American Dental Association: Advancing Health Literacy Within and by the Dental Profession

American Dental Association: Advancing Health Literacy Within and by the Dental Profession

Sharon R. Clough, RDH, MS Ed

ABSTRACT Poor oral health literacy is associated with poorer oral health knowledge, increased dental caries severity and increased rates of patient no-show rates. The American Dental Association has made health literacy a priority since 2006 with the development of the National Advisory Committee on Health Literacy in Dentistry and an action plan to guide its work. This article summarizes the ADA’s efforts to improve the oral health literacy of the public and current and future dental professionals.

Effective communication is the cornerstone of patient safety. [1] There are numerous cases where ineffective communication jeopardized the health of the patient. A Hmong-speaking family was unable to communicate that their infant child, Lia Lee, was having epileptic seizures, and the physicians misdiagnosed the symptoms as pneumonia. The language barrier and difficulty with understanding the family’s cultural beliefs led to continued health issues. [2] Due to a number of circumstances including access barriers and poor oral health literacy, Deamonte Driver, a 12-year-old boy from Maryland, died as a result of an infected tooth. These and other stories offer compelling reasons for providing both written and oral information to patients that can be understood and easily acted upon.

Health literacy is defined as “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.” [3] This also includes the educational, social and cultural factors that impact individuals’ desires and expectations and encompasses how well health care providers can meet those needs and expectations. [4] The Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for Healthy People 2030 includes this statement that reflects the evolution of the field: “Health literacy occurs when a society provides accurate health information and services that people can easily find, understand and use to inform their decisions and actions.” [5] The statement supports new appreciation for its multidimensionality in that health literacy is affected not only by an individual’s abilities, but also system demands and complexities that impact the ability to access, understand and use health information and health services. [5]

Lack of health literacy contributes to socioeconomic and health disparities. If patients receive information they do not understand and cannot act upon, then health disparities remain a problem. Results from the 2003 National Assessment of Adult Literacy (NAAL) demonstrate the necessity for improving health literacy. The report found that only 12% of Englishspeaking adults surveyed had proficient levels of health literacy. Twenty-two percent had basic levels of proficiency and 14% had below basic health literacy skills. [4]

A more recent population surveillance confirmed previous NAAL findings that males, Spanish speakers and those with less education are at risk of low health literacy. [6] Additionally, individuals with lower health literacy experience a greater chronic disease burden and more days of poor physical health per month than those who have higher health literacy. [6] Similar to previous findings, the data from this survey showed that older adults scored below the median in health literacy; however, young adults scored below the median, indicating that health literacy is an important consideration for this age group also. [6]

When the discussion shifts to oral health literacy, the same concerns regarding use of health literacy skills exist. Research shows that communication between dentists and their patients plays an important role in the use of dental services. [7–9] Patients with poor oral health literacy have poorer oral health, including lower levels of oral health knowledge, [10,11] an increase in dental caries severity [12] and an increase in the number of patient no-show rates. ]10] Conversely, when dental providers use good communication skills and provide clearly written instructions, oral health literacy increases, resulting in improved oral health. [7–9]

The American Dental Association (ADA) policies on health literacy support clear, accurate and effective communication between the dental professional and the patient for effective dental practice and acknowledges that limited oral health literacy of patients and communication skills for health providers is a potential barrier to effective prevention, diagnosis and treatment of oral diseases. [13,14] Furthermore, the ADA recognizes that improving health literacy makes patients better stewards of their own health and that of their children and supports the use of health literacy principles and plain language for all patients and providers for easier understanding, navigation and use of oral health information. [15,16] Accordingly, written information should be written to be easily understood and formatted in such a way that the material is inviting to read. For spoken instruction, dental providers should offer information that is easy to understand and use communication strategies, such as teach-back, that confirm for the provider that the patient understands the information received.

Individuals with lower health literacy experience a greater chronic disease burden and more days of poor physical health per month than those who have higher health literacy.

The ADA has made health literacy a priority for over a decade. Efforts began in 2006 when the House of Delegates adopted a resolution recommended by the Council on Access, Prevention and Interprofessional Relations (CAPIR) (now called the Council on Advocacy for Access and Prevention, CAAP) that the ADA president appoint a three-year oral health literacy ad hoc advisory committee. [17] In April 2007, the National Oral Health Literacy Advisory Committee (NOHLAC), consisting of representatives from dentistry, public health, literacy and other advocacy organizations, convened at the ADA Chicago headquarters. The advisory committee was charged with developing policy recommendations, targeted educational strategies and other health programs to address oral health literacy issues. The committee developed the ADA 2010–2015 Health Literacy in Dentistry Plan, which directed their work.

The ad hoc committee met for the last time in November 2012. However, with the support of ADA Executive Director Kathleen O’Loughlin, DMD, MPH, and by the recommendation of CAAP, then CAPIR, the committee reconvened in 2014 as the National Advisory Committee on Health Literacy in Dentistry (NACHLD). To provide health information that reflects the intent of the ADA’s policies, the committee began its work by developing an updated action plan (ADA Health Literacy in Dentistry Action Plan 2016–2020). The plan, which includes goals for advocacy, training and education, dental practice, research and coalition building, continues to provide guidance for the work of the committee.

The ADA has made substantial progress in addressing the action-plan goals and objectives with successful outcomes. These actions have brought the ADA to the forefront in being a health care association that has made great strides in establishing the organization as a health literate association. The purpose of this article is to summarize the ADA’s efforts to improve the oral health literacy of the public and current and future dental professionals.

Training and Educational Activities

Studies indicate that health literacy impacts effective prevention, diagnosis and treatment of oral diseases, whereas limited health literacy affects many types of health (including oral health) diseases’ outcomes and costs. [18–23] Effective communication techniques by providers can make it easier for patients to follow their prescribed plan of care. 20 However, research indicates that patients and health care providers, including dentists and dental hygienists, lack the necessary skills to assess patients’ literacy levels and provide information at a literacy level that is appropriate for the patient. [24–27] Accordingly, continued efforts are needed to include health literacy as an element of training for current and future dental professionals. [21,22,28,29] To ensure that health literacy is addressed in dental school curricula, the Council on Advocacy for Access and Prevention and its National Advisory Committee on Health Literacy in Dentistry requested that health literacy be incorporated into the Commission on Dental Accreditation (CODA) Predental Program Accreditation Standards. A definition of health literacy as well as the addition of a standard that includes health literacy was adopted by CODA during its 2019 winter meeting. The additions to the standards were implemented in January 2020.

Oral health outcomes can be expected to be less than desired when provider/patient interactions are not clear. 18 Advanced patient/provider communication skills result in improved oral health literacy for the patient, which in turn decreases patient anxiety and improves motivation and satisfaction. 30,31 If students are taught the importance of good communication skills while in dental school, the likelihood that these skills will continue into professional practice following graduation is increased. [30]

To promote student interest about health literacy, cultivate their plain-language writing skills and help them become better communicators, the ADA sponsors a health literacy essay contest. The contest began in 2015 when Sorin Teich, DMD, MBA, then assistant dean at Case Western Reserve University Dental School, requested that the ADA sponsor a contest to encourage students to become good communicators. The pilot project began with one dental school participating in the contest and has grown to include all accredited U.S. dental schools. Contestants are required to complete two brief online health literacy courses offered by the Centers for Disease Control and Prevention (CDC) to increase their knowledge of health literacy and plain writing. Using the knowledge gained from the online training courses, they are assigned the task of writing an essay on a specific dental topic. Previous topics included diabetes and oral health, sweetened beverages and their effect on oral health and important things to know about baby teeth and cavities: What are they and how do we prevent them?

For the essay, students are required to provide evidence-based information that is easy for the average reader to understand. The winning essay is posted on ADA’s consumer website MouthHealthy. org. The first-place winner and four runners-up receive cash awards. The contest is evaluated annually and changes are made based on feedback from the evaluations and on the quality of the essays submitted. The goal is to sponsor a contest that provides a true learning experience for the competing students.

Dental providers who use effective communication techniques contribute to greater oral health literacy — the patients’ ability to understand and act upon the information provided to improve their oral health. [21,23] However, continued efforts are needed in educating the dental community about health literacy. [24–27] Health literacy environmental scans of health center dental clinics in Maryland showed that current practices related to oral health literacy lack consistency. [26,27] To provide educational opportunities for dental professionals, CAAP offers various continuing education programs at dental conferences including the ADA’s annual meeting. For those seeking immediate information, resources about health literacy are available on the ADA’s health literacy website. The website provides an overview of health literacy, information about creating a health literate environment for the dental practice and links to health literate consumer education materials.

Assessment of Dental Students’ Health Literacy Knowledge and Skills

In 2017, upon the recommendation of NACHLD, CAAP adopted a resolution to conduct an assessment of health literacy skills, practices and content from students from dental schools and allied programs. The intent was to gain insight into dental students’ knowledge, understanding and attitudes regarding patient communication and caries prevention activities. The most recent assessment of dentists and dental hygienists skills was completed in 2008 with results for dentists published in the Journal of the American Dental Association. 26 Because there had been no recent national surveys on the topic, NACHLD recommended that a survey be conducted to assess dental students’ health literacy knowledge and attitudes.

CAAP instructed NACHLD to move forward with the survey. A workgroup consisting of NACHLD members developed and conducted the online survey during the 2018 summer semester. Dental hygiene students were surveyed during the 2019 spring semester. Increasing collaboration to advance health literacy is one of the goals of the action plan. Development and distribution efforts provided opportunities for CAAP to collaborate with other dental associations on this project. Accordingly, the American Dental Education Association and the ADA’s Council on Education and Licensure reviewed and commented on the draft survey. The ADA’s client services department, the American Student Dental Association and the American Dental Hygienists’ Association provided assistance in distributing the survey and informing faculty and students about the assessment. A data analysis is in process and results will be published with the hope that the findings will help identify gaps in education and guide curriculum development for health literacy courses for dental and dental hygiene programs.

Patient Education Materials

The average American reads at an eighth- to ninth-grade level. 4 Fourteen percent of Americans have below basic health literacy. 4 Despite these statistics, health information is usually written at a higher reading level (12th grade or college level) making it difficult for the average American to understand and successfully and safely act on the information in managing their own care. 4,25,28 Designing clearly written patient education materials is a critical step to ensuring understanding of the health information provided. [29–33]

Knowing the importance of providing clearly written information for the consumer, ADA’s product and development and sales (PDS) department hired a consulting firm to assess a few of its patient education brochures for readability and usability. Changes were made based on suggestions from the review. Ongoing training efforts continue to better prepare ADA staff who are directly responsible for writing patient education materials in order to enhance their understanding of health literacy and plain writing skills. Periodically, PDS facilitates an advisory committee comprised of ADA volunteers who review and suggest edits to draft patient education brochures. To provide expertise for this endeavor, a member of NACHLD is a member of the PDS advisory committee to provide valuable insight and assistance during this process.

Conclusion

On the day he was administered the oath for surgeon general, former Surgeon General Vivek H. Murthy, MD, MBA, stated that it is necessary to “combat misinformation with clear communication” and “give the American people the best information so they can make good decisions for their own health.” [34] The ADA has made substantial strides in achieving that goal. To ensure that health literacy is addressed in dental school curricula, CAAP requested that health literacy be incorporated into the CODA Predental Program Accreditation Standards. To identify gaps in education and guide curriculum development for health literacy courses for dental and dental hygiene programs, CAAP developed and conducted a survey to assess dental and dental hygiene students’ health literacy knowledge and skills. To promote student interest about health literacy, cultivate their plain-language writing skills and help them become better communicators, the ADA sponsors a health literacy essay contest. To provide educational opportunities for dental professionals, CAAP offers various continuing education programs at dental conferences including ADA’s annual meeting. Dental professionals seeking immediate information on the topic can easily access numerous resources on ADA’s health literacy webpage. Finally, to make certain that the ADA provides consumers clearly written dental health information, patient education materials are assessed for readability and usability and edited for clarity when needed. Acknowledging that staff cannot write clear communication if they do not have a good understanding of health literacy and plain writing skills, the ADA offers training opportunities for staff who are responsible for developing and writing patient education information.

The ADA will continue its efforts with making the association a health literate organization and improve the oral health literacy of the public and current and future dental professionals. Next steps include developing a new action plan that expands current endeavors and offers new opportunities. Suggested actions include developing a toolkit that provides health literacy resources to dental professionals, encouraging additional research on oral health literacy and identifying opportunities to collaborate with external agencies on health literacy projects.

REFERENCES

1. Joint Commission. “What Did the Doctor Say?” Improving Health Literacy to Protect Patient Safety. Accessed Sept. 10, 2019.

2. Fadiman A. The spirit catches you and you fall down. New York: Farrar, Straus and Giroux; 1998.

3. U.S. Department of Health and Human Services. Healthy People 2010: Understanding and improving oral health. 2nd ed. Washington D.C.: U.S. Government Printing Office; 2000:11–20.

4. Kutner M, Greenberg E, Jin Y, Paulsen C. The health literacy of America’s adults: Results from the 2003 national assessment of adult literacy (NCES 2006-483). U.S. Department of Education. Washington, D.C.: National Center for Education Statistics; 2006.

5. Federal Register. Solicitation for written comments on an updated health literacy definition for Healthy People 2030. U.S. Department of Health and Human Services. 2019 June;84(107). www.federalregister.gov/ documents/2019/06/04/2019-11571/solicitation-forwritten-comments-on-an-updated-health-literacy-definition-forhealthy-people-2030. Accessed Aug. 23, 2019.

6. Rubin D. Health literacy report: Analysis of 2016 BRFSS health literacy data office of the associate director for communication centers for disease control and prevention. www.cdc.gov/healthliteracy/pdf/Report-on-2016-BRFSSHealth-Literacy-Data-For-Web.pdf. Accessed Aug. 9, 2019.

7. Schönwetter DJ, Wener ME, Mazurat N. Determining the validity and reliability of clinical communication assessment tools for dental patients and students. J Dent Educ 2012 Oct;76(10):1276–90.

8. Sachdeo A, Konfino S, Icyda RU, et al. An analysis of patient grievances in a dental school clinical environment. J Dent Educ 2012 Oct;76(10):1317–22.

9. Horowitz AM, Kleinman DV. Oral health literacy: A pathway to reducing oral health disparities in Maryland. J Public Health Dent 2012 Winter;72 Suppl 1:S26–30. doi: 10.1111/j.1752- 7325.2012.00316.x.

10. Sabbahi DA, Lawrence HP, LImebvack H, Rootman I. Development and evaluation of an oral health literacy instrument for adults. Community Dent Oral Epidemilol 2009 Oct;37(5):451–62. doi: 10.1111/j.1600- 0528.2009.00490.x.

11. Jones M, Lee JY, Rozier RG. Oral health literacy among adult patients seeking dental care. J Am Dent Assoc 2007 Sep;138(9):1199–208; quiz 1266–7. doi: 10.14219/jada. archive.2007.0344.

12. Miller E, Lee JY, DeWalt DA, Vann WF Jr. Impact of caregiver literacy on children’s oral health outcomes. Pediatrics 2010 Jul;126(1):107–14. doi: 10.1542/peds.2009-2887. Epub 2010 Jun 14.

13. American Dental Association Policy Communication and Dental Practice (Trans.2008:454; 2013:342). Resolved, that the ADA affirms that clear, accurate and effective communication is an essential skill for patient-centered dental practice.

14. American Dental Association Policy Limited Oral Health Literacy Skills and Understanding in Adults (Trans.2006:317; 2013:342). Resolved, that the ADA recognizes that limited oral health literacy is a potential barrier to effective prevention, diagnosis and treatment of oral disease.

15. American Dental Association Policy Universal Healthcare Reform (Trans.2008:433). Resolved, that the following be adopted as the Association’s policy on oral health care for utilization during discussions on health care reform.

16. American Dental Association. Policy Use of Health Literacy Principles for All Patients. Transactions. Chicago: 2006:322. Resolved, that ADA supports the use of health literacy principles and plain language for all patients and providers to make it easier for them to navigate, understand and use appropriate information and services to help patients be stewards of their oral health.

17. American Dental Association. Definition of Oral Health Literacy Transactions. Chicago: 2005:322; 2006:316. Resolved, that it is the ADA’s position that oral health literacy is 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.

18. Horowitz A, Kleinman D. Oral health literacy: The new imperative to better oral health. Dent Clin N Am Apr;52(2):333–44.

19. U.S. Department of Health and Human Services. National Call to Action to Promote Oral Health. Rockville, Md.: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Dental and Craniofacial Research. NIH Publication No. 03- 5303, 2003.

20. Barrett SE, Dyer C, Westpheling K. Language access: Understanding the barriers and challenges in primary care settings. Perspectives from the field. McLean, Va.: Association of Clinicians for the Underserved; 2008. www.clinicians.org/ images/upload/Language_Access_Report.pdf. Accessed July 29, 2019.

21. Yedidia MJ, Gillespie CC, Kachur E, et al. Effect of communications training on medical student performance. JAMA 2003;290(9):1157–1165. doi:10.1001/ jama.290.9.1157.

22. Parker R, Ratzan SC, Lurie N. Health literacy: A policy challenge for advancing high-quality health care. Health Aff (Millwood) 2003 Jul–Aug;22(4):147–53. doi: 10.1377/ hlthaff.22.4.147.

23. Howard DH, Gazmararian J, Parker RM. The impact of low health literacy on the medical costs of Medicare managed care enrollees. Am J Med 2005 Apr;118(4):371–7. doi: 10.1016/j.amjmed.2005.01.010.

24. Kripalani S, Weiss BD. Teaching about health literacy and clear communication. J Gen Intern Med 2006 Aug;21(8):888–90. doi: 10.1111/j.1525- 1497.2006.00543.x.

25. Tam A, Yue O, Atchison KA, Richards JK, BS; Holtzman JS. The association of patients’ oral health literacy and dental school communication tools: A pilot study. J Dent Educ 2015 May;79(5):530–8.

26. Rozier RG, Horowitz AM, Podschun G. Dentistpatient communication techniques used in the United States: The results of a national survey. J Am Dent Assoc 2011 May;142(5):518–30. doi: 10.14219/jada. archive.2011.0222.

27. Maybury C, Horowitz AM, Wang MQ, Kleinman DV. Use of communication techniques by Maryland dentists. J Am Dent Assoc 2013 Dec;144(12):1386–96. doi: 10.14219/jada. archive.2013.0075.

28. Nielsen-Bohlman L, Panzer AM, Kindig, DA, eds. Health literacy: A prescription to end confusion. Washington, D.C.: National Academies Press; 2004.

29. Guo Y, Logan HL, Dodd VJ, Muller KE, Marks JG, Riley JL. Health literacy: A pathway to better oral health. Am J Public Health 2014 Jul;104(7):e85–91. doi: 10.2105/ AJPH.2014.301930. Epub 2014 May 15.

30. Bress LE. Improving oral health literacy — The new standard in dental hygiene practice. J Dent Hyg 2013 Dec;87(6):322–9.

31. U.S. Department of Health and Human Services, Office of Disease Prevention and Promotion. Plain language: A promising strategy for clearly communicating health information and improving health literacy. www.michigan.gov/documents/ mdch/LiteracyHHSarticle_205541_7.pdf.

32. U.S. Department of Health and Human Services Oral Health Coordinating Committee. U.S. Department of Health and Human Services Oral Health Strategic Framework, 2014–2017. Public Health Reports 2016 March–April;131.

33. Brach C, Keller D, Hernandez LM, et al. Ten attributes of health-literate health care organizations. Discussion paper, Institute of Medicine Roundtable on Health Literacy, 2012. nam.edu/wp-content/uploads/2015/06/BPH_Ten_HLit_ Attributes.pdf. Accessed July 29, 2019.

34. Centers for Disease Control and Prevention. Leaders Talk About Health Literacy. “Build the Great Community,” April 22, 2015. www.cdc.gov/healthliteracy/leaders-talk-about-healthliteracy.html. Accessed Aug. 27, 2019.

THE AUTHOR, Sharon R. Clough, RDH, MS Ed, can be reached at sclough50@gmail.com.

AUTHOR Sharon R. Clough, RDH, MS Ed, was the manager of preventive health activities at the American Dental Association, Council on Advocacy for Access and Prevention. She facilitated the work of the American Dental Association’s National Advisory Committee on Health Literacy in Dentistry. She retired in 2019. Prior to working at the ADA, she was a clinical dental hygienist, was adjunct faculty for two dental hygiene programs and was the oral health network coordinator for the Illinois Primary Health Care Association. Conflict of Interest Disclosure: None reported.