight areas that organizations (e.g., dental practices, payors, FQHCs) might focus on in pursuit of organizational health literacy. We recommend focusing on one of five areas as you get started in considering the examples highlighted for applying an organizational health literacy perspective to organizational change. They include clear communication, safety, plain language and access in multiple languages, quality improvement and systems (TABLE 2).

In 2006, the leadership of the American Dental Association (ADA) established the National Advisory Committee on Health Literacy in Dentistry (NACHLD) in recognition of the important role of health literacy in achieving or maintaining good oral health. In the same year, the ADA adopted a health literacy definition for its institutional operations and practices and developed two additional health literacy-related policy statements soon after. To date, the NACHLD has developed three health literacy organizational action plans (2010-2015, 2016-2020 and 2020-2024) outlining strategic health literacy focus areas in its role in providing guidance to the ADA. [28]

Over the years, the NACHLD has served as an important resource to identify and advise on opportunities in oral health and health literacy for the ADA. As a health care professional organization, the ADA’s mission focuses on helping dentists succeed in advancing the public’s oral health. To serve this purpose, the ADA is working toward shaping the 10 attributes and the objectives to fit its unique context. They followed the example of the Centers for Disease Control and Prevention’s (CDC) modification to the original 10 attributes to adapt to organizations supporting a population, such as a dental practice. They divided the attributes into two main categories: attributes about leadership, priorities, training, access and special situations and attributes about audience and group participation and feedback in health communication and information activities. [29] A NACHLD workgroup met with ADA staff to map its unique organizational structure, including departmental relationships and responsibilities as well as past and current health literacy-related initiatives. Next, they reviewed each attribute to explore whether the attribute applies to the ADA organizational structure, previous and/or current health literacy-related efforts and potential future application strategies. This process of adapting the attributes is in progress and critical to appropriately align the process of becoming a health literate organization. In an effort to have “leadership that makes health literacy integral to its mission, structure and operations” (attribute 1), the workgroup highlighted the ADA’s unique organizational leadership and workforce model, comprised of both paid staff members and volunteer dentists. To achieve greater continuity, staff liaisons from various ADA departments have been appointed to the NACHLD to enhance cross-departmental collaboration. Additionally, the need for health literacy training for paid ADA staff as well as new and existing ADA board and trustee members (i.e., rotating, volunteer dentists) has been established. To further enhance the design and distribution of print, audiovisual and social media content that is easy to understand and act on (attribute 10), ADA departments also collaborate with NACHLD members so they may more fully incorporate health literacy into their practices (e.g., NACHLD review of COVID-19 health information materials prior to public release). In tandem with the ADA’s health literacy work, a need was identified for the dental profession to take the lead in oral health quality improvement efforts and development of clinical performance measures. As such, the ADA established the Dental Quality Alliance (DQA) in 2010. [30] The group is composed of key stakeholders in oral health care delivery whose mission is “to advance performance measurement as a means to improve oral health, patient care and safety through a consensus building process.” [31] Over the years, the DQA has implemented a comprehensive strategy to develop and validate cariesrelated measures that are used to evaluate utilization, quality and cost of programs and plans. This aligns with attribute 2 to integrate health literacy into strategic and operational planning, quality improvement, goals and measures.

The ADA also sponsors a variety of outward-facing health literacy training opportunities for dentists, the oral health community and the greater public (e.g., national conference presentations, webinars aimed at oral health professionals and the nationwide Health Literacy in Dentistry Essay Contest for dental students). Additionally, NACHLD’s work on initial recommendations for the teaching and application of health literacy in dental education was adopted by the Commission on Dental Accreditation (CODA). These initiatives are a result of cross-organization and cross-level, collaborative efforts prompted by an organizational health literacy perspective.

Atrium Health is a large nonprofit based in Charlotte, North Carolina, with over 1,500 care delivery locations and nearly 70,000 employees across academic medical centers, hospitals, urgent care clinics and medical practices. Spanning three states (North Carolina, South Carolina and Georgia), Atrium Health has become a dynamic innovator in the delivery of quality, compassionate care at the individual, community and population levels. While Atrium Health has not incorporated an oral health component, their experience highlights the realities of a health system applying an organizational health literacy perspective in that the path is not typically linear and often initially quite fragile. The first milestone for Atrium was the creation of the Health Literacy Learning Collaborative, which created and enacted an action plan to extend a health literacy initiative across the system. Nine measures were generated and then evaluated at the end of one year. The plan’s goals were to improve health outcomes, patient satisfaction and value. A chief nurse executive (CNE) was hired to catalyze progress by focusing on two key, systemwide health literacy approaches (Teach Back and Ask Me 3) across levels: provider, staff and patients. Shortly thereafter, the new position of senior vice president of patient experience helped to solidify these organizational changes. The Ten Attributes are now assessed on an annual basis to inform progress, new goals and board decision-making.

Organizational health literacy initiatives are a focal point of statewide coalition work dedicated to improving population health outcomes by promoting health literacy practices. The Minnesota Health Literacy Partnership is one such coalition comprised of 43 members who represent health systems, payers, nonprofits and the Minnesota Department of Health. Formed in 2006, a coalition action plan was developed to prioritize six activities for members and other health organizations: [35]

■ Adopt and use health literacy best practices.

■ Make information about health useful and accessible.

■ Increase and improve patientcentered resources.

■ Provide opportunities for education about health literacy at all levels.

■ Streamline processes to make it easier for patients to navigate the health care system.

■ Invest in resources to ensure that health information is culturally appropriate and in a patient’s preferred language.

By leveraging the expertise and resources of members, the partnership has made great strides toward achieving health care equity and affordability, improving health system safety and quality and addressing community needs particularly around language and culture. Their stewardship has created a state focus on organizational health literacy with the goal of making it easier for Minnesotans to understand, navigate and use information and services to take care of their health. For example, HealthPartners, an accountable care organization offering medical and dental care, is using an organizational health literacy perspective to achieve organizational goals as one of the 43 members of the Minnesota Health Literacy Partnership. This perspective has generated health literacy action in concrete ways. One is the creation of a formal patient council, which is charged with bringing the patient perspective so leadership can incorporate this lens in discussions and decisions. Another is focused on continual assessment of the patient experience through questions such as whether the patient receives information from their doctor in a way that they can understand and whether the patient is encouraged to be part of the decision-making regarding their care. [36] Statewide learning, strategizing and collaboration have characterized the Minnesota Health Literacy Partnership’s pursuit of applying health literacy at organization and state levels.

Similar to the ADA, the California Dental Association (CDA) has a history of supporting health literacyrelated policies that have informed activities across the organization. An important example is the development of the 2012 Access Plan approved by CDA’s governing body. It guides the organization in efforts to improve the oral health of Californians. The first recommendation was to “establish oral health leadership and build an oral health infrastructure” by hiring a state dental director and staff to prioritize six objectives, including to promote “evidence-based approaches to increase oral health literacy.” [32] This objective was recently accomplished with development of the California Oral Health Literacy Toolkit in collaboration with the California Office of Oral Health and the Health Research for Action Center at the University of California, Berkeley, School of Public Health. [32,33] The toolkit has a set of six resources to guide dental providers in incorporating oral health literacy best practices and strategies into their clinical environments. Resources include a practice assessment checklist, a printable poster on how to use Teach Back and plain language patient education materials focused on “going to the dentist.” Finally, CDA continues to fund a seat on the National Academies’ Health Literacy Roundtable to ensure advancements in health literacy research and policy benefit from oral health expertise. [34] CDA initiatives are a direct consequence of incorporating an organizational health literacy perspective across the organization.

The California Oral Health Technical Assistance Center (COHTAC) was created by a group of oral health experts and researchers from the University of California, San Francisco, to work in partnership with the state Office of Oral Health with the goal of improving the overall health of Californians. Funded by Proposition 56, the California Healthcare, Research and Prevention Tobacco Tax Act of 2016, the programmatic focus has centered on school oral health programs, tobacco cessation and water fluoridation. Additionally, the group provides technical assistance for local, community-based oral health programs under the direction of the state dental director. The COHTAC website also maintains a collection of evidence-based communication resources that are accessible to all.

In addition, Sesame Street in Communities began a partnership in 2018 with More LA Smiles, a dental pilot program led by the University of California, Los Angeles (UCLA). The goal was to improve the oral health of children in Los Angeles County who are enrolled in the Medi-Cal Dental Program. With funding from the California Department of Health Care Services, More LA Smiles was created through a collaboration of multisector stakeholders that included state-funded health plans, early childhood education experts, quality improvement organizations, professional organizations and family support programs. The partnership uses performance measures in the delivery of high value care and to improve oral health access through a number of strategies, such as the development of professional education programs, practice and systemslevel improvements and information technology innovations. Sesame Street has long been a pioneer in the development of family-informed and evidence-based early childhood programming. As part of the partnership, a children’s oral health awareness campaign was created to inform families and caregivers about the importance of early childhood oral health and finding a dental home by age 1. All new videos and downloadable graphics feature beloved Sesame Street characters and are available free at morelasmiles.org.

An organizational health literacy perspective in dental practice is essential to achieve oral health equity. While there are many areas of important focus as outlined previously (TABLE 2), we will highlight safety here, in particular, preventable adverse oral health outcomes as described by the NASEM 2000 report “To Err is Human: Building a Safer Health System.” [37] Health literacy issues related to safety across levels include medical/dental errors; lack of team member communication (e.g., safe practice discussions among team members, patients and families); and lack of care coordination within the health care system. [38–40] Preventable adverse events in dental practice include wrong tooth extractions, sedation complications and foreign body aspiration, among others. Related environmental safety issues in dentistry include dental unit waterlines and infectious disease transmission. [41] Subsequently, calls for a stronger dental safety culture have been raised within the ADA. [42,43] However, thus far, many of the considerations regarding safety have focused on the physical provision of care. [44] An organizational health literacy perspective can help broaden the focus so that dental practices can respond to all three critical aspects of the NASEM safety culture: patient-centered care, equitable care and effective care.

There are many ways to tackle these safety pillars from an organizational health literacy perspective. For example, patientcentered care considers the patients’ health needs and preferred outcomes. [45] Part of accomplishing this requires that dental practices incorporate a plain language focus for clear communication and collaboration between the health system, the dental practitioner and the patient. Plain language also helps to counter misinformation, which creates safety problems in both dental and medical care. Patient-centered care is also linked to rebuilding pervasive feelings of distrust and disregard for public health and oral health care safety recommendations, such as community water fluoridation and vaccine uptake. Likewise, delivering equitable care means attending to “digital divide” issues, whereby lower income and rural patients and dental practices might be disproportionately impacted in their ability to engage in optimal dental care because of inconsistent, or completely absent, internet infrastructure. Equitable care also involves providing plain language information in multiple languages.

Recently, many safety initiatives have blossomed to provide information that meet the above considerations, particularly related to COVID-19 and the vaccine. For example, UCLA launched a COVID-19 vaccination website with information in 17 different languages. [46] Similarly, the Health Literacy Solutions Center COVID-19 Plain Language Resources site became a clearinghouse for health professionals seeking materials following health literacy principles. [47] Effective care is also central to safety and can be optimized by coordination of health literacy at a practice level, making “it easier for people to navigate, understand and use information and services to take care of their health.” [40] For example, informed consent and after-visit summaries that meet health literacy principles (e.g., plain language, multiple languages, accessible, actionable) are crucial to safe, effective care. [48] Some dental practices prioritize being a health literate environment by designating one staff member as the “health literacy manager.” This professional works with staff to build a health literate organizational culture step by step, including bringing in resources and practices such as those mentioned in this article.. Creating a health literate dental practice is key to delivering excellent care, and it requires resolving organizational barriers to safety, among other factors. The Oral Health Literacy Toolkit is a great place to get started.

Organizations that use an organizational health literacy perspective to meet safety, communication and other health literacy goals are well-equipped to face challenges to the provision of equitable, quality oral health care. [49,50] Likewise, working toward becoming a health literate organization aligns directly with safety goals put forward by the Joint Commission’s 2007 report “What Did the Doctor Say?”, which propelled the health literacy field forward to conceptualize a health literate approach as “universal precautions.” [51] Clear, usable and actionable information and processes are preferable, whether by patients, oral health professionals or the public.

In a health literate oral health organization (TABLE 2), plain language guidelines for clear communication are applied to elevate all patient or publicfacing materials: forms, websites, postoperative instructions, educational materials and provider/patient interactions, including clinical treatment decision-making. For safety and other goals, communication and other organizational processes are discussed, practiced and revisited; this can include techniques like Teach Back and Ask Me 3. Information and conversation are also available in multiple languages, preferably the top three to five languages of the intended audience. Processes should be in place if information or conversation is needed in languages not routinely offered. A health literate organization also consistently uses quality improvement methods to rigorously plan, explore, try out and revise best practices that are attuned with the organization’s audience and the field’s evidence base. [31] A health literate oral health organization is also one that regularly incorporates a systems perspective to understand and design interactions that account for multiple levels and actors engaging daily in oral health care. Finally, it identifies actions across levels and invites staff and the intended audience to the table to discuss what these issues are and how to address them.

Whether you’re considering oral health outcomes, insurance complexities or structural racism, consider the many levels on which these concerns operate and the role of multisector systems, collaboration and policy in solving them. [52,53] A health literacy and equity focus are part of the process, across levels, not just a desired outcome. Consistent with the Healthy People 2030 health literacy framework, the health literate oral health organization (FIGURE) rigorously and continuously considers clear communication, safety, plain language/ multiple languages, continuous quality improvement and cross-organizational, collaborative systems (TABLE 2) to achieve equitable oral health outcomes. Use TABLE 3 to plan your next action steps, for tomorrow and over the next year.

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THE CORRESPONDING AUTHOR, Lindsay Rosenfeld, ScD, ScM, can be reached at ler@brandeis.edu.