Health Literacy: A Path to Oral Health Equity

Homa Amini, DDS, MS, MPH, and James R. Boynton, DDS, MS

ABSTRACT Health equity has been defined as “the absence of systematic disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage/disadvantage.” [1] The social determinants of health include literacy. Health literacy, including oral health literacy, is a driver of inequity of population health. Oral health professionals have an important role to improve structural systems and interpersonal communication, working toward health equity through focus on health literacy.

With the release of Healthy People 2020, the U.S. Department of Health and Human Services established the 10-year agenda for improving the nation’s health. The plan outlined four overarching goals: attainment of longer lives, elimination of disparities, creation of healthy environments and promotion of quality of life across all life stages. These goals emphasized the concept of social determinants of health and factors that would influence health beyond one’s biology. [2] The World Health Organization describes social determinants of health as “the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life.” [3] Factors such as income, race and ethnicity, geographic location, language and education/literacy influence health outcomes more than medical care. [4] These factors help explain the root causes of health disparities experienced by many populations, as greater than 80% of health outcomes are due to socioeconomic factors, health behaviors, and the physical environment. [5]

The social determinants of health are the varied health-related circumstances in which people live, including housing stability, nutrition security, safety and literacy (TABLE). [6] The social determinants of health are a primary driver of health inequity. Health disparities are found in myriad of communities — African American, Hispanic, Native American, Asian, Pacific Islander, mixed race, lesbian/gay/bisexual/transgender, the disabled, military veterans and urban/ rural communities all face health inequity. [7] Health equity has been defined as “the absence of systematic disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage/disadvantage. [1] Key principles underlying the concept of health equity include the following: All people should be valued equally; nondiscrimination and equality; health is of special importance for society; individuals have rights to health and to a standard of living adequate for health; health differences adversely affecting socially disadvantaged groups are particularly unacceptable because ill health can be an obstacle to overcoming social disadvantage; the resources needed to be healthy (i.e., the determinants of health, including living and working conditions necessary for health as well as medical care) should be distributed fairly; and health equity is the value underlying a commitment to reduce and ultimately eliminate health disparities. [8]

TABLE Examples of Social Determinants of health [6] SEE TABLE IN THE FULL ISSUE OF THE JOURNAL

Screening for the social determinants of health in clinical care settings has gained momentum. Research supports screening for social risk factors within routine clinical care as part of strategies for improving population health and reducing health inequities. There are various screening tools that have been developed, but there is no standardization of approaches. An example of a screening tool for social determinants of health is the self-administered Centers for Medicare & Medicaid Innovation Health-Related Social Needs Screening Tool to determine if an individual might have an unmet health-related social need. This 26-item questionnaire focuses on five core domains: housing instability, food insecurity, transportation problems, utility help needs and interpersonal safety (FIGURE). [9]

FIGURE CMS health-related social needs screening tool [9] — selected questions. SEE FIGURE IN THE FULL ISSUE OF THE JOURNAL

The social determinants of health have a crucial bearing on health outcomes. Over the past decade, there has been great focus on the Triple Aim model developed by the Institute on Healthcare Improvement (IHI) to improve health outcomes. The model calls for simultaneous pursuit of three dimensions of health system: improving the patient experience of care (including quality and satisfaction), improving the health of populations and reducing the per capita cost of health care. [10] Improving the patient experience of care and the health of populations must take into account the social determinants of health; addressing these issues would have a positive effect on health equity. Among many strategies to achieve these goals are improving the population’s health literacy. [11]

The Role of Health Literacy

In the 1990s, evidence began to emerge about the prevalence of low literacy in health care settings and its adverse effects on health outcomes.[12] Health literacy is now recognized as an important component of health care. [13] The impact of poor health literacy is broad. Low health literacy is associated with increased risks of hospitalization and death with patients with heart failure. [14] Patients with low health literacy are more likely to utilize emergency services, have less knowledge of disease management and self-report poorer health status. [15] Patients with chronic kidney disease and low health literacy are at increased risk of adverse clinical events, increased health care use and mortality. [16] Limited health literacy is an important factor that influences children’s asthma control and health care utilization. [17]

Healthy People 2020 defines health literacy as “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.” [18] In simple terms, it refers to having the skills to navigate the health care system successfully. Health literacy is not only about education; many other skills are also important, such as speaking, listening and being able to advocate for oneself in the health system. [13] Literacy levels correlate with health in adults, both in developing countries and in the U.S. [19,20] Healthy People 2030’s proposed definition reflects that health literacy is not only affected by an individual’s capacity, but by accessibility, clarity and ability to act on health information and services: “Health literacy occurs when a society provides accurate health information and services that people can easily find, understand and use to inform their decisions and actions.” [21] Health literacy affects an individual’s health, health behaviors and health outcomes. [22]

Low health literacy, as a contributor to poorer health outcomes, is of particular concern for vulnerable populations, including children. If a parent is unable to read and comprehend instructions, prescription labels, consent forms and other information, it may lead to problems such as incorrect drug doses, improperly mixed infant formula, missed appointments and noncompliance with immunization schedules. Parental health literacy is associated with worse asthma care measures in children, greater incidence of hospitalizations and emergency department visits and days missed from school. [23]

Health literacy is commonly linked to other social determinants of health. Studies have shown the rate of low literacy is significantly associated with race, ethnicity, income, educational attainment and age and is an independent risk factor even after adjustment for age, race, gender, income, education, health status and other sociodemographic variables in an array of diseases and health settings. [22]

Health Literacy in Dentistry

As with general health, achieving and maintaining oral health requires patients to be able to understand, interpret and act on various health information. [24] Health literacy is an emerging topic in dentistry as poor oral health literacy may result in poor dental outcomes. [25] Difficulty comprehending instructions, understanding preventive and home care instruction and navigating the system can make achievement and maintenance of oral health a challenge.

Although oral health in the U.S. has significantly improved since the 1960s, dental caries is the most common chronic disease of children aged 5 to 17 and is five times more common than asthma. [26] With an understanding of the etiology, prevention and treatment of dental caries, it has been thought that low oral health literacy may play a role in the disease process. [27]

More than 50 instruments have been developed to screen for health literacy. [28] These tests can alert clinicians to the possibility that a patient may have difficulty with printed materials and oral communication. Word recognition tests are strongly correlated with general reading ability and reading comprehension. [29] Oral health literacy can be assessed using the Rapid Estimate of Adult Literacy in Dentistry (REALD-30), a word-recognition test. [30] Jones et al. examined the association of dental knowledge, dental care visits and oral health status with oral health literacy in dental patients. Patients who had incorrect dental knowledge and no dental visit in the last year and who reported having fair or poor oral health had lower REALD-30 scores than the reference group. This study concludes that a significant number of patients may have a low level of oral health literacy, which may interfere with the ability to understand oral health information. [25] A study conducted on oral health literacy levels among a low-income population demonstrated differences in oral health literacy levels between racial groups. Whites were found to have significantly higher oral health literacy levels when compared to African Americans and American Indians, who have among the poorest oral health among all ethnic groups. [31]

Many Americans experience a mismatch between their literacy skills and the information demands that dental care places on them. [32] Rozier et al. conducted a national survey to examine dentist-patient communication techniques used in the U.S.; the findings reveal that routine use of many communication techniques is low among dentists, including those techniques thought to be most effective with patients with low literacy skills. [33] Parents of children enrolled in Medicaid expressed concerns that dentists do not provide the information needed to ensure good oral health for their children. [34] With the growing awareness that many Americans have poor health literacy skills, effective communication becomes of paramount importance in patient education. Schwartzberg et al. conducted a survey of health care providers to explore the techniques used to communicate with patients faced with low literacy. Ninety-five percent of the respondents most frequently employ the communication technique of using simple language and avoiding technical jargon; 70% of respondents routinely hand out printed material to patients; and 60% of respondents read patient education material aloud. Less than 40% of the surveyed health care professionals routinely used the teach-back technique, asking the patient to state in their own words what they need to know or do about their health, recommended by health literacy advocates to improve patient-provider interaction. Findings of this study led to the conclusion that many providers may need specific education about low literacy and its implications for the health care system as well as training in communication techniques aimed at addressing low health literacy. [35]

Health literacy experts have suggested that health care providers can improve communication with patients with low health literacy by using the following techniques: slowing down while speaking to patients, using nonmedical language, showing or drawing pictures, limiting the amount of information and repeating it and using the teach-back technique. [35] Research indicates that the teachback technique is effective, not just for improving patients’ understanding but also for improving outcomes. Patients with diabetes whose physician assessed patients’ comprehension and recall with the teachback technique had significantly better diabetes control than patients whose physicians did not use the technique. [36] These techniques may be helpful for many patient conversations, as even among persons of proficient literacy, conditions such as pain or stress may negatively affect communication and understanding.

Encouraging and expecting patients to ask questions is also an effective tool to reduce the impact of limited literacy. The National Safety Foundation’s Ask Me 3 campaign was designed by health literacy experts and encourages patients to ask the following questions: What is my main problem? What do I need to do? Why is it important for me to do this? [37] This initiative can be strengthened by having health care providers encourage and remind patients to think of questions while preparing for their visits and to focus learning around these questions. [38]

Following a workshop focusing on health equity and patient-centeredness, the Institute of Medicine concluded that health care providers must be able to communicate effectively with all patients, regardless of their health literacy abilities, to allow health care providers to provide patient-centered, equitable and good quality care that will help reduce the national disparities in health. [39] The Centers for Medicare & Medicaid Services has also developed two goals related to health literacy as part of its quality strategy: Improve safety by teaching health care professionals how to better communicate with those who have limited health literacy and practice person-centered care and empower individuals and families through strategies that are culturally, linguistically and health literacy appropriate. [40]

Promoting Health Literacy To Advance Health Equity

Health equity was one of the six aims outlined in the 2001 Institute of Medicine report “Crossing the Quality Chasm: Health Care in the 21st Century.” The report identified six aims for improvement of the U.S. health care system: Health care should be safe, effective, patientcentered, timely, efficient and equitable — providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socioeconomic status. [41] The National Quality Forum outlined The Four I’s for Health Equity as a roadmap for promoting health equity and reducing disparities: Identify and prioritize reducing health disparities; implement evidence-based interventions to reduce disparities; invest in the development and use of health equity performance measures; and incentivize the reduction of health disparities and achievement of health equity. [42] Although identification and implementation of evidence-based interventions are in the realm of the individual provider, advocacy is necessary for investment and incentives to achieve health equity. Oral health literacy has become a focus of oral health advocacy organizations and organized dentistry, with the American Dental Association advocating for national legislation HR 4678, the Oral Health Literacy and Awareness Act. The Oral Health Literacy and Awareness Act would authorize the Health Resources and Services Administration to develop a nationwide oral health literacy campaign across all of the agency’s relevant divisions to promote literacy and awareness programs that are evidence based and focused on oral health care education, including education on prevention of oral disease such as early childhood caries, periodontal disease and oral cancer. [43]

Health literacy improvement has increasingly been viewed as a systems issue. [44] Although historically health literacy has been viewed as individual skill sets, it is evident that health care organizations, including small oral health care organizations such as a dental office, play an important role in alleviating system-level factors that impede one’s ability to make informed health care decisions. To that end, the roundtable hosted by the National Academies Roundtable on Health Literacy has developed a list of attributes to describe health-literate organizations. Many of these system/organizational attributes can be adapted for use in the dental practice environment.

Ten attributes of a health-literate health care organization: [45]

1. Has leadership that makes health literacy integral to its mission, structure and operations.

2. Integrates health literacy into planning, evaluation measures, patient safety and quality improvement.

3. Prepares the workforce to be health literate and monitors progress.

4. Includes populations served in the design, implementation and evaluation of health information and services.

5. Meets the needs of populations with a range of health literacy skills while avoiding stigmatization.

6. Uses health literacy strategies in interpersonal communications and confirms understanding at all points of contact.

7. Provides easy access to health information and services and navigation assistance.

8. Designs and distributes print, audiovisual and social media content that is easy to understand and act on.

9. Addresses health literacy in highrisk situations, including care transitions and communications about medicines.

10. Communicates clearly what health plans cover and what individuals will have to pay for services.

Conclusion

There have been significant improvements in the collective understanding of the impact of social determinants of health, including literacy. One’s health literacy has an important impact on health outcomes, and appropriate action can lead to improvements in health. Dentists can incorporate changes on an individual provider level, at the structural (practice) level, and advocate for system improvement at the policy level to advance health equity.

REFERENCES

1. Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health 2003 Apr;57(4):254–8. doi: 10.1136/jech.57.4.254.

2. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2019). About Healthy People. www.healthypeople.gov/2020/abouthealthy-people. Accessed Nov. 30, 2019.

3. World Health Organization. Social determinants of Health. 2019. www.who.int/social_determinants/en/. Accessed Nov. 30, 2019.

4. Braveman P, Gottlieb L. The social determinants of health: It’s time to consider the causes of the causes. Public Health Rep 2014 Jan–Feb;129 Suppl 2:19–31. doi: 10.1177/00333549141291S206.

5. Hood CM, Gennuso KP, Swain GR, Catlin BB. 2016. County health rankings: Relationships between determinant factors and health outcomes. Am J Prev Med 2016 Feb;50(2):129–35. doi: 10.1016/j.amepre.2015.08.024. Epub 2015 Oct 31.

6. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Social Determinants of Health 2019. www.healthypeople. gov/2020/topics-objectives/topic/social-determinants-ofhealth. Accessed Nov. 30, 2019.

7. National Academies of Sciences, Engineering and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Community-Based Solutions To Promote Health Equity in the United States; Baciu A, Negussie Y, Geller A, et al., eds. Communities in Action: Pathways to Health Equity. Washington D.C.: National Academies Press (US); 2017 Jan 11. 2, The State of Health Disparities in the United States. www.ncbi.nlm.nih.gov/books/NBK425844.

8. Braveman PA, Kumanyika S, Fielding J, LaVeist T, Borrell LN, Manderscheid R, Troutman A. Health disparities and health equity: The issue is justice. Am J Pub Health 2011 Dec;101 Suppl 1:S149–55. doi: 10.2105/AJPH.2010.300062. Epub 2011 May 6.

9. Department of Health and Human Services Centers for Medicare and Medicaid Services. The Accountable Health Communities Health-Related Social Needs Screening Tool. 2019. innovation.cms.gov/Files/worksheets/ahcmscreeningtool.pdf. Accessed Nov. 30, 2019.

10. Institute for Healthcare Improvement. (2019). IHI Triple Aim Initiative. 2019. www.ihi.org/engage/initiatives/ TripleAim/Pages/default.aspx. Accessed Nov. 30, 2019.

11. Parker RM, Ratzan SC, Lurie N. Health literacy: A policy challenge for advancing high quality health care. Health Aff (Millwood) 2003 Jul–Aug;22(4):147–53. doi: 10.1377/ hlthaff.22.4.147.

12. DeWalt DA, Berkman ND, Sheridan SL, Lohr KN, Pignone M. Literacy and health outcomes: A systemic review of the literature. J Gen Intern Med 2004 Dec;19(12):1228–39. doi: 10.1111/j.1525-1497.2004.40153.x

13. Nielson-Bohlman L, Panzer AM, Kindig DA. Committee on Health Literacy: Health Literacy: A prescription to end confusion. Washington, D.C.: National Academics Press; 2004.

14. Fabbri M, Yost K, Finney Rutten LJ, et al. Health literacy and outcomes in patients with heart failure: A prospective community study. Mayo Clin Proc 2018 Jan;93(1):9–15. doi: 10.1016/j.mayocp.2017.09.018. Epub 2017 Dec 6.

15. Horowitz AM, Kleinman DV. Oral health literacy: The new imperative to better oral health. Dent Clin N Am 2008 Apr;52(2):333–44, vi. doi: 10.1016/j.cden.2007.12.001.

16. Taylor DM, Fraser S, Dudley C, et al. Health Literacy and Patient Outcomes in Chronic Kidney Disease: A Systematic Review. Nephrol Dial Transplant 2018 Sep 1;33(9):1545–1558. doi: 10.1093/ndt/gfx293.

17. Tzeng YF, Chiang BL, Chen YH, Gau BS. Health literacy in children with asthma: A systematic review. Pediatr Neonatol 2018 Oct;59(5):429–438. doi: 10.1016/j. pedneo.2017.12.001. Epub 2017 Dec 8.

18. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Health Literacy. 2019. www.healthypeople.gov/2020/topics-objectives/ topic/social-determinants-health/interventions-resources/ health-literacy. Accessed Nov. 30, 2019.

19. Grosse R, Auffrey C. Literacy and health status in developing countries. Annu Rev Public Health 1989;10:281–97. doi: 10.1146/annurev.pu.10.050189.001433.

20. Weiss B, Hart G, McGee D, D’Estelle S. Health status of illiterate adults: Relation between literacy and health status among persons with low literacy skills. J Am Board Fam Pract 1992 May–Jun;5(3):257–64.

21. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Solicitation for Written Comments on an Updated Health Literacy Definition for Healthy People 2030. Fed Reg 2019;84(107):25817–8.

22. National Academy of Medicine. (2015). Health literacy: A necessary element for achieving health equity. nam.edu/ wp-content/uploads/2015/07/NecessaryElement.pdf. Accessed Nov. 30, 2019.

23. DeWalt DA, Dilling MH, Rosenthal MS, Pignone MP. Low parental literacy is associated with worse asthma care measures in children. Ambul Pediatr 2007 Jan;7(1):25–31. doi: 10.1016/j.ambp.2006.10.001.

24. National Institute of Dental and Craniofacial Research, National Institutes of Health, U.S. Public Health Services, U.S. Department of Health and Human Services. The invisible barrier: Literacy and its relationship with oral health. A report of a workgroup sponsored by the National Institute of Dental and Craniofacial Research, National Institute of Health, U.S. Public Health Service, Department of Health and Human Services. J Public Health Dent 2005 Summer;65(3):174–82. doi: 10.1111/j.1752-7325.2005.tb02808.x.

25. Jones M, Lee J, Rozier G. Oral health literacy among adult patients seeking dental care. J Am Dent Assoc 2007 Sep;138(9):1199–1208; quiz 1266–7. doi: 10.14219/ jada.archive.2007.0344.

26. Benjamin RM. Oral health: The silent epidemic. Public Health Rep 2010 Mar–Apr;125(2):158–9. doi: 10.1177/003335491012500202.

27. Vann WF, Lee JY, Baker D, Divaris K. Oral health literacy among female caregivers: Impact on the oral health outcomes in early childhood. J Dent Res 2010 Dec;89(12):1395–1400. doi: 10.1177/0022034510379601.

28. Haun JN, Valerio MA, McCormack LA, Sorensen K, Paasche-Orlow MK. Health literacy measurement: An inventory and descriptive summary of 51 instruments. J Health Commun 2014;19 Suppl 2:302–33. doi: 10.1080/10810730.2014.936571.

29. Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults: A new instrument for measuring patients’ literacy skills. J Gen Intern Med 1995 Oct;10(10):537–41. doi: 10.1007/bf02640361.

30. Lee JY, Rozier RG, Lee SYD, Bender D, Ruiz RE. Development of a word recognition instrument to test health literacy in dentistry: The REALD-30. J Public Health Dent 2007 Spring;67(2):94–8. doi: 10.1111/j.1752- 7325.2007.00021.x.

31. Lee JY, Divaris K, Baker D, Rozier G, Lee SY, Vann W. Oral health literacy levels among a lowincome WIC population. J Public Health Dent 2011 Spring;71(2):152–60. doi: 10.1111/j.1752- 7325.2011.00244.x.

32. Rudd RE. Health literacy skills of U.S. adults. Am J Health Behav 2007 Sep–Oct;31:Suppl 1:S8–S18. doi: 10.5555/ ajhb.2007.31.supp.S8.

33. Rozier GR, Horowitz AM, Podschun G. Dentistpatient communication techniques used in the United States: The results of a national survey. J Am Dent Assoc 2011 May;142(5):518–30. doi: 10.14219/jada. archive.2011.0222.

34. Mofidid M, Rozier RG, King RS. Problems with access to dental care for Medicaid-insured children: What caregivers think. Am J Public Health 2002 Jan;92(1):53–8. doi: 10.2105/ajph.92.1.53.

35. Schwartzberg JG, Cowett A, VanGeest J, Wolf MS. Communication techniques for patients with low health literacy: A survey of physicians, nurses and pharmacists. Am J Health Behav 2007 Sep-Oct;31 Suppl 1:S96–104. doi: 10.5555/ajhb.2007.31.supp.S96.

36. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: Physician communication with diabetic patients who have low health literacy. Arch Intern Med 2003 Jan 13;163(1):83–90. doi: 10.1001/archinte.163.1.83.

37. Institute for Healthcare Improvement. Ask Me 3: Good Questions for Your Good Health. 2019. www.ihi.org/ resources/Pages/Tools/Ask-Me-3-Good-Questions-for-YourGood-Health.aspx. Accessed Nov. 30, 2019.

38. Institute of Medicine. (2012). How Can Health Care Organizations Become More Health Literate? Workshop Summary. www.nap.edu/catalog/13402/how-can-healthcare-organizations-become-more-health-literate-workshop. Accessed Nov. 30, 2019.

39. Institute of Medicine Forum on the Science of Health Care Quality Improvement and Implementation; Institute of Medicine Roundtable on Health Disparities; Institute of Medicine Roundtable on Health Literacy. Toward Health Equity and Patient-Centeredness — Integrating Health Literacy, Disparities Reduction and Quality Improvement: Workshop Summary. Washington, D.C.: National Academies Press; 2009.

40. Centers for Medicare & Medicaid Services. (2016). CMS Quality Strategy. www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/QualityInitiativesGenInfo/ Downloads/CMS-Quality-Strategy.pdf. Accessed Nov. 30, 2019.

41. Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academies Press; 2001.

42. National Quality Forum. A Roadmap for Promoting Health Equity and Eliminating Disparities: The Four I’s for Health Equity. 2017. www.qualityforum.org/ Publications/2017/09/A_Roadmap_for_Promoting_Health_ Equity_and_Eliminating_Disparities__The_Four_I_s_for_ Health_Equity.aspx. Accessed Nov. 30, 2019.

43. American Dental Association. ADA supports oral health literacy legislation. www.ada.org/en/publications/adanews/2019-archive/november/ada-supports-oral-healthliteracy-legislation. Accessed Nov. 30, 2019.

44. Brach C. The journey to become a health literate organization: A snapshot of health system improvement. Stud Health Technol Inform 2017;240:203–7.

45. Institute of Medicine. Ten Attributes of Health Literate Health Care Organizations. 2012. gahealthliteracy.org/ wp-content/uploads/2014/07/BPH_Ten_HLit_Attributes.pdf. Accessed Nov. 30, 2019.

THE CORRESPONDING AUTHOR, Homa Amini, DDS, MS, MPH, can be reached at homa.amini@nationawidechildrens.org.

AUTHORS

Homa Amini, DDS, MS, MPH, is a professor of clinical dentistry, in the division of pediatric dentistry at the Ohio State University College of Dentistry in Columbus. Conflict of Interest Disclosure: None reported.

James R. Boynton, DDS, MS, is a clinical associate professor and pediatric dentistry division head in the department of orthodontics and pediatric dentistry at the University of Michigan School of Dentistry in Ann Arbor. Conflict of Interest Disclosure: None reported.