Oral health is integral to overall health and wellbeing, with poor oral health and untreated oral conditions having a deleterious impact on quality of life [1
]. Preventable and treatable oral diseases remain widespread, particularly amongst poor and underserved populations [2
Indigenous Australians identify as being of Aboriginal and/or Torres Strait Islander descent, and represented 2.5% of the total Australian population in 2006. The median age is 21 years, compared with 37 years for the non-Indigenous population [3
]. The majority of Indigenous Australians live outside major cities, with 43% living in regional and 25% in remote areas in 2006.
Indigenous Australians have poorer self-reported health and suffer a greater burden of disease than non-Indigenous Australians [3
]. Indigenous adults accessing public dental services in Australia have higher levels of periodontal disease and fewer filled teeth, but greater numbers of missing teeth than non-Indigenous patients [4
]. Indigenous children in Australia experience significantly higher levels of dental caries than their non-Indigenous counterparts [5
] with greater levels of untreated disease and less preventive therapies [7
Although recently gaining more attention, there has been little work in the field of oral health literacy or, more specifically, the impact of oral health literacy on oral health outcomes, amongst disadvantaged groups such as Indigenous Australians. Health literacy has been defined as "the degree to which individuals can obtain, process and understand the basic health information and services they need to make appropriate health decisions" [8
]. In the oral health context, literacy can be considered as the skills necessary for people to understand the causes of poor oral health, to learn and adopt fundamental aspects of positive oral self-care behaviours, to communicate with oral health care providers, to place their names on dental treatment waiting lists or organise appointments, to find their way to the dental clinic, to fill out the necessary forms and to comply with any required regimes, including follow-up appointments and compliance with prescribed medication [9
]. This definition addresses functional oral health literacy, encompassing knowledge as well as ability to use that knowledge in making appropriate oral health-related decisions. Oral health literacy, in this definition, encompasses far more than reading; it involves writing, numeracy, speaking, listening and 'understanding the system' [10
]. It is suggested that the complexity of both verbal and written oral health communications create a significant barrier to improving oral health [2
] and that oral health literacy is required in order to promote oral health and to prevent oral disease [1
]. It has also been proposed that health literacy may be associated with barriers to accessing care, oral health behaviours such as prevention and to follow-up care [11
Although the precise relationship between literacy and oral health outcomes has not been established [1
], one model that may be useful when conceptualising the interplay between oral health literacy, culture and society, the health system, the education system, and their collective role in determining oral health literacy-related outcomes and costs is outlined in Figure [12
]. As depicted in the model, literacy is hypothesized as being one of many factors that influences oral health. The first step toward discerning the role of literacy in a multidimensional model of oral health is to therefore determine if literacy skills explain oral health disparities, or if disparities still exist among those with equivalent levels of literacy. Once the relationship between literacy and oral health (independent of education and other social determinants) is assessed, other factors in the explanatory model can be incorporated to see how they interact with oral health literacy. According to the model, such determinants include economics, cultural and other social factors, education and various aspects of the health system.
Figure 1 Conceptual framework of oral health literacy and oral health literacy-related outcomes (modified from ).
Word recognition tests demonstrate a strong correlation with general reading ability and reading comprehension [13
], with evidence suggesting that if a person has difficulty pronouncing dental-related words, then that person may additionally have difficulty with comprehension; a higher order skill [14
]. In the general health realm, those with limited health literacy skills are more likely to miss important preventative measures such as mammograms, Pap smears and influenza shots [15
], and be late presenters to the health care system [16
]. Low health-literate individuals often have chronic conditions and are less able to effectively manage them, for example, low-literate people with diabetes [17
], asthma [18
] or HIV/AIDS [19
] have been shown to have less knowledge of their illness and its management than their more literate counterparts. Limited health literacy is associated with poor self-ratings of health [20
], and an increase in preventable hospital admissions, with higher rates of hospitalisation and use of emergency services being reported among those with limited literacy [21
]. Based on the Rapid Estimate of Adult Health Literacy in medicine (REALM), an instrument to measure dental health literacy (Rapid Estimate of Adult Literacy in Dentistry; REALD) was developed by Richman and colleagues [22
]. A shortened version, REALD-30, was also developed and validated, with low REALD-30 scores being associated with poor oral health-related quality of life and poor self-rated oral health [23
This study aims to contribute to an increased understanding of the impact of oral health literacy, and oral health literacy-related outcomes, on self-reported oral health among rural-dwelling Indigenous Australians. Specifically, the aims are: 1) to determine the relationship between oral health literacy, as assessed by REALD-30, and oral health literacy-related outcomes; defined in this study as oral health knowledge, oral health self-care and utilisation of dental services and; 2) to determine if oral health literacy-related outcomes are risk indicators for 7 domains of poor self-reported oral health.