Health literacy, as defined in the Institute of Medicine

report, is the interaction between skills of individuals and

demands of the health care system".

The Patient Protection and Affordable Care Act of 2010, Title V,
defines health literacy as the degree to which an individual has
the capacity to obtain, communicate, process, and understand
basic health information and services to make appropriate health
decisions.

Healthy People definition is similar. The only difference is the
addition of "communicate" to the legislative definition.
The American Dental Association (ADA) defines
oral 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 oral health
decisions.
U.S. Department of Health and Human Services(2000)
NIDCR Working Group on Functional Health Literacy (2004)
American Dental Associaiton (2006)


Health literacy is meant to include both words and
numbers(numeracy)
The public needs to acquire, understand, and use
information about their health and health services
to make appropriate and informed health
decisions;
Research indicates that today's health information
is presented in ways that are not usable by most
adults. "Limited health literacy" occurs when people
can't find and use the health information and
services they need.
www.cdc.gov/healthliteracy/Learn
Anyone, regardless of age, race, income and education, can be
challenged by the tasks required to find and understand
information about their health. A new healthcare problem, a new
health care provider or health care system can increase those
challenges.

Any person may
not be familiar with medical/dental terms or how their bodies
work.
Be scared/anxious or confused with a new or serious diagnosis,
which limit understanding of information presented to them
Have difficulty understanding numbers and words associated
with risk or prognosis; this can limit decision making.
www.cdc.gov/healthliteracy/Learn

Less likely to engage in screening &
prevention
Less likely to have chronic disease under
control
More likely to be hospitalized
More likely to report poor health
More likely to die earlier
Rudd, http://www.hsph.harvard.edu/wp-
content/uploads/sites/135/2012/09/overview_slides.pdf
know how to locate and navigate a health facility;
read, understand, and complete many kinds of forms to receive
treatment and payment reimbursement;
articulate their signs and symptoms;
listen to providers;
know about various types of health professionals and what
services they provide and how to access those services;
trust the provider;
know how and when to ask questions or ask for clarification
when they do not understand;
understand their options in all procedures; and
understand that oral health is part of total health and that
individuals can keep their mouths healthy
A. Horowitz. IOM Roundtable on Health Literacy: Oral Health
Literacy Workshop Summary, 2013
The following slide is one framework for how multiple factors
are related to produce oral health. This is just one model there
are others.

Given what you know or have experienced in your patient
population regarding oral health literacy, would place it in the
same spot in this model? Why or why not?
Change daily habits: brush, floss, improve dietary choices (read
labels)

Monitor and describe symptoms: bleeding gums

Compliance: brush, floss, protocol for chlorhexidine use (time, dose)

Access care: make and keep more frequent recalls

What literacy skills are needed for each of these actions?
General Health Literacy; Oral Health Literacy

Available Tools
REALM; REALM-D are word recognition lists varying from 84 to
20-items. Useful in research, shown to have validity, but may not
be practical for clinic.

HeLD (Health Literacy in Dental scale; 29-items, new

Single item screeners; 2 items often used; patient indicates how
often they need help completing medical forms and how confident
in completing medical forms; quick, easy, some validity with more
complex assessments.
A validated screener for health literacy that has a patient
demonstrate reading a nutrition label; called the NVS

Its short, but should be administered by a staff person, not
patient self-administered

Not dental specific, but demonstrates prose and numeracy skills.

Has been used in various settings, but not dental (that I can find)
See Resources for this module.

Combined with a 2-item screener, quick & easy assessment
(there is not sufficient evidence to call this best practices, but it
is interesting)

If you screen for OHL and confirm its presence, what will you do
about it?
Improve the literacy skills of your patients

Improve your communication skills

Redesign or choose other materials that you use in
education/health promotion

Language: simplified language swap-out
periodontal -> gum
hypertension -> high blood pressure
occlusal -> chewing surface

Motivational Interviewing-Based: patient centered
respects patient autonomy; patient defines goals; skills for
communicating about behavior change

Teach-Back Method: Patient repeats instructions, demonstrates a skill;
enhances clarity and confirms understanding; particularly good
for self-care skills



Health information should be:
Accurate: Using health literacy best practices does not mean
"dumbing-down" the information. Health literacy practices ensure
that the information is presented accurately AND in ways that people
can understand.

Accessible: the issue of access. Are you providing reading materials
from other sources? Does your office/clinic stock brochures on
specific topics? Posters? Are they linguistically appropriate for your
patient population?
Are you creating your own brochures/ messages? What is the
reading level? Pictures can match/enhance the text.
Do your patients ask for information?
Do your patients ask for clarification of what you mean when
explaining a procedure or treatment plan?

http://www.cdc.gov/healthliteracy/developmaterials/index.html
Health information should be:

Actionable: In the health field, we typically want people to start
or stop doing something, or do more or less of something. If
you are creating a health message, the information should be

relevant (how does it affect them),

they need to perceive a need to make the change (how is their
current behavior not in line with they really want for their
health),

they need to believe they can make the change (self-efficacy),

they need to hear/see the ACTION required to perform(what
actionable recommendation is being made),
they typically need to believe there is a benefit to their action.
Take a look at the materials you currently use

Apply the previous guidelines to them

There are some standardized ways to assess materials (check the
cdc website in the References)

Use the above guidelines if you develop your own materials

At a minimum, there is a reading level indicator in Word that you can
apply to your materials or any written communication with your
patients.

Get administration involved
Consider collaboration with medical
Choose an assessment instrument/method
Assess OHI
Choose a topic or
patient subgroup
Choose a format to
change
Parents; prevention
Patients with diabetes
Look for evidence-
based practices
Adapt the evidence to your setting
Use the PDSA cycle
Test in your setting


Written materials
Commmunication methods
Best practices for health literacy interventions;
Motivational Interviewing; Teach-back
Think of health literacy across medical &
dental
Obviously there are condition-specific terms,
but that may be addressable in individual
conversation with patients.
Assessing the patients level of health literacy
would benefit the patients total care and is
information that should be shared, like vital
signs, among healthcare providers, for true
patient-centered care

CDC website: www.cdc.gov/healthliteracy:
http://www.cdc.gov/healthcommunication/

lots of information on these websites

Oral Health Workshop Summary, published by National Academy Press(NAP),
2013.
http://www.nap.edu/openbook.php?record_id=13484
You can read this online or download the entire proceedings for free.

Gironda M, et al. A brief 20-item dental/medical health literacy
screener(REALMD-20). Journal of Public Health Dentistry 75 (2013) 5055

Shah LC, et al. Health literacy instrument in family medicine: the newest
vital sign ease of use and correlates. (J Am Board Fam Med 2010;23:195
203.)