|Year : 2014 | Volume
| Issue : 3 | Page : 209-214
Association between oral health literacy and oral health-related quality of life among undergraduate students in Bengaluru city
Gaurav Sharma, Manjunath P Puranik, KR Sowmya
Department of Public Health Dentistry, Government Dental College and Research Institute, Bengaluru, Karnataka, India
|Date of Web Publication||15-Nov-2014|
Room No. 9, Department of Public Health Dentistry, Government Dental College and Research Institute, Victoria Hospital Campus, Fort, Bengaluru 560 002, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Oral health literacy (OHL) is the new imperative for better oral health as health literacy is now considered a determinant of health. The complexity of both verbal and written oral health communications creates a significant barrier to improving oral health. Aim of the Study: To determine the association between OHL and oral health-related quality of life (OHRQoL) among undergraduate students in Bengaluru City. Materials and Methods: For a cross-sectional survey among 400 undergraduate students (PUC, BA, B.Com, BBM, B.Sc, BE), 10 colleges were randomly selected in Bengaluru city. The structured proforma including oral health impact profile-14 (OHIP-14) was administered to the study participants. Rapid estimate of adult literacy in dentistry-30 (REALD-30) was provided to each participant to be read aloud in front of the interviewer. The data were analyzed using descriptive statistics, ANOVA and correlation coefficient test. A P < 0.05 was considered to be significant. Results: Mean OHIP-14 score ranged from 16.2 ± 3.52 (BBM) to 21.5 ± 7.5 (BA) with significant differences among streams (P = 0.036). Mean REALD-30 ranged from 12.76 ± 4.61 to 18.85 ± 3.42 with significant differences between groups (P < 0.001). OHIP-14 and REALD-30 showed positive correlation for PUC (r = 0.072), B.Com (r = 0.314), B.Sc (r = 0.448) and BE (r = 0.245); negative correlation for BBM (r = −0.09). However significant correlation was observed among B.Sc and BE students (P < 0.05). Conclusion: Oral health literacy was significantly associated with OHRQoL. Hence raising OHL levels may have an impact on OHRQoL.
Keywords: Health literacy, oral health literacy, OHIP-14, OHRQoL, REALD, quality of life
|How to cite this article:|
Sharma G, Puranik MP, Sowmya K R. Association between oral health literacy and oral health-related quality of life among undergraduate students in Bengaluru city. J Indian Assoc Public Health Dent 2014;12:209-14
|How to cite this URL:|
Sharma G, Puranik MP, Sowmya K R. Association between oral health literacy and oral health-related quality of life among undergraduate students in Bengaluru city. J Indian Assoc Public Health Dent [serial online] 2014 [cited 2020 Jan 28];12:209-14. Available from: http://www.jiaphd.org/text.asp?2014/12/3/209/144801
| Introduction|| |
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 (QoL). Preventable and treatable oral diseases remain widespread, particularly amongst poor and underserved populations.  Poor general literacy and in particular poor health literacy skills are recognized as a possible cause of health disparities. 
The multi-level consequences of low health literacy have been reviewed extensively, and these include negative health behaviors, reduced utilization of preventive health services, and poorer adherence to therapeutic protocols.  Limited reading skills are not only associated with a limited understanding of the concepts of risk, probability, and chronicity but also with specific health risks, chronic diseases, and their associated treatment protocols. These individuals are also less likely to engage in screening programs, to follow-up after an abnormal test, and to comply with treatment protocols or preoperative instructions. Finally, individuals with limited literacy may be less likely to become actively involved in healthcare choices, referred to as participatory decision-making, and may face significant challenges in navigating the health system. 
In the oral health context, oral health literacy (OHL) 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 behaviors; to communicate with oral health care providers; to place their names on dental treatment waiting lists or organize 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.  National Institutes of Dental and Craniofacial Research defined OHL as "The degree to which individuals have the capacity to obtain, process, and understand basic oral health information and services needed to make appropriate health decisions." 
Many dental instructions and brochures have a level of sophistication beyond the average patient's reading ability and often contain jargon, making them difficult to understand.  It is suggested that the complexity of both verbal and written oral health communications create a significant barrier to improving oral health and that OHL is required in order to promote oral health and to prevent oral disease. 
On the other hand, QoL assessment is being regarded as an essential component for assessing outcomes of health care, including outcomes for public health programs. The impact of oral diseases on the QoL is very obvious. The concept of oral health related (OHR) QoL is significant to all areas of dental health including clinical practice of dentistry, dental education and dental research. 
The link between low health literacy skills and poor health outcomes has been well established.  An accumulating body of evidence links low OHL with worse oral health outcomes such as oral health status and dental neglect. Also, research has shown that OHL is associated with increased prevalence of OHRQoL impacts. 
India has a distinct advantage in a population profile concentrated in the younger age group.  Assessing OHL in this age group could be helpful to oral health professionals to know how to tailor health information and improve QoL.
Although recently gaining more attention, there has been little work in the field of OHL or, more specifically, the interrelation of OHL and OHRQoL.  With this background, a study was conducted to explore the association between OHL and OHRQoL among undergraduate students studying in Bengaluru city.
To determine the association between OHL and OHRQoL among undergraduate students in Bengaluru city.
- To assess OHL using rapid estimate of adult literacy in dentistry-30 (REALD-30)
- To assess OHRQoL using oral health impact profile-14 (OHIP-14)
- To determine whether OHL is associated with OHRQoL.
| Materials and Methods|| |
A cross-sectional study was conducted among undergraduate students studying in Bengaluru city. The study was conducted from May to July 2013. Ethical approval for the study was obtained from institutional ethical board. Informed consent was obtained from the participants after obtaining the necessary permission from college authorities.
Undergraduate students studying in degree (Government and Private) colleges of Bengaluru city, excluding students from medical, dental, nursing and pharmacy streams.
Sample size estimation
Prior to the commencement of the main study, a pilot study was conducted among 70 students to assess the feasibility of the study and sample-size estimation.
Sample size was estimated by using the formula: Sample size = (Z 2 × [p] × [1 − p]) D/E 2 , with P = 50%, design effect (D) =1 and margin of error (E) = 5%. The sample size was 384.16~384 or 400.
Method of sampling
List of colleges affiliated to Bengaluru University was obtained from the website of Bangalore University (http://www.bangaloreuniversity.ac.in).  These colleges were marked on the Bengaluru city map. Bengaluru city was divided into North and South Zone and 10 colleges were selected randomly that is, 5 from each North and South Zone. The colleges thus included had streams related to PUC, BA, B.Com, BBM, B.Sc and BE.
English speaking undergraduate students in Bengaluru city.
Students with known history of cognitive impairment, vision or hearing problems.
The principal investigator was trained in the Department of Public Health Dentistry regarding administering of OHIP-14  and REALD-30  on 10 subjects reporting to the out-patient department.
The study was conducted by a single trained investigator. A structured proforma was used for data collection. The first part consisted of sociodemographic variables such as age, gender, course of study, parents' education, occupation and income. Socioeconomic status was assessed using Kuppuswamy's scale (parent's education, occupation and family income).  Dental history included reasons for dental visits. The second part consisted of OHIP-14 that was rated on a five-point scale. The third part consisted of REALD-30 consisting of 30 dental words.
The structured proforma was administered to the study participants in their respective colleges and participants were asked to fill the first and second part of the proforma. Later the list of words in REALD-30 was provided to each participant to be read aloud in front of the interviewer. Adequate time was provided to pronounce each word clearly and also participants were instructed to skip the word in case of nonfamiliarity with the term.
The data was analyzed using Statistical Package for Social Sciences, IBM Corporation, SPSS Inc., Chicago, IL, USA version 18 software package (SPSS). Descriptive statistics with frequency, mean and standard deviation was computed. In scoring REALD-30, one point was assigned for each word pronounced correctly and summed to get the overall score. The total score has a possible range of 0 (lowest literacy) to 30 (highest literacy).
ANOVA was used to test the difference in REALD-30 score among students pursuing different courses. Pearson's correlation tests were used to assess the correlation between REALD-30 and OHIP-14, and between REALD-30 and domains of OHIP-14. A P < 0.05 was considered as significant.
| Results|| |
Among 400 participants, above two-third were in 18-20 years category, and as much as 69% were males [Table 1]. Parents' of most study participants (71.5% mothers and 76.26% fathers) had attained education of Higher School Certificate or higher across the streams. Mothers who did not finish high school (i.e. primary education or less) ranged up to 10.25% whereas fathers who did not finish high school ranged up to 3.25%.
|Table 1: Distribution of study participants according to age and gender |
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Approximately 50% of the study population across the streams had monthly family income that ranged between Rs. 8000 and 16000. Regarding socioeconomic status, >70% in B.Com group represented lower middle or higher class, whereas >50% of study participants in PUC, BBM, B.Sc and BE belonged to upper middle or higher class.
Dental visits across the streams ranged from 32.35% among BBM students to 72.32% among BE students with predominant reason for dental visit being pain (18-23.3%) and fillings (6.66-30%).Visit for orthodontic reasons was reported by 10% of the students in PUC and BE. Reasons for not visiting a dental clinic was admitted as "having no dental problems" by above 75% study participants across streams.
Mean OHIP-14 score among study groups ranged from 16.2 ± 3.52 in BBM stream to 21.5 ± 7.5 among BA stream. Significant differences in mean OHIP-14 were seen among groups (P < 0.036). Overall BA students had better average in four domains-psychological discomfort, physical disability, social handicap and handicap whereas BBM students excelled in other three domains namely functional limitation, physical pain and psychological disability [Table 2].
Rapid estimate of adult literacy in dentistry-30 scores were divided into six categories with intervals of five from 0 to 30. Mean REALD-30 scores ranged from 12.76 ± 4.61 to 18.85 ± 3.42 with significant differences between groups (P < 0.001). Score wise, B.Sc students were more likely to perform at 11 or more when compared with other groups [Figure 1].
|Figure 1: Distribution of study groups according to rapid estimate of adult literacy in dentistry-30 score|
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Oral health impact profile-14 and REALD showed positive correlation for PUC (r = 0.072), B.Com (r = 0.314), B.Sc (r = 0.448) and BE (r = 0.245); negative correlation for BBM (r = −0.09). However, significant correlation was observed between REALD and OHIP-14 scores among B.Sc and BE students (P < 0.05) [Table 3].
| Discussion|| |
Health literacy is a term introduced in the 1970s and is of increasing importance in public health and healthcare. It is concerned with the capacities of people to meet the complex demands of health in a modern society.  OHL is likewise considered one of the many factors that influence oral health. The other major factors include cultural and social factors, education and various aspects of health system. 
Dental treatment needs of patients (met and unmet) have influence on their OHRQoL. Met dental needs lead to improved oral health and thus better OHL. Unmet dental needs on the other hand account for deterioration of oral health and associated OHRQoL. OHL is thus influenced by dental visits and can be linked with OHRQoL.
Youth is a special period of human development, not just physically but also emotionally and cognitively. Eighteen is the age at which these youngsters are about to begin a new chapter in their lives and the society legally deems them as an adult. In the present study, mean age of participants was 19.8 ± 1.71 years studying in various streams. The results are in contrast with studies conducted by Lee et al.  (26.5 years), Divaris et al.  (26.5 years), Vann et al.  (25 years) and Lee et al.  (26.6 years) as these study participants were recruited from hospitals , or field setting. ,
Regarding gender distribution, 69.25% were males and 30.75% were females. Most of the studies are done on a female population, ,,,,,,,,, whereas a study by Atchison et al. (males 57%, females 43%)  included both males and females similar to the current study.
Level of education varied among the parents with 3.25% of the fathers who did not finish high school when compared to 10.25% of the mothers. This is comparable to parents education in studies conducted by Richman et al. (4%),  Gong et al. (4%),  Richman et al. (7%).  Whereas our results are in contrast to studies done by Divaris et al. (24%),  Lee et al. (23.9%),  and Vann et al. (23.9%)  in regards with parents' education.
Studies in the past have measured OHL using Test of Functional Health Literacy in Dentistry,  99-item REALD-99  and 30-item REALD-30.  OHRQoL, on the other hand, has been estimated using numerous inventories, OHIP-14 and OIDP being most commonly used tools.  Very few studies have reported relationship between OHL and QoL, so comparisons are done wherever possible.
Norms for what constitutes "low OHL" have not been established to the best of our knowledge, however in previous investigations a threshold of <13 on the 30-point REALD-30 scale was used to define a "low OHL" group.  In the present study, REALD-30 were expressed in six categories, only 17.38% in B. Com stream scored above 50% (REALD-30 score 16-30) when compared to 85% in B.Sc. Overall BE (>70%) and B.Sc (85%) students had scored >50% in REALD-30. These scores may depend on their educational background and past dental visits.
Statistically a significant difference was noted among the study group for mean OHIP-14 scores although domain-wise difference remained insignificant. This may imply cumulative impact of several domains of OHIP-14.
Oral health literacy can have a positive impact on OHRQoL. To understand this relationship, correlation test were performed between OHIP-14 scores and REALD-30. Mixed results were obtained with positive correlation being significant among B.Sc and BE students while negative correlation was observed in BBM students that were not significant. Although there is a positive correlation between OHL and OHRQoL, a closer inspection of the scores indicates little impact on OHRQoL with concomitant higher literacy levels.
This could be due to various reasons, first being the compatibility between the scales. OHIP-14 is a self-administered tool in categorical scale with 7 domains further divided into 14 questions with five unidirectional choices. To make it amenable for statistical analysis, weights are suggested, and mean OHIP-14 scores are computed. Second, dental visits may enhance OHL. In spite of higher OHL, unmet treatment needs can lead to higher OHIP-14 scores.
Strength of the study
- This exploratory study adopted a cross-sectional research design to establish relationship between OHL and OHRQoL. Although evidence from cross-sectional designs is considered weaker, it can act as a stepping stone for further research to confirm the relationship between OHL and OHRQoL
- In this research, study participants were recruited from colleges with a varied background. Thus represents the existing scenario of OHL among undergraduate students
- The tools used for this study (REALD-30 and OHIP-14) are validated tools that are often used in research across the world
- Assessment was made by a single trained and calibrated investigator.
Limitations and recommendations
- Although the participants conversed in English with the examiner, their English fluency was not assessed in this study. Hence, tools to assess literacy and English fluency might be incorporated in future research
- Using REALD instruments we only tested a person's reading ability and could not capture comprehension,  as reading is considered intermediate to decoding and comprehension.  Additional research also is needed to examine the full array of literacy skills, which includes reading, writing, speaking and listening
- This study involved undergraduate students pursuing their education in various streams other than health sciences. Further studies are recommended in a cross section of the population represented by all sections of society
- In the present study, OHL was found to be associated with OHRQoL. Further trials are suggested to understand the nature and extent of this association. This will aid in developing better oral health care programs for the population
- The identification of subjects with low OHL can alert healthcare providers to the possibility that these individuals may have difficulty with printed educational materials. Patients who score very poorly on a health literacy test may also have trouble with oral health provider-patient communication.  So special efforts may be taken to develop culturally sensitive OHL assessment tools
- Since students present on the day of study were included, the distribution is not uniform across the streams. Hence the interpretation should be done with caution.
| Conclusions|| |
- Mean REALD-30 ranged from 12.76 ± 4.61 to 18.85 ± 3.42 and mean OHIP-14 scores ranged from 16.2 ± 3.52 to 21.5 ± 7.5
- Positive correlation between REALD-30 and OHIP-14 was observed for B.Com, B.Sc and BE. The OHL and OHRQoL varied with streams and correlation was observed between them
- Interventions towards improving OHL should be undertaken to achieve better OHRQoL. REALD-30 is simple, less time consuming and may be used in dental practice on a routine basis, to determine its ability in classifying patients based on their OHL levels and designing appropriate patient-centered communication approach to improve their oral health
- More studies are required using REALD-30 in various settings to confirm its ability to detect various degrees of OHL existing in the population. Hence, professional intervention is crucial for improving OHL, thereby improving QoL.
| References|| |
Parker EJ, Jamieson LM. Associations between indigenous Australian oral health literacy and self-reported oral health outcomes. BMC Oral Health 2010;10:3.
Jackson RD, Coan LL, Hughes E, Eckert GJ. Introduction of health literacy into the allied dental curriculum: First steps and plans for the future. J Dent Educ 2010;74:318-24.
Divaris K, Lee JY, Baker AD, Vann WF Jr. The relationship of oral health literacy with oral health-related quality of life in a multi-racial sample of low-income female caregivers. Health Qual Life Outcomes 2011;9:108.
Schonlau M, Martin L, Haas A, Derose KP, Rudd R. Patients' literacy skills: More than just reading ability. J Health Commun 2011;16:1046-54.
National Institute of Dental and Craniofacial Research, National Institute of Health, U.S. Public Health Service, Department of Health and Human Services. The invisible barrier: Literacy and its relationship with oral health. A report of a workgroup sponsored by the National Institute of Dental and Craniofacial Research, National Institute of Health, U.S. Public Health Service, Department of Health and Human Services. J Public Health Dent 2005;65:174-82.
Richman JA, Lee JY, Rozier RG, Gong DA, Pahel BT, Vann WF Jr. Evaluation of a word recognition instrument to test health literacy in dentistry: The REALD-99. J Public Health Dent 2007;67:99-104.
Al Shamrany M. Oral health-related quality of life: A broader perspective. East Mediterr Health J 2006;12:894-901.
Flaherty MG. Health literacy: An overview of an emerging field. Stud Res J 2011;1:[In this issue]. Available from: http://www.scholarworks.sjsu.edu/slissrj/vol1/iss2/4. [Last accessed on 2014 Mar 20].
Bordia A. India will become a developed country by 2020 and all activities be taken up in a mission mode. National university of educational planning and administration. Available from: http://www.educationforallinindia.com/Education-of-Youth-and-Adolescents-in-India.pdf. [Last accessed on 2014 Mar 20].
Colleges Affiliated to Bangalore University, Bangalore. Available from: http://www.bangaloreuniversity.ac.in. [Last accessed on 2013 Mar 10].
Slade GD. Derivation and validation of a short-form oral health impact profile. Community Dent Oral Epidemiol 1997;25:284-90.
Lee JY, Rozier RG, Lee SY, Bender D, Ruiz RE. Development of a word recognition instrument to test health literacy in dentistry: The REALD-30- a brief communication. J Public Health Dent 2007;67:94-8.
Patro BK, Jeyashree K, Gupta PK. Kuppuswamy's socioeconomic status scale 2010-the need for periodic revision. Indian J Pediatr 2012;79:395-6.
Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, et al.
Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health 2012;12:80.
Lee JY, Divaris K, Baker AD, Rozier RG, Lee SY, Vann WF Jr. Oral health literacy levels among a low-income WIC population. J Public Health Dent 2011;71:152-60.
Vann WF Jr, Lee JY, Baker D, Divaris K. Oral health literacy among female caregivers: Impact on oral health outcomes in early childhood. J Dent Res 2010;89:1395-400.
Lee JY, Divaris K, Baker AD, Rozier RG, Vann WF Jr. The relationship of oral health literacy and self-efficacy with oral health status and dental neglect. Am J Public Health 2012;102:923-9.
Gong DA, Lee JY, Rozier RG, Pahel BT, Richman JA, Vann WF Jr. Development and testing of the Test of Functional Health Literacy in Dentistry (TOFHLiD). J Public Health Dent 2007;67:105-12.
Richman JA, Huebner CE, Leggott PJ, Mouradian WE, Mancl LA. Beyond word recognition: Understanding pediatric oral health literacy. Pediatr Dent 2011;33:420-5.
Atchison KA, Gironda MW, Messadi D, Der-Martirosian C. Screening for oral health literacy in an urban dental clinic. J Public Health Dent 2010;70:269-75.
Shanahan T. The national reading panel report: Practical advice for teachers. Available from: http://www.learningpt.org. [Last accessed on 2014 Mar 20].
[Table 1], [Table 2], [Table 3]