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1.  Oral health literacy comparisons between Indigenous Australians and American Indians 
Community dental health  2013;30(1):52-57.
Objectives
To compare oral health literacy (OHL) levels between two profoundly disadvantaged groups, Indigenous Australians and American Indians, and to explore differences in socio-demographic, dental service utilisation, self-reported oral health indicators, and oral health-related quality of life (OHRQoL) correlates of OHL among the above.
Methods
OHL was measured using REALD-30 among convenience samples of 468 Indigenous Australians (aged 17–72 years, 63% female) and 254 female American Indians (aged 18–57 years). Covariates included socio-demography, dental utilisation, self-reported oral health status (OHS), perceived treatment needs and OHRQoL (prevalence, severity and extent of OHIP-14 ‘impacts’). Descriptive and bivariate methods were used for data presentation and analysis, and between-sample comparisons relied upon empirical contrasts of sample-specific estimates and correlation coefficients.
Results
OHL scores were: Indigenous Australians - 15.0 (95% CL=14.2, 15.8) and American Indians - 13.7 (95% CL=13.1, 14.4). In both populations, OHL strongly correlated with educational attainment, and was lower among participants with infrequent dental attendance and perceived restorative treatment needs. A significant inverse association between OHL and prevalence of OHRQoL impacts was found among American Indians (rho=−0.23; 95% CL=−0.34, −0.12) but not among Indigenous Australians.
Conclusions
Our findings indicate that OHL levels were comparable between the two groups and lower compared to previously reported estimates among diverse populations. Although the patterns of association of OHL with most examined domains of correlates were similar between the two groups, this study found evidence of heterogeneity in the domains of self-reported OHS and OHRQoL.
PMCID: PMC3709981  PMID: 23550508
oral health literacy; oral health; Indigenous populations; Australian Indigenous; Native American; American Indian; quality of life
2.  The relationship of oral health literacy with oral health-related quality of life in a multi-racial sample of low-income female caregivers 
Background
To investigate the association between oral health literacy (OHL) and oral health-related quality of life (OHRQoL) and explore the racial differences therein among a low-income community-based group of female WIC participants.
Methods
Participants (N = 1,405) enrolled in the Carolina Oral Health Literacy (COHL) study completed the short form of the Oral Health Impact Profile Index (OHIP-14, a measure of OHRQoL) and REALD-30 (a word recognition literacy test). Socio-demographic and self-reported dental attendance data were collected via structured interviews. Severity (cumulative OHIP-14 score) and extent of impact (number of items reported fairly/very often) scores were calculated as measures of OHRQoL. OHL was assessed by the cumulative REALD-30 score. The association of OHL with OHRQoL was examined using descriptive and visual methods, and was quantified using Spearman's rho and zero-inflated negative binomial modeling.
Results
The study group included a substantial number of African Americans (AA = 41%) and American Indians (AI = 20%). The sample majority had a high school education or less and a mean age of 26.6 years. One-third of the participants reported at least one oral health impact. The OHIP-14 mean severity and extent scores were 10.6 [95% confidence limits (CL) = 10.0, 11.2] and 1.35 (95% CL = 1.21, 1.50), respectively. OHL scores were distributed normally with mean (standard deviation, SD) REALD-30 of 15.8 (5.3). OHL was weakly associated with OHRQoL: prevalence rho = -0.14 (95% CL = -0.20, -0.08); extent rho = -0.14 (95% CL = -0.19, -0.09); severity rho = -0.10 (95% CL = -0.16, -0.05). "Low" OHL (defined as < 13 REALD-30 score) was associated with worse OHRQoL, with increases in the prevalence of OHIP-14 impacts ranging from 11% for severity to 34% for extent. The inverse association of OHL with OHIP-14 impacts persisted in multivariate analysis: Problem Rate Ratio (PRR) = 0.91 (95% CL = 0.86, 0.98) for one SD change in OHL. Stratification by race revealed effect-measure modification: Whites--PRR = 1.01 (95% CL = 0.91, 1.11); AA--PRR = 0.86 (95% CL = 0.77, 0.96).
Conclusions
Although the inverse association between OHL and OHRQoL across the entire sample was weak, subjects in the "low" OHL group reported significantly more OHRQoL impacts versus those with higher literacy. Our findings indicate that the association between OHL and OHRQoL may be modified by race.
doi:10.1186/1477-7525-9-108
PMCID: PMC3248838  PMID: 22132898
oral health literacy; oral health-related quality of life; OHIP-14; racial differences; effect measure modification
3.  Caregivers’ oral health literacy and their young children's oral health-related quality of life 
Acta odontologica Scandinavica  2011;70(5):390-397.
Objectives
To investigate the association of caregivers’ oral health literacy (OHL) with their children's oral health related-quality of life (C-OHRQoL) and explore literacy as a modifier in the association between children's oral health status (COHS) and C-OHRQoL.
Methods
We relied upon data from structured interviews with 203 caregivers of children ages 3-5 from the Carolina Oral Health Literacy (COHL) Project. Data were collected for OHL using REALD-30, caregiver-reported COHS using the NHANES-item, and COHRQoL using the Early Childhood Oral Health Impact Scale (ECOHIS). We also measured oral health behaviors (OHBs) and socio-demographic characteristics and calculated overall/stratified summary estimates for OHL and C-OHRQoL. We computed Spearman's rho and 95% confidence limits (CL) as measures of correlation of OHL/COHS with C-OHRQoL. To determine whether OHL modified the association between COHS and C-OHRQoL, we compared literacy-specific summary and regression estimates.
Results
Reported COHS was: excellent—50%, very good—28%, good—14%, fair—6%, poor—2%. The aggregate C-OHRQoL mean score was 2.0 (95% CL:1.4, 2.6), and the mean OHL score 15.9 (95% CL:15.2, 16.7). There was an inverse relationship between COHS and C-OHRQoL: rho=-0.32 (95% CL:-0.45, -0.18). There was no important association between OHL and C-OHRQoL; however, deleterious OHBs were associated with worse C-OHRQoL. Literacy-specific linear and Poisson regression estimates of the association between COHS and C-OHRQoL departed from homogeneity (Wald X2 P<0.2).
Conclusion
In this community-based sample of caregiver/child dyads, we found a strong correlation between OHS and C-OHRQoL. The association's magnitude and gradient were less pronounced among caregivers with low literacy.
doi:10.3109/00016357.2011.629627
PMCID: PMC3305855  PMID: 22150574
Oral Health Literacy; Oral Health-related Quality of Life; Children; Early Childhood; Subjective Oral Health; REALD-30
4.  The Relationship of Oral Health Literacy and Self-Efficacy with Oral Health Status and Dental Neglect 
American Journal of Public Health  2011;102(5):923-929.
Objectives
We examined the associations of oral health literacy (OHL) with oral health status (OHS) and dental neglect (DN), and explored whether self-efficacy (SE) mediated or modified these associations, among a sample of female clients of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC).
Methods
We used interview data that were collected from 1280 female WIC clients as part of the Carolina Oral Health Literacy (COHL) Project between 2007 and 2009. OHL was measured with a validated word recognition test (REALD-30) and oral health status with the self-reported NHANES item. Analyses relied upon descriptive, bivariate, and multivariate methods.
Results
Less than one-third of participants rated their oral health as very good or excellent. Higher OHL was associated with better oral health status (multivariate PR=1.29; 95% CL=1.08, 1.54, for 10-unit REALD increase). OHL was not correlated with DN but SE showed a strong negative correlation with DN. SE remained significantly associated with DN in a fully-adjusted model that included OHL.
Conclusions
Increased OHL was associated with better OHS but not DN. Self-efficacy was a strong correlate of DN and may mediate the effects of literacy on oral health status.
doi:10.2105/AJPH.2011.300291
PMCID: PMC3267012  PMID: 22021320
5.  An oral health literacy intervention for Indigenous adults in a rural setting in Australia 
BMC Public Health  2012;12:461.
Background
Indigenous Australians suffer substantially poorer oral health than their non-Indigenous counterparts and new approaches are needed to address these disparities. Previous work in Port Augusta, South Australia, a regional town with a large Indigenous community, revealed associations between low oral health literacy scores and self-reported oral health outcomes. This study aims to determine if implementation of a functional, context-specific oral health literacy intervention improves oral health literacy-related outcomes measured by use of dental services, and assessment of oral health knowledge, oral health self-care and oral health- related self-efficacy.
Methods/design
This is a randomised controlled trial (RCT) that utilises a delayed intervention design. Participants are Indigenous adults, aged 18 years and older, who plan to reside in Port Augusta or a nearby community for the next two years. The intervention group will receive the intervention from the outset of the study while the control group will be offered the intervention 12 months following their enrolment in the study. The intervention consists of a series of five culturally sensitive, oral health education workshops delivered over a 12 month period by Indigenous project officers. Workshops consist of presentations, hands-on activities, interactive displays, group discussions and role plays. The themes addressed in the workshops are underpinned by oral health literacy concepts, and incorporate oral health-related self-efficacy, oral health-related fatalism, oral health knowledge, access to dental care and rights and entitlements as a patient. Data will be collected through a self-report questionnaire at baseline, at 12 months and at 24 months. The primary outcome measure is oral health literacy. Secondary outcome measures include oral health knowledge, oral health self-care, use of dental services, oral health-related self-efficacy and oral health-related fatalism.
Discussion
This study uses a functional, context-specific oral health literacy intervention to improve oral health literacy-related outcomes amongst rural-dwelling Indigenous adults. Outcomes of this study will have implications for policy and planning by providing evidence for the effectiveness of such interventions as well as provide a model for working with Indigenous communities.
doi:10.1186/1471-2458-12-461
PMCID: PMC3416720  PMID: 22716205
6.  Impact of Caregiver Literacy on Children's Oral Health Outcomes 
Pediatrics  2010;126(1):107-114.
Objective
To examine the relationship of primary caregivers’ literacy with children's oral health outcomes.
Design
We performed a cross-sectional study of children ages six and younger who presented for an initial dental appointment in the teaching clinics at the University of North Carolina at Chapel Hill School of Dentistry. Caregiver literacy was measured using the Rapid Estimate of Adult Literacy in Dentistry (REALD-30). The outcome measures included oral health knowledge, oral health behaviors, primary caregiver's reports of their child's oral health status, and the clinical oral health status of the child as determined by a clinical exam completed by trained, calibrated examiners.
Results
Among the 106 caregiver/child dyads enrolled, 59% of the children were male, 52% were white, and 86% caregivers were the biological mothers. The bivariate results showed no significant relationships between literacy and oral health knowledge (p=0.16) and behaviors (p=0.24); however, there was an association between literacy and oral health status (p<0.05). The multivariate analysis controlled for race, and income; this analysis revealed a significant relationship between caregiver literacy scores and clinical oral health status as determined using a standardized clinical exam. Caregivers of children with mild to moderate treatment needs were more likely to have higher REALD-30 scores than those with severe treatment needs (OR=1.14; 95%CI 1.05:1.25, p=0.003).
Conclusions
Caregiver literacy is significantly associated with children's dental disease status.
doi:10.1542/peds.2009-2887
PMCID: PMC2896459  PMID: 20547644
oral health; health literacy; child health outcomes
7.  Caregivers’ Health Literacy and Their Young Children’s Oral-health–related Expenditures 
Journal of Dental Research  2013;92(7 Suppl):S55-S62.
Caregivers’ health literacy has emerged as an important determinant of young children’s health care and outcomes. We examined the hypothesis that caregivers’ health literacy influences children’s oral-health-care–related expenditures. This was a prospective cohort study of 1,132 child/caregiver dyads (children’s mean age = 19 months), participating in the Carolina Oral Health Literacy Project. Health literacy was measured by the REALD-30 (word recognition based) and NVS (comprehension based) instruments. Follow-up data included child Medicaid claims for CY2008-10. We quantified expenditures using annualized 2010 fee-adjusted Medicaid-paid dollars for oral-health–related visits involving preventive, restorative, and emergency care. We used descriptive, bivariate, and multivariate statistical methods based on generalized gamma models. Mean oral-health–related annual expenditures totaled $203: preventive—$81, restorative—$99, and emergency care—$22. Among children who received services, mean expenditures were: emergency hospital-based—$1282, preventive—$106, and restorative care—$343. Caregivers’ low literacy in the oral health context was associated with a statistically non-significant increase in total expenditures (average annual difference = $40; 95% confidence interval, -32, 111). Nevertheless, with both instruments, emergency dental care expenditures were consistently elevated among children of low-literacy caregivers. These findings provide initial support for health literacy as an important determinant of the meaningful use and cost of oral health care.
doi:10.1177/0022034513484335
PMCID: PMC3706176  PMID: 23690350
cohort studies; dental care; health expenditures; health services; Medicaid; WIC
8.  Oral Health Literacy among Female Caregivers: Impact on the Oral Health Outcomes in Early Childhood 
Journal of dental research  2010;89(12):1395-1400.
The aim of this study was to investigate the association of female caregivers’ oral health literacy with their knowledge, behaviors, and the reported oral health status of their young children. Data on caregivers’ literacy, knowledge, behaviors, and children’s oral health status were used from structured interviews with 1,158 caregiver/child dyads from a low-income population. Literacy was measured using REALD-30. Caregivers’ and children’s median age were 25 years (range=17–65) and 15 months (range=1–59), respectively. The mean literacy score was 15.8 (SD=5.3; range=1–30). Adjusting for age, education, and number of children, low literacy scores (<13 REALD-30) were associated with decreased knowledge (OR=1.86; 95% CI=1.41, 2.45) and poorer reported oral health status (OR=1.44; 95% CI=1.02, 2.05). Lower caregiver literacy was associated with deleterious oral health behaviors including no daily brushing/cleaning and nighttime bottle use. Caregiver oral health literacy has a multidimensional impact on reported oral health outcomes in infants and young children.
doi:10.1177/0022034510379601
PMCID: PMC3123718  PMID: 20924067
oral health literacy; infant oral health; early childhood caries; oral health knowledge; oral health outcomes in young children
9.  Oral Health Literacy among Female Caregivers 
Journal of Dental Research  2010;89(12):1395-1400.
The aim of this study was to investigate the association of female caregivers’ oral health literacy with their knowledge, behaviors, and the reported oral health status of their young children. Data on caregivers’ literacy, knowledge, behaviors, and children’s oral health status were used from structured interviews with 1158 caregiver/child dyads from a low-income population. Literacy was measured with REALD-30. Caregivers’ and children’s median ages were 25 yrs (range = 17-65) and 15 mos (range = 1-59), respectively. The mean literacy score was 15.8 (SD = 5.3; range = 1-30). Adjusted for age, education, and number of children, low literacy scores (< 13 REALD-30) were associated with decreased knowledge (OR = 1.86; 95% CI = 1.41, 2.45) and poorer reported oral health status (OR = 1.44; 95% CI = 1.02, 2.05). Lower caregiver literacy was associated with deleterious oral health behaviors, including nighttime bottle use and no daily brushing/cleaning. Caregiver oral health literacy has a multidimensional impact on reported oral health outcomes in infants and young children.
doi:10.1177/0022034510379601
PMCID: PMC3123718  PMID: 20924067
oral health literacy; infant oral health; early childhood caries; oral health knowledge; oral health outcomes in young children
10.  Determinants of Oral Health: Does Oral Health Literacy Matter? 
ISRN Dentistry  2013;2013:249591.
Objective. To evaluate oral health literacy, independent of other oral health determinants, as a risk indicator for self-reported oral health. Methods. A cross-sectional population-based survey conducted in Tehran, Iran. Multiple logistic regression analysis served to estimate the predictive effect of oral health literacy on self-reported oral health status (good versus poor) controlling for socioeconomic and demographic factors and tooth-brushing behavior. Results. In all, among 1031 participants (mean age 36.3 (SD 12.9); 51% female), women reported brushing their teeth more frequently (P < 0.001) and scored higher for oral health literacy (mean 10.9 versus 10.2, P < 0.001). In the adjusted model, high age (OR = 1.01, 95% CI 1.003–1.034), low education (OR = 1.88, 95% CI 1.23–2.87), small living area in square meters per person (OR = 1.85, 95% CI 1.003–3.423), poor tooth brushing behavior (OR = 3.35, 95% CI 2.02–5.57), and low oral health literacy scores (OR = 1.58, 95% CI 1.02–2.45) were significant risk indicators for poor self-reported oral health. Conclusions. Low oral health literacy level, independent of education and other socioeconomic determinants, was a predictor for poor self-reported oral health and should be considered a vital determinant of oral health in countries with developing health care systems.
doi:10.1155/2013/249591
PMCID: PMC3610341  PMID: 23577262
11.  Development of the Two Stage Rapid Estimate of Adult Literacy in Dentistry (TS-REALD) 
This work proposes a revision of the 30 item Rapid Estimate of Adult Literacy in Dentistry (REALD-30), into a more efficient and easier-to-use two-stage scale. Using a sample of 1,405 individuals (primarily women) enrolled in a Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), the present work utilizes principles of item response theory and multi-stage testing to revise the REALD-30 into a two-stage test of oral health literacy, named Two-Stage REALD or TS-REALD, which maximizes score precision at various levels of participant ability. Based on the participant’s score on the 5-item first-stage (i.e., routing test), one of three potential stage-two tests is administered: a 4-item Low Literacy test, a 6-item Average Literacy test, or a 3-item High Literacy test. The reliability of scores for the TS-REALD is greater than .85 for a wide range of ability. The TS-REALD was found to be predictive of perceived impact of oral conditions on well-being, after controlling for educational level, overall health, dental health, and a general health literacy measure. While containing approximately one-third of the items on the original scale, the TS-REALD was found to maintain similar psychometric qualities.
doi:10.1111/j.1600-0528.2011.00619.x
PMCID: PMC3165105  PMID: 21592170
Dental Health Literacy; Dental Care; Oral Health Quality of Life; Health Literacy; Psychometrics
12.  Oral Health Literacy Levels among a Low-income WIC Population 
Objectives
To determine oral health literacy (OHL) levels and explore potential racial differences in a low-income population.
Methods
This was a cross-sectional study of caregiver/child dyads who completed a structured 30-minute, in-person interview conducted by two trained interviewers in seven counties in North Carolina. Socio-demographic, OHL, and dental health related data were collected. OHL was measured with a dental word recognition test (REALD-30). Descriptive, bivariate and multivariate methods were used to examine the distribution of OHL and explore racial differences.
Results
Of 1,658 eligible subjects, 1,405 (85%) participated and completed the interviews. The analytic sample (N=1,280) had mean age 26.5 (SD=6.9) years with 60% having a high school degree or less. OHL varied between racial groups as follows: Whites—mean score=17.4 (SE=0.2); African American (AA)—mean score=15.3 (SE=0.2); American Indian (AI)—mean score=13.7 (SE=0.3). Multiple linear regression revealed that after controlling for education, county of residence, age and Hispanic ethnicity, Whites had 2.0 points (95%CI=1.4, 2.6) higher adjusted REALD-30 score versus AA and AI.
Conclusions
Differences in OHL levels between racial groups persisted after adjusting for education and socio-demographic characteristics.
PMCID: PMC3145966  PMID: 21774139
oral health literacy; WIC; racial differences
13.  A cross sectional study examining social desirability bias in caregiver reporting of children’s oral health behaviors 
BMC Oral Health  2013;13:24.
Background
Our previous research (Pediatrics 2010:126) found a strong association between caregiver oral health literacy (OHL) and children’s oral health status; however, we found a weak association with oral health behaviors (OHBs). We hypothesize that this may be due to social desirability bias (SDB). Our objectives were to compare caregivers’ responses to traditional OHB items and newer SDB-modulating items, and to examine the association of caregiver literacy with OHBs.
Methods
We performed a cross-sectional study of 102 caregiver-child dyads, collecting data for OHBs using both traditional and new SDB-modulating items. We measured OHL using REALD-30, a validated word recognition test. We relied upon percent agreement and Cohen’s kappa (k) to quantify the concordance in caregivers’ responses and multivariate log-binomial regression to estimate the impact of OHL on OHBs.
Results
Caregivers’ mean REALD-30 score was 20.7 (SD = 6.0), range 1-30. We found an association between OHL and 4 of 8 OHBs examined. A subset of behavior questions compared traditional versus SDB-modulating items: history of bottle-feeding: agreement = 95%, k = 0.83 (95% CL:0.68,0.99); daily tooth brushing: agreement = 78%, k = 0.25 (95% CL:0.04,0.46); fluoridated toothpaste use: agreement = 88%, k = 0.67 (95% CL:0.49,0.85). After controlling for caregivers’ race, marital status and study site, higher literacy scores remained associated with a decreased prevalence of parental report of “decided not brush the child’s teeth because it would be frustrating”.
Conclusions
Agreement between responses was high for 2 of 3 behavior items. Item 3 (tooth brushing frequency) revealed discordance, likely due to SDB. Use of the SDB-modulating items appears to yield a better estimate of OHB.
doi:10.1186/1472-6831-13-24
PMCID: PMC3680187  PMID: 23725221
Caregivers children; Oral health; Oral hygiene; Health literacy; Oral health literacy; Oral health behaviors; REALD-30; Social desirability bias
14.  Lower Health Literacy is Associated with Poorer Health Status and Outcomes in Chronic Obstructive Pulmonary Disease 
ABSTRACT
BACKGROUND
Limited health literacy is associated with poor outcomes in many chronic diseases, but little is known about health literacy in chronic obstructive pulmonary disease (COPD).
OBJECTIVE
To examine the associations between health literacy and both outcomes and health status in COPD.
PARTICIPANTS, DESIGN AND MAIN MEASURES
Structured interviews were administered to 277 subjects with self-report of physician-diagnosed COPD, recruited through US random-digit telephone dialing. Health literacy was measured with a validated three-item battery. Multivariable linear regression, controlling for sociodemographics including income and education, determined the cross-sectional associations between health literacy and COPD-related health status: COPD Severity Score, COPD Helplessness Index, and Airways Questionnaire-20R [measuring respiratory-specific health-related quality of life (HRQoL)]. Multivariable logistic regression estimated associations between health literacy and COPD-related hospitalizations and emergency department (ED) visits.
KEY RESULTS
Taking socioeconomic status into account, poorer health literacy (lowest tertile compared to highest tertile) was associated with: worse COPD severity (+2.3 points; 95 % CI 0.3–4.4); greater COPD helplessness (+3.7 points; 95 % CI 1.6–5.8); and worse respiratory-specific HRQoL (+3.5 points; 95 % CI 1.8–4.9). Poorer health literacy, also controlling for the same covariates, was associated with higher likelihood of COPD-related hospitalizations (OR = 6.6; 95 % CI 1.3–33) and COPD-related ED visits (OR = 4.7; 95 % CI 1.5–15). Analyses for trend across health literacy tertiles were statistically significant (p < 0.05) for all above outcomes.
CONCLUSIONS
Independent of socioeconomic status, poor health literacy is associated with greater COPD severity, greater COPD helplessness, worse respiratory-specific HRQoL, and higher odds of COPD-related emergency health-care utilization. These results underscore that COPD patients with poor health literacy may be at particular risk for poor health-related outcomes.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2177-3) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-012-2177-3
PMCID: PMC3539035  PMID: 22890622
chronic obstructive pulmonary disease; health literacy; health status; health outcomes; utilization
15.  Health Literacy and the Patient With Heart Failure—Implications for Patient Care and Research: A Consensus Statement of the Heart Failure Society of America 
Journal of cardiac failure  2009;16(1):9-16.
Background
Low health literacy compromises patient safety, quality health care, and desired health outcomes. Specifically, low health literacy is associated with decreased knowledge of one’s medical condition, poor medication recall, nonadherence to treatment plans, poor self-care behaviors, compromised physical and mental health, greater risk of hospitalization, and increased mortality.
Methods
The health literacy literature was reviewed for: definitions, scope, risk factors, assessment, impact on health outcomes (cardiovascular disease and heart failure), and interventions. Implications for future research and for clinical practice to address health literacy in heart failure patients were summarized.
Results
General health literacy principles should be applied to patients with heart failure, similar to others with chronic conditions. Clinicians treating patients with heart failure should address health literacy using five steps: recognize the consequences of low health literacy, screen patients at risk, document literacy levels and learning preferences, and integrate effective strategies to enhance patients’ understanding into practice.
Conclusion
Although the literature specifically addressing low health literacy in patients with heart failure is limited, it is consistent with the larger body of health literacy evidence. Timely recognition of low health literacy combined with tailored interventions should be integrated into clinical practice.
doi:10.1016/j.cardfail.2009.10.026
PMCID: PMC2909843  PMID: 20123313
Heart failure; health literacy; communication; self-care
16.  Functional health literacy and health‐promoting behaviour in a national sample of British adults 
Objectives
To measure the prevalence of limited functional health literacy in the UK, and examine associations with health behaviours and self‐rated health.
Design
Psychometric testing using a British version of the Test of Functional Health Literacy in Adults (TOFHLA) in a population sample of adults.
Setting
UK‐wide interview survey (excluding Northern Ireland and the Scottish Isles).
Participants
759 adults (439 women, 320 men) aged 18–90 years (mean age = 47.6 years) selected using random location sampling.
Main outcome measures
Functional health literacy, self‐rated health, fruit and vegetable consumption, physical exercise and smoking.
Results
We found that 11.4% of participants had either marginal or inadequate health literacy. Multivariable logistic regression analysis indicated that the risk of having limitations in health literacy increased with age (adjusted odds ratio 1.04; 95% confidence interval 1.02 to 1.06), being male (odds ratio = 2.04; 95% confidence interval 1.16 to 3.55), low educational attainment (odds ratio = 7.46; 95% confidence interval 3.35 to 16.58) and low income (odds ratio = 5.94; 95% confidence interval 1.87 to 18.89). In a second multivariable logistic regression analysis, every point higher on the health literacy scale increased the likelihood of eating at least five portions of fruit and vegetables a day (odds ratio = 1.02; 95% confidence interval 1.003 to 1.03), being a non‐smoker (odds ratio = 1.02; 95% confidence interval 1.0003 to 1.03) and having good self‐rated health (odds ratio = 1.02; 95% confidence interval 1.01 to 1.04), independently of age, education, gender, ethnicity and income.
Conclusions
The results encourage efforts to monitor health literacy in the British population and examine associations with engagement with preventative health behaviours.
doi:10.1136/jech.2006.053967
PMCID: PMC2465677  PMID: 18000132
health literacy; health communication; health behaviour; self‐rated health
17.  Beyond Reading Alone: The Relationship Between Aural Literacy And Asthma Management 
Patient education and counseling  2010;82(1):110-116.
Objectives
To examine the relationship between literacy and asthma management with a focus on the oral exchange.
Methods
Study participants, all of whom reported asthma, were drawn from the New England Family Study (NEFS), an examination of links between education and health. NEFS data included reading, oral (speaking), and aural (listening) literacy measures. An additional survey was conducted with this group of study participants related to asthma issues, particularly asthma management. Data analysis focused on bivariate and multivariable logistic regression.
Results
In bivariate logistic regression models exploring aural literacy, there was a statistically significant association between those participants with lower aural literacy skills and less successful asthma management (OR:4.37, 95%CI:1.11, 17.32). In multivariable logistic regression analyses, controlling for gender, income, and race in separate models (one-at-a-time), there remained a statistically significant association between those participants with lower aural literacy skills and less successful asthma management.
Conclusion
Lower aural literacy skills seem to complicate asthma management capabilities.
Practice Implications
Greater attention to the oral exchange, in particular the listening skills highlighted by aural literacy, as well as other related literacy skills may help us develop strategies for clear communication related to asthma management.
doi:10.1016/j.pec.2010.02.023
PMCID: PMC2944911  PMID: 20399060
literacy; aural literacy; asthma; asthma management; health communications; provider-patient communication; oral exchange
18.  The Association between Health Literacy and HIV Treatment Adherence: Further Evidence from Objectively Measured Medication Adherence 
Background
People with lower health literacy are vulnerable to health problems. Studies that have examined the association between literacy and medication adherence have relied on self-reported adherence, which is subject to memory errors, perhaps even more so in people with poor literacy.
Purpose
To examine the association between health literacy and objectively assessed HIV treatment adherence.
Methods
Men and women (N = 145) receiving antiretroviral therapies completed a test of health literacy and measures of common adherence markers. Medication adherence was monitored by unannounced pill counts.
Results
Median adherence was 71%; Participants with lower health literacy also demonstrated poorer adherence compared to individuals with higher literacy. Hierarchical regression showed literacy predicted adherence over and above all other factors. Sensitivity tests showed the same results for 80% and 90% adherence.
Conclusions
The association between literacy and adherence appears robust and was confirmed using an objective measure of medication adherence.
doi:10.1177/1545109708328130
PMCID: PMC3015090  PMID: 19056866
19.  How the stigma of low literacy can impair patient-professional spoken interactions and affect health: insights from a qualitative investigation 
Background
Low literacy is a significant problem across the developed world. A considerable body of research has reported associations between low literacy and less appropriate access to healthcare services, lower likelihood of self-managing health conditions well, and poorer health outcomes. There is a need to explore the previously neglected perspectives of people with low literacy to help explain how low literacy can lead to poor health, and to consider how to improve the ability of health services to meet their needs.
Methods
Two stage qualitative study. In-depth individual interviews followed by focus groups to confirm analysis and develop suggestions for service improvements. A purposive sample of 29 adults with English as their first language who had sought help with literacy was recruited from an Adult Learning Centre in the UK.
Results
Over and above the well-documented difficulties that people with low literacy can have with the written information and complex explanations and instructions they encounter as they use health services, the stigma of low literacy had significant negative implications for participants’ spoken interactions with healthcare professionals.
Participants described various difficulties in consultations, some of which had impacted negatively on their broader healthcare experiences and abilities to self-manage health conditions. Some communication difficulties were apparently perpetuated or exacerbated because participants limited their conversational engagement and used a variety of strategies to cover up their low literacy that could send misleading signals to health professionals.
Participants’ biographical narratives revealed that the ways in which they managed their low literacy in healthcare settings, as in other social contexts, stemmed from highly negative experiences with literacy-related stigma, usually from their schooldays onwards. They also suggest that literacy-related stigma can significantly undermine mental wellbeing by prompting self-exclusion from social participation and generating a persistent anxiety about revealing literacy difficulties.
Conclusion
Low-literacy-related stigma can seriously impair people’s spoken interactions with health professionals and their potential to benefit from health services. As policies increasingly emphasise the need for patients’ participation, services need to simplify the literacy requirements of service use and health professionals need to offer non-judgemental (universal) literacy-sensitive support to promote positive healthcare experiences and outcomes.
doi:10.1186/1472-6963-13-319
PMCID: PMC3751726  PMID: 23958036
Low literacy; Patient-provider communication; Patient-provider relationships; Person-centred care; Qualitative
20.  A Case Report of Tooth Wear Associated with a Patient's Inappropriate Efforts to Reduce Oral Malodor Caused by Endodontic Lesion 
Here, we report a case of severe tooth wear associated with a patient's inappropriate efforts to reduce oral malodor. A 72-year-old male patient visited our breath clinic complaining of strong breath odor. Former dentists had performed periodontal treatments including scaling and root planing, but his oral malodor did not decrease. His own subsequent breath odor-reducing efforts included daily use of lemons and vinegar to reduce or mask the odor, eating and chewing hard foods to clean his teeth, and extensive tooth brushing with a hard-bristled toothbrush. Oral malodor was detected in our breath clinic by several tests, including an organoleptic test, portable sulphide monitor, and gas chromatography. Although patient's oral hygiene and periodontal condition were not poor on presentation, his teeth showed heavy wear and hypersensitiving with an unfitted restoration on tooth 16. Radiographic examination of the tooth did not reveal endodontic lesion, but when the metal crown was removed, severe pus discharge and strong malodor were observed. When this was treated, his breath odor was improved. After dental treatment and oral hygiene instruction, no further tooth wear was observed; he was not concerned about breath odor thereafter.
doi:10.1155/2009/727481
PMCID: PMC2836914  PMID: 20339568
21.  A Randomized Controlled Trial of a Literacy-Sensitive Self-Management Intervention for Chronic Obstructive Pulmonary Disease Patients 
Background
Low literacy skills are common and associated with a variety of poor health outcomes. This may be particularly important in patients with chronic illnesses such as chronic obstructive pulmonary disease (COPD) that require appropriate inhaler technique to maintain quality of life and avoid exacerbations.
Objective
To explore the impact of a literacy-sensitive self-management intervention on inhaler technique scores in COPD patients and to determine if effects differ by literacy.
Design
Randomized controlled trial.
Participants
Ninety-nine patients with COPD.
Intervention
Patients were randomly assigned to a one-on-one self-management educational intervention or usual care. The intervention focused on inhaler technique, smoking cessation, and using a COPD action plan.
Main Measures
At baseline, an inhaler technique assessment, literacy assessment, health-related quality of life questionnaires, and pulmonary function tests were completed. Inhaler technique was re-evaluated after two to eight weeks.
Key Results
Mean age 63, 65% female, 69% Caucasian, moderate COPD severity on average, 36% with low literacy, moderately impaired health-related quality of life, and similar baseline metered dose inhaler technique scores. Patients in the intervention group had greater mean improvement from baseline in metered dose inhaler technique score compared to those in the usual care group (difference in mean change 2.1, 95% CI 1.1, 3.0). The patients in the intervention group also had greater mean improvements in metered dose inhaler technique score than those in the usual care group whether they had low health literacy (difference in mean change 2.8, 95% CI 0.6, 4.9) or higher health literacy (1.8, 95% CI 0.7, 2.9).
Conclusions
A literacy-sensitive self-management intervention can lead to improvements in inhaler technique, with benefits for patients with both low and higher health literacy.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-011-1867-6) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-011-1867-6
PMCID: PMC3270237  PMID: 21935752
COPD; inhaler technique; health literacy; self-management; randomized controlled trial
22.  Measuring health literacy in populations: illuminating the design and development process of the European Health Literacy Survey Questionnaire (HLS-EU-Q) 
BMC Public Health  2013;13:948.
Background
Several measurement tools have been developed to measure health literacy. The tools vary in their approach and design, but few have focused on comprehensive health literacy in populations. This paper describes the design and development of the European Health Literacy Survey Questionnaire (HLS-EU-Q), an innovative, comprehensive tool to measure health literacy in populations.
Methods
Based on a conceptual model and definition, the process involved item development, pre-testing, field-testing, external consultation, plain language check, and translation from English to Bulgarian, Dutch, German, Greek, Polish, and Spanish.
Results
The development process resulted in the HLS-EU-Q, which entailed two sections, a core health literacy section and a section on determinants and outcomes associated to health literacy. The health literacy section included 47 items addressing self-reported difficulties in accessing, understanding, appraising and applying information in tasks concerning decisions making in healthcare, disease prevention, and health promotion. The second section included items related to, health behaviour, health status, health service use, community participation, socio-demographic and socio-economic factors.
Conclusions
By illuminating the detailed steps in the design and development process of the HLS-EU-Q, it is the aim to provide a deeper understanding of its purpose, its capability and its limitations for others using the tool. By stimulating a wide application it is the vision that HLS-EU-Q will be validated in more countries to enhance the understanding of health literacy in different populations.
doi:10.1186/1471-2458-13-948
PMCID: PMC4016258  PMID: 24112855
Health literacy; Survey; Measurement; Tool; Population
23.  Health Literacy, Diabetes Self-Care, and Glycemic Control in Adults with Type 2 Diabetes 
Diabetes Technology & Therapeutics  2010;12(11):913-919.
Abstract
Background
Although limited health literacy is a barrier to disease management and has been associated with poor glycemic control, the mechanisms underlying the relationships between health literacy and diabetes outcomes are unknown. We examined the relationships between health literacy, determinants of diabetes self-care, and glycemic control in adults with type 2 diabetes.
Methods
Patients with diabetes were recruited from an outpatient primary care clinic. We collected information on demographics, health literacy, diabetes knowledge, diabetes fatalism, social support, and diabetes self-care, and hemoglobin A1c values were extracted from the medical record. Structural equation models tested the predicted pathways linking health literacy to diabetes self-care and glycemic control.
Results
No direct relationship was observed between health literacy and diabetes self-care or glycemic control. Health literacy had a direct effect on social support (r = −0.20, P < 0.05) and through social support had an indirect effect on diabetes self-care (r = −0.07) and on glycemic control (r = −0.01). More diabetes knowledge (r = 0.22, P < 0.05), less fatalism (r = −0.22, P < 0.05), and more social support (r = 0.27, P < 0.01) were independent, direct predictors of diabetes self-care and through self-care were related to glycemic control (r = −0.20, P < 0.05).
Conclusions
Our findings suggest health literacy has an indirect effect on diabetes self-care and glycemic control through its association with social support. This suggests that for patients with limited health literacy, enhancing social support would facilitate diabetes self-care and improved glycemic control.
doi:10.1089/dia.2010.0058
PMCID: PMC3000637  PMID: 20879964
24.  Integrating Health Literacy and ESL: An Interdisciplinary Curriculum for Hispanic Immigrants 
Health promotion practice  2012;14(2):263-273.
Adult Hispanic immigrants are at a greater risk of experiencing the negative outcomes related to low health literacy, as they confront cultural and language barriers to the complex and predominately monolingual English-based U.S. health system. One approach that has the potential for simultaneously addressing the health, literacy, and language needs of Hispanics is the combination of health literacy and English as a second language (ESL) instruction. The purpose of the project was to evaluate the feasibility of using ESL instruction as a medium for improving health literacy among Hispanic immigrants. Objectives included the development, implementation, and evaluation of an interdisciplinary health literacy/ESL curriculum that integrates theories of health literacy and health behavior research and practice, sociocultural theories of literacy and communication, and adult learning principles. This article describes the curriculum development process and provides preliminary qualitative data on learners’ experiences with the curriculum. Results indicate that the curriculum was attractive to participants and that they were highly satisfied with both the format and content. The curriculum described here represents one example of an audience-centered approach designed to meet the specific health and literacy needs of the Hispanic population on the U.S.–Mexico border. The combination of ESL and health literacy contributed to a perceived positive learning experience among participants. Interdisciplinary approaches to health literacy are recommended.
doi:10.1177/1524839912452736
PMCID: PMC3587681  PMID: 22982707
health literacy; Latino; minority health; theory; university/college health
25.  Prevalence of Self-Perceived Oral Malodor in a Group of Thai Dental Patients 
Objective:
To determine the prevalence and correlated factors of self-reported oral malodor in Thai dental patients from Chulalongkorn Dental Hospital.
Materials and Methods:
A self-administered questionnaire was developed to assess the self-reported perception of oral malodor in 839 patients. Significant associations between self-perceived oral malodor and sociodemographics, oral problems and oral hygiene practice variables were determined by Chi-square test.
Results:
The prevalence of currently self-perceived oral malodor was 61.1%. A higher prevalence of self-perceived oral malodor was significantly correlated with a number of factors including being 30 years of age or older, having a high school or lower educational level, tongue coating, xerostomia, bleeding when brushing teeth, never receiving professional tooth cleaning and a lower toothbrushing frequency. However, multivariable analysis showed that tongue coating was the factor most strongly associated with self-perceived oral malodor (OR=3.53; CI=2.05–6.08), followed by bleeding when brushing teeth (OR= 2.96) and being 30 years of age or older (OR=2.46). Subjects with oral malodor perceived by themselves and others had a higher level of self-perceived oral malodor, a higher prevalence of bad odor when talking, in the morning and throughout the whole day, and a higher prevalence of consulting with other people in comparison with those with perception by themselves alone.
Conclusion:
Tongue coating, bleeding when brushing teeth and being 30 years of age or older were significantly associated with self-perceived oral malodor. The level of self-perceived oral malodor and consulting with other people was more prevalent in subjects with oral malodor perceived by themselves and others.
PMCID: PMC3184763  PMID: 21998795
Epidemiology; Halitosis; Oral Hygiene; Prevalence; Self Concept

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