摘要：Objectives. We conducted health literacy environmental scans in 26 Maryland community-based dental clinics to identify institutional characteristics and provider practices that affect dental services access and dental caries education. Methods. In 2011–2012 we assessed user friendliness of the clinics including accessibility, signage, facility navigation, educational materials, and patient forms. We interviewed patients and surveyed dental providers about their knowledge and use of communication techniques. Results. Of 32 clinics, 26 participated. Implementation of the health literacy environmental scan tools was acceptable to the dental directors and provided clinic directors with information to enhance care and outreach. We found considerable variation among clinic facilities, operations, and content of educational materials. There was less variation in types of insurance accepted, no-show rates, methods of communicating with patients, and electronic health records use. Providers who had taken a communication skills course were more likely than those who had not to use recommended communication techniques. Conclusions. Our findings provide insight into the use of health literacy environmental scan tools to identify clinic and provider characteristics and practices that can be used to make dental environments more user friendly and health literate. The first assessments of health literacy among US adults found that a majority of them have difficulty using health information with accuracy and consistency. 1,2 These findings are especially relevant for chronic diseases such as oral disease, which require continual self-care and ongoing professional interactions. In the early stages of health literacy inquiry, health literacy was defined as “the degree to which individuals can obtain, process, and understand basic health information and services needed to make appropriate health decisions.” 3 (p21) Although the initial focus was on the individual, health literacy has evolved to be understood as an outcome of the match or mismatch between health literacy skills of the public and both the skills of health professionals and the characteristics and expectations of the health systems. 4,5 Oral health literacy has embraced this expanded framework for understanding some of the barriers to optimal oral health. The report, “The Invisible Barrier: Literacy and Its Relationship With Oral Health,” addresses several barriers. This report acknowledges that many health care providers are not trained to assess and address the literacy needs of their patients. As a consequence, they may orally present information without ensuring that the patient understands what has been communicated. Next, many health care providers use educational materials that may not have been developed with plain language and are difficult to understand and use. In addition, patients are often reluctant to admit that they do not understand something a health care provider says or are reluctant to ask questions or do not know how to ask questions for more information. Furthermore, many low-literacy patients either do not perceive that they have a problem or do recognize that they have a problem and work to conceal it because of shame or embarrassment. 6 Oral health literacy is of critical concern for the health of the nation because higher levels of oral health literacy have been shown to be associated with enhanced oral health knowledge, recency of dental care visits, lower levels of dental caries, lower no-show rates, and improved oral health–related quality of life. 7–11 Furthermore, recent data indicate that adults with young children do not understand how to prevent dental caries. This finding is especially true for adults with lower levels of education or whose children are Medicaid recipients. 12 However, the health sector cannot improve the literacy skills of the public, nor can health professionals wait until the education sector improves. Instead, health professionals and health care institutions can work to remove literacy-related barriers to health information, to preventive services, and to care. 13–16 To deliver high-quality, patient-centered care, health care organizations must take steps to reduce the complexity of the health care system, which can help address the mismatch between the health literacy skills of the public and the demands of the health system. 17,18 A “health literate organization” is one that makes it easier for people to navigate, understand, and use information and services to ensure their health. For example, steps organizations can take to become more health literate include integrating health literacy into planning, providing staff with health literacy training, providing print materials that are easy to understand and act on, and using health literacy strategies in interpersonal communications with patients. 19,20 In this feasibility study, we focused on the use of a health literacy environmental scan (HLES) to identify institutional or agency characteristics that enhance or inhibit access to oral health information and preventive and treatment services. Environmental scans include reviewing accessibility, signage, navigation, written communications (print materials posted in the clinic, online, and distributed to clients), and spoken communication. 19 This HLES included dental clinics in Maryland located in federally qualified health centers (FQHCs) and county and city health departments. These clinics are essential safety nets that expand access to comprehensive primary and preventive health care, and provide quality, affordable health care to the underserved, underinsured, and uninsured. This HLES is part of a statewide model of oral health literacy assessment. The Maryland health literacy model has focused on prevention of dental caries among parents of young children and for children younger than 6 years. The model includes assessments of health literacy skills and knowledge and practices of caries prevention among health care providers, the public, and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and Head Start staff. 12,21–23
