Improving Oral Health Literacy in California: A Perspective

Jayanth Kumar, DDS, MPH

During the past century, the oral health of Americans improved significantly as a result of healthy behavior, improved access to care, great strides in research and practice and the adoption of community water fluoridation across the country. In spite of this, dental caries remains the most common childhood disease and disparities in oral health are widespread. Although the knowledge exists to prevent and manage oral health diseases, it has been difficult to translate into effective, real-world practice. Current research indicates that improving oral health literacy will be critical to advance oral health for all. Oral health literacy is defined as the capacity to obtain, process and understand basic oral health information needed to make appropriate health decisions and has been a focus of many national and state efforts to improve oral health. The 2000 surgeon general’s report “Oral Health in America” concluded that improving oral health requires educating the public, providers and policymakers about science-based interventions that prevent oral diseases. [1] The 2011 Institute of Medicine report “Advancing Oral Health in America” found that the public lacked understanding about how to prevent and manage oral diseases and how to navigate the oral health system. [2] The report recommended that all relevant agencies of the Department of Health and Human Services undertake health literacy and education efforts aimed at individuals, communities and health care professionals. This included recommendations to enhance professional education on best practices in patient-provider communication skills with a focus on how to communicate to an increasingly diverse population about prevention of oral cancers, dental caries and periodontal disease. The 2011 California Dental Association Access Report suggested that raising the dental IQ of all Californians should be a core principle for every health care provider in every program and setting. [3]

In California, the percentage of the population aged 16 and older that lacks basic prose literacy skills varied from a low of 6.7% in Placer County to a high of 41.5% in Imperial County. [4] Such low literacy will likely impact oral health literacy. According to the Centers for Disease Control and Prevention, nine out of 10 adults struggle to understand and use health information when it is unfamiliar, complex or jargon-filled. [5] Several factors, such as poverty, education, race/ethnicity, age and disability, are associated with lower health literacy skills. Although health literacy skills are needed for all populations, some of the greatest disparities in health literacy occur among racial and ethnic minority groups from different cultural backgrounds and those who do not speak English as a first language.[6]

The 2017 report “Status of Oral Health in California: Oral Disease Burden and Prevention” concluded that oral diseases are highly prevalent in all stages of life among California residents. Further, these diseases are correlated with socioeconomic factors such as income, race and ethnicity and educational attainment. Although effective preventive measures are available, both clinical dental services and community-level interventions are underutilized. To improve oral health over the course of the next 10 years, the California Department of Public Health published the California Oral Health Plan 2018–2028 that provides a roadmap for all Californians. [7] It presents a framework for addressing the oral disease burden and the disparities in local communities and statewide. The framework is built with six focus areas: determinants of health, utilization of dental services, infrastructure, capacity and payment systems, communication strategies and surveillance and evaluation.

The California Oral Health Plan recognizes that social, economic and physical environments influence health and risks that are common to many chronic diseases, including oral diseases.

Over the past two years, the California Office of Oral Health has supported oral health programs in 59 local health jurisdictions (LHJs) through funding from the California Healthcare, Research and Prevention Tobacco Act of 2016 to conduct needs assessments, identify resources and assets and develop oral health programs. Thirty-one out of 35 LHJs that have approved oral health improvement plans as of December 2019 identified the priority to educate the public and professionals in their communities about improving oral health. The California Oral Health Plan recognizes that social, economic and physical environments influence health and risks that are common to many chronic diseases, including oral diseases. Addressing factors such as education, poverty, housing and transportation will require broader societal actions, but steps can be taken by the oral health community to mitigate the effects of these determinants of health through policies and programs that encourage healthy habits, self-management, dental insurance benefits, timely dental assessments, preventive measures and prompt quality, evidence-based dental care. For these interventions to be effective, information needs to be communicated in such a way that it helps people make healthier decisions. Recognizing this, the California Oral Health Plan has set an objective to increase the proportion of patients (and caregivers) who report that their dental care teams give them easy-to-understand instructions about what to do to take care of their oral health and how to prevent or treat oral diseases. This is aligned with the current working definition proposed by the National Health Promotion and Disease Prevention Objectives for 2030 that states 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. [8] Therefore, dental professionals can play a key role in increasing oral health literacy and recommended oral health practices through community-wide messages and provider-patient communication in dental offices.

A national survey of dentists found low routine use of 18 communication techniques thought to be important in promoting patient and caregiver health literacy. [9] These techniques included creating a patient-friendly practice, using simple language, limiting the number of concepts presented, showing pictures or models and incorporating “teach-back.” “Teach-back” (or “teach-to-goal”) is considered an especially effective technique in which the health provider asks the patient or caregiver to summarize in their own words the key points about their health condition and what actions they will take. The University of California, Berkeley, Health Research for Action Center recently conducted a study about oral health literacy needs of dental professionals and resources available to them. The report concluded: “Although health care providers may know what messages they need to communicate to patients and parents/caregivers (i.e., what patients should do and not do), most lack training and skills on how to communicate effectively to ensure concise, culturally sensitive, educationally appropriate, bidirectional, motivational and supportive communication to engage and empower patients to care for their own and their children’s oral health. [10]

The American Dental Association has proposed an ambitious oral health literacy action agenda that includes advocacy, training of dental providers and creation of health-literate oral health resources. [11] To make progress toward this agenda, a number of initiatives are underway in California. The Office of Oral Health has contracted with the Health Research for Action Center to conduct trainings and create materials for an oral health literacy toolkit for dental teams and practices to improve uptake of information about oral health literacy. The ADA National Advisory Committee on Oral Health Literacy is providing input on toolkit development with the expectation that these resources can be adapted for use nationally. This will help dental professionals assess the patient-friendliness of their practices and find ways to make their practices “more health literate,” especially for lower literacy patients and families. The toolkit will include information on oral health literacy and specific communication strategies including plain language communication, the teach-back method and creating a shame-free and welcoming clinical environment. In addition, the California Oral Health Technical Assistance Center at the University of California, San Francisco has created resources for local health departments and dental practitioners to promote kindergarten oral health assessment, water fluoridation, school-based/linked programs and tobacco cessation counseling. The Medi-Cal (Medicaid) Dental Program has launched “Smile, California,” a campaign to increase members’ use of Medi-Cal’s dental benefit. [12] It is intended to educate eligible members about the services available to promote oral health and make it easier for members to access care. The California Dental Association (CDA) expressly used its dental care event, CDA Cares, to educate the public and policymakers on the importance of good oral health and access to dental care. Additionally, CDA has developed an online course, Treating Young Kids Every Day, which instructs dental professionals on how to engage families in daily activities to prevent the initiation of dental disease in very young children. Dental professionals are encouraged to use these resources to support patients’ efforts to improve their oral health. By using these oral health literacy strategies and practices, we at the Office of Oral Health are hopeful that the dental office environment will be easier to navigate, patients’ adherence to their recommended treatment plan will be higher and improved health outcomes will be achieved.

ACKNOWLEDGMENT The author thanks Linda Neuhauser, DrPH, MPH, clinical professor, School of Public Health, University of California, Berkeley, for her helpful suggestions.

REFERENCES

1. Department of Health and Human Services. Oral health in America: A report of the surgeon general. Rockville, Md.: U.S. Department of Health and Human Services; 2000.

2. Institute of Medicine. Advancing Oral Health in America. Washington, D.C.: The National Academies Press; 2011.

3. California Dental Association. Phased Strategies for Reducing the Barriers to Dental Care in California. California Dental Association Access Report; 2011.

4. County Health Rankings and Roadmaps. Illiteracy. Percentage of population age 16 and older that lacks basic prose literacy skills. www.countyhealthrankings.org/app/ california/2012/measure/factors/66/data?sort=sc-2.

5. Centers for Disease Control and Prevention. www.cdc.gov/ healthliteracy/shareinteract/TellOthers.html.

6. U.S. Department of Health and Human Services. Healthy People 2020. Health Literacy. www.healthypeople.gov/2020/ topics-objectives/topic/social-determinants-health/interventionsresources/health-literacy.

7. California Department of Health. California Oral Health Plan 2018–2028. www.cdph.ca.gov/Programs/CCDPHP/DCDIC/ CDCB/Pages/OralHealthProgram/OralHealthProgram.aspx. Accessed Dec. 5, 2019.

8. U.S. Department of Health and Human Services. Solicitation for Written Comments on Updated Health Literacy Definition for Healthy People 2030. www.federalregister.gov/ documents/2019/06/04/2019-11571/solicitation-forwritten-comments-on-an-updated-health-literacy-definition-forhealthy-people-2030.

9. Rozier RG, Horowitz AM, Podschun G. Dentist-patient communication techniques used in the United States. The results of a national survey. J Am Dent Assoc 2011;142(5):518–530. doi:

10.14219/jada.archive.2011.0222. 10. University of California, Berkeley, Health Research for Action Center. Promoting oral health literate practice in dental team providers: Knowledge of oral health literacy, use of communication strategies and improving uptake at dental practice sites, and environmental scan of training resources on oral health literacy for health care providers and review of selected oral health education materials for patients. Technical reports submitted to the Office of Oral Health. October 2019.

11. American Dental Association. Health Literacy in Dentistry Strategic Action Plan 2010–2015.

12. Smile, California. smilecalifornia.org/about. Accessed Dec. 5, 2019.

THE AUTHOR, Jayanth Kumar, DDS, MPH, can be reached at jayanth.kumar@cdph.ca.gov.

AUTHOR Jayanth Kumar, DDS, MPH, is the California state dental director. He is a board-certified specialist in dental public health and a former director and president of the American Board of Dental Public Health. Conflict of Interest Disclosure: None reported.