Journal of Health Communication International Perspectives

ISSN: 1081-0730 (Print) 1087-0415 (Online) Journal homepage: http://www.tandfonline.com/loi/uhcm20

Toward a Comprehensive Instrument of Oral Health Literacy in Spanish María del Carmen Villanueva Vilchis, Ana Wintergerst & Socorro Aída Borges Yáñez To cite this article: María del Carmen Villanueva Vilchis, Ana Wintergerst & Socorro Aída Borges Yáñez (2015) Toward a Comprehensive Instrument of Oral Health Literacy in Spanish, Journal of Health Communication, 20:8, 930-937, DOI: 10.1080/10810730.2015.1018568 To link to this article: http://dx.doi.org/10.1080/10810730.2015.1018568

Published online: 05 May 2015.

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Date: 08 November 2015, At: 23:09

Journal of Health Communication, 20:930–937, 2015 Copyright # Taylor & Francis Group, LLC ISSN: 1081-0730 print/1087-0415 online DOI: 10.1080/10810730.2015.1018568

Toward a Comprehensive Instrument of Oral Health Literacy in Spanish ´N ˜ EZ MARI´A DEL CARMEN VILLANUEVA VILCHIS, ANA WINTERGERST, and SOCORRO AI´DA BORGES YA

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Oral Public Health and Epidemiology Department, School of Dentistry, National Autonomous University of Mexico, Mexico City, Mexico

To develop and assess the Spanish Oral Health Literacy Scale (SOHLS) in a Mexican adult population, a repeated survey was undertaken in 227 adults. Participants were interviewed and asked to complete the SOHLS on the basis of the Health Literacy Test developed by the Educational Testing Service. The SOHLS covered literacy skills: location, integration, generation, calculation and return. Cronbach’s a was obtained for internal consistency and intraclass correlation coefficient for test–retest reliability. Construct validity was obtained comparing the test score with self perceived oral health and the Oral Health Impact Profile-14 (OHIP-14). Mean age was 47.2 years (SD ¼ 14.3 years). Average time for test completion was 24.6  11 minutes; mean score was 24.2  3.8 and Cronbach’s a was .748; the intraclass correlation coefficient was 0.766. Spearman’s correlation was 0.426 between the test and self perceived oral health. Pearson’s correlation was 0.336 between the total test score and the OHIP-14. The instrument has good values of reliability; construct validity is significant but could be improved.

Oral health literacy is defined 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’’ (US Department of Health and Human Services, 2010). This construct, goes beyond the ability of reading, since most procedures in the clinical area (e.g., filling forms, schedule appointments, follow medical prescriptions or read a consent form) require other abilities like writing, speaking or listening (Yin et al., 2009). People with low oral health literacy tend to have a reduced ability to follow a prescribed treatment (Yin et al., 2010), more self-reported complications with chronic diseases (Shillinger et al., 2002; Tang et al., 2008), and reduced adherence to medical treatment for chronic conditions (Kalichman, Ramachandran, & Catz, 1999; Murray et al., 2009). Regarding oral health, a relation between low oral health literacy and poor knowledge and practices of oral hygiene has been observed. People with low literacy have wrong beliefs about oral hygiene practices (e.g., not brushing their teeth or brushing only once daily; Parker & Jamieson, 2010) and putting children in bed with a bottle (Vann, Lee, Baker, & Divaris, 2010). Also, children of parents with low literacy receive less fissure sealants (Mejı´a et al., 2011). Most of the instruments that assess oral and general health literacy focus mainly on two abilities: word Address correspondence to Marı´a del Carmen Villanueva Vilchis, Oral Public Health and Epidemiology Department, School of Dentistry, National Autonomous University of Mexico, Avenida Universidad 3000, Circuito Exterior s=n, Col. Copilco El Bajo, Ciudad Universitaria, Delegacio´n Coyoaca´n, Mexico City, 04510 Mexico. E-mail: [email protected]

recognition (Lee, Rozier, Lee, Bender, & Ruiz, 2007; Richman et al. 2007) and text comprehension (Gong et al., 2007; Sabbahi, Lawrence, Limeback, & Rootman, 2009). Word recognition tests evaluate the ability to pronounce words, they are easy and quick to apply and are good predictors of the reading capacity. The Rapid Estimate of Adult Literacy in Dentistry (REALD; Lee et al., 2007) is the most frequently used word recognition test. Another group of instruments test text comprehension (Gong et al., 2007; Sabbahi et al., 2009). The Test of Functional Health Literacy in Dentistry (TOFHLiD; Gong et al., 2007) and the Oral Health Literacy Instrument (OHLI; Sabbahi et al., 2009) are comprehensive instruments that evaluate reading comprehension using the Cloze procedure: sentences with every fifth word missing; after reading a text, spaces must be filled in choosing between several options (Baker, Williams, Parker, Gazmararian, & Nurss, 1999; Parker, Baker, Williams, & Nurss, 1995). The first instrument focused on Spanish speakers (Oral Health Literacy Assessment in Spanish [OHLA-S]; J. Lee, Stucky, Rozier, & Lee, 2012) was published in December 2012. This instrument has been tested in Spanish speakers living in the United States, shows good psychometric behavior and has the advantage of being easily applied. It is considered a word recognition test with a comprehension component; it is administered conditionally, meaning that there is a list with several words, if the subject pronounces them correctly, he or she is asked to associate these words with some others based on the meaning. A word recognition and reading comprehension test does not evaluate all the dimensions of the health literacy construct. For example it does not include the way in which the individual uses the information or does not

Instrument of Oral Health Literacy in Spanish ensure that the individual has a good management of the arithmetic skills also considered as part of the literacy concept. The cultural aspects that surround the individual are important when developing a tool for a specific population. The Educational Testing System Organization developed the Health Activities Literacy Scale (Educational Testing System, 2009). Its objective is to assess the literacy skills needed by adults to perform activities in the health area. The aim of this project was to develop the Spanish Oral Health Literacy Scale (SOHLS) using a skills-based approach and to assess its reliability and validity.

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Method To develop the SOHLS, definitions of oral health literacy, functional health literacy and its domains were reviewed. The definition selected to guide the study was the one proposed by the National Assessment of Adult Literacy (Cutilli & Bennett, 2009) that establishes that health literacy ‘‘is the ability to use printed and written information associated with a broad range of health related tasks to accomplish one’s goals at home, in the workplace, and in the community including health care settings’’, this concept is restricted to the written field, making the development and measurement of the test more valid. As areas that the test should cover, we selected the activities proposed by ETS which include five areas: health promotion (activities aiming to improve and maintain health), health protection (those aiming to preserve health at a community level), disease prevention (preventive measures and engagement with early detection), health care maintenance (search of information to contact healthcare providers), and systems navigation (to read and understand bureaucratic information, for example, rights). The next step in the construction of the SOHLS was to gather written information given to patients at the School of Dentistry of the UNAM including receipts, pamphlets, consent forms, and manuals. This information was classified by two specialists in Public Health into the aforementioned health literacy activities. Once the information was classified, representative material pertaining to each of these activities (in different types of text) was selected by the same two specialists. These texts were given to 20 randomly selected faculty members (pediatric dentists [n ¼ 2], orthodontists [n ¼ 3], prosthodontists [n ¼ 2], oral public health professionals [n ¼ 3], oral health education professionals [n ¼ 3], oral surgeons [n ¼ 2], endodontists [n ¼ 2], and periodontists [n ¼ 2]). These professors ordered the texts according to their perception of the importance of each for patients and completed a questionnaire on the reading difficulty of each text using a Likert scale, ordering them from the most difficult to the easiest. The complete list of topics included the following: instructions for maintaining dentures, postoperative instructions after an oral surgery, toothbrushing instructions, oral self-exam, informed consent, medication intake, the use of topical fluoride, care when using braces, baby oral care, signs of periodontal disease, and the use of mouthwashes. We asked the faculty members to grade the reading difficulty of the texts because the only available formula to

931 measure the readability difficulty of texts in Spanish requires more than 100 words (Blanco-Perez & Gutierrez-Couto, 2002), and many of the materials included in this initial evaluation were shorter. The topics kept in the test were those in which there was at least 80% agreement on the importance of the information for the patients and the difficulty on reading the text: toothbrushing instructions, use of mouthwashes, postoperative instructions after an oral surgery, informed consent and signs of periodontal disease. Once the topics were identified, questions for each topic were developed following the evaluation strategies proposed by ETS, centered on five domains: location of information in a text (match information with similar or identical information; in this case searching and finding specific information on the indications of an antibiotic prescription=multiple choice questions), integration (linking two or more pieces of information based on a specific relation; in this case, answering questions about a consent form and the correct use of mouthrinses=multiple choice questions), cycling (matching two different kinds of information to satisfy conditions stated in the question; in this case, relating names to images: toothbrush, a denture, a crown, etc.=matching sets), calculation or arithmetic skills (in this case to apply basic arithmetic operations calculating the schedule to take a medicine and the number of doses=multiple choice questions); and generation (to process information and create a new category or main idea answering questions in their own words after reading a text on periodontal disease=open questions). The initial SOHLS had 40 items, which were analyzed by three experts in oral public health to verify face validity, two pilot tests were also performed. Inclusion criteria were as follows: Spanish speaking individuals (>18 years old) who agreed to participate (informed consent). Individuals with mental disabilities, severe vision problems or who were illiterate were excluded. The first pilot test was performed on 50 persons to verify the understanding of the questions. The second one was submitted to obtain sociodemographic information and verify content validity using difficulty and discrimination tests. The difficulty test consisted in calculating the proportion of persons who answered correctly over the total number of participants who answered the test; the closer each item is to 0.50, the difficulty of the item is better. To identify item discrimination, the tertiles of each item according to the number of correct answers were obtained; the group with the highest scores was compared with the lowest scores. The 11 items with no significant differences between the upper and lower tertiles were eliminated (5 for cycling, 3 for generation, 1 for calculation, and 2 for integration skills). The final version has 29 items: 9 correspond to cycling skills, 4 to location, 2 to formulation, 3 to generation, and 11 to integration skills. Each item had a value of one if answered correctly. The complete test has a summative score from 0 (lowest literacy) to 29 (highest literacy). To estimate construct validity the score of the scale was compared with self-perceived oral health during the past 3 months, self-perceived oral health of people of the same age and with the OHIP-EE-14 (Castrejo´n & Borges-Ya´n˜ez, 2012).

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M. D. C. Villanueva Vilchis et al.

The next phase was the application of the test; inclusion criteria were the same as those for the pilot test. The study universe was approximately 1500 attendees to the Admission Clinic of the School Dentistry from UNAM during 2 months. Sample size calculation was based on an intraclass correlation coefficient (ICC ¼ 0.70 according to the null hypothesis) and considering an a ¼ .05 with two observations. We stratified by schooling (six levels), a variable closely related to health literacy; to have at least 30 participants for each. We oversampled with 25% to have enough individuals to participate in the retest. The sociodemographic variables considered were as follows: sex, age, schooling, number of years of study, and the number of years that had passed since their last formal course. Participants were interviewed on socioeconomic data (by two standardized examiners) and were asked to complete the paper test on oral health literacy. For validation purposes two questions on self-perception of health and the OHIP-EE-14 were also applied. The last phase corresponded to the reapplication of the test (not the interview); it was reapplied to a subset of 40 participants 2 weeks later, under the same conditions. Statistical Methods To evaluate internal consistency, Cronbach’s a analysis was applied. The ICC was obtained to estimate the test–retest reliability. Construct validity was estimated with a Pearson correlation coefficient between the SOHLS and the Spanish Reduced Version of the Oral Health Impact Profile. Spearman’s correlation coefficient between the new instrument and self-perceived oral health (during the past 3 months and compared with people of the same age) was also obtained.

Results Sociodemographic Data We evaluated 227 patients of the School of Dentistry at UNAM (Admission Clinic), and 64.3% were women. Mean age was 47.6 years (SD ¼ 15.3 years); there was no significant difference in age between men and women (Table 1). The mean number of years of formal education was 10.21  4.5, and the mean of years without studying was 29.6  18. The schooling levels considered were incomplete primary, complete primary, secondary school, technical studies, preparatory school, professional studies. There were no significant differences between the number of participants in each group because we stratified by schooling. Regarding self-perceived oral health, 45.9% women and 48.1% men considered their oral health similar to other people of their same age, while 30.8% women and 35.8% men considered it better. Concerning self-perceived oral health during the past 3 months, 37.9% considered their health as good, while 12.8% considered it bad. Test The mean time required to complete the test was 24.7  11 min. The items with best difficulty level (the proportion of people who answered each item correctly) were explanation of a text=generation skill (0.577); order a sequence (0.638) and true–false questions on informed consent (0.622)=integration skills. Items that did not discriminate well were the relation of an image to the words anesthesia and toothpaste=cycling (Table 2). The median score obtained for the test was 25.0; the value of percentile 25 was 23.0 and the value for percentile 75 was 27.0. The highest scores were found in subjects with

Table 1. Sociodemographic characteristics, School of Dentistry, Universidad Nacional Auto´noma de Me´xico (UNAM) Female

Male

Total

v2

p

n 146

% 64.3

n 81

% 35.7

n 227

% 100

18.612

Toward a Comprehensive Instrument of Oral Health Literacy in Spanish.

To develop and assess the Spanish Oral Health Literacy Scale (SOHLS) in a Mexican adult population, a repeated survey was undertaken in 227 adults. Pa...
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