JADA Continuing Education
Oral Health Literacy Among Adult Patients Seeking Dental Care
Micheala Jones, PhD, MPH,
Jessica Y. Lee, DDS, MPH, PhD and
R. Gary Rozier, DDS, MPH
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ABSTRACT
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Background. This study examined the association of knowledge, dental care visits and oral health status with oral health literacy in dental patients.
Methods. The authors administered to adult patients in two private dental offices the short version of the Rapid Estimate of Adult Literacy in Dentistry-30 (REALD-30), a word-recognition test. An interview provided primary predictor variables for REALD-30 and variables that would serve as controls in multivariate logistic regression analyses.
Results. About 29 percent of the sample scored below 22 on the 30-point test, a score that the authors defined as a low literacy level. Those with incorrect knowledge (odds ratio [OR] = 5.98; P < .01) and fair-to-poor oral health status (OR = 3.08; P = .06) were more likely to have a low literacy level than were their reference groups. Not having had a dental care visit in the last year was not associated with literacy (OR = 2.26; P = .17). A change from an unfavorable to favorable category for the primary predictor variables would decrease the probability of having a low literacy level by 35 to 61 percent.
Conclusions. A significant number of patients may have a low level of oral health literacy, which possibly interferes with their ability to process and understand oral health information.
Practice Implications. Providers should identify patients who are having difficulty understanding and using dental health information and address their needs.
Key Words: Oral health literacy; medical literacy; Rapid Estimate of Adult Literacy in Dentistry-30; Rapid Estimate of Adult Literacy in Medicine; oral health knowledge; dental care use; oral health statusAbbreviations: ANOVA: Analysis of variance • OR: Odds ratio • REALD-30: Rapid Estimate of Adult Literacy in Dentistry-30 • REALM: Rapid Estimate of Adult Literacy in Medicine
The public can encounter an overwhelming amount of complex health information in everyday life. The growth in information technology and the rapid advances in dental scientific knowledge require that the public have an ever-increasing understanding of oral diseases to make good decisions about their oral health. The increasing availability and complexity of health information places large demands on the public’s literacy skills. But poor literacy can impede one’s ability not only to seek out needed health information but also to process, understand and use it to make appropriate health care decisions.1–4
The most recent national survey of English literacy included the first-ever assessment of adults’ ability to perform literacy tasks by using written health-related information.5 This study is important because the skills required to perform a health literacy task are not the same as those required for general literacy tasks, although they are related. The study showed that 30 million adults have no more than the most basic of health literacy skills, and another 47 million can only perform simple, everyday tasks. These findings mean that almost 80 million adults are unable, for example, to consult reference materials to determine which foods contain a particular vitamin or interpret a table about blood pressure, age and physical activity. Those who experience difficulties are more likely to be men, minorities, elderly and less educated; report worse health; and have public insurance.5,6 Patients with a low literacy level generally are 1.5 to three times more likely to experience poor outcomes in areas such as knowledge, intermediate disease markers, morbidity, general health status and use of health resources.7
Little research has been done on the role of literacy in oral health. However, an important dimension of health literacy is that one’s individual capacity to acquire and use information depends on the health problem, the type of health care provider and the setting in which one is seeking services.8 Therefore, we could expect someone with cardiovascular disease, for example, to perform literacy tasks more effectively when interacting with the medical care system in the management of that disease than he or she might with the dental care system for the management of periodontal disease. Oral Health in America: A Report of the Surgeon General,9 the National Call to Action to Promote Oral Health10 and Healthy People 2010,2 major policy documents charting the course for reducing disparities in oral health, all hypothesized that poor oral health literacy may be a barrier to the use of information and, thus, may result in poor dental outcomes. A white paper commissioned by the National Institute of Dental and Craniofacial Research concluded that poor oral health literacy is widespread and that its effects on disparities in oral health may be large, particularly when combined with other known barriers.3
As with general health, achieving and maintaining oral health requires one to be able to understand, interpret and act on various types of health information.3 Research is needed to determine the level of oral health literacy among members of the public and its effect on their ability to make good decisions about oral health. The purpose of our study was to determine oral health literacy among dental patients and examine factors that might be associated with their oral health literacy levels.
Our previous research with patients seeking care at a university-based medical clinic has produced a reliable and valid oral health literacy instrument that is brief enough to be used with dental patients.11 This study extends that work into the private practice setting and provides an opportunity to test the feasibility of its use in that setting while determining literacy among dental patients. An understanding of the prevalence of oral health literacy and how it differs among dental patients is an important beginning step in determining the relative importance of this barrier to oral health and how it might be addressed in dental practice.
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SUBJECTS, MATERIALS AND METHODS
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We used a cross-sectional design to collect information about oral health literacy in a sample of adult patients seeking care at two dental practices in North Carolina. We assessed dental patients’ dental health literacy during dental office visits occurring between Feb. 14 and May 26, 2006. We also interviewed them during the visit to solicit factors that might be associated with literacy levels.
Enrollment of dental practices and patients.
We sought the involvement of private practice dentists who were in close proximity to the University of North Carolina at Chapel Hill and who had a diverse patient population with respect to race, ethnicity and types of dental insurance. Through the Meharry Medical College Alumni Association, we identified two dentists in separate solo practices in two urban areas near Chapel Hill (2005 population: 106,436 and 231,962) who agreed to participate in the study. The dentists had been in practice at these locations for seven and eight years, respectively. To be eligible for the study, patients had to speak English and be older than 18 years but younger than 80 years. For purposes of another study, we limited initial enrollment to new patients to ensure an adequate number and then opened it to returning patients who met the study criteria. Except for a few patients whom we judged to be uncooperative, we asked all patients who met the inclusion criteria and sought dental care on the days on which interviewers were present in the practice during the four and one-half months of data collection to participate in the study.
Measurement of dental 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."2 No medical or dental tests are available to comprehensively measure a person’s reading fluency, vocabulary, ability with numbers, oral and written communication skills and his or her capacity to meet the demands placed on these abilities by the health care system.8 However, valid and reliable instruments are available to measure key aspects of these literacy skills.
We assessed oral health literacy using the Rapid Estimate of Adult Literacy in Dentistry (REALD-30), a newly developed word-recognition test designed to assess oral health literacy.11 The REALD-30 is structured in a way similar to the Rapid Estimate of Adult Literacy in Medicine (REALM), the test most commonly used in health care settings to identify patients with a low health literacy level.12,13 Word-recognition tests demonstrate a strong correlation with general reading ability and reading comprehension.14 Studies also have shown that if someone has difficulty pronouncing medical or dental words, a beginning-level reading skill, then he or she can have difficulty with comprehension, a higher-order skill.13,15 He or she also will demonstrate poorer health outcomes than do those who are better at recognizing words. These tests can alert clinicians to the possibility that a patient may have difficulty with printed materials and oral communication. The 30 words in the REALD-30 represent a spectrum of dental conditions and their prevention and treatment. Subjects read aloud the list of words arranged in order of increasing difficulty. The person administering the test assigns a point for each word pronounced correctly. Points are summed to obtain the overall literacy score, which can range from 0 (low literacy level) to 30 (high literacy level).
Survey instrument.
We based the survey content on frameworks that suggest that health literacy is one of many factors that interact with other characteristics of people to determine their health.1,16,17 In selecting constructs to be included in the survey, we relied heavily on the framework proposed by Lee and colleagues.17 It suggests that people with poor health literacy are likely to lack important health knowledge, have unhealthy personal behaviors and have poor compliance with routine medical visits. These factors, in turn, may delay a person’s seeking timely and appropriate care, produce poor health outcomes and increase the use of emergency and complex treatment services. Lee and colleagues17 proposed that factors at the individual and community levels—such as socioeconomic status, age, sex, ethnicity and health insurance coverage—can affect the relationship between literacy and health outcomes.
Each patient completed an interview with 23 questions measuring components of the health literacy framework. Where possible, we selected items from a bank of questions already tested in large-scale national surveys (such as the Behavioral Risk Factor Surveillance System, the Medical Expenditure Panel Survey, the National Health and Nutrition Examination Survey and the National Health Interview Survey).18 The questionnaire included factors in the hypothesized causal pathway between literacy and its effects: overall dental knowledge, scored as incorrect if answers to one or both of two multiple-choice questions regarding dental caries prevention and periodontal disease were incorrect; whether the patient had had a visit to the dentist in the last 12 months; and self-assessment of oral health status on a five-point Likert-type scale (from "excellent" to "poor"). Variables that could confound the relationship between oral health literacy and these main variables of interest included the value the patient placed on oral health (as gauged by treatment preference for a bad tooth being $155 for extraction at one visit or $1,600 for endodontic treatment and crown completed in five visits), patient type (new, established), dental insurance status (private, public, none), socioeconomic status (annual income, educational attainment, home ownership) and several individual demographic characteristics (sex, age, race, ethnicity, marital status).
Data collection.
One of the authors (M.J.), who is experienced in health literacy assessments, trained one member of the front-office staff in each of the dental offices in study procedures. In-office training consisted of didactic instruction, practice in completing the assessments and pretesting with eight patients. The staff member also completed a Web-based training course on issues relating to human subjects research.
A single staff member in each of the two dental practices and one of the authors (M.J.) enrolled the study subjects, conducted the interviews and administered the REALD-30. They conducted the literacy assessments, which took approximately 10 minutes to complete, in the privacy of the dental operatory before the patient was seen by any clinical personnel. The interview was followed immediately by administration of the REALD-30. No monetary incentives were provided for patients or anyone in the practice.
Data analysis.
The primary aim of our analysis was to determine the association of each of the main predictor variables (knowledge, dental care visits, oral health status) with oral health literacy, while controlling for the variables not in the causal chain but hypothesized to have a potential effect on oral health literacy (for example, age). Oral health literacy is reported descriptively as means and frequency distributions of REALD-30 scores. We examined the association between each of the covariates and oral health literacy by using Pearson’s 
2 statistics for categorically defined REALD-30 scores and analysis of variance (ANOVA) for mean scores. For the categorical analysis, we used tertiles to divide REALD-30 scores into three categories (high literacy level, 
26; moderate literacy level, 22–25; low literacy level, 
21) of approximately equal sample sizes.
We examined the association between low oral health literacy and each of the three main effect predictor variables in separate logistic regression models. In this analysis, low oral health literacy, defined by the lower one-third of REALD-30 scores ( 21), was predicted. We developed three separate models because, owing to the small sample size, we were unable to fully test mediation effects between the main predictor variables and the REALD-30 score. Also because of the sample size, we developed parsimonious models by including only the control variables that had a P value of less than .2 in the ANOVA analysis. We developed models with and without the education variable to determine potential bias that might be introduced by the use of a predictor variable that conceptually is measuring the same thing as REALD-30. This covariate had minimal effect on the primary associations of interest ( 10 percent change in measures of association); thus, we included it in models under the assumption that it was a broader composite measure of a person’s characteristics than was literacy alone. We calculated odds ratios (ORs) to quantify the strength of the association between each of the variables and oral health literacy. We considered P values of .05 or less to be statistically significant, but we considered those between .05 and .10 to be marginally significant because of the preliminary nature of the study. We performed all analyses by using SAS/STAT 9.1 (SAS Institute, Cary, N.C.).
To simplify interpretation of the effects of each of the three main predictor variables (knowledge, dental care visits, oral health status) on literacy, we determined marginal effects for the change in predicted REALD-30 values for a unit change in each binary predictor variable by using output from the logistic regression.19 We computed the effect of changing a predictor from one level to another (1 to 0) directly by estimating the difference in REALD-30 probabilities at each level of the predictor variables for each observation in the sample and then averaging that difference across all values. Thus, the marginal effect estimates any change in the predicted probability of attaining low REALD-30 scores when the average person in the sample with incorrect knowledge, for example, gains dental knowledge. We estimated marginal effects by using Stata 9.0 (Stata-Corp LP, College Station, Texas).
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RESULTS
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Table 1
presents characteristics of the sample (n = 101). Almost 31 percent of participants reported having a fair or poor oral health status, while 31 percent reported having not visited a dentist in the past year. Slightly less than 32 percent responded incorrectly to the dental caries knowledge question and 12 percent to the question about periodontal disease. Twenty-one percent had received a high school diploma or did not graduate from high school, and 50 percent had an income of less than $30,000. African-Americans were the largest race group.
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TABLE 1 Percentage distribution of overall sample and subsets of sample with incorrect knowledge, no visit in last 12 months and fair-poor oral health.
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The mean REALD-30 score per person was 23.9 (standard deviation [SD] = 1.29). The percentage distribution of REALD-30 scores was skewed toward higher scores, but close to one-third (28.7 percent) of the sample scored below 22, defined as a low literacy level for purposes of this study (Figure 1, page 1204).
The bivariate analysis of mean scores revealed that patients who answered one or both of the dental knowledge questions incorrectly, had not visited the dentist in the past year, reported fair or poor oral health, were new patients, had lower incomes, had a high school education or less and were unmarried scored lower on the REALD-30 than did their reference groups (P .05) (Table 2, page 1205). Age was associated with mean scores, but at a P value between .05 and .10. The bivariate analysis of the association between REALD-30 categories and covariates demonstrated similar relationships, although levels of statistical significance were not as strong.
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TABLE 2 Predicted percentage distribution and mean scores on Rapid Estimate of Adult Literacy in Dentistry (REALD)-30, by predictor variables.
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The three logistic regression models with just the single main effect in the model found that those who had incorrect knowledge, who had had no dental care visit in the last year and who reported having fair or poor oral health were 3.20 (P = .01), 3.75 (P = .01) and 2.89 (P = .02) times more likely, respectively, to have low REALD-30 scores than were their reference groups. Table 3 (page 1206) displays results, adjusted for important covariates, from the three regression models predicting low levels of oral health literacy. Those with incorrect knowledge and who reported fair or poor oral health status were 5.98 (95 percent confidence interval [CI] = 1.82–22.38; P < .05) and 3.08 (95 percent CI = 0.95–10.61; P = .06) times more likely to have low oral health literacy, respectively, than were their reference groups. The association of dental visits with REALD-30 was confounded by other variables in the model and did not reach statistical significance (OR = 2.26; 95 percent CI = 0.69–7.65; P = .17). Age and marital status were the only significant covariates.
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TABLE 3 Results of three logistic regression analyses predicting low scores on the Rapid Estimate of Adult Literacy in Dentistry-30.
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Figure 2 (page 1207) displays the effect of a change for the average patient from the unfavorable to the favorable category for each of these three primary predictor variables. On average, if a patient changed from incorrect knowledge to correct knowledge, the probability of having a low literacy level would decrease by 29 percentage points, or 61.0 percent. The effects of a change in dental care visits and oral health status were smaller (35.3 and 45.5 percent differences, respectively) and, for change in visits, nonsignificant.
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Figure 2. Percentage of patients with low Rapid Estimate of Adult Literacy in Dentistry-30 scores, by primary predictor variables.
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DISCUSSION
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Our scientific understanding of oral health literacy is based primarily on a small number of studies that have indicated the mismatch between the reading levels required by dental health education materials and the reading ability of those who use them.20 Although very little research has been undertaken in dentistry, ample justification exists for pursuing research in this area. Studies of medical care demonstrate the importance of health literacy in various health outcomes,1,7 and many peripheral studies show that those with low levels of education also tend to have poor dental behaviors and bad oral health outcomes.9 As with general health, maintenance of oral health requires one to be able to understand, interpret and act on various types of health information, whether it is communicated orally or in written form.3 This study, to our knowledge, is the first to attempt an assessment of oral health literacy among dental patients seeking care in private dental offices.
Our study of patients in these dental practices provides several conclusions about oral health literacy. A large number of patients are classified by REALD-30 scores as having low levels of literacy skill and likely would have difficulty with oral health information. Scores were as low as 10 on the 30-point scale, with about 12 percent and 29 percent of patients being able to correctly pronounce fewer than 20 and 22 words, respectively. On the other end of the scale, only 7 percent of patients pronounced all 30 words correctly.
The analytical results suggest an association between oral health literacy levels and factors that we consider to be the consequences of poor literacy. Although they must be interpreted with caution because other variables might influence the associations, results of analyses that did not adjust for covariates demonstrated that those with low literacy levels were more likely than those with higher literacy levels to have low levels of dental knowledge, less recent dental care visits and worse perceived oral health status. Dental use was not significant in the final analysis, in which we adjusted for covariates that also could be related to literacy and dental care visits, and oral health status reached only a marginal level of significance. The effects of a low literacy level, particularly on dental knowledge, appear to be large. Estimates from this study suggest that improvements in literacy among these dental patients classified as having low literacy levels could change the probability of low dental knowledge and poor-to-fair oral health status by 61 percent and 46 percent, respectively.
Some literacy models consider knowledge to be part of literacy, but from the perspective of dental care, it should be thought of as a separate part of a person’s capacity to understand and use health information.8 Vocabulary and conceptual knowledge about dental disease and its care at the time of the dental visit, for example, affect one’s ability to communicate orally about oral health and comprehend written materials available before, during and after the visit. Preventive dental services might be less effective in patients with low knowledge and a low literacy level because they do not understand instructions or the importance of preventive procedures, so they may be less compliant with recommended practices—thus exacerbating the effects of poverty and other factors contributing to disparities. Evidence suggests that counseling can be effective in increasing knowledge and thus may be a strategy that dental providers can use to address low literacy.21 The relationship between knowledge and literacy also is bidirectional—literacy skills can help increase vocabulary because of reading fluency, and increased vocabulary improves comprehension of health information that is read. Therefore, patient counseling in the dental office environment to help increase dental knowledge should be considered an important component of literacy interventions.
Our causal model hypothesizes that use of dental services can mediate the effects of oral health literacy on dental outcomes. The small sample size prevented a test of this potential moderating effect of dental use. The association between use and REALD-30 reached a statistically significant level in the unadjusted analysis (unadjusted OR = 3.75; P = .01) but was confounded by other variables in our model (adjusted OR = 2.26; P = .17). The association between use of dental care and oral health literacy was in the expected direction in both analyses, but definitive conclusions about the role of dental care visits in moderating the effect of a low literacy level on oral health cannot be made on the basis of this study’s results. This association will need to be investigated in a larger study that assesses the characteristics of the dental environment and its ability to meet the literacy needs of its patients.
The association between perceived oral health status and oral health literacy also was not strong in regression models (OR = 3.08; P > .05 .10). Dental studies generally find a relationship between self-reported oral health and actual clinical status,22,23 which lends support to the validity of the use of self-reported oral health status. Although causal models propose an effect of literacy on health status, the extent to which health literacy is associated with self-reported general health status is mixed in the small number of studies in which researchers have examined this association.7
Future studies will need to determine clinical oral health status to explore the association between oral health literacy and oral health status outcomes. Testing of more proximal measures to dental health literacy such as adherence to recommended follow-up visits also may be useful in understanding the effects of oral health literacy. Downstream outcomes such as oral health status are subject to many determinants other than literacy, and precise measures of effects will require large studies that can control for many determinants. Understanding the effect of literacy on intermediate outcomes will help improve the quality of dental care. For example, multiple missed appointments can have detrimental ramifications on patients’ oral health status. Studies that provide insights into the role of literacy in visit patterns can provide insights into strategies to improve care for those who have low oral health literacy and thus help reduce disparities.
Several of the general health literacy instruments are not practical for use in a clinical setting such as a busy dental office because they take too long to administer. Although comprehensive tests of oral health literacy are important for research purposes, practical but accurate tools are needed to identify patients with limited literacy in clinical settings. This study provides an important test of the use of REALD-30 in dental practices. We found that staff members could be trained easily in its use and it took little time for them to assess the oral health literacy of dental patients. Some health literacy experts suggest that formal screening of individual patients should not be undertaken in the health care setting unless educational interventions are to be tailored to the needs of these patients.13 Future research will need to test the acceptability of literacy tools in dental practice formally on a broader scale and will need to determine whether their use results in improved dental care and oral health outcomes.
This study has several limitations. First, our measurement of oral health literacy is based on a newly developed word-recognition test. Comparable instruments are used successfully in medicine and are correlated strongly with reading fluency. Nevertheless, word-recognition instruments measure only selected aspects of literacy skills and are not comprehensive.8 Second, oral health literacy was assessed at one point. This cross-sectional design prevents an analysis of cause-and-effect relationships, which are important in determining how and with which patients dental providers should intervene. Finally, the study samples of practices and patients were small and selected by nonrandom methods, so they may not represent patients seen at most private dental practices.
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CONCLUSIONS
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Communication with patients is an important part of providing good dental care. Results of this study suggest that a large number of patients have low levels of oral health literacy that may interfere with their ability to process and understand basic oral health information. Providers need to identify patients who are having difficulty understanding and using dental health information and should take steps to address their needs. These steps might include strategies such as receiving continuing education in effective patient communication techniques and ensuring that educational materials for patients are written at an appropriate reading level.
This study also suggests that dental knowledge is a strong predictor of low oral health literacy; therefore, patient education and counseling may be an important component of the care for patients with low literacy levels. Research is needed to establish the causal relationship between literacy and patients’ ability to function in the dental health care environment, as well as the extent to which assessment and intervention literacy tools for providers can be used effectively in dental practice.
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FOOTNOTES
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Dr. Jones was a student in health policy and administration and a postdoctoral fellow, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, when the study described in this article was conducted. She now is a medical science manager (anesthesia), Organon USA, Roseland, N.J.
Dr. Lee is an associate professor, Department of Pediatric Dentistry, University of North Carolina at Chapel Hill.
Dr. Rozier is a professor, Department of Health Policy and Administration, University of North Carolina at Chapel Hill, 1105F McGavran-Greenberg Hall, CB#7411, Chapel Hill, N.C. 27599-7411, e-mail "gary_rozier{at}unc.edu". Address reprint requests to Dr. Rozier.
The research described in this article was conducted with the support of Agency for Healthcare Research and Quality grant T-32HS000032.
The authors offer special thanks to Sandra Diaz and Jennie Privette for collecting data and to Drs. Herbert McNeal and Carlos Privette for participating in the study.
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REFERENCES
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- Committee on Health Literacy, Institute of Medicine. Health literacy: a prescription to end confusion. Washington: National Academies Press; 2004.
- U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. Washington: U.S. Department of Health and Human Services; 2000.
- National Institute of Dental and Craniofacial Research, National Institutes of Health, U.S. Public Health Service, 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 Institutes of Health, U.S. Public Health Service, Department of Health and Human Services. J Public Health Dent 2005;65:174–82.[Medline]
- American Dental Association House of Delegates. Limited oral health literacy skills and understanding in adults (resolution 14H-2006). Chicago: American Dental Association; 2006.
- Kutner ME, Greenberg E, Jin Y, Paulsen C. The health literacy of America’s adults: results from the 2003 National Assessment of Adult Literacy. Washington: National Center for Education Statistics; 2006. U.S. Department of Education, National Center for Education Statistics publication 2006–483.
- Kiresh IS, Jungeblut A, Jenkins L, Kolstad A. Adult literacy in America: a first look at the results of the National Adult Literacy Survey (NALS). Washington: U.S. Department of Education, Office of Educational Research and Improvement, National Center for Education Statistics; 1993. National Center for Education Statistics publication 1993–275.
- DeWalt DA, Berkman ND, Sheridan S, Rohr KN, Pignone MP. Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med 2004;19:1228–39.[Medline]
- Baker DW. The meaning and the measure of health literacy. J Gen Intern Med 2006;21:878–83.[Medline]
- U.S. Public Health Service, Office of the Surgeon General; National Institute of Dental and Craniofacial Research. Oral health in America: A report of the surgeon general. Rockville, Md.: U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research; 2000.
- U.S. Department of Health and Human Services. A national call to action to promote oral health. Rockville, Md.: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institutes of Health, National Institute of Dental and Craniofacial Research; 2003. NIH publication 03-5303.
- 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;67:94–8.[Medline]
- Davis TC, Long SW, Jackson RH, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med 1993;25:391–5.[Medline]
- Davis TC, Michielutte R, Askov EN, Williams MV, Weiss BD. Practical assessment of adult literacy in health care. Health Educ Behav 1998;25:613–24.[Abstract]
- 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;10:537–41.[Medline]
- Gong DA, Lee JY, Rozier RG, Pahel BT, Richman JA, Vann WF. Development and testing of the Test of Functional Health Literacy in Dentistry (TOFHLiD). J Public Health Dent 2007;67:105–12.[Medline]
- Rootman I, Orson B. Literacy and health research in Canada: where have we been and where should we go? Can J Public Health 2005;96(supplement 2):S62–S77.[Medline]
- Lee SYD, Arozullah AM, Cho YI. Health literacy, social support, and health: a research agenda. Soc Sci Med 2004;58:1309–21.[Medline]
- National Institute of Dental and Craniofacial Research and Centers for Disease Control and Prevention. NIDCR/CDC Dental, Oral and Craniofacial Data Resource Center: Oral health questions arranged by domain. Available at: "http://drc.hhs.gov/surveyq/bydomain.htm". Accessed Dec. 1, 2005.
- Long J, Freese J. Models for binary outcomes. In: Regression models for categorical dependent variables using Stata. College Station, Texas: Stata Press; 2006:132–81.
- Emmer C. Oral health literacy annotated bibliography. Harvard School of Public Health, Health Literacy Studies Web site. Updated 2003. Available at: "www.hsph.harvard.edu/healthliteracy/literature/lit_oral.html". Accessed Dec. 1, 2006.
- Kay EJ, Locker D. Is dental health education effective? A systematic review of current evidence. Community Dent Oral Epidemiol 1996;24:231–5.[Medline]
- Talekar BS, Rozier RG, Slade GD, Ennett ST. Parental perceptions of their preschool-aged children’s oral health. JADA 2005;136:364–72.
- Gift HC, Atchison KA, Drury TF. Perceptions of the natural dentition in the context of multiple variables. J Dent Res 1998;77:1529–38.[Abstract/Free Full Text]
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ABSTRACT
SUBJECTS, MATERIALS AND METHODS
