| Abstract|| |
Aims: To evaluate the association of oral health literacy (OHL) with oral health behavior and oral health outcomes among dental patients in Hyderabad City. Settings and Design: Cross-sectional study among dental patients. Materials and Methods: A convenience sample of 605 adults >18 years of age visiting the out-patient Department of Public Health Dentistry of Government Dental College and Hospital, Hyderabad, were recruited. The five-item scale developed by Ishikawa was used to measure communication and critical OHL. Socioeconomic status was assessed using Modified Kuppuswamy's scale and questions for oral health behavior included frequency of toothbrushing, frequency of dental visit, and reason for visit. Dentition status, periodontal status, and loss of attachment were recorded according to World Health Organisation Survey methods. Statistical Analysis Used: Frequency distribution was done and association between the variables and predictors (oral health behavior and oral health status) of OHL was calculated using odds ratio. Results: The mean age of the study population was 31.5 + 11.2 years. None of the individuals' questions of OHL questionnaire had 50% response of strongly agree or agree. The oral health parameters of decayed and filled teeth emerged as a significant predictor for model 1 (adjusted by sex and age) and model 2 (adjusted by sex, age, and social class). Likewise, toothbrushing frequency was significantly associated with low OHL. Conclusions: This study shows a high prevalence of low OHL in the study population, with decayed teeth and filled teeth and oral health behavior like toothbrushing only once as a significant predictor for low OHL.
Keywords: Decayed teeth, oral health literacy, socioeconomic status, toothbrushing
|How to cite this article:|
Sukhabogi JR, Doshi D, Vadlamani M, Rahul V. Association of oral health literacy with oral health behavior and oral health outcomes among adult dental patients. Indian J Dent Res 2020;31:835-9
|How to cite this URL:|
Sukhabogi JR, Doshi D, Vadlamani M, Rahul V. Association of oral health literacy with oral health behavior and oral health outcomes among adult dental patients. Indian J Dent Res [serial online] 2020 [cited 2021 Jun 12];31:835-9. Available from: https://www.ijdr.in/text.asp?2020/31/6/835/311651
| Introduction|| |
Oral health being a multidimensional concept is influenced by an array of factors, with oral health literacy (OHL) emerging as a noteworthy determinant in the recent years. OHL has been regarded to have profound effect on dental health knowledge and oral health promoting behaviors. As defined by US Department of Health and Human Service Policy, it 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.”
OHL is crucial as it determines the manner in which one encompasses, comprehends, and utilizes oral health information for the maintenance and management of oral health. Low rates of OHL has a myriad of consequences such as high risk for dental diseases, poorer oral health status, higher rates of missed appointments, lower use of preventive services,,, thereby inadvertently contributing to enhanced burden of oral diseases. Also, variables such as socioeconomic status and demographic factors considerably influence OHL, which, in turn, affect appropriate dental health and treatment decisions impacting oral health outcomes.
OHL is an invisible barrier attributing significantly to oral health disparities across various populations. It has surfaced as a significant challenge in a culturally, socially, and economically diverse Indian population. Dental healthcare services in India are rendered primarily by government or private sectors that may include hospitals, teaching institutes, or clinics. In a dental teaching hospital organization (either government or private), patients often enter a system to seek range of services under one roof and thus corresponding, communicating, and gathering information from several healthcare providers. Thus, patient's inability to comprehend health information can add to their disadvantage. Identifying this need, our study aimed to determine the association of OHL with oral health behavior and oral health outcomes among dental patients visiting in Hyderabad City. We hypothesized that oral health literacy is not predicted by oral health behavior and oral health outcomes.
| Materials and Methods|| |
A pilot study was conducted to assess the sample size based on the caries experience as measured by DMFT (decayed missing filled teeth) index with a desired confidence interval (CI) of 95% with precision of 5%. The prevalence of dental caries (decayed teeth) was 77.5%. Applying the formula, n = Z2pq/d2, where p denotes prevalence (77.5%); q denotes 100 − p (22.5); Z = 2.58 at 95% CI and the d is the precision (5%), the minimum sample required was 464. To adjust for the probable losses, 30% was added; hence, a total sample of 605 was ascertained. A convenience sample of adults >18 years of age with documented informed consent visiting the out-Hyderabad was recruited. The study was conducted from July 1 to September 5, 2018. Ethical clearance was obtained from Sri Sai College of Dental Surgery, Vikarabad (Ref No. 652/PHD/SSCDS/IRB-E/2018). The study was conducted in accordance with the Declaration of Helsinki.
The five-item scale developed by Ishikawa was used to measure communication (1–3) and critical (4 and 5) OHL. The items were translated into vernacular language (Hindi and Telugu) for easy understanding. Each item was rated on a five-point Likert scale, and for the purpose of analyses, the scores were dichotomized as “1” for responses of agree and strongly agree and “0” for do not agree, disagree, or strongly disagree. Hence, the overall score ranged from 0 to 5. A score of 5 was considered “high” OHL and a score of 4 or less as “low” OHL.
Age, gender, and socioeconomic status information was obtained for all respondents. Socioeconomic status was assessed using Modified Kuppuswamy's scale for the year 2018 and based on the occupation, education, and monthly family income was classified into five social class. For this study, social class was divided into upper (social class I) middle (social II and III), and lower (IV and V).
Questions for oral health behavior included frequency of toothbrushing (once/twice/more than twice), frequency of dental visit (emergency/regularly), and reason for visit (pain/need/routine). The toothbrushing frequency was dichotomized as once or more than once.
Oral health examination was carried out by a single pretrained and precalibrated examiner and recorder. It included assessment of dentition status (to evaluate decayed, missing, and filled teeth), periodontal status (for bleeding and pocket), and loss of attachment according to World Health Organisation (WHO) Survey methods.
For the decayed (D) and filled (F) component, presence of at least one decayed or filled tooth was considered as “yes” and “no” for absence of the decayed or filled teeth, respectively. The component of missing (M) teeth was segregated into more than five missing teeth and less than five missing teeth. Bleeding gums, pocket, and loss of attachment was considered yes, if any sextant exhibited bleeding (code 1), pocket (code 1 or 2), and loss of attachment (code 1 or more), the condition was regarded as “present,” respectively, as according to WHO criteria.
The P-value for this study was set at 0.05. The validity of the questionnaire was evaluated using Cronbach's alpha and the intraexaminer reliability was tested using Kappa statistics. Descriptive statistics in the form of number and percentage was done for the study population based on variables. Association between the variables and predictors (oral health behavior and oral health status) of OHL was calculated using odds ratio. All statistical calculations was done using SPSS software version 21.0.
| Results|| |
The internal validity of the questionnaire in the vernacular language was 0.78 and the intraexaminer reliability as determined by Kappa statistics was 0.89. Out of the 605 participants, 545 completed the questionnaires and agreed for oral examinations (response rate – 90%). The age-range for the study population was 18–65 years with a mean age of 31.5 + 11.2 years. Around 58.5% (319) of the population examined were male and majority of the study population belonged to middle socioeconomic status (76%; 415). Only 2% (11) of the study population visited the dentist on routine basis, whereas 53.1% visited on need basis.
Segregating the study population based on OHL (low and high) revealed a significant difference based on socioeconomic status (P-value: upper = 0.0001; middle = 0.01), frequency of tooth brushing (P = 0.04) and filled teeth (P = 0.01) [Table 1]. Surprisingly, none of the individuals' questions of OHL questionnaire had 50% response of strongly agree or agree [Table 2].
|Table 1: Distribution of the study population based on oral health literacy (OHL)|
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|Table 2: Distribution of communicative and critical oral health literacy scale - items (n=545|
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The oral health parameters of decayed and filled teeth emerged as a significant predictor for model 1 (adjusted by sex and age) and model 2 (adjusted by sex, age, and social class). Likewise, toothbrushing frequency was significantly associated with low OHL in both the models [Table 3] and [Table 4].
|Table 3: Oral health literacy (low) as a predictor for oral health outcomes|
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|Table 4: Oral health literacy (low) as a predictor of oral health behavior|
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| Discussion|| |
Previously, OHL was limited to word recognition and pronunciation, but definition of what constitutes OHL has progressed beyond that. The need to understand, follow, and adapt the instructions has a more vital role to play in healthcare sectors. Health literacy as outlined by Nutbeam falls into three categories: basic/functional (reading and writing skills for daily life, e.g., understanding the prescription); communicative/interactional literacy (cognitive and literacy skills along with social skills, i.e., ability to extract information and apply it to personal situations), and critical literacy aims at empowerment to critically analyze and apply the information to control health situations.
Initial tools like Rapid Estimate of Adult Literacy in Dentistry-99 (REALD-99), REALD-30, Test Of Functional Health Literacy in Dentistry (TOFHLiD), and Oral Health Literacy Instrument (OHLI) estimated the reading skills relative to oral health and did not essentially gauge OHL. Hence, in this study, we employed communicative and critical literacy by Ishkawa et al., which evaluated patient's ability to assimilate health information from various sources and assess whether the information is pertinent and true to his/her current health situation.
Around 70% (365) of this study participants had low OHL, which was similar to the Brazilian population of Piracicaba. With not even half of the study population strongly agreeing/agreeing to any of the items of the study questionnaire may exhibit the lack of interest or inability to understand their oral health condition. This was further supported by the low response of ~40% to the question. “I can collect oral health information from various sources.” This brings to light the need to advertise and make health resources more accessible and guide people to obtain health information.
A noteworthy finding of our study was the lower prevalence of high OHL among lower socioeconomic group. Most commonly, the three factors which determine the socioeconomic status are education, occupation, and income, which are encompassed in Kuppuswamy scale and hence was utilized in this study. This finding may further emphasize the role education plays in determining the level of OHL. Even Alpolinaro et al. reported a good association of schooling with health literacy.
Apart from filled teeth which showed significant difference for the level of OHL (high/low), none of the oral health outcomes showed any significant difference. This could be attributed to the fact that to obtain a dental treatment such as restoration, one must visit a dental hospital/clinic, which might have got them acquainted to the dental setting. Therefore, a higher percentage (68.6%) of population who did not have filled teeth showed low OHL, and on the contrary, more number of people with filled teeth had high OHL (47.3%).
The oral health promoting behavior that significantly affected OHL in the current population was tooth-brushing frequency. This reflects a person's own efforts to maintain his/her oral hygiene and thereby seeking out more information on oral health and adopting healthy oral health behaviors. Similar findings were noted among Japanese, American, Slovakian, and Iranian populations. In our study, no relationship was found between frequency of dental visit with OHL; this was further supported by the meta-analysis report by Firmino RT et al., wherein no association between OHL and frequency of visit to the dentist for adults, either through bivariate analysis (OR = 1.25; 95% CI: 0.95–1.63) or multivariate analysis (OR = 1.90; 95% CI: 0.77–4.84) was seen.
Focusing on health literacy may provide an additional tool to promote oral health improvement and thereby plan relevant intervention for the vulnerable population. As outlined by ophelia process, the strengthening of healthcare system involves optimizing health literacy of individuals and optimising health literacy of responsiveness of organizations. This may involve collaborations of various sectors to develop health literacy interventions based on health needs, thereby enhancing the utilisation healthcare information and knowledge.
The strength of this study lies in the response rate (90%), also a high reliability of the translated questionnaire adds to the merit of the study. Utilizing the standard guidelines by WHO for oral health outcomes will permit future comparisons with other population groups. Inclusion of most common oral health behaviors (tooth-brushing frequency) and demographic variables can help to identify the risk factor for poor OHL. However, a single teaching hospital sample is a recognized demerit of this study. Additionally, the cross-sectional design of the study fails to establish a causal relationship between the various parameters. Even though, the reliability of the questionnaire in vernacular language has been good, the self-reported nature may add to the bias. Nevertheless, this study provides an insight into the OHL levels among Indian population.
| Conclusion|| |
Considering the sociodemographic and cultural diverse population of hospital patients, assessing their OHL can help identifying a more efficient way of communicating oral health information. This study shows a high prevalence of low OHL with decayed teeth and filled teeth and oral health behavior like toothbrushing only once as a significant predictor for low OHL.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Dolar Doshi
Assistant Professor, Department of Public Health Dentistry, Room No. 311, Government Dental College and Hospital, Afzalgunj Police Station Road, Hyderabad - 500 012, Telangana
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]