摘要：Objectives. We assessed the impact of health literacy and acculturation on oral health status of Somali refugees in Massachusetts. Methods. Between December 2009 and June 2011, we surveyed 439 adult Somalis who had lived in the United States 10 years or less. Assessments included oral examinations with decayed, missing, and filled teeth (DMFT) counts and measurement of spoken English and health literacy. We tested associations with generalized linear regression models. Results. Participants had means of 1.4 decayed, 2.8 missing, and 1.3 filled teeth. Among participants who had been in the United States 0 to 4 years, lower health literacy scores correlated with lower DMFT (rate ratio [RR] = 0.78; P = .016). Among participants who had been in the country 5 to 10 years, lower literacy scores correlated with higher DMFT (RR = 1.37; P = .012). Literacy was not significantly associated with decayed teeth. Lower literacy scores correlated marginally with lower risk of periodontal disease (odds ratio = 0.22; P = .047). Conclusions. Worsening oral health of Somali refugees over time may be linked to less access to preventive care and less utilization of beneficial oral hygiene practices. Among refugees newly arrived in Massachusetts, oral abnormalities are the most common health problem in children 1 and the second most common problem in adults. One major determinant of oral health disparities is access to preventive and restorative dental care. 2 Other determinants include oral hygiene practices and diet. 2 Linguistic and cultural factors may play important roles in determining access to oral health services as well as personal oral hygiene practices, and limited literacy skills have been hypothesized as a likely barrier to better oral health outcomes. 3 Health literacy, reflecting an individual’s capacity to obtain, process, and understand basic health information and services, affects a variety of determinants of oral health and is thought to play a pervasive role in all aspects of health care and oral health status. 3,4 Inadequate health literacy has been associated with a long and growing list of adverse health outcomes. 5 Inadequate literacy has been associated with limited access and utilization of care, 6,7 poor clinical outcomes, 8 hospitalization, 9 and mortality. 10 However, the relationship between health literacy and oral health has never been studied in a refugee population. Somalis compose one of the largest refugee populations to have entered the United States in recent years. As a result of civil war over the past 20 years, many Somalis have lived in refugee camps for long periods. More recently arrived Somalis have very low English literacy. 11 Somalis are almost all practicing Muslims and have relative homogeneity of language, culture, and religion. 12,13 In the United States, Somali refugees have also tended to cluster geographically through a process known as secondary migration to create cohesive communities. Past research indicated a strong role for such social structures as moderators of health literacy and its impact on health status. 14 A refugee with low literacy may be able to effectively access care with the help of the community network. Thus, health literacy may function differently in the context of the Somali community, with its strong social support network. The degree to which an individual identifies with the traditional community and social structure or that of the dominant, host community varies and may affect how an individual negotiates competing priorities related to personal oral hygiene, diet, and access to dental care. Behavioral acculturation is a measure of such factors as with whom people spend time, the types of media they are exposed to, the language in which they feel most comfortable conversing and reading, and with whom they identify. The effects of acculturation on oral health have been studied in Haitian immigrants in the United States who had a low baseline rate of caries. Acculturation was found to be associated with lower rates of development of caries. 15 In Australia, a study of Vietnamese refugees revealed associations between acculturation and dental health status. 16 The Vietnamese also had very good oral health status, and those with extensive acculturation had even better oral health status. This finding suggested that more acculturation led to protective practices and care that added to those of the refugees’ traditional culture. However, the findings documented a nonlinear relationship in which refugees with moderate levels of acculturation had worse oral health status. The researchers hypothesized that the cultural marginality model, previously applied to oral health research, 17,18 offered an explanation: refugees with moderate levels of acculturation were alienated from their traditional culture without adequate integration into the dominant culture. Thus, moderately acculturated refugees might adopt behaviors deleterious to oral health, such as Western dietary habits, without adopting preventive aspects of Western oral hygiene and related behaviors. 16 By contrast, individuals with a low level of acculturation may have continued beneficial traditional practices and not adopted a cariogenic Western diet. In the Somali community, one such practice might be use of a stick brush ( miswak or aday ). Studies have found stick brushes to be effective in removing plaque. 11,19 These brushes also have an inhibitory effect on oral cariogenic streptococci 20,21 and periodontal pathogens. 21 In light of the importance of health literacy to health in the general population, we sought to determine the relationship of health literacy (assessed in English) with oral health clinical outcomes of Somali refugees in Massachusetts. We hypothesized that after control for acculturation, participants with high health literacy would be more likely than others to have (1) less lifetime history of decay, untreated dental decay, and periodontal disease; (2) a higher rate of traditional or Western personal hygiene practices and behaviors known to be associated with better oral health outcomes; and (3) more utilization of professional dental care for preventive services. We also assessed functional and mental health outcomes and a variety of social and cultural factors relevant to the effects of literacy, acculturation, oral health care, and personal hygiene practices on oral health status in the Somali community.
