摘要：Objectives. We examined whether health literacy was associated with self-rated oral health status and whether the relationship was mediated by patient–dentist communication and dental care patterns. Methods. We tested a path model with data collected from 2 waves of telephone surveys (baseline, 2009–2010; follow-up, 2011) of individuals residing in 36 rural census tracts in northern Florida (final sample size n = 1799). Results. Higher levels of health literacy were associated with better self-rated oral health status (B = 0.091; P < .001). In addition, higher levels of health literacy were associated with better patient–dentist communication, which in turn corresponded with patterns of regular dental care and better self-rated oral health (B = 0.003; P = .01). Conclusions. Our study showed that, beyond the often-reported effects of gender, race, education, financial status, and access to dental care, it is also important to consider the influence of health literacy and quality of patient–dentist communication on oral health status. Improved patient–dentist communication is needed as an initial step in improving the population’s oral health. Oral health status is inexorably linked with general health, 1 as evidenced by the association between poor oral health and chronic diseases, such as diabetes, 2 cardiovascular disease, 3 and respiratory disease. 4 Among US adults, the burden of oral disease falls heaviest on vulnerable population groups, 5–7 particularly those living in rural areas. 8 Although improving oral health is named as one of the top 5 health priorities in Rural Healthy People 2010 , 9 little progress has been made in establishing public health programs to address this priority area. To achieve the goal of improved oral health, it is essential to study the risk factors associated with the oral health status of individuals residing in rural areas and to understand the relationships among these risk factors. The association between low dental care utilization and poor oral health outcomes has been proposed as a partial explanation for urban–rural disparities in oral health status. 10–13 The rate of dental care utilization is lower among US rural than general populations, and dental visits tend to be problem—rather than prevention—oriented. 14–17 Low levels of financial security and a lack of dental providers in rural areas are cited as major reasons for the low utilization rates in rural populations. 12,18,19 However, evidence that individuals with dental insurance benefits choose to forgo regular preventive dental care suggests the presence of additional determinants in dental care utilization. 20 Previous research showed that communication between dentists and their patients plays an important role in the use of dental services. 21–24 Effective patient–dentist communication increases utilization of dental services by lessening dental anxiety and, as a result, increasing patient perceptions of provider competence. 25 Conversely, deficient communication skills, on either side of the patient–provider equation, are likely to increase dental anxiety and overall dissatisfaction with care. Health literacy deficits can interfere with effective patient–dentist communication. Individuals with low health literacy skills often have difficulty describing dental problems to their dentist and understanding dental conditions described by the dentist. 26 Rozier et al. surveyed about 2000 dentists in the United States regarding the use of the 5 domains of communication techniques: interpersonal communication, teach-back method, patient-friendly materials and aids, assistance, and patient-friendly practice. 27 Findings revealed low routine use by dentists of each communication technique, including those thought to be most effective with patients who demonstrate low health literacy. The association between low health literacy and poor health outcomes is well established. 28–30 However, in the context of oral health, the literature offers few studies identifying the relationship between health literacy and oral health outcomes. It has been suggested that those with low health literacy are at highest risk for oral diseases and problems 31 and that low health literacy may be associated with barriers to accessing care and with oral health behaviors such as seeking preventive care. 32 Furthermore, rural residents have lower health literacy skills than urban residents. 33 However, how health literacy is related to oral health status among rural populations remains an unanswered question. Frequently acknowledged risk factors for poor oral health include gender (male), race (Black), educational attainment (low), financial status (low), and access to dental care (none). We controlled for these factors in an examination of the effects of health literacy, patient–dentist communication, and dental care patterns on self-rated oral health status. In addition, we tested mediational pathways between health literacy and self-rated oral health. We hypothesized that greater health literacy would be associated with better patient–dentist communication, and in turn, that better patient–dentist communication would be associated with an increased likelihood of seeking regular dental care, ultimately leading to better self-rated oral health.
