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ORIGINAL ARTICLE
Year : 2022  |  Volume : 13  |  Issue : 4  |  Page : 157-162

Assessment of adult oral health literacy among patients visiting Government dental college, Shimla, Himachal Pradesh: A cross-sectional study


Department of Public Health Dentistry, HP Govt Dental College and Hospital, Shimla, Himachal Pradesh, India

Date of Submission26-Aug-2022
Date of Decision02-Nov-2022
Date of Acceptance02-Nov-2022
Date of Web Publication15-Dec-2022

Correspondence Address:
Dr. Deepak Gurung
HP Government Dental College, Shimla, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/srmjrds.srmjrds_111_22

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  Abstract 

Background: The major role of oral health literacy (OHL) lies in the utilization of health services as low literacy leads to reduced participation and engagement in preventive health programs. Aim: This study aimed to assess the adult OHL among patients visiting the Tertiary care institute in north India. Materials and Methods: The source of data for this descriptive qualitative study was patient visiting the outpatient department. Data collection procedure included information obtained from the subject recorded on a structured pro forma using OHL-Adults Questionnaire. Mann–Whitney U test, Kruskal–Wallis test with post hoc Bonferroni test, and Spearman's rho correlation were applied. Multiple logistic regressions were used and the dependent variable (OHL) was regressed for predicted independent variables. Parameter estimate of inadequate and marginal OHL for various predictor variables was regressed considering the adequate OHL as standard reference. Results: The inadequate literacy score was statistically significant for age, educational qualification, and number of times of visit to dentist in lifetime in the final regression model. The marginal score was significant for age, educational qualification, and frequency of visit to dentist in the final regression model. Conclusion: Total dental visit in lifetime is an important indicator for better OHL in this study. Orientation of oral health promotion programs requires due importance for both the marginal and inadequate OHL.

Keywords: Health literacy, oral health literacy, oral health literacy-adults questionnaire, oral health promotion, psychometrics


How to cite this article:
Gurung D, Bhardwaj VK, Fotedar S, Thakur AS. Assessment of adult oral health literacy among patients visiting Government dental college, Shimla, Himachal Pradesh: A cross-sectional study. SRM J Res Dent Sci 2022;13:157-62

How to cite this URL:
Gurung D, Bhardwaj VK, Fotedar S, Thakur AS. Assessment of adult oral health literacy among patients visiting Government dental college, Shimla, Himachal Pradesh: A cross-sectional study. SRM J Res Dent Sci [serial online] 2022 [cited 2023 Feb 7];13:157-62. Available from: https://www.srmjrds.in/text.asp?2022/13/4/157/363795


  Introduction Top


Health literacy is defined as "the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health."[1] Oral health literacy (OHL) refers to empowered capacity to obtain, process, and understand basic oral health information and services needed to make appropriate health decisions.[2] OHL is an integral part of the broader health literacy related to cognitive development. Evidence is suggestive of that patient with adequate OHL have better health outcomes.[3] A better understanding of OHL leads to better engagement in making informed choices, in the area of oral health services. Higher levels of OHL are more likely to have better utilization of oral health services in forms of dental appointments, frequent dental visits, improved oral health knowledge, oral health status, and oral health-related quality of life.[4],[5]

OHL is a multidimensional and psychometric concept. Various OHL assessment tools are available and each emphasizes on different construct of OHL. These OHL construct ranges from skills to recognition of common dental terminology. Instruments assessing word recognition ability include – Rapid Estimate of Adult Literacy in Medicine (REALM) based developed by Davis et al.[6] in 1993. Various adapted version based on REALM includes REALM and Dentistry consisting of 84 questions, Rapid Estimate of Adult Literacy in Dentistry (REALD)–30 consisting 30 questions, REALD–99 consisting 99 questions.[4],[6] Other instruments assessing other constructs of reading comprehension and numeracy of OHL are Test of Functional Health Literacy in Dentistry (TOFHLiD) developed by Gong et al.[4],[6] consisting of 67 questions, the OHL Instrument developed by Sabbahi et al.[4],[6] consisting of 57 questions and the Comprehensive Measure of Oral Health Knowledge measuring the conceptual knowledge consisting of 44 questions.[4] The OHL-Adults Questionnaire (OHL-AQ) developed by Naghibi Sistani et al.[4],[7],[8] in 2013 is unique though most tools are based on either REALM or TOFHLiD inflicted toward word recognition, numeracy, and reading skills. It measures two unique OHL psychometric construct not included in other OHL tools. It includes items that measure reading comprehension, listening, numeracy, and decision-making.[7],[8] Listening measuring the ability to make mental representation and decision-making, measuring the higher cognitive development of the individuals. OHL-AQ further addresses the limitation of other tools in being shorter which increases its feasibility and more generalizability across the population.[6] The major role of OHL lies in health utilization services which are low in limited literacy subject and are unlikely to participate and engage in preventive and screening programs of health.[8] Further, there are very few literature available using this novel OHL-AQ questionnaire to assess the OHL in our region and other parts of the world. With this background, the study aimed to assess the adult OHL among patients visiting the tertiary care institute of North India.


  Materials and Methods Top


Study design

The source of data for this descriptive cross-sectional study was patient visiting the outpatient department of public health dentistry of a tertiary institution.

Study setting

The information obtained from the subject was recorded on a structured pro forma, self-administered except for the listening part which was read out to the patient. Data collection was done for 3 months from March 1, 2022, to May 31, 2022. The information collected were demographic details, frequency of visit, and OHL questions. The OHL question was taken from the prevalidated OHL-AQ in English. The internal consistency, as measured by Cronbach's alpha, was found to be 0.72, and the Intraclass Correlation Coefficient was 0.84 as reported by the previous study.[8] The reading comprehension section included three questions with six missing words or phrases on oral health knowledge, numeracy section included four questions, listening section included two questions on postextraction questions and decision-making section included five multiple-choice questions related to common oral health problems and information from medical history forms. The correct answer was scored as "1" and incorrect answer was scored as "0" with the OHL total scores ranging from 0 to 17. OHL-AQ scores were categorized into the three groups – inadequate (0–9), marginal (10–11), and adequate (12–17) OHL.[7]

Ethical considerations

The ethical approval was obtained from the Institutional Ethical Committee of the tertiary institution with approval number HFW(GDC)B(12)50/2015-1162. Written informed consent was obtained from all participants for the present study which was voluntary and anonymous. The study was conducted in accordance with the ethical standard given by 1964 Declaration of Helsinki, as revised in 2013.

Participants

The study included adults visiting the outpatient department of the institute aged between 18 and 65 years and are willing to participate. Those who were not willing to participate in the study and any physical or medical condition which does not permit participation were excluded.

Study size

The sampling technique used was nonprobability convenience sampling. As there is no consensus on a specific number of sample size that is most appropriate, based on a previous study done using the item response theory study on OHL-AQ states a sample size 250–500 is adequate.[4] Further considering 1:25 ratio for each item to the response for the questionnaire, a total of 350 samples were taken.

Statistical methods

All the collected data were processed using the statistical software Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA, version 22 for windows). A P < 0.05 was considered statistically significant. The data distribution was nonnormal. Mann–Whitney U test, Kruskal–Wallis test with post hoc Bonferroni test and Spearman's rho correlation was applied. Chi-square statistics were not significant for gender and frequency of visit to dentist in a year and was statistically significant for age, educational qualification, and the number of times of visit to dentist in lifetime. Multiple logistic regressions were used and the dependent variable (OHL) was regressed for predicted independent variables. The model fit information for the regression of each determinant was obtained using the log-likelihood based on Pseudo R-square of Cox and Snell, Nagelkerke and McFadden. Values close to zero was considered good fit. Parameter estimate of inadequate and marginal OHL for various predictor variables was regressed considering the adequate OHL as standard reference. The interpretation of the parameter estimate was done considering the regression coefficient, for the unit change in predictor variables for the dependent variables in reference to the standard. This was similarly done considering the odds ratio and confidence interval (CI). The final parameter estimate for controlled variables was derived using regression.


  Results Top


There were 54% female and 44% male participants among which 33.1% were undergraduate, 25.7% were graduate, and 25.4% were postgraduate. 38.3% visited their dentist after every 10–12 months, 29.1% visited after every 1–3 months, and those visiting after every 4–6 months and 7–9 months were comparable to 16%. [Table 1] shows that among the items of OHL-AQ question number 4 had the highest proportion of correct response (76.3%) and question number 7 had the lowest proportion of correct response (17.7%). [Table 2] shows the mean OHL total score as 8.44. [Table 3] shows the mean total score was 8.49 among 18–29 years, comparable for gender and high for postgraduate individuals. The mean total score was high among those who visited dentist after every 4–6 months and those who visited dentist <5 times in their lifetime.
Table 1: Frequency of distribution among various Oral Health Literacy-Adults Questionnaire questions/items

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Table 2: Mean total scores of Oral Health Literacy-Adults Questionnaire with its four constructs

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Table 3: Descriptive statistics of baseline sample characteristics for Oral Health Literacy-Adults Questionnaire

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[Table 4] shows that individual with less than and equal to intermediate educational qualification had odds ratio of 3.84 (CI 1.52–9.71) for inadequate score than those with postgraduate individuals. Similarly, those with ≤5 visits of dentist in life had a higher odds ratio of 3.84 (CI 2.21–6.68) for inadequate score than those with >5 visits in lifetime. Similarly, individual with less than and equal to intermediate educational qualification had odds ratio of 3.86 (CI 1.23–12.16) for marginal score than those with postgraduate individuals. Similarly, those with 4–6 months of frequent dentist visit had a higher odds ratio of 3.38 (CI 1.15–9.93) for marginal score than those with 10–12 months. [Table 5] shows inadequate literacy score was statistically significant for age, educational qualification, and number of times of visit to dentist in lifetime in the final regression model. Marginal score significant for age, educational qualification, and frequency of visit to the dentist in the final regression model.
Table 4: Parameter estimate for inadequate and marginal oral health literacy based on multiple logistic regression analysis among adult patients (n=350)

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Table 5: Parameter estimate for inadequate and marginal oral health literacy based on final multiple logistic regression analysis among adult patients (n=350)

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  Discussion Top


OHL is one of the main indicators for given determinants of the oral health status. Various studies have used different OHL tools to assess the various determinants of the OHL. The evidence suggested a lack of association of OHL with frequency of visits to the dentist.[9] This important indicator for OHL apart from other determinants was also considered in this cross-sectional study. The constructs of OHL-AQ are multidimensional and take lesser time to complete the given questionnaire which is the main advantage over the other OHL tools. Further, it helps to assess the lower as well as the higher cognitive process and functioning of OHL in qualitative research. Listening component of OHL-AQ which is at the basic level of senses and perception in the cognitive development of the individual. Reading, comprehension, and numeracy component of OHL-AQ is an integral part of linguistics in cognitive psychology. Finally, the decision-making component of OHL-AQ is considered the highest level of mental processes in cognitive psychology. Studies reported that the most of the available instruments for OHL only measures one specific psychometric dimension of OHL, i.e., word recognition or knowledge or reading or comprehension.[9] This limited use restricted the capabilities of researchers to explore the subject's OHL level as a whole and this present study is one such attempt at studying the OHL using OHL-AQ in our region.

The present study showed that low literacy level was independent of gender and the frequency of visit in a year and dependent on age, educational qualification, and total visit to dentist in lifetime. Item number 4 of OHL-AQ had the highest correct response in our study compared to item number 3 as reported by Pattanaik et al.[4] The mean total score for all the constructs of OHL-AQ was lower than Vyas et al.[10]

Less than one-fourth of the participant had an adequate level of OHL which was lower than reported by Naghibi Sistani et al.,[7],[8] Mohammadi et al.,[11] Pattanaik et al.[4] but was similar to Fazli et al.[12] The mean OHL-AQ score was lower than mean score reported in other studies Jones et al.,[13] Shin et al.[18] Baskaradoss et al.[19] but was reported higher than Fazli et al.[12] The probable reason for such finding could be due to the various sample size in the studies. The marginal OHL score (10–11) for this study was similar to Fazli et al.[12] but was lower than Naghibi Sistani et al.[7],[8] The earlier studies have focused on adequate and inadequate OHL scores, ignoring the fact that the marginal scores had a better chance of increasing their level of literacy scores compared to inadequate scores, in oral health promotion outcomes. Age was statistically significant for inadequate OHL for the age group of 18–29 years in our study. This finding could be due to low cognitive level at this age which increases with age-related OHL experience in our study. A study reported no gender difference for OHL and similar findings were reported by other studies[7],[13] but only Vyas et al.[10] found it to be significant. However, females have reported adequate level of OHL as reported in this as well as in other studies.[7],[8],[10],[11] The possible reason for such finding could be more awareness about oral health among females. Studies have reported that females brushing their tooth more, their pattern of dental visit and more usage of fluoridated toothpaste than males.[16],[17],[18] Inadequate OHL level was dependent on the educational qualification which was also reported by other studies[7],[10] in contrast to Naghibi Sistani et al.[8] reporting it to be independent. A study reported inadequate OHL in 18–29 years and with educational qualification less than intermediate. The findings clearly indicated the importance of the early introduction of oral health promotion in school programs. Further continued intervention is needed at the college level which is indicated by the marginal scores. This shift of scores from inadequate to the marginal level of oral literacy reflects that OHL is based on the cognitive development of the individual.

This study found that those with a higher education qualification and total dental visit in lifetime had adequate levels of literacy in view of life course approach towards oral health by the individual. To the best of our knowledge, this is the only study considering the frequency of dental visit and total dental visits in lifetime on OHL using OHL-AQ. The frequency of visits to dentist in a year though not statistically significant in our study was reported significant using other OHL tools.[14],[15],[19],[20] This explains that people with adequate level of literacy are able to use the information and knowledge to promote and maintain their oral health. This sufficient level of literacy helps individuals to make better informed choices in the utilization of dental health services which is translated to better oral health outcomes. Understanding the OHL is important for directing and targeting oral health promotion programs not only to inadequate score groups but also to marginal score groups leading to oral behavioral changes and right practices.

The strength of the study was first, the use of OHL-AQ, which comprehensively covers various dimensions of given construct of OHL ranging from reading and comprehension, numeracy, listening, and decision-making. Second, there was no missing data which was ensured after the completion of the questionnaire by the participants, during the data collection. Third, gender discrimination was eliminated as there was equal number of males and females even though our sampling technique in the study was nonprobability convenient/accidental sampling. Fourth, the sample size of our study was adequate for the given range of 250–500 when item response study for the OHL-AQ was done and reported by Pattanaik et al.[4] Fifth, marginal scores were well considered in the result of our present study as these scores were ignored in other studies.

The limitation of our study is nonprobability convenience sampling technique, which limits its generalizability and further studies are necessary in this regard. Our study being cross-sectional epidemiological type fails to provide necessary evidence on OHL and oral health outcome and further prospective studies with enhanced methodology are recommended. Further, the socioeconomic status of the subject was also not included in this study.


  Conclusion Top


Total dental visit in lifetime is an important indicator for better OHL in this study. The orientation of oral health promotion programs requires due importance for both the marginal and inadequate OHL. Higher OHL level leads to better oral health outcomes in the oral health promotion research. These comprehensive oral health promotion programs empower patient by overcoming all the barriers to achieve and maintain adequate oral health. Further prospective studies on OHL outcomes are the need of the hour in qualitative oral health research for necessary evidence.

Acknowledgment

I would like to extend my thanks to Madam Kusum Chopra, Statistician from Chandigarh for doing statistical analysis for this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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