The Importance of Health Literacy

Dental hygienists are on the frontline of prevention. They are often the first oral health professional to review patients’ medical histories, obtains vital signs, complete assessments, and provide dental hygiene diagnoses. As such, dental hygienists need to equip themselves with the skills needed to advance positive oral health outcomes. Supporting patients with low health literacy is key to helping them maintain and/or improve their oral health.

Health literacy is defined as the ability to obtain, process, and understand the health information necessary to make informed health decisions.¹ This is not simply the ability to read; rather, health literacy requires a complex mix of reading, listening, analytical, and decision-making skills and the ability to apply these skills to health situations.^2,3 This skill set includes the ability to interpret documents, read and write prose (print literacy), use quantitative information (numeracy), and speak and listen effectively (oral literacy).⁴

EFFECTS OF LOW AND LIMITED HEALTH LITERACY

Limited health literacy can interfere with the efficacy of prevention, diagnosis, and treatment of disease. In 2003, approximately 80 million adults in the United States (36%) had limited or poor health literacy.^5–7 Rates of poor health literacy were significantly higher among older adults, minorities, individuals without a high school diploma, adults for whom English is a second language, and those of low socioeconomic status.^2,6–9 These populations face barriers to attaining the information needed to make well-informed decisions about their health.^10–12 Low health literacy is also related to patients’ lack of familiarity with medical terminology and basic human anatomy; limited ability to analyze and interpret risks that affect their health and safety; and reduced comprehension of diagnosis and treatment outcomes.^4,13

Besides the impact on health outcomes, low health literacy is also expensive. Horowitz and Kleinman¹⁴ report that low health literacy costs the US between $106 billion and $238 billion each year, representing 17% of personal health care spending.

THE DENTAL COMPONENT

Health literacy is an issue in dentistry as well. Three major policy documents describe the problem and suggest ways to improve it: Oral Health in America released by the US Surgeon General, Healthy People 2010 published by the US Department of Health and Human Services, and A National Call to Action to Promote Oral Health produced by the National Institute of Dental and Craniofacial Research.^15–17 These reports emphasize disparities in dental health and suggest that low health literacy may result in poor oral health outcomes.¹⁵ Healthy People 2010 in particular highlighted the epidemic of oral diseases affecting pediatric, geriatric, and racial/ethnic minority populations and called upon health care professionals to take action.¹⁶

One of the goals of Healthy People 2010 was to change patients’ perceptions about oral health, as it has often been seen as separate and less important than overall health. This directive has inspired action to increase health literacy. Oral health professionals, including dental hygienists, should strive to improve health literacy in order to boost overall health out­comes.¹⁷ A continuation of the first initiative, another program was established—Healthy People 2020—that suggested improvement of health communication strategies would positively impact population health outcomes and overall health care quality.¹²

A significant barrier to effective communication in the dental setting is clinicians’ inability or difficulty in addressing patients’ literacy needs.¹⁰ Thirty-six percent of American adults have intermediate health literacy scores.^4,18 Patients with low health literacy scores are more afraid to ask questions and request information when presented with a dental and/or dental hygiene treatment plan than individuals with higher scores.^5,19 Low health literacy also contributes to other barriers to improved health, such as the cost of care, access to care, the complexity of health care systems, and lack of insurance coverage.²⁰

INDICATORS AND RISK FACTORS FOR LOW HEALTH LITERACY

Many signs of low health literacy are easily identified by dental hygienists or other members of the dental team.²¹ Table 1 provides a list of indicators.^8,11,21,22 Patients with low health literacy often show little or no interest in written communication such as pamphlets or health history forms.²¹ They often express frustration or impatience when encouraged to use printed materials.²³

Oral health professionals need to be able to assess patients’ health literacy so that verbal instructions and patient materials can be matched to patients’ literacy skills. Clinicians may also opt to use to nonprinted teaching materials, such as videos, audiotapes, and demonstrations, to ensure their messaging is understood.²³ Assessing patients health literacy skills can be challenging. A screening test called Newest Vital Sign is available and is quick, accurate, and bilingual (English and Spanish). It assesses general literacy, numeracy, and comprehension skills and is designed for use in primary care settings.²⁴ Another way to evaluate and screen for low health literacy is to ask patients to read their prescription bottles and then explain how to take their medications.¹⁴ When considering the use of a health literacy test, clinicians must be sensitive to their pa­tients’ feelings. If literacy testing is suggested, patients may feel shame and alienation, which may discourage them from returning for additional treatment.^24,25

Older adults are at increased risk of low health literacy. Reading ability scores decline considerably after age 55.²¹ Many older adults have experienced varying degrees of auditory, visual, or cognition losses that affect health literacy levels. Furthermore, differences in generational cultures can also impact communication with health care providers.^21,22

Cultural differences may also adversely affect communication in the dental setting.²⁶ Patients from different cultures may involve their whole family in health-care decision making. Additionally, cultural attitudes regarding gender and status of health care providers may prevent patients from asking questions related to their health or treatment. Language barriers may exist. In such cases, a medical interpreter should be engaged. Providing written materials in patients’ language of origin is also helpful. Providing culturally competent care can help improve health literacy.^5,14

Most patients are not intimately familiar with anatomy or medical terminology, but for patients with low health literacy, these deficits can prevent them from receiving much needed care.²⁷ Dental hygienists are fluent in medical terminology and may need to self-remind to use more general terms. Table 2 provides alternative terminology for common medical vernacular.²⁸

RESOURCES FOR IMPROVING HEALTH LITERACY

The resources available to improve health literacy are based on the main factors that contribute to it: culture and ethnicity, age, education level, and language.¹ While culture and ethnicity are only a part of health literacy, they are important pieces of a complicated issue. Recognizing that culture plays an important role in communication provides clinicians with a better understanding of health literacy.¹⁸

Many educational materials on health are written at levels beyond the skills of an average high-school student.²⁹ Clinicians need to search out print and nonwritten materials or create their own that provide education in a clear and concise manner. The information needs to be delivered in plain language that is easy to understand.¹⁸ Print, audio, computer applications, and video can all be used to provide patient education.^18,30

The American Medical Association, Agency for Healthcare Research and Quality, and Health Resources and Services Administration provide tools and education for health care providers to support their efforts in improving the health literacy of their patients.^31–33 Table 3 provides an example of suggestions to make a health care or dental office more inviting to patients with varying levels of health literacy.³⁴

STRATEGIES FOR DENTAL HYGIENISTS

Dental hygienists can significantly impact the oral health outcomes of their patients.²² They are well positioned to note low health literacy skills and to take action to ensure patients fully understand their treatment needs.²¹ Dental hygiene appointments provide patients with opportunities to ask questions, learn the skills required for effective self-care, and receive additional information on health promotion strategies. The skills needed for health literacy include evaluating information for quality, analyzing risks and benefits, calculating doses, interpreting test results, and locating health information.²⁹ Therefore, dental hygienists need to focus their efforts toward improving these skills.

Information initially given to patients should be limited to what they need to know in order to prevent overwhelming patients. Clinicians should focus on the most important three points to five points to aid in comprehension of the information.²¹

The teach-back technique is a useful tool to ensure that patients understand the instructions provided. In this method, practitioners confirm whether patients understand what was communicated by asking them to repeat the information in their own words.²¹ This technique also helps clinicians assess patients’ comprehension levels and whether the information was provided in a clear and concise manner.²⁰ Table 4 provides additional information on implementing the teach-back method.³²

Dental hygienists can also participate in professional development activities on the importance of health literacy.³⁵ These may include receiving additional training in effective patient communication techniques and ensuring that educational materials are written at an appropriate reading level. Additionally, dental hygienists should encourage and educate all team members to recognize and respond appropriately to pa­tients with literacy and language deficits.^35,36

CONCLUSION

Patients’ health literacy is a stronger predictor of their health status than income, employment, education level, and racial or ethnic group.¹⁹ Low health literacy, once identified, can be effectively addressed and managed to improve overall health outcomes. A necessary component of health care decision making, health literacy impacts patients’ abilities to be engaged in their own health management. Low health literacy is a barrier to effective patient-provider communication and the prevention, diagnosis, and treatment of disease. The ability to recognize health literacy issues enables dental hygienists to improve patient communication and education and find alternative strategies for engaging patients in health management.

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From Dimensions of Dental Hygiene. November 2015;13(11):68–71.