The importance of health literacy in addressing health disparities has been gaining increasing recognition,20
and improving dental health literacy, especially among racial/ethnic minority groups, is an important goal.16,17
Our hypotheses that low-income and ethnic/racial minorities would experience a greater prevalence of health literacy-related problems and that patients receiving care at EDs and physician offices would experience more health literacy-related problems than patients receiving care from dentists were not generally supported. There were no differences between treatment sites in respondent reports of problems with the health literacy-related markers, nor were their differences associated with respondent income. Hispanic respondents, however, did voice more health literacy-related concerns than did white respondents.
It was expected that dental problem-related patient interactions with dentists would exhibit fewer health literacy-related difficulties than interactions involving physicians or EDs. That this was not the case may reflect the fact that respondents had higher expectations for their interactions with dentists than they did for those with physicians or EDs.21
Although other reports have found associations between problems with patient-provider communication and respondent age,22,23
we found no such association. The reason for these differences was not readily apparent. Our finding that Hispanics experienced greater difficulty with health literacy was consistent with other reports.23,24
Respondent strategies for dealing with difficulties in communication were generally constructive. The primary exception was those individuals who had difficulty understanding what they were being told and who chose to act as if there was no problem.
This study did not attempt to establish levels of health literacy nor factors that might be associated with those levels. Rather, we attempted to quantify the percentage of respondents who reported experiencing health literacy-related problems. The most unexpected finding was the relatively small percentage of respondents, 10 percent or fewer, who reported experiencing problems. This contrasts with national estimates that as many as one-third of Americans lack health literacy.2,3
Similarly, the most recent national study of health literacy found that approximately 80 million adults experience difficulties with health literacy.24,25
These two studies are consistent with a recent report that found approximately 29 percent of adult patients seeking dental care suffered low levels of oral health literacy.15
The difference in our findings and general health literacy findings may be due at least in part to the more direct and less complicated nature of patent-provider interactions surrounding dental problems.13
Dental encounters generally involve less complicated diagnoses, diagnostic procedures, treatment, and subsequent requirements for patient participation in the management of their conditions (following post-treatment directions, taking medications, dietary restrictions, etc.) than do medical encounters. In addition, differences may be due to the manner in which health literacy was assessed. For example, the study that examined oral health literacy among adult patients seeking dental care utilized a word-recognition test that required subjects to read aloud a list of words representing dental conditions, their prevention, and treatment, arranged in increasing difficulty, with points assigned for each word correctly pronounced.15
This approach has the advantage of being useful in identifying patients in advance who may experience problems in communication resulting from poor health literacy, but does not establish that they actually experienced a problem as a result of poor oral health literacy. The approach used in our study, however, was more direct, asking patients specifically about health literacy-related communication problems they actually experienced. Therefore, it is possible that respondents might have experienced a breakdown in communication of which they were not aware. That is, they may have thought they understood what was being said but in reality did not.
All cross-sectional surveys share the limitation that they ask questions about the past that depend on the respondent’s memory. This challenge was mitigated in our study because dental problems/injuries are not likely to be quickly forgotten.26
Furthermore, the time frame was limited to the most recent twelve-month period. One potential drawback to telephone surveys is the amount of noncoverage of the target population. In our case, there is a risk that a disproportionate number of low-income households will not have a listed telephone. However, the 2000 U.S. census reported that only 1.6 percent of Maryland households did not have telephone service in 1999, and only 7.9 percent of households with incomes below the Federal Poverty Level did not have telephone service.27
More recent national data from the National Health Interview Survey (January–December 2007) indicate that nationally the percentage of households with only wireless service has increased to 14.7 percent.28
Nevertheless, research has shown this not to have been a significant source of bias. For example, estimates from the 2004 and 2005 National Health Interview Survey of the use of health care services for adults with landline telephones showed relatively small differences from those for all adults.29
Differences between face-to-face surveys and telephone surveys have generally found few statistically significant differences and even fewer differences of practical significance.30
Although noncoverage bias has not resulted in discontinuing the use of general population telephone surveys in helping guide public health policy and program decisions,29
the ever-increasing use of cell phones will pose an increasing problem for public health data collection.31
Finally, although the findings are representative of Maryland residents with recent dental problems/injuries who visited an ED, physician, or dentist, they should be generalized to other populations with caution.
Doctor-patient communication plays an important role in the delivery of health care services. A recent initiative by the Agency for Healthcare Research and Quality encourages patients to become more involved with their health care by asking appropriate questions of their health care providers.32
At the same time, the Centers for Disease Control and Prevention has developed a free Health Literacy for Public Health Professionals online training program designed to educate health professionals about limited health literacy.33
Communication problems may contribute to racial or ethnic disparities evident in the delivery of health care services and concomitant disparities in health.34
In our study, only a few respondents expressed health literacy-related problems. Further, the covariates we examined that we thought might influence whether respondents experienced health literacy-related communication problems resulted in only a modest pseudo-R squared, suggesting that the variables in the model added only modestly to our understanding of the factors that influence communication difficulties associated with health literacy. There is clearly opportunity to investigate what other factors play an important role. Perhaps most importantly, future studies are needed to confirm the connection between health literacy and communication difficulties in actual patient encounters and subsequent health outcomes.