Fall 2009
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Scientific Article Oral
Health Literacy and Behavior: |
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INTRODUCTION Literacy, in the most basic sense, is a founding principal of education that consists of reading, writing, oral language, and quantitative skills, and may be for practical purposes referred to as one’s “reading level,” (Rudd et al. 2005). Literacy has been proven to play a large role in the medical field; low literacy levels are associated with higher hospitalization rates, poorer management of chronic diseases, and less engagement in preventative and screening behaviors, (Rudd et al. 2005). Although literacy could prove to be equally important in the dental field, there is currently limited research available on the topic. Oral health literacy could have a strong impact on a patient’s dental treatment, ranging from the understanding of postoperative instructions, taking prescriptions as directed, to following a proper oral hygiene regimen. Literacy directly relates not only to the ability to seek out and obtain basic health information, but also to process and understand that information to make appropriate health care decisions, (Jones et al. 2007). A recent study conducted by the American Association of Public Health Dentistry discussed that patients with an increased understanding and comprehension of medical and oral health information are more likely to adhere to health care provider’s instructions, provided prescription schedules, and doctor visits, as measured by the TOFHLiD survey instrument. This instrument, as compared to others that focus mainly on dental word recognition, is a better measure of functional oral health literacy, (Gong et al. 2007). The first ever Surgeon General’s Report on Oral Health in 2000 documents a growing oral health care crisis in America and identifies profound disparities of oral health and access to care issues, (The Invisible Barrier 2005). The report also recognized oral health is as a valued, integral part of overall health and well being. An association is suspected between the silent epidemic of oral health diseases with the widespread low health literacy levels. According to the National Institute of Health, low health literacy affects more than ninety million adults in the United States, (Understanding 2008). The Department of Health and Human Services also addresses literacy in Health People 2010, Objective 11: Health Communication. The objective states that “even with access to information and services, however, disparities may still exist because many people lack health literacy. Health literacy is increasingly vital to help people navigate a complex health system and better manage their own health,” (Health People 2010). The most vulnerable populations to dental diseases are those of pregnant women and young children, particularly those from low income families and racial and ethnic minority groups. This study focused mainly on pregnant women, because women are typically more receptive to positive health messages during pregnancy. Also, our efforts would have an effect on both the mother and her child. Many oral health disparities have been linked to pregnancy, including increased gingival inflammation and risk of periodontal disease. This is due to the hormonal and vascular changes associated with pregnancy that can exaggerate the response of the gingiva to bacterial plaque. Furthermore, periodontal disease could be a potential risk factor for preterm birth and low birthweight babies, as well as an increased risk for preeclampsia during pregnancy, (Habashneh et al. 2005). These studies, however, have yet to reach a consensus and thus remain inconclusive. Although a vast amount of knowledge exists concerning oral health consequences during pregnancy, limited information is unfortunately known about how women perceive oral heath care during their pregnancy, as well as their perception of and reactive behaviors toward such information. Analyzing such information and gaining a better understanding of the attitudes and behaviors of pregnant women would help to better understand the causes behind the oral health crisis at hand, and may also pinpoint what types of information practitioners should convey to ensure the health of their pregnant patients and their developing babies. The overall purpose of this experiment was to assess the knowledge, behaviors, and attitudes toward oral health, as well as personal, demographic, and pregnancy-related factors that may be related to oral health literacy. Figure 1
MATERIALS AND METHODS The cross sectional study design used for this project was actually used as a continuation from a previous research project last summer. The questionnaire was written at a fifth grade reading level, and IRB approval was received before data collection began: protocol #070609. The survey instrument that was constructed for this investigation addressed past and current knowledge of oral health, and also whether or not pregnant women are aware of the consequential and beneficial effects that oral health will eventually have on their bodies and the potential effects on their developing fetus. It gathered details on specific oral-related behaviors and habits that pregnant women develop during their pregnancy, while also analyzing the women’s attitudes on the importance of oral care as a whole. The questionnaire was ten pages long and consisted of fifty-four questions distributed into several subsections as follows: Socio-demographic, General Health and Prenatal care, Oral Health Behaviors, Oral Health Literacy, and Oral Health Perception. The fourteen socio-demographic questions included issues of lifestyle, financial background, age, and race. The next seven questions addressed issues of general health, such as physical and mental health and if the participant had a regular family doctor. The fourteen questions on oral health behaviors revolved around both oral health home care and professional care. The literacy section of the survey consisted of a small informative passage concerning pregnancy and oral health, with three subsequent questions to test the comprehension of the educational material. The survey concluded with fourteen questions on the participant’s perception of oral health. Data was collected at the Samuel U. Rodgers Health Center in three main departments: the OB/GYN and Women’s Health department, WIC department, and Dental department. The dental department was included as a site for collecting participants, because they are currently beginning a program targeted at pregnant women to encourage regular dental visits. Therefore, the two projects coincided. The principal investigator approached pregnant women over the age of eighteen and gave a brief explanation of the survey by giving the participant an informational letter, (see Appendix 1 and 2). After voluntary consent was obtained, the investigator provided the participant with the questionnaire and a free oral hygiene kit. The investigator personally collected each survey back from the participants once completed and verified that there was not any identifying information on the survey to ensure anonymity of the participants. Data management and analysis was then performed in SPSS 16.0 using frequency measures to gather descriptive statistics. |
Table 2
RESULTS A total of fifty-seven subjects were recruited for this study. However, three subjects under the age of eighteen were inadvertently recruited during data collection. Since these subjects did not qualify for the study based on IRB approved protocol, the three surveys were discarded, and only the remaining fifty four subjects were included into final data analysis. The results for the first subsection of the questionnaire were as follows: Less than one-third of the participants had an education level above that of high school, (see figure 1). This is an important consideration when creating and distributing educational materials to patients and making sure the information is written at an appropriate reading level for the targeted audience. While thirty-four percent of participants had a regular family doctor, only thirteen percent had a regular family dentist, (tables 2 and 3). Sixty-eight percent of the subjects started prenatal care during the first trimester, suggesting that dental educational efforts could target women early on and coordinate dental care into the general prenatal care of the first trimester, (table 2). Although the women had been receiving prenatal care, only twenty-one percent of them had received any form of oral instruction during their pregnancy thus far, (table 3). Only fourteen percent of the participants did not think that dental work performed during pregnancy would harm the developing baby, (see table 4). The other eighty-six percent of women were fearful of the potentially harmful effects of dental work on the developing fetus. This demonstrates a need for increased communication between dental health care providers and pregnant women, so that women are aware that dental work during pregnancy is indeed safe. DISCUSSION Our study was based on data collected from a convenience sample; therefore our results may not be representative of the general population. A limitation for both the principal investigator and the study as a whole was a large communication barrier. Although there were numerous translators on site for our usage whenever necessary, there was no way to verify that the translated survey was direct and without any explanation to the participant concerning any of the questions. Future studies could have the survey instrument directly translated and printed into other languages, so that the survey could be distributed without the need for a translator. Another limitation was the single isolated data collection site. Future research could use the same survey instrument distributed at different locations and compare the results with this experiment to see how both the literacy levels and socio-demographics differ. This would also be helpful in analyzing specific minority and age groups separately in order to stratify the data analysis, identify the high-risk groups, and design future interventions to fit those groups. Interventions could also be tailored by analyzing how the social, cultural, and environmental factors differ between the different populations, and also explore the role of the K-12 education systems in establishing these existing beliefs. A third limitation is whether or not the low literacy results were simply due to a misunderstanding of the question wording, or whether there was a true lack of comprehension of the information. It would be interesting to examine compensatory mechanisms of persons with limited literacy levels, and whether those methodologies are more or less harmful to the patients. Another future research idea would be to follow specific survey participants throughout the course of their pregnancy, and analyze how their knowledge level, attitudes, and oral health practices may or may not change. Table 3
CONCLUSIONS This study fulfilled its purpose of assessing the knowledge, behaviors, and attitudes toward dental care that women possess during pregnancy. Our results are in agreement with the National Institute of Health in that oral health literacy levels are low. Our data also showed a limited access to care that parallels that of the general population and is in agreement with the Pregnancy Risk Assessment Monitoring System, (PRAMS). The PRAMS study found that only twenty-eight percent of women had visited the dentist during their pregnancy, and our study showed a similar, but even smaller value of sixteen percent. Further research would be necessary in order to differentiate this as a matter of choice or simply lack of awareness of the care that is available. The participants could be making oral health decisions based on a number of deterrents, ranging from previous health beliefs to fear or misconceptions. On the other hand, a lack of awareness could be a direct result of limited oral health literacy and a general lack of understanding, which could be improved by increased educational efforts. Dental health care providers have an important role in making sure their patients are provided with the information needed to understand oral health and make educated decisions. Seventy-three percent of the surveyed participants had not received oral instruction during their pregnancy. Improved communication efforts are needed to both pregnant women in the dental office, and also outreaching to women’s health clinics. According to the National Adult Literacy Survey in 1993, the average adult in the United States reads at an 8th grade level. Given that, greater efforts are needed to ensure that informative materials are written appropriately for the educational level of the targeted audience. Table 4
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