Associations between General Health Literacy Levels Measured by a Short Instrument and Oral Health OutcomesABSTRACT
Objective: To evaluate the health literacy (HL) levels in a sample of Brazilian adults and their associations with self-perceived oral health (SPOH) and tooth extraction due to dental caries (TE).
Material and Methods: A cross-sectional study was conducted with 667 adults, aged 40.6 ± 14.1 years, users of public dental services in a medium-sized city located in the state of São Paulo, Brazil. Participants answered a sociodemographic and health outcomes questionnaire. HL was measured using the HLS-EU-Q47 instrument, short-short form (HLS-EU-Q6). Logistic regression models were used to analyze the associations between predictor variables and the studied outcomes.
Results: Most participants had inadequate HL levels (n=575; 86.2%) per the HLS-EU-Q6. Regarding SPOH, participants with long-term oral health problems, who had already undergone TE and brushed their teeth up to twice per day, were, respectively, 1.85 (95% CI: 1.26-2.72), 3.88 (95% CI: 2.71-5.54) and 1.97 (95% CI: 1.39-2.80) times more likely to rate SROH as bad (p<0.05). As for TE, female participants and those with low motivation to take care of their oral health were, respectively, 1.56 (95% CI: 1.12-2.16) and 1.79 (95% CI: 1.27-2.54) times more likely to undergo TE (p<0.05). HL levels showed no association with the oral outcomes evaluated.
Conclusion: Most participants had inadequate health literacy levels, as indicated by HLS-EU-Q6 scores, and this variable was not associated with the oral health outcomes evaluated.
Keywords:
Health Literacy; Self Concept; Oral Health.
Introduction
According to the World Health Organization, health literacy (HL) constitutes the personal knowledge and competencies that accumulate through daily activities, social interactions, and across generations. Personal knowledge and competencies are mediated by the organizational structures and availability of resources, which enable people to access, understand, appraise, and use information and services in ways that promote and maintain good health and wellbeing for themselves and those around them [1].
Some authors describe HL as one’s ability to obtain, evaluate, understand, translate, and use information and knowledge to make decisions and perform actions that have some positive impact on health status [2,3]. In addition to personal skills, the environment and context also influence individuals’ ability to understand and use health information, highlighting the importance of health professionals in facilitating access and understanding of information for health system users and society [2].
Recognized as an important social determinant of health [4], low HL levels are related to greater inequalities in health care access, worse clinical outcomes, higher costs to the health system, and worse self-rated health [5-7].
Among the instruments developed to measure HL, the European Health Literacy Survey Questionnaire (HLS-EU-Q47) evaluates this construct in a multidimensional manner and assesses the difficulty perceived by individuals in performing certain health-related activities [8]. HLS-EU-Q47 is one of the most used tools to comprehensively measure HL worldwide and has been adapted into several languages [9]. But despite its qualities, the instrument is considered too long for individual assessments in the daily context of health services [10]. Consequently, two shorter versions were developed, namely the short-form, HLS-EU-Q16, with 16 questions, and HLS-EU-Q6, with only 6 questions and named short-short-form, which takes about a minute of interviewing time to complete [10].
In recent years, HL has been increasingly studied in the context of oral health, constituting one’s oral health literacy [11,12]. However, the relationship between general health literacy (GHL) and dental outcomes has rarely been investigated in the international literature, despite the few published studies that verified associations between GHL levels and dental outcomes [11,13,14]. Among the instruments used to measure HL in these studies, to date, only one has used the HLS-EU-Q6 [14] to evaluate whether HL mediates the relation between socioeconomic variables and preventive dental care (preventive dental visit vs. no preventive dental visit). HLS-EU-Q6 is the short-short version of the HLS-EU-Q47, composed of 47 questions, which assess individuals’ self-reported difficulties in making decisions within three contexts: health care, disease prevention, and health promotion [10]. Moreover, no study has been conducted using a more “solid” criterion to classify HL levels using HLS-EU-Q6 [15].
Thus, this study evaluated the HL levels among adult users of the Brazilian Unified Health System (SUS) in a medium-sized city located in the state of São Paulo, Brazil, and investigated their associations with self-perceived of oral health and tooth extraction due to dental caries using the short-short version (HLS-EU-Q6) of the multidimensional instrument HLS-EU-Q47.
Material and Methods
Study Design and Ethical Clearance
This cross-sectional observational study was approved by the Research Ethics Committee of a Dental School (CAEE 61605316.5.0000.5418). The research was initiated after participants signed the informed consent form.
Sampling
The study sample consisted of 667 individuals aged from 18 to 80 years, of both sexes, users of dental services from ten Family Health Strategy units in a medium-sized city located in the state of São Paulo, Brazil, who sought this type of service between February and August 2020. Sample size calculation considered the study objectives, design, variables, minimum detectable effect size (odds ratio), significance level, and test power. Thus, the sample of 667 participants enabled estimating the proportions of the outcomes self-perception of oral health (regular and poor) and tooth extraction (yes), with a 4% sampling error and a 95% confidence level. This sample size also provided an 80% test power (β=0.20) to detect a minimum odds ratio of 2.0 in the association analyses between GHL levels (HLS-EU-Q6) and the outcomes, considering a 5% significance level (α=0.05). Sample size was calculated using EpiInfo.
Participants and Data Collection
Users were randomly selected and invited to participate in the research in waiting rooms of the family health units and in their homes by home visits. With self-applied questionnaires, the following sociodemographic variables were collected: sex, age (dichotomized by the sample median), housing condition (lives alone or lives with someone), family income (≤ 2 Brazilian minimum wages [BMW] and above 2BMW by sample median), and schooling (dichotomized into: up to middle school and above middle school). The oral health outcomes questionnaire covered the following questions: “Do you have any long-term illness or health problem?” (6 months or more: yes or no), “Have you ever had to extract/take out any of your teeth due to toothache or cavities?” (yes or no), “How many times do you brush your teeth in a day?” (up to two times per day or more than 2 times per day), “Do you feel motivated to take care of your oral health?” (dichotomized into: always or frequently or sometimes, rarely or never).
Health literacy was measured using the European Health Literacy Survey Questionnaire short-short form (HLS-EU-Q6) instrument [10,16], which presents six questions related to individuals’ self-perception of some health-related tasks. HLS-EU-Q6 presents the following statement: [On a scale that goes from “very easy” to “very difficult,” how easily you can] 1. Assess when you need a second opinion from another doctor?; 2. Use the information that your doctor gives you to make decisions about your illness?; 3. Find information on how to deal with mental health problems, such as stress or depression? 4. Assess whether the information on health risks available in the media is reliable? (e.g., TV, Internet or other means of communication); 5. Find information about activities that are good for your mental well-being? (e.g., meditation, exercise, walking, Pilates, etc.); 6. Understand the information available in the media on how to stay healthier? (e.g., Internet, newspapers, magazines)] [10,16]. These statements can be answered on a five-scale response as follows: very difficult=1, difficult=2, easy=3, very easy=4, and a fifth alternative for when participants did not answer or did not have a definitive answer. According to the instrument developers, the final individual score is a mean calculated by summing up the answers to the six questions divided by the number of items answered [16]. The score is calculated as long as at least five of the six questions are answered differently from 0, and ranges from 1 to 4, with higher values indicating better HL levels. As such, the final score values classify individuals according to three HL levels: (likely) inadequate (≤ 2); (likely) problematic (> 2 and ≤ 3); and (likely) sufficient (> 3) [10,16].
The instrument was adapted into Brazilian Portuguese [17], and the classification criteria originally suggested were later re-evaluated for a sample of the Brazilian adult population [15] through a more robust psychometric analysis. Results showed that a model with three cut-off ranges, which classify individuals as “low or inadequate” HL (6-15 points), “moderate or problematic” HL (16-17 points), and “high or sufficient” HL (18-24 points) has greater validity for the Brazilian adult population [15]. This study evaluated two outcome variables. The first was self-perception of oral health (SPOH), assessed by the question “How do you rate your oral health?”, which participants could classify as excellent, very good, good, regular, and poor. The responses were later dichotomized into excellent/very good and good vs. regular/poor. The second outcome was tooth extraction, assessed by the question “Have you ever had to extract/take out any of your teeth due to toothache or tooth decay?” (yes or no).
Statistical Analysis
Frequency distribution tables were constructed, associating the outcome variables with the independent variables. Subsequently, simple logistic regression models were estimated between each independent variable and outcome. Variables with p<0.20 in the crude analyses (simple regressions) were tested in multiple logistic regression models. Variables with p≤0.05 remained in the final model after adjustment for the other variables. Based on the regression models, crude and adjusted odds ratios were estimated with 95% confidence intervals. Model fit was assessed using Akaike Information Criterion (AIC) and -2 Log L (log likelihood). All analyses were performed using the R program.
Results
Most participants were female (65.7%), with a mean age of 40.6 ± 14.1 years, lived with someone (92.8%), had schooling above middle school (83.2%), and HL levels (HLS-EU-Q6) scored as inadequate (86.2%). Additionally, most participants reported no health problems (75.3%), brushing their teeth more than twice per day (65.2%), and over half had already undergone tooth extraction due to caries (55.0%) (Table 1). Regarding SROH, participants with long-term health problems, who had already undergone tooth extraction due to caries, and who brushed their teeth up to twice per day were, respectively, 1.85 (95% CI: 1.26-2.72), 3.88 (95% CI: 2.71-5.54), 1.97 (95% CI: 1.39-2.80) more likely to classify their oral health as worse (regular or poor) (p<0.05) (Table 1).
As for tooth extraction due to caries, female participants and those who sometimes, rarely, or never had the motivation to take care of their oral health were, respectively, 1.56 (95% CI: 1.12-2.16) and 1.79 (95% CI: 1.27-2.54) more likely to have their tooth extracted (p<0.05) (Table 2).
Discussion
Our study investigated the HL levels among a sample of adult users of primary health care in a Brazilian municipality using the HLS-EU-Q6 instrument and compared their scores with oral health outcomes. To our knowledge, this is the first study conducted in Brazil to investigate the associations of this instrument with dental outcomes.
Results showed that most participants had inadequate HL levels (86.2%). Another study in Brazil, conducted with a sample of adult SUS users and using the same instrument, identified that 46% of the participants had low/inadequate HL levels [15,17]. Studies using other instruments to measure HL observed the same trend in Brazil and Latin America, indicating that nearly half of the study samples had low HL [18].
Considering the variety of HL instruments employed by Brazilian researchers and their applications with different social groups, studies have unanimously pointed out a relevant prevalence of inadequate HL levels in the country [18,19]. Such a finding reflects the challenges experienced by the Brazilian population to seek health information and interact with healthcare providers due to personal, social, and professional barriers [20,21].
In dentistry, studies evaluating associations between HL and oral health outcomes are very scarce, and authors who used HL-specific instruments generally applied tools that measure only its functional aspects, such as S-TOFHLA, TOFHLA, REALM, NVS, or single screening questions [22,23]. Few studies investigated dental outcomes using more comprehensive instruments like the 14-Item Health Literacy Scale (HLS-14), employed by Tenani et al. [24] to investigate associations between HL and tooth loss among adults and older adults in Brazil. In the final model adjusted by sociodemographic variables, HL showed no association with tooth loss.
Another comprehensive HL instrument used in dentistry research is the Health Literacy Questionnaire (HLQ), applied by Cepova et al. [11] and Timková et al. [25] to investigate relationships between HL and oral health-promoting behavior and periodontal disease, respectively, among Slovak adults. Cepova et al. [11] found statistically significant associations between certain HLQ domains and oral health outcomes, including visiting the dentist for a preventive check-up or dental hygiene procedure, use of fluoride toothpaste, frequency of tooth-brushing, and use of dental hygiene aids (interdental brush/thread) after adjustment for gender, age, and schooling level. Tinková et al. [25] observed an association between higher HL in seven domains and a lower likelihood of diagnosed periodontal disease, even after adjustment for sociodemographic variables. In Brazil, Morais et al. [26] used HLQ to investigate associations between general HL and non-adherence to dental treatment among young adults. The results of the adjusted analysis revealed associations between those who did not adhere to dental treatment and almost all HLQ domains. Both HLS-14 and HLQ measure not only the functional dimensions of HL, but also communicative and critical aspects of the construct [14,26], but in different ways.
The HLS-EU-Q6 scores and the studied outcomes (self-rated oral health and tooth extraction due to caries) presented no statistical associations. Several factors may explain this lack of correlation, such as HLS-EU-Q6 questions that, despite having consolidated validation evidence of its factorial properties [15,17], may not be directly related to the investigated outcomes, considering that the instrument was developed solely from the researchers’ point of view of what should be measured in the construct [10,16]. Unfortunately, this is a very common occurrence in developing of HL instruments [27]. Another explanation could be the different ways in which scores are calculated by the instruments used to measure HL. Similar to the HLS-EU-Q6, the HLS-14 final score is the mean value of the sum of the instrument items. Conversely, there is no total summation of all items in the HLQ, and the analyses are performed based on each of the instrument’s domains [26]. These different formats in score calculation may influence the probability of associations between the investigated variables.
Our results differ from a study conducted in the Netherlands, which found that limited-health literate patients exhibited increased odds of having poor self-reported oral health outcomes, such as edentulism and gingivitis [28]. In that study, HL was measured by a self-report questionnaire based on the S-TOFHLA and REALM tools, which evaluated HL’s functional dimension, thus differing from the instrument used in the present study. Hence, divergences in study results may occur because the HL instruments used measure different constructs.
In another perspective, Berete et al. [14] investigated HL (using HLS-EU-Q6) not as a predictive factor, but as a mediator between socioeconomic status and preventive dental care, that is, the percentage of the Belgian adult population who went to at least one dental visit in 2018 for preventive care such as oral examination, prophylactic cleaning, scaling, etc. The authors observed no significant mediating role for HL in the association between schooling level and preventive dental care, but this was statistically significant with income (OR of the indirect effect = 0.98, 95% CI: 0.97-0.99), accounting for 2.1% of the variance. This study supports Schillinger’s theory that HL mediates the relation between social determinants of health and health outcomes and disparities, including oral health outcomes [14].
As for the variables associated with the outcomes assessed here, SROH showed association with participants with long-term health problems, who had already undergone tooth extraction due to caries, and who brushed their teeth up to twice a day. These results confirm that both general health and oral health are integrated, aligning with Oliveira Junior and Mialhe [29] who evinced that primary care users with worse self-perception of general health and more than one missing tooth were more likely to have worse self-rated oral health. In investigating a rural population in northeastern Brazil, Santillo et al. [30] also found an association between tooth loss and negative self-reported oral health, which corroborates our result, with high strength of patients with tooth loss being 3.88 times more likely to classify their SROH as poor. Salvador and Toassi [31] also showed, in their qualitative study, reports from Brazilian adults and older adults about a negative self-perceived oral health related to aesthetic problems, missing teeth, and dissatisfaction with appearance. Thus, self-reported oral health appears to be related to general health, integrating biological, psychosocial, and social dimensions [32], in addition to oral hygiene habits, and the perceived need for treatment in advanced stages of oral problems, which may result in late seeking of dental services [33].
Regarding the outcome tooth extraction due to dental caries, female participants and individuals with less frequent motivation to take care of their oral health were more likely to develop this outcome. When it comes to gender differences, research shows that women tend to seek preventive care and are more likely to adhere to recommended treatment than men [34]. Nonetheless, other studies identified no differences according to sex for tooth loss [35] or have identified women as a group presenting higher oral hygiene [36], which may reduce chances of tooth loss, differing from our results. Tenani et al. [24] found an association between tooth loss and irregular use of dental floss and dental services, and with having visible biofilm - such factors are directly related to one’s motivation to take care of oral health, which corroborates our study. While motivation is a broad concept, it is also strictly related to improving one’s oral health behavior, considering that an efficient two-step strategy that includes regular professional teeth cleaning and daily at-home dental care depends not only on clear and effective oral hygiene guidance provided by professionals but also on patients being motivated to consistently practice these essential habits [37]. Thus, our findings enhance the correlation between motivation and tooth loss among the observed population.
As for study limitations, the cross-sectional design adopted hinders making inferences about causality in addition to associations, since exposure and outcomes are simultaneously assessed in these types of studies. Hence, a temporal relation between HL and proposed outcomes cannot be established. Despite having evaluated a significant sample of patients, our findings cannot be generalized to the entire Brazilian adult population since the sample was drawn from health care waiting rooms and home visits, whose public may have different features from the general population. Additionally, the present analyses did not provide explanations about the complex interplay between general health literacy and oral health outcomes. Future studies should use other types of analysis, such as structural equation modeling, to examine whether or not these paths exist.
Conclusion
There was no statistically significant association between health literacy scores of the HLS-EU-Q6 instrument and the outcomes SPOH and TE due to caries. However, participants with chronic diseases, history of tooth extraction, and less frequent tooth brushing were more likely to self-report their oral health as worse. Women and individuals with less motivation to take care of their oral health presented a higher chance of tooth extraction due to caries. These findings reinforce the importance of health education strategies to improve oral health literacy and encourage further studies about general HL impact on oral health outcomes, using different instruments to measure the construct.
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Financial SupportNone.
Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.
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Academic Editor: Alessandro Leite Cavalcanti
