A growing number of adult Americans are functionally illiterate. These people often do not understand educational documents written by health care professionals, especially if English is the reader's second language. This problem has received little attention in dentistry.
Methods
In this study, the author selected a sampling of 24 patient educational documents from several dental resources and reviewed them for readability, using a computer-based program that assigns a reading level of understanding on the basis of a standard formula known as the Flesch-Kincaid Formula. The author also conducted a subjective review of each document to identify seemingly unnecessary professional jargon and words that were unlikely to be understood by many readers.
Results
Reading levels varied from third to 23rd grade (according to the Flesch-Kincaid Formula), and 41.7 percent of the materials were written at greater than the recommended level for understanding by most patients (mean level: seventh to ninth grade). Many dental specialty publications were written at or near college levels. Many documents had multiple grammatical errors. Seventy-nine words in the reviewed documents were considered to be jargon or potentially obscure to many lay readers.
Conclusions
More attention needs to be focused on the preparation of written educational materials for dental patients, to make the documents more understandable to the average patient. Guidelines for acceptable writing are available in the medical, nursing and pharmaceutical literature.
Section snippets
METHODS AND MATERIALS
In all, I reviewed 23 brochures and pamphlets, all of which were available in various dental-school patient waiting areas: nine (37.5 percent) were publications of the American Dental Association; four (16.7 percent) of the American Association of Oral and Maxillofacial Surgeons, or AAOMS; two (8.3 percent) of the U.S. Department of Health and Human Services' Public Health Service; one (4.2 percent) each of the American Red Cross, the American Cancer Society, the Columbus (Ohio) Health
RESULTS
The content of the group of patient educational documents was highly variable, ranging from a Flesch-Kincaid reading level of third grade to 13th grade, with portions of one document reading at a 23rd-grade level. Using the median reading level of eighth grade (from the mean reading level of seventh to ninth grade as recommended in the medical literature), I found that 10 of the 24 documents (41.7 percent) were written at high-school levels, which are higher than the levels of understanding of
DISCUSSION
The pharmacology and nursing professions have long recognized the disparity between the writings of health care professionals and the reading abilities of the patient population, and they have actively promoted more understandable patient educational materials. This dichotomy still exists in the writings of the medical profession, however, and it may extend into dentistry as well.
If this relatively small sample of documents is representative of the patient educational materials generally
CONCLUSIONS
Numerous booklets, brochures, forms and other documents have been created to educate the dental patient population, and these are widely distributed in dental offices and other venues. Unfortunately, many of these documents are written at reading levels that are higher than the comprehension level of the target audience. Many are filled with grammatical errors, and many have excessive use of difficult words and professional jargon that compromise their understanding. Future documents should be
2022, American Journal of Orthodontics and Dentofacial Orthopedics
The purpose of this study was to determine if written rehearsal of informed consent improved 6-month recall and comprehension compared with the current best practices.
A consultation was provided and subjects read the modified informed consent document. They were randomized to group A (received the core and up to 4 custom elements of treatment, wrote what each image displayed) or group B (presentation of the 18 elements with core elements chunked at the end followed by up to 4 custom elements). Interviews recording knowledge recall/comprehension occurred immediately and after months later.
Overall, no significant differences in baseline or 6-month follow-up scores were found between groups. Initially, group A outperformed group B in some core domains. There were no significant differences between groups in the change of scores from initial to follow-up. Follow-up scores were significantly lower than baseline scores (P <0.05). Higher initial scores were associated with larger drops at follow-up. A decrease in knowledge >20% was common.
Overall the methods are comparable at baseline and 6-months. Initial content retention was roughly 60+%, with 6%-9% deterioration. For areas of treatment methods, risk, discomfort, and resorption at 6-months, the current processes failed the patient and left the practitioner vulnerable to risk management issues. Results support the rehearsal method with immediate feedback for misunderstandings as the preferred method for informed consent.
2021, American Journal of Orthodontics and Dentofacial Orthopedics
Proper informed consent allows patients to take an active role in their own treatment decisions, and enhanced compliance might improve treatment outcomes. The objective of this research was to determine if handwritten rehearsal of core and custom consent items would increase short-term recall and comprehension.
A total of 90 patient-parent pairs were randomly assigned to 2 groups. After case presentation, each subject was provided 10 minutes to read a modified informed consent document. Group A received visual printouts containing the 4 core elements (root resorption, decalcification, pain, and relapse/retention) likely to be encountered by all patients and up to 4 custom elements (eg, impacted teeth, orthognathic surgery, or other case-specific treatment issues). Subjects identified and wrote what the image depicted and how it could affect treatment. Group B viewed a slideshow presentation on all 18 consent elements arranged from general to specific. All participants were interviewed, and each provided their sociodemographic data, as well as completed literacy, health literacy, and state anxiety questionnaires. The groups were compared for recall and comprehension through an analysis of covariance.
The rehearsal intervention significantly improved recall and comprehension of the core elements (P = 0.001). Rehearsal also improved custom recall and comprehension, but not significantly. Group B performed significantly better on treatment questions (P = 0.001). Overall, as anxiety increased, correct responses decreased.
The rehearsal group improved recall and comprehension of the core and custom elements of informed consent and proved a more efficient method than an audiovisual presentation to provide informed consent. It also improved meeting legal obligations.
The purpose of this study was to evaluate the readability and quality of online patient educational materials (PEMs) for orthognathic surgery.
Two internet searches were performed using the search terms orthognathic surgery and jaw surgery. The presence of content related to the risks, benefits, procedure, and postoperative care was recorded. Readability was measured using 4 validated scales: Flesch-Kincaid grade level, Gunning Fog index, Coleman-Liau index, and Simple Measure of Gobbledygook index. Materials were readable if they were written at or below an eighth-grade reading level as recommended by the American Medical Association (AMA) and the National Institutes of Health (NIH). Quality was assessed using 2 metrics: the DISCERN instrument and the Journal of the American Medical Association benchmark criteria. A DISCERN score of 50 was set as the lower limit of acceptable quality. Mann-Whitney U and Fisher exact tests were used to compare the readability, quality, and presence of content between private practice and non-private practice PEMs.
Fifty websites were included in the study after removing duplicates and applying exclusion criteria. On average, PEMs were written at a 13.4-grade level (range, 7.8 to 17.3). Nearly every website (n = 49; 98%) mentioned the benefits of surgery; however, very few websites discussed the surgical procedure (n = 12; 24%), postoperative care (n = 10; 20%), and risks or complications (n = 6; 12%). The mean DISCERN score was 25.5 of 80 (range, 18 to 63), and only 2 websites achieved DISCERN scores of acceptable quality. Private practice websites reported less content related to the surgical procedure (P = .03) and had lower DISCERN scores (P = .02).
As a whole, online PEMs for orthognathic surgery failed to meet AMA and NIH readability recommendations and yielded poor quality scores. Increasing the presence of content related to treatment risks and postoperative care will help improve the quality of PEMs.
2015, American Journal of Orthodontics and Dentofacial Orthopedics
Previous research has demonstrated that current methods of informed consent are relatively ineffective as shown by poor recall and comprehension by adolescent patients and their parents. The purpose of this study was to determine whether adding a short videotape presentation reiterating the issues related to informed consent to a modified informed consent document that emphasizes a limited number of core and patient-specific custom “chunks” at the beginning of an informed consent presentation improved the recall and comprehension of the risks, benefits, and alternatives of orthodontic treatment. A second objective was to evaluate the current related data for recommendable practices.
Seventy patient-parent pairs were randomly divided into 2 groups. The intervention group (group A) patients and parents together reviewed a customized slide show and a short videotape presentation describing the key risks of orthodontic treatment. Group B followed the same protocol without viewing the videotape. All patients and parents were interviewed independently by research assistants using an established measurement tool with open-ended questions. Interviews were transcribed and scored for the appropriateness of responses using a previously established codebook. Lastly, the patients and parents were given 2 reading literacy tests, 1 related to health and 1 with general content followed by the self-administered demographic and psychological state questionnaires.
There were no significant differences between the groups for sociodemographic variables. There were no significant differences between the groups for overall recall and comprehension; recall and comprehension for the domains of treatment, risk, and responsibility; and recall and comprehension for core, general, and custom items. The positional effects were limited in impact. When compared with previous studies, these data further demonstrate the benefit of improved readability and audiovisual supplementation with the addition of “chunking.”
There is no benefit to adding a short video to the previously established improved readability and audiovisual supplementation. There is a significant benefit of improved readability and audiovisual slide supplementation with the addition of “chunking” over traditional informed consent methods in terms of patient improvement in overall comprehension, treatment recall, and treatment comprehension. The treatment domain is the most affected.
The initial and, to date, dominant focus on functional levels of (oral) health literacy is reflected in the definitions in Table 1a. OHL studies adopting a functional focus have yielded fruitful results regarding the readability of health materials [9] and the assessment of patient reading skills, including word recognition [10,11] and comprehension [12]. As a more recent evolution from the HL agenda, particularly in the USA [13–16], OHL is proving to be developing as a distinct field.
To describe the relationship between caregivers’ oral health literacy (OHL) and the oral health status of their children in an Asian population.
A random sample of 301 child/caregiver dyads was recruited from kindergartens in Hong Kong. Two locally-developed and validated OHL assessment tasks were administered to caregivers with Hong Kong Rapid Estimate of Adult Literacy in Dentistry-30 (HKREALD-30) assessing word recognition and Hong Kong Oral Health Literacy Assessment Task for Paediatric Dentistry (HKOHLAT-P) assessing comprehension. Their children's oral health status was assessed [dental caries experience – decayed, missing, filled teeth index – (dmft) and oral hygiene status – Visible Plaque Index (VPI)].
Caregivers’ literacy was associated with children's oral health status. The HKOHLAT-P had a stronger association with children's oral health than HKREALD-30. HKOHLAT-P and HKREALD-30 remained associated with dmft in the adjusted negative binomial regression models (accounting for socio-demographics), Incidence Rate Ratio (IRR) 0.97, p = 0.02, and 0.96, p = 0.03, respectively. In the adjusted model, HKOHLAT-P was associated with VPI (IRR 0.90, p < 0.05), but no association between HKREALD-30 and VPI was evident.
The main conclusion of this study was that caregiver oral health literacy was associated with their child's oral health status. A comprehension instrument had a more robust association with children's oral status than a word recognition instrument.
This study has implications for general public health education for designing community-level interventions.
Health literacy is recognized as an important determinant of health as well as a causal factor in health disparities among different population groups. However, the paucity of information on oral health literacy makes urgent the need for more research on this important topic. The objective of this study was to investigate how oral health literacy relates to oral health behaviors, as well as clinical dental and periodontal condition.
A self-administered questionnaire and dental examination collected information on demographics of 589 adult residents of Akita prefecture, Japan, including: oral health behaviors; oral hygiene status; oral health literacy; number of natural teeth, decayed teeth, and functional tooth units (FTUs); and community periodontal index.
Less than half of the participants knew the Japanese words such as “dental plaque,” “scaling,” “gingivitis,” “fluoride mouth rinsing,” “8020 campaign,” “mouthwash,” and “denture plaque,” or answered “true” in response to the statement: “Scaling is related to periodontal disease.” The higher a participant’s oral health literacy, the more often they brushed their teeth or dentures, self-checked oral condition with a mirror, had regular dental checkups, and the better their oral hygiene status. Furthermore, individuals with higher oral health literacy had higher mean numbers of natural teeth, n-FTUs, and nif-FTUs. Participants with higher oral health literacy also had fewer decayed teeth. Participants with low oral health literacy were more likely to fall into a higher category of the community periodontal index code compared to those with high oral health literacy.
Our findings indicate that oral health literacy is associated with differences in oral health behaviors and clinical oral health status. An understanding of participants’ oral health literacy levels is crucial for designing effective health educational materials and creating intervention programs to promote oral health.
Dr. Alexander is an associate professor, Baylor College of Dentistry (an institution of The Texas A&M University System Health Sciences Center), Department of Oral & Maxillofacial Surgery & Pharmacology, P.O. Box 660677, Dallas, Texas 75266-0677
