+
Oral Health Literacy and Dental Public Health
+
Course created by:
Jessica Richards BS
Jennifer S. Holtzman DDS MPH
Kathryn A. Atchison DDS MPH
UCLA School of Dentistry
Acknowledge the review and input of Michelle McQuistan, DDS, MPH, U. Iowa
+ Course Competency
Demonstrate the ability to communicate and
collaborate with relevant stakeholders in
order to advocate for oral and general
health.
3
© AAPHD 3
+ This project is supported by the Health Resources and
Services Administration (HRSA) of the U.S. Department
of Health and Human Services (HHS) under grant
number D83HP19949 Predoctoral Training in General,
Pediatric, and Public Health Dentistry and Dental
Hygiene, grant amount $650,000. This information or
content and conclusions are those of the author and
should not be construed as the official position or
policy of, nor should any endorsements be inferred by
HRSA, HHS or the U.S. Government.
4
© AAPHD 4
Learning objectives:
+

Students will be able to:

Define health literacy & oral health literacy for the health care
provider and dental public health professional

Describe the individual, community and public health
implications of low oral health literacy

Explain the association between health, health literacy, health
beliefs and culture

Explain and describe strategies to communicate more clearly
with patients, the public, or community

Identify aspects of an oral health literate organization and be able
to suggest ways to implement best practices

Describe ways to identify low health literacy through various
measurement strategies
© AAPHD
+ Lecture 1
Definition of health literacy &
oral health literacy
6
© AAPHD 6
+ Lecture Objective
Define health literacy & oral health literacy for the
health care provider and dental public health
professional
© AAPHD
What is health literacy?
+

Watch this 6 minute video to see how complicated the health
system is, and why health literacy matters!

http://www.youtube.com/watch?v=ImnlptxIMXs
© AAPHD
+ What is health literacy?
“Health literacy is a shared function of social and individual
factors, which emerges from the interaction of the skills of
individuals and the demands of social systems” 1
1. IOM. 2004. Health literacy: A prescription to end confusion. Washington, DC: The National Academies Press.
© AAPHD
+ What is oral health literacy?
Oral health literacy is “…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”1
1. NIDCR (National Institute of Dental and Craniofacial Research). 2005. The invisible barrier: Literacy and its relationship with oral
health. Journal of Public Health Dentistry 65(3):174-192. As cited in IOM (Institute of Medicine). 2011. Advancing Oral Health in
America. Washington, DC: The National Academies Press.
© AAPHD
+ What is individual health
literacy?

The wide range of skills, and competencies that people develop to
seek out, comprehend, evaluate, and use health information and
concepts to make informed choices, reduce health risks, and
increase quality of life 1

Ability to read, speak, and listen

Quantitate

Interpret/understand risk and benefit

Understand specific knowledge about disease

Navigate the health care system

Perform a specific task

Live/work in a community that supports health practices
1. Zarcadoolas C, Pleasant A, Greer DS. Understanding health literacy: an expanded model. Health Promot Int. 2005 Jun;20(2):195-203
© AAPHD
+ Levels of Public Health
literacy1,2
1. Basic/functional literacy:
•
Basic skills in reading, writing, and interpreting numbers necessary to
function in daily situations
2. Communicative/interactive literacy: Advanced skills, including science and
technology:
•
Extract information and derive meaning from different forms of
communication
3. Critical & civic literacy: Advanced skills that can be applied to:
•
Critically analyze information
•
Recognize and use collective beliefs, customs, world-view and social
identity in order to interpret and act on health information
•
Support effective social and political action
1. Nutbeam D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies
into the 21st century. Health Promot Int. 2000, 15(3):259-267
2. Zarcadoolas C, Pleasant A, Greer DS. Understanding health literacy: an expanded model. Health Promot Int. 2005 Jun;20(2):195-203
© AAPHD
+
Levels of Public Health
literacy1,2
1. Basic/functional literacy:

The basic skills in reading, writing, and interpreting numbers that
are necessary to function in everyday situations
1. Nutbeam D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies
into the 21st century. Health Promot Int. 2000, 15(3):259-267
2. Zarcadoolas C, Pleasant A, Greer DS. Understanding health literacy: an expanded model. Health Promot Int. 2005 Jun;20(2):195-203
© AAPHD
+ Levels of Public Health
literacy
2. Communicative/interactive literacy:

More advanced cognitive and literacy skills, including
competence with science and technology

Combined with social skills, can be used to extract information
and derive meaning from different forms of communication
© AAPHD
Levels of Public Health
literacy
+
3. Critical literacy/civic literacy:

More advanced cognitive and literacy skills that can be applied to
critically analyze information

The ability to recognize and use collective beliefs, customs,
world-view and social identity in order to interpret and act on
health information

Oriented towards supporting effective social and political action
© AAPHD
+ National assessment of health
literacy (NAAL)

A national survey 2003, NAAL:1

First large-scale national assessment in the United States to
contain a component designed specifically to measure health
literacy

Uses open-ended questions that require short-answer responses
1. Kutner, M., Greenberg, E., Jin,Y., and Paulsen, C. (2006). The Health Literacy of America’s Adults: Results From the 2003 National
Assessment of Adult Literacy (NCES 2006–483).U.S. Department of Education. Washington, DC: National Center for Education
Statistics.
© AAPHD
+ National Assessment of Adult
Literacy (NAAL)

Prose: the ability to read and understand written materials

Document: the ability to find, understand and use information
from noncontinuous texts in various formats

Numeracy: the ability to make simple calculations including risks
and benefits
1. Kutner, M., Greenberg, E., Jin,Y., and Paulsen, C. (2006). The Health Literacy of America’s Adults: Results From the 2003 National
Assessment of Adult Literacy (NCES 2006–483).U.S. Department of Education. Washington, DC: National Center for Education
Statistics pages 2-6
© AAPHD
+ National Assessment of Adult
Literacy (NAAL)

Prose: the ability to read and understand written materials
 Ex: Prevention, basic health literacy – How does one prevent
dental decay?

Ex. Person determines if a specific medical condition, based on
1-page article
1. Kutner, M., Greenberg, E., Jin,Y., and Paulsen, C. (2006). The Health Literacy of America’s Adults: Results From the 2003 National
Assessment of Adult Literacy (NCES 2006–483).U.S. Department of Education. Washington, DC: National Center for Education
Statistics pages 2-6
© AAPHD
Example of a health education message
Preventing Dental Problems
Keep Your Blood Glucose Under Control
High blood glucose can cause problems with your
teeth and gums. Work with your health care team to
keep your glucose levels as close to normal as you can.
http://www.cdc.gov/diabetes/pubs/tcyd/dental.htm#signs
© AAPHD
+ Adults with Below Basic Prose
Literacy Levels in 2003 NAAL
survey
Percent in Prose
Percent in Total
Below Basic literacy NAAL Population
Population
Did not graduate from
high school
No English spoken
before starting school
Hispanic adults
Black adults
Age 65+
Multiple disabilities
55
15
44
13
39
20
26
21
12
12
15
9
http://nces.ed.gov/NAAL/kf_demographics.asp#2
© AAPHD
+ National Assessment of Adult
Literacy (NAAL)

Document: the ability to find, understand and use information
from non-continuous texts in various formats
 Ex: (clinical, intermediate) Determine a healthy weight range
for a person from a body mass index (BMI) graph.
1. Kutner, M., Greenberg, E., Jin,Y., and Paulsen, C. (2006). The Health Literacy of America’s Adults: Results From the 2003 National
Assessment of Adult Literacy (NCES 2006–483).U.S. Department of Education. Washington, DC: National Center for Education
Statistics pages 2-6
© AAPHD
Place a point on the chart that would end the upward trend.
Q: Refer to the chart to answer the following question.
Place a point on the chart that would end the upward
trend.
A
B
C
© AAPHD
+ National Assessment of Adult
Literacy (NAAL)
 Numeracy: the
ability to make simple calculations
including risks and benefits
 Ex: (navigating
the health care system, proficient
health literacy). Calculate an employee’s share of
health insurance costs for a year, using a table that
shows how the employee’s monthly cost varies
depending on income and family size.
1. Kutner, M., Greenberg, E., Jin,Y., and Paulsen, C. (2006). The Health Literacy of America’s Adults: Results From the 2003 National
Assessment of Adult Literacy (NCES 2006–483).U.S. Department of Education. Washington, DC: National Center for Education
Statistics pages 2-6
© AAPHD
+ Refer to the medicine label to
answer the following question.
The patient forgot to take this medicine before lunch at 12:00
noon. What is the earliest time he can take it in the afternoon?
GARFIELD, Robert M.
16 April 01
Dr. LUBIN, Michael
DOXYCYCLINE
100 MG
Take one tablet on an empty stomach one hour before a meal
or two to three hours after a meal unless otherwise directed by
your doctor.
© AAPHD
NAAL demographic and
health literacy results1
+

Older adults (65+)
 More older adults have ‘below basic’ health literacy than adults
in any of the younger age groups

Racial and ethnic minorities
 Hispanic adults had lower average health literacy than any
adults in any of the other racial/ethnic groups

Non-native speakers of English

Those with less than a high school degree or GED
 Starting with adults who had graduated from high school or
obtained a GED, average health literacy increased with each
higher level of educational attainment

Adults living below the poverty line
1. Kutner, M., Greenberg, E., Jin,Y., and Paulsen, C. (2006). The Health Literacy of America’s Adults: Results From the 2003 National
Assessment of Adult Literacy (NCES 2006–483).U.S. Department of Education. Washington, DC: National Center for Education
Statistics. Pg 9-14
© AAPHD
+
Clues to low health literacy
 Patient:
 Takes
a long time completing forms
 Asks
to take forms home to complete rather than
at the office
 States “I
 Looks
have lost my glasses.”
confused.
© AAPHD
+ Lecture 2
Association of low health literacy and
health, dental outcomes, health beliefs
and culture
29
© AAPHD 29
+ Lecture Objective

Describe the individual, community and
public health implications of low oral health
literacy
 Explain
the association between health,
health literacy, health beliefs and culture
1. IOM. 2004. Health literacy: A prescription to end confusion. Washington, DC: The National Academies Press.
© AAPHD
+ Association of low health
literacy and dental outcomes
Lower health literacy:
 Poorer understanding of medical
questionnaires
 Higher mortality1
 More severe periodontal disease2
 Poorer oral health3,4,5
1. Bostock S, Steptoe A. Association between low functional health literacy and mortality in older adults: longitudinal cohort study. BMJ. 2012 Mar
15;344:e1602
2. Wehmeyer MM, Corwin CL, Guthmiller JM, Lee JY. The impact of oral health literacy on periodontal health status. . J Public Health Dent. 2012 Nov 2.
3. Miller E, Lee JY, DeWalt DA, Vann WF Jr. Impact of caregiver literacy on children's oral health outcomes.Pediatrics. 2010 Jul;126(1):107-14
4. Vann WF Jr, Lee JY, Baker D, Divaris K. Oral health literacy among female caregivers: impact on oral health outcomes in early childhood. J Dent Res.
2010 Dec;89(12):1395-400.
5. Garrett GM, Citi AM, Gansky SA. Parental functional health literacy relates to skip pattern questionnaire error and to child oral health. J Calif Dent
Assoc. 2012 May;40(5):423-30.
© AAPHD
+ Low health literacy and oral
quality of life







Oral pain
Difficulty chewing
Avoiding eating any food
Difficulty speaking/communicating
Worry about oral problems
Limiting interaction with others (eg, avoids going out)
Being self-conscious about oral/mouth issue
1. Lee JY, Rozier RG, Lee SY, Bender D, Ruiz RE. . Development of a word recognition instrument to test health literacy in dentistry: the REALD-30--a
brief communication. Public Health Dent. 2007 Spring;67(2):94-8
2. Richman JA, Lee JY, Rozier RG, Gong DA, Pahel BT, Vann WF Jr. Evaluation of a word recognition instrument to test health literacy in dentistry: the
REALD-99. . J Public Health Dent. 2007 Spring;67(2):99-104.
3. Parker EJ, Jamieson LM. Associations between indigenous Australian oral health literacy and self-reported oral health outcomes. BMC Oral Health.
2010 Mar 26;10:3.
4. Divaris K, Lee JY, Baker AD, Vann WF Jr. Caregivers' oral health literacy and their young children's oral health-related quality-of-life. Acta Odontol
Scand. 2012 Sep;70(5):390-7.
5. Garrett GM, Citi AM, Gansky SA. Parental functional health literacy relates to skip pattern questionnaire error and to child oral health. J Calif Dent
Assoc. 2012 May;40(5):423-30.
© AAPHD
+ Association of low health
literacy and dental behaviors
Lower health literacy:
 Poorer understanding of health information
 Report fewer oral health promoting behaviors2,3
 Toothbrushing1
 Interdental cleaning
 Dental cleanings (prophylaxis)
 Low-cariogenic diets
 Limiting cariogenic snacks
1. Parker EJ, Misan G, Chong A, Mills H, Roberts-Thomson K, Horowitz AM, Jamieson LM. An oral health literacy intervention for Indigenous adults
in a rural setting in Australia. BMC Public Health. 2012 Jun 20;12:461
2. Mejia GC, Weintraub JA, Cheng NF, Grossman W, Han PZ, Phipps KR, Gansky SA. Language and literacy relate to lack of children's dental sealant
use. Community Dent Oral Epidemiol. 2011 Aug;39(4):318-24.
3. Parker EJ, Jamieson LM. Associations between indigenous Australian oral health literacy and self-reported oral health outcomes. BMC Oral Health.
2010 Mar 26;10:3
© AAPHD
+ Low health literacy and failing
to show

Reasons for failing to show
 Forgetting1,2
 Health belief1,4
 Environmental factors1,2,4
 Communication factors1,2
 Psychosocial factors 1,3
 Cost1,4
 Health literacy and number of information sources used to get
health information5
1.
Herrick J, Gilhooly ML, Geddes DA. Non-attendance at periodontal clinics: forgetting and administrative failure. Journal of dentistry. 1994;22(5):307-9. Epub
1994/10/01.
2.
Casaverde NB, Douglass JM. The effect of care coordination on pediatric dental patient attendance. J Dent Child (Chic). 2007;74(2):124-9. Epub 2008/05/15
3.
Hallberg U, Camling E, Zickert I, Robertson A, Berggren U. Dental appointment no-shows: why do some parents fail to take their children to the dentist?
International journal of paediatric dentistry / the British Paedodontic Society [and] the International Association of Dentistry for Children. 2008;18(1):27-34. Epub
2007/12/19
4.
Maserejian NN, Trachtenberg F, Link C, Tavares M. Underutilization of dental care when it is freely available: a prospective study of the New England Children's
Amalgam Trial. Journal of public health dentistry. 2008
5.
Holtzman J, Atchison KA, Gironda MW, Radbod R, Gornbein J. The association between oral health literacy and failed appointments in adults attending a university
based general dental clinic. Community Dentistry and Oral Epidemiology. 2013 Dec 24. doi: 10.1111/cdoe.12089. (NIHMS545230)
© AAPHD
+ Public health implications of
low oral health literacy

Those with low health literacy:1
 Enter the healthcare system sicker
 Make more frequent use of emergency rooms and inpatient
care
 Use fewer preventative strategies
 Are less likely to adhere to treatment regimens (take
medications appropriately, comply with follow-up care)
1. Berkman ND,.Sheridan SL, Donahue KE , Halpern DJ, and Crotty K. Low Health Literacy and Health Outcomes: An Updated
Systematic Review. Ann Intern Med. 2011;155:97-107.
© AAPHD
Health and Culture
+

Cultural competence: a set of congruent behaviors,
attitudes, and policies that come together in a system, agency
or among professionals and enable that system, agency or
those professions to work effectively in cross-cultural
situations. (founding definition Cross, 1989)

Culture: the integrated pattern of human behavior that
includes thoughts, communications, actions, customs, beliefs,
values and institutions of a racial, ethnic, religious or social
group.

Competence is used because it implies having the capacity
to function effectively.

Ref: Cross, T. et al (1988, 1989). Toward a culturally competent system of care. Washington, DC: CAASP
Technical Assistance Center, Georgetown University Child Development Center; National Center for
Cultural Competence. (2009). Conceptual frameworks/models, guiding values and principles.
Washington, DC: Georgetown University. Retrieved April 11, 2015 from
http://files.eric.ed.gov/fulltext/ED330171.pdf
© AAPHD
5 Essential Elements to an institution’s
cultural competence
+
 Valuing
diversity
 Capacity
 Being
for cultural self-assessment
conscious of cultural interaction
 Having
institutionalized culture knowledge
 Adapting
to cultural diversity in their
service delivery

Cross et al, 1989
© AAPHD
+ Health literacy and culture

Influence of culture on oral health self-care, diet and use of
health services

Acculturation embraces changes in belief, behaviors, and
lifestyles

Health beliefs
 “I’d rather get my teeth pulled than take the time and
money to keep them”
 “There are many things more important than my
health”
 “Good health is a matter of good fortune”
 “Whatever happens to my health is God’s will”
© AAPHD
+ Health beliefs and self-care

Fatalistic beliefs
 Ex: children will develop dental cavities
 May access less care
 Less self-care1

Specific cultural health beliefs
 Ex: Traditional Chinese beliefs in hot and cold disease
 Visible symptoms eg. inflamed/bleeding gums
=“hot”disease
 Treat with a cool substance (eg. powdered alum, or
musk)
 Invisible symptoms eg. tooth mobility = “cold” disease
1. Norman BJ, Robinson E, Razzoog ME. Societal determinants of cultural factors related to the dental health of a selected older black
population. Spec Care Dentist. 1986 May-Jun;6(3):120-3.
© AAPHD
+ Health beliefs and self-care

Ethnic and religious beliefs
 May be impolite to have eye contact or touch patients
 Restrictions of the kinds of preventive medicaments they
will use

Dietary customs
 Ex: sucking on lemon dipped in sugar
 Ex: rewarding children with candy
© AAPHD
+ Cultural influence and
outcomes
•
Assimilation: movement toward the dominant culture
•
Rejection: reaffirmation of the traditional culture
•
Marginalization: alienation from both cultures
Education, insurance and acculturation are predictors of
access to dental services!
© AAPHD
How to implement
Cultural Competency
+

Policy making;

Infra-structure building;

Program administration and evaluation;

Service delivery and enabling supports; and

At the level of the individual.

At the individual level, this means an examination of one’s
own attitude and values, and the acquisition of the values,
knowledge, skills and attributes that will allow an individual
to work appropriately in cross cultural situations.
© AAPHD
Ways to implement cultural
competency (continued)
+

Re-examination of mission statements

Re-examine state laws, policies, procedures and
administrative practices

Emphasize diversity in staff recruitment, hiring and retention;
professional development and in-service training

Translate and interpret processes in plain language

Offer health care practices, health promotion, and
interventions that address beliefs of racially/ethnically health
populations.
© AAPHD
Classroom Activity
+

Divide students into teams

Each team selects an oral disease (e.g. periodontitis,
oral cancer) and discusses the implications associated
with poor health literacy, culture and health beliefs and
managing the disease.

Discuss the health communication issues the health
care professionals face related to assuring adequate
oral health promotion and disease management to
people of differing health literacy, culture and health
beliefs.

Each team will report on their discussion and
management strategies for the health professionals.
© AAPHD
+ Lecture 3
The Health Literate
Organization
45
© AAPHD 45
+ Lecture Objectives
 Explain
and describe strategies to communicate
more clearly with patients, the public, and the
community
 Identify
aspects of an oral health literate
organization and be able to suggest ways to
implement oral health literate best practices
© AAPHD
+ Oral health literate organizations


Definition: “makes it easier for people to navigate,
understand, and use information and services to take care
of their health”1
Create a more equal power relationship between health
care providers and patients2
1.Brach C, Dreyer B , Schyve P, Hernandez LM, Baur C, Lemerise AJ, and ParkerR. Attributes of a health literacte organization.
Retrieved 2.4.1013 from http://www.iom.edu/~/media/Files/Perspectives-Files/2012/Discussion-Papers/BPH_HLit_Attributes.pdf
2. Coleman, Clifford, Kurtz-Rossi, Sabrina, McKinney, Julie, Pleasant, Andrew, Rootman, Irving, & Shohet, Linda (2011). Calgary
Charter on Health Literacy. Retrieved February 04, 2013, from
http://www.nald.ca/library/research/cfl/calgary_charter_2011/calgary_charter_2011.pdf
© AAPHD
+ Framework for a health literate
organization
© AAPHD
+ Best practices: Communication
in a health literate
organization

Use universal health literacy precautions

Universal precautions are recommendations that can be applied
“universally”. The most commonly described example is the
guidelines to reduce transmission of infectious agents

Recommendations that can be applied in all health care
settings using common principles that can be modified to
reflect setting specific needs
© AAPHD
+ Health Literacy Universal
Precautions Toolkit1




Improve health providers’ support for people with limited HL
Ensure that people have the information they need to make
informed health decisions
Available at
http://www.ahrq.gov/qual/literacy/healthliteracytoolkit.pdf
To determine the health literacy of the population within a
county visit: http://nces.ed.gov/naal/estimates/index.aspx
1. DeWalt DA, Callahan LF, Hawk VH, Broucksou KA, Hink A, Rudd R, Brach C. Health Literacy Universal Precautions Toolkit.
(Prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research, The University of North
Carolina at Chapel Hill, under Contract No. HHSA290200710014.) AHRQ Publication No. 10-0046-EF) Rockville, MD. Agency for
Healthcare Research and Quality. April 2010.
© AAPHD
+ Spoken communications






Present yourself as interested in your patient’s questions
Use plain non-medical language
Speak slowly and clearly
Stick to 3-5 main points
Avoid using Y/N questions
 Instead say: “I want to be sure I explained everything clearly.
Can you please tell me what you will tell your (mother, spouse)
in your own words?”
Confirm that your patient understands
© AAPHD
+ Nonverbal communication

Use open body language
 Sit up straight with legs and arms uncrossed
 Sit at the same level as your patient

Eye contact
 Look at person when you are speaking with them
© AAPHD
+ Improve written communications




Evaluate written materials for reading level and content
 Use a readability tool like SMOG or Flesch-Kincaid
 Visit: http://www.read-able.com
Ask patients for feedback on your forms and education
materials
Offer help with filling out forms
Review post op/dosage instructions
 Personalize the materials by adding the patient’s name
or specific instructions
 Demonstrate the instructions if possible
 Use Ask 3 in materials
© AAPHD
+ Help your patient develop healthy
habits
Is patient motivated to make a change?
Help them write an action plan1

Identify an important goal

View this as a collaborative effort (Patient and health care provider)

Set small, specific and achievable goals

Create an outline of the steps in plain language

Assess patient’s confidence in accomplishing the goal

Put a copy of the plan in patient’s chart

Follow-up with patient to monitor success and challenges

Ask how you can help support patient’s efforts
1. DeWalt DA, Callahan LF, Hawk VH, Broucksou KA, Hink A, Rudd R, Brach C. Health Literacy Universal Precautions Toolkit. (Prepared by North
Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, under
Contract No. HHSA290200710014.) AHRQ Publication No. 10-0046-EF) Rockville, MD. Agency for Healthcare Research and Quality. April 2010.
© AAPHD
+ Create a supportive
environment for people to
improve or maintain health

Patients may need non-medical support in order to maintain
their health


Ex: you made a referral for follow up treatment. Did it
happen? If not, is there something the office can do to
address the barrier?
Assess patient’s needs

Listen to your patient. There may be non-health factors that
are affecting your patient’s health
© AAPHD
+ Evaluate your patient’s support
system

Informal support: friends and family provide
information, transportation, etc.

Formal support: case managers and agencies can
help connect patients to needed services

Community resource list:




Transportation services, medication resources, and
aging/caregiver services
Directions to your office, including access to public
transit
Special services for the elderly
Additional community groups that may be helpful
(medication delivery, meals on wheels, etc)
© AAPHD
+ Develop low literate patient
education materials

Use symbols and shapes to distinguish different types of
information on a handout.

Include white space between sections of a document.

Use the same type of font and limit the number of colors of
font that are used in the document.

Include“Ask Me 3”.

Use videos.
© AAPHD
+ Ask Me 3

Patient education program to improve communication between
patients and health care providers

Encourages patients to become active members of their health
care team

Promote improved health outcomes.

Designed by the National Patient Safety Foundation

http://www.npsf.org/for-healthcare-professionals/programs/ask-me-3/
© AAPHD
+ Ask Me 3

What is my main problem?

What do I need to do?

Why is it important for me to do this?
© AAPHD
+ Oral health literacy is a
collaborative effort

Health literacy applies to everyone1

Individuals: use the skills needed to find, understand, evaluate,
communicate, and use information

Health care professionals: present information to improve
people’s understanding and ability to act on the information

Systems: provide equal, easy, and shame-free access to health
care and health information
1. Coleman, Clifford, Kurtz-Rossi, Sabrina, McKinney, Julie, Pleasant, Andrew, Rootman, Irving, & Shohet, Linda (2011). Calgary Charter on
Health Literacy. Retrieved February 04, 2013, from
http://www.nald.ca/library/research/cfl/calgary_charter_2011/calgary_charter_2011.pdf
© AAPHD
+
Cultural Competency Activity for
Classroom or Homework
CALIFORNIA LEGISLATURE— 2013–2014 REGULAR SESSION
Introduced by Assembly Member Mitchell
February
19, 2013
AB-459 Public contracts: healthy and sustainable food.
“Existing law regulates various aspects of the provision of food
and beverages in vending machines, including requiring a
vendor that operates or maintains a vending machine on
designated state property to offer food and beverages in the
vending machine that meet accepted nutritional guidelines, as
defined, in accordance with certain content percentages. “(see
handout for complete text)
Task: Review AB-459 and describe why this is or is not a
culturally competent bill that is presented in literate sensitive
language. Consider whether you, as a DPH would advocate for
or against this Bill.
© AAPHD
Readability results for AB-459
+

Flesch Kincaid Grade Level 9.5

SMOG Index
9.5

Readability Index
9.3

Percent of complex words in tested paragraphs: 15.75%

Discuss whether this level of complexity is literate sensitive,
that is, easy or difficult for various people/ groups to
understand.

Would you use this Bill in advocacy or health promotion
programs, and if yes, how?
© AAPHD
+ Lecture 4
Health literacy measurement
strategies
63
© AAPHD 63
+ Lecture Objective
 Describe
ways to identify low health
literacy through various measurement
strategies
© AAPHD
+ How do we measure health
literacy?

Health literacy metrics focus on skills in multiple
context 1

Reading

Writing

Listening

Speaking

Numeracy

Critical analysis

Communication and interaction skills
1.Pleasant A, Kuruvilla S. A tale of two health literacies: public health and clinical approaches to health literacy. Health Promot Int.
2008 Jun;23(2):152-9
© AAPHD
+ Identifying low health literacy

Shame and stigma: patients are unlikely to self-identify
difficulty understanding health information

How do we identify those with low health literacy?

REALM (Rapid Estimate of Adult Literacy in Medicine)

REALMD (Rapid Estimate of Adult Literacy in Medicine and
Dentistry)

REALD (Rapid Estimate of Adult Literacy in Dentistry)

TOFHLA (Test of Functional Health Literacy in Adults)

TOFHLiD (Test of Functional Health Literacy in Dentistry)

NVS (Newest Vital Sign)
© AAPHD
+ Rapid Estimate of Adult
Literacy in Medicine (REALM)1

Individual reads a list of words out loud and their score is
based on their pronunciation of words

Available in short and long format

Assesses word recognition, not comprehension

Grade range estimate of reading ability

English only

SAHLSA (Short Assessment of Health Literacy for
Spanish-speaking Adults)
1. Davis TC, Crouch M, Long S. Rapid estimate of adult literacy in medicine. FamMed. 1993;25:391-5.
© AAPHD
+ Rapid Estimate of Adult
Literacy in Medicine and
Dentistry (REALMD)1

An individual reads a list of words out loud and their score
is based on their ability to pronounce words correctly

Available in short and long format:
• REALMD: 84 medical and dental words of varying
difficulty
• REALMD-202: 20 selected words

Available only in English
1. Atchison KA, Gironda MW, Messadi D, Der-Martirosian C.Screening for oral health literacy in an urban dental clinic. J Public Health
Dent. 2010 Fall;70(4):269-75
2. Gironda M, Der-Martirosian C, Messadi D, Holtzman J, Atchison K. J Public Health Dent. 2013 Jan 7. doi: 10.1111/jphd.12005. [Epub
ahead of print]A brief 20-item dental/medical health literacy screen (REALMD-20).
© AAPHD
+ REALMD1
REALMD-20 words are highlighted
1. Atchison KA, Gironda MW, Messadi D, Der-Martirosian C.Screening for oral health literacy in an urban dental clinic. J Public
Health Dent. 2010 Fall;70(4):269-75
© AAPHD
+ Rapid Estimate of Adult
Literacy in Dentistry (REALD)



An individual reads a list of words out loud and their score is
based on their ability to pronounce words correctly
Several different formats available

REALD 301: 30 common dental words with varying difficulty

REALD 992: REALD 30 words plus additional 69 dental words
with varying difficulty

TS-REALD3: Two-stage REALD 30
Available in English only
1.Lee JY, Rozier RG, Lee SY, Bender D, Ruiz RE. Development of a word recognition instrument to test health literacy in dentistry: the REALD-30--a
brief communication. J Public Health Dent. 2007 Spring;67(2):94-8.
2. Richman JA, Lee JY, Rozier RG, Gong DA, Pahel BT, Vann WF Jr . Evaluation of a word recognition instrument to test health literacy in dentistry:
the REALD-99. J Public Health Dent. 2007 Spring;67(2):99-104.
3. Stucky BD, Lee JY, Lee SY, Rozier RG. Development of the two-stage rapid estimate of adult literacy in dentistry. Community Dent Oral
Epidemiol. 2011 Oct;39(5):474-80. doi: 10.1111/j.1600-0528.2011.00619.x. Epub 2011 May 18.
© AAPHD
+ Test of Functional Health
Literacy in Adult (TOFHLA)1

Assesses reading comprehension and numeracy

Uses written material that might be given in a hospital

Fill in the blank (Cloze technique) requires an individual to
select the correct word to fit in medical instructions

Short form (S-TOFHLA) only includes reading
comprehension

Available in English and Spanish
1. 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.
© AAPHD
+ Test of Functional Health
Literacy in Dentistry
(TOFHLiD)1

Assesses numeracy and comprehension with questions related to:
fluoridated toothpaste, dental appointment, fluoride drops and
fluoride tablet

Cloze format for follow-up instructions after a dental procedure
1. Gong DA, Lee JY, Rozier RG, Pahel BT, Richman JA, Vann WF Jr.Development and testing of the Test of Functional Health Literacy
in Dentistry (TOFHLiD). J Public Health Dent. 2007 Spring;67(2):105-12.
© AAPHD
+ Test of Functional Health Literacy
in Dentistry (TOFHLiD)1
1. Gong DA, Lee JY, Rozier RG, Pahel BT, Richman JA, Vann WF Jr. Development and testing of the Test of Functional Health Literacy
in Dentistry (TOFHLiD). J Public Health Dent. 2007 Spring;67(2):105-12.
© AAPHD
+ Newest Vital Sign (NVS) 1

Assesses both reading comprehension and numeracy

Fictional label from a container of ice cream

Questions require the subject to find information
embedded in the label and make several computations

No dental equivalent

Available in English and Spanish
1.Weiss BD, Mays MZ, Martz W, Castro KM, DeWalt DA, Pignone MP, Mockbee J, Hale FA.Quick assessment of literacy in primary
care: the newest vital sign. Ann Fam Med. 2005 Nov-Dec;3(6):514-22.
© AAPHD
+ Classroom Activity: Complete
the Newest Vital Sign
Accessed 1/25/2013 at : http://www.pfizerhealthliteracy.com/asset/pdf/NVS_Eng/files/nvs_flipbook_english_final.pdf
© AAPHD
If you eat the entire
container, how many calories
will you eat?
© AAPHD
b.
1000
c.
120
d.
480
© AAPHD
25%
25%
48
0
250
25%
10
00
a.
25
0
25%
12
0
If you eat the entire container,
how many calories will you eat?
If you are allowed to eat 60
grams of carbohydrates as
a snack, how much ice
cream could you have?
© AAPHD
If you are allowed to eat 60 grams of
carbohydrates as a snack, how
much ice cream could you have?
nt
a
co
ar
eb
ft
he
A
an
d
C
Ha
l
© AAPHD
ct
A and C are both
correct
rre
d.
co
One cup
ot
h
c.
cu
p
½ cup
On
e
b.
½
Half the container
in
er
a.
cu
p
25% 25% 25% 25%
Your doctor advises you to reduce
the amount of saturated fat in your
diet. You usually have 42 grams of
saturated fat each day, which
includes one serving of ice cream.
If you stop eating ice cream, how
many grams of saturated fat would
you be consuming each day?
© AAPHD
b.
0
c.
33
d.
29
© AAPHD
25%
25%
29
31
25%
33
a.
31
25%
0
Your doctor advises you to reduce the
amount of saturated fat in your diet. You
usually have 42 grams of saturated fat each
day, which includes one serving of ice
cream. If you stop eating ice cream, how
many grams of saturated fat would you be
consuming each day?
If you usually eat 2500
calories in a day, what
percentage of your daily
value of calories will you be
eating if you eat one
serving?
© AAPHD
8%
c.
10%
d.
12.5%
© AAPHD
12
.5
%
b.
10
%
5%
8%
a.
5%
If you usually eat 2500 calories in a day,
what percentage of your daily value of
calories will you be eating if you eat one
serving?
25%
25%
25%
25%
Pretend you are allergic to
the following substances:
penicillin, peanuts, latex
gloves, and bee stings.
Is it safe to eat this ice cream?
© AAPHD
Yes
b.
No
© AAPHD
50%
No
a.
50%
Ye
s
Pretend you are allergic
to the following
substances: penicillin,
peanuts, latex gloves,
and bee stings.
Is it safe to eat this ice
cream?
If you answered that is it is not safe to eat this ice
cream, explain why.
a.
Because the ice cream contains Carrageenan.
b.
Because the ice cream contains high levels of
carbohydrates.
c.
Because the ice cream contains peanut oil.
d.
Because the ice cream contains high levels of
fat.
© AAPHD
If you answered that is it is not safe to
eat this ice cream, explain why.
Because the ice cream contains:
of
c
ls
ve
le
of
fa
t
ls
ve
le
hy
dr
a
ar
bo
ra
Ca
r
gh
hi
© AAPHD
gh
high levels of fat
to
il
d.
hi
Peanut oil
an
u
c.
Pe
high levels of
carbohydrates
te
s
b.
n
Carrageenan
ge
en
a
a.
25% 25% 25% 25%
+ Other health literacy measures

HeLMS (Health Literacy Measurement Scale) modified by Parker1
 29 item screener covers 8 domains (eg, attitude towards health,
social support, being proactive, and communicating with health
professionals)
 Ex: “Are you able able to make time for things that are good
for your health”

OHLI (Oral Health Literacy Instrument)2
 Cloze with passages on dental caries and periodontal disease

OH-LIP (Oral Health Literacy Inventory for Parents)3
 Combination of word recognition and comprehension of
pediatric oral health terms
1.Parker EJ, Misan G, Chong A, Mills H, Roberts-Thomson K, Horowitz AM, Jamieson LM. An oral health literacy intervention for
Indigenous adults in a rural setting in Australia. BMC Public Health. 2012 Jun 20;12:461. doi: 10.1186/1471-2458-12-461.
2. Sabbahi DA, Lawrence HP, Limeback H, Rootman I. Development and evaluation of an oral health literacy instrument for adults.
Community Dent Oral Epidemiol. 2009 Oct;37(5):451-62. doi: 10.1111/j.1600-0528.2009.00490.x.
3.Richman JA, Huebner CE, Leggott PJ, Mouradian WE, Mancl LA. Beyond word recognition: understanding pediatric oral health
literacy. Pediatr Dent. 2011 Sep-Oct;33(5):420-5.
© AAPHD
+ Challenges to health literacy
measurement

Strong consensus that the existing measures of health
literacy are inadequate or incomplete

Need to address a broader array of skills and content areas

Need to consider the health literacy capacity of information
givers (e.g., health care provider) and information seeker
(e.g., a patient)1,2
1. Pleasant A, McKinney J, Rikard RV. Health literacy measurement: a proposed research agenda. J Health Commun. 2011;16
Suppl 3:11-21.
2. Sorenson C, Drummond M, Chalkidou K. Comparative effectiveness research: the experience of the National Institute for Health
and Clinical Excellence. J Clin Oncol. 2012 Dec 1;30(34):4267-74.
© AAPHD